Wk 3, Case 1 - Review

Patient History

New left facial droop.

Findings

MRI Brain:

There is a hyperacute infarct involving the right middle cerebral artery territory, predominantly right centrum semiovale and corona radiata extending to the frontal operculum and insula.

There is a large perfusion deficit with increased mean transit time and time to peak. Volume of tissue with Tmax>6 s is 37 ml and volume of core infarct is calculated at 5 mL, compatible with a large penumbra at risk. No associated FLAIR signal abnormality seen.

There is a focus of susceptibility in the proximal M2 segment of the right middle cerebral artery in the sylvian fissure, compatible with thrombus. Developmental venous anomaly is noted in the right corona radiata with expected perfusion abnormality. No evidence of intracranial hemorrhage seen on susceptibility weighted images. Thrombus is seen in the proximal M2 segment of the right middle cerebral artery in the sylvian fissure.

No abnormal enhancement following administration of intravenous contrast.

MRA Head:

There is occlusion of the proximal M2 segment/superior division of the right middle cerebral artery. There is no distal reconstitution. There is slight irregularity of the distal M1 segment of the right middle cerebral artery and proximal M2 segment/posterior division.

The intracranial carotid arteries are patent. The left anterior and middle cerebral arteries are patent.

The right vertebral artery is slightly dominant. Basilar, bilateral superior cerebellar and posterior cerebral arteries are patent.

Conclusion

1. Hyperacute right middle cerebral artery territory infarct with calculated core infarct of 5 mL and tissue with Tmax >6 sec of 37 ml, compatible with large penumbra at risk. No discrete FLAIR signal abnormalities seen.

2. Intraluminal thrombus in the proximal M2 superior division of the right middle cerebral artery with abrupt complete cut off of the proximal M2 segment without distal reconstitution.