0:00

Our first case is a 61-year-old male

0:04

who had acute left-sided weakness.

0:08

So I'm going to look at the non-contrast

0:09

CT, and the first thing I'm going to

0:10

look for is intracranial hemorrhage, or

0:12

contraindication to thrombolysis, and I don't

0:16

see any, uh, obvious intracranial hemorrhage.

0:19

Now, the next thing I'm going to

0:20

do is look for a dense vessel sign.

0:22

And usually, I look on the thin

0:23

section, one-millimeter-thick slices.

0:25

Those initial images were

0:26

five-millimeter-thick slices.

0:28

I'm going to start at the bottom and I know

0:30

I'm pretty much looking for an MCA stroke.

0:32

So I'm going to look carefully at

0:33

the MCA and you can see in the M1

0:36

segment, there's hyperdensity, and

0:40

so that's consistent with the clot.

0:43

It's nice if you see it,

0:44

but you have to be careful.

0:45

Sometimes the hyperdensity can be

0:47

from beam hardening or a motion effect.

0:50

And sometimes you don't see

0:50

hyperdensity, but we see it here.

0:53

And then I'm going to look to

0:54

see how big the core is or tissue

0:55

that's already dead on arrival is.

0:57

And I'm going to narrow up the windows a little

1:00

bit, because you can see strokes a little bit

1:02

better with narrow windows and non-contrast CT.

1:05

You can see some loss of gray-white

1:06

differentiation in the anterior temporal

1:08

lobe, the insula, the subinsular

1:10

region, maybe some subtle differences

1:13

in the basal ganglia, hard to tell.

1:16

You certainly see differences in

1:17

the more superior frontal lobe

1:18

and the perirolandic region.

1:22

So we have, um, calculation of the ASPECTS

1:25

score here, and this confirms what we were

1:29

thinking that there's involvement of the

1:30

internal capsule, the lenticulostriate nucleus.

1:33

It's the insula and parts of the

1:36

intertemporal lobe and inferior frontal lobe.

1:39

And then this more superior frontal lobe

1:41

and the perirulandic region, specifically

1:44

the motor strip and adjacent frontal lobe.

1:48

And that means there's an aspects score of four.

1:52

10 and we have an ASPECTS score of four.

1:54

So that's kind of borderline whether

1:56

you're going to treat or not.

1:57

It just depends on the patient's

2:00

comorbidities and other factors.

2:03

Okay.

2:04

So we're gonna get more into the CTAs

2:06

later, not too much for seeing on the next

2:07

CTA, but I want to show you the head CTA.

2:10

So this is the axial maximum

2:12

intensity projection image.

2:14

And you can see the cutoff right

2:16

at the proximal MCA, right?

2:17

Where we saw the hyperdense

2:18

basal sign on the left.

2:20

You see the nice.

2:21

MCA branches on the right, you hardly

2:23

see any vessels at all, so this

2:24

patient has very poor collaterals.

2:26

If you have poor collaterals, your strokes

2:28

grow quickly, and usually you have a pretty big

2:30

infarct on arrival, so that goes with the pretty

2:32

big infarct and low ASPECTS score that we saw.

2:37

So the MR, obtained a little bit later, this

2:41

is the DWI image, and this confirms what

2:44

we saw in the non-contrast CT, involvement

2:47

of the anterior temporal lobe and the

2:49

insula, and more anterior frontal

2:52

lobe, and then the perirolandic region.

2:54

So pretty big stroke on arrival, non-contrast

2:57

CT, subtle, but showed the tissue that was dead.

3:02

MRI, the gold standard, confirmed it.