Case - Subacute Stroke Evaluation (Case 3)
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These are images of a 71-year-old
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female who was last seen well five days
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ago and had left-sided hemiparesis.
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This is a non-contrast CT, and what we see
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on the non-contrast CT is some hypodensity
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in the temporal lobe and the insula, and we
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see areas of hemorrhage within the insula
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and the basal ganglia, and this goes up to
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involve the inferior parietal lobe and the
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right corona radiata, there's some mass effect.
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So, hemorrhagic lesion.
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First thing I'm going to say is this
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corresponding to a vascular territory?
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Well, it does fit the right MCA territory.
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So, we got a CTA, so let's look at the CTA, and
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you can see the CTA looks completely normal.
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MCA branches look normal, they're
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symmetric compared to the other side.
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The PCA is normal.
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We didn't see any major
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thing going on in the neck.
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So it kind of looks like it might be
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in a vascular territory or not 100 percent
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sure, not a tumor, a little weird for
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venous infarction, but that's another
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possibility amongst other etiologies.
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And so the next thing we did was.
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Get an MR.
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You can see the FLAIR-weighted image, similar
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to the CT, where you've got these areas
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of edema and mass effect and some areas of
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T2 dark signal, which is consistent with
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the hemorrhage and on the SWI image, we
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confirm that the hyperdensity is hemorrhage.
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This is.
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There's parenchymal hematomas in the
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posterior insula and in the basal
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ganglia and in the right parietal lobe.
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There are some other tiny areas
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of scattered microhemorrhages.
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And what really helps us here is that what we
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see on the diffusion-weighted image is areas
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of restricted diffusion throughout This lesion.
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So the dark signals, the hemorrhage, but
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the rest of it, it's restricted diffusion.
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And so this helps us confidently say
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that, um, this was a subacute stroke
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and not caused by another etiology.
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The reason the vessels looked normal is because
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there had been reperfusion, and with the pre
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perfusion there were parenchymal hematomas.
Pamela W Schaefer, MD, FACR
Professor of Radiology, Vice Chair of Education
Massachusetts General Hospital
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