Wk 4, Case 4 - Review

Patient History

History of seizure disorder with new leftward gaze deviation and right-sided weakness.

Findings

CT Head:

Brain Parenchyma: Encephalomalacia from prior infarct involving the right cerebellar hemisphere.

Ventricles and Sulci: Moderate to marked ventriculomegaly out of proportion to sulcal enlargement, widening of the sylvian fissures, and crowding of the sulci towards the vertex.

Extra-Axial Spaces: No extra-axial fluid collection.

CTA Head and Neck:

Extracranial

Arch & subclavian arteries: Left vertebral artery arises directly from the aortic arch. Subclavian arteries are normal bilaterally.

Common carotid arteries: Normal bilaterally.
Cervical ICAs: Patent bilaterally.

Vertebral arteries: Absent opacification of the right vertebral artery from its origin to the confluence, with threadlike opacification of a few segments of V2 and V3. Patent left vertebral artery without dissection, aneurysm, or hemodynamically significant stenosis.

Intracranial

Intracranial ICAs: Atherosclerotic calcification of the cavernous ICA with approximately 75% narrowing of the right and 50% narrowing of the left.

MCAs: Normal bilaterally.

ACAs: Normal bilaterally.

ACom: Normal

P-Comms: Hypoplastic bilaterally.

Basilar artery: Distal basal artery is small in caliber.

Vertebral arteries: Occlusion of the right vertebral artery. Left vertebral artery is patent.

PCAs: Normal bilaterally.

Other: Chronic right PICA occlusion.

Neck and Chest:

Visualized pharynx and larynx within normal limits. Salivary glands within normal limits. No lymphadenopathy by size criteria.

1.5 cm enhancing mass at the carotid bifurcation on the right.

Partially visualized intraluminal filling defect within the right distal pulmonary artery.

CT Perfusion Head:

Qualitative Tmax delay within the right watershed distribution, likely secondary to combination of artifact and transit delay related to ipsilateral stenoses.

AIF/VOF placement: Technically adequate

Stroke Location: None

CBF<30% volume (mL): 0

Tmax>6.0s volume (mL): 109, likely artifactual with erroneous inclusion of the remote right cerebellar infarct.

Mismatch volume (mL): 109. As above.

Mismatch ratio: Infinity

Hypoperfusion Intensity Ratio (Tmax > 10 secs volume/ Tmax > 6 secs volume): 0

Conclusion

1. No evidence of core infarct on CTA or CTP evaluation. Calculated Tmax volume of 109 mL is overestimated due to erroneous inclusion of the remote right cerebellar infarct. Qualitative Tmax delay within the right watershed is likely related to a combination of artifact and chronic stenoses.

2. No large vessel occlusion.

3. Chronic occlusion of the right vertebral artery with segmental threadlike opacification. Atherosclerotic calcification of the cavernous ICA with approximately 75% stenosis on the right and 50% stenosis on the left.

4. 1.5 cm enhancing mass in the right carotid bifurcation, likely representing a paraganglioma.

5. Moderate to marked ventriculomegaly, with crowding of sulci near the vertex and widening of sylvian fissure; findings can be seen in the setting of normal pressure hydrocephalus.

6. Partially visualized intraluminal filling defect within the right distal pulmonary artery, concerning for pulmonary embolism. Dedicated CT chest with PE protocol is recommended for further characterization.