Case Challenge

Brain

Vascular

Daniel Cornfeld

Gain confidence interpreting Subtle Strokes Cases on CT and MRI with MRI Online. Quiz yourself using real-world, interactive scrollable cases &amp; earn CME. Try it free!

Case Review

Neuroradiology

Vascular Imaging

Case 1 - 60-year-old with double vision and dizziness.

Case 2 - 65-year-old with altered mental status.

Case 3 - 65-year-old. Altered mental status.

Case 4 - 68-year-old. Dysphagia and aphasia.

Case 5 - 82-year-old with right hemiparesis.

Case 6 - 70-year-old with confusion.

Case 7 - 60-year-old with right sided weakness.

Case 8 - 70-year-old with right-sided weakness.

Case 9 - 68-year old with aphasia.

Case 10 - 50-year-old with right-sided weakness.

Case 11 - 65-year-old with right visual field defects.

Case 12 - 65-year-old with right-sided weakness.

Case 13 - 60-year-old with left-sided weakness.

Case 14 - 60-year-old with left-sided stroke symptoms.

Case 15 - 60-year-old with bilateral weakness.

Case 16 - 50-year-old with right-sided weakness.

Case 17 - 65-year-old with right-sided weakness.

Case 18 - 60-year-old with altered mental status.

Case 19 - 55-year-old with aphasia.

Case 20 - 60-year-old with left-sided weakness.

Case 21 - 60-year-old with left hemiparesis.

Case 22 - 60-year-old with left visual field defects.

Case 23 - 68-year-old with weakness.

Case 24 - 60-year-old with bilateral weakness.

Case 25 - 90-year-old with acute left hemiplegia.

Subtle Stroke Case Challenge

Course Evaluation

Post-Course Activities

Learn to master subtle stroke cases on CT and MRI! Gain experience detecting strokes on CT by reviewing the 25 cases of subtle strokes presented in this module. The purpose is not to comprehensively explain the role of imaging in the evaluation of acute stroke or to teach a junior physician how to approach a CT scan of the brain. Instead, by reviewing these difficult cases, the reader will become better at detecting the subtle CT findings of acute stroke. Some of these cases were initially interpreted correctly. Many were not.

Subtle Strokes Case Challenge

Case Findings (Scan 1)
Hemorrhage: No
Hydrocephalus: No
Herniation: No
Gray-white differentiation/wedge-shaped hypodensity/cortical involvement: None
Deep gray nuclei: Hypodensity in the left posterior leticular nuclei (putamen, globus pallidus).
Hyperdense vessels: Hyperdense left middle cerebral artery M1 and proximal M2 vessels.


Case Discussion:
1. Conscientious and systematic interpretation is essential for detecting subtle infarcts. Initial review likely found no acute intracranial hemorrhages, hydrocephalus, herniation, or transcortical infarct. However, upon trying to assess the deep gray nuclei (anteriorly to posteriorly: Caudate, putamen, globus pallidus, thalamus), there is difficulty discerning the left lenticular grey nuclei (putamen and globus pallidus) on a few axial images, readily apparent when adapting a slow slice-by-slice approach.
2. Initial head CT imaging also demonstrates a hyperdense left middle cerebral artery M1 and proximal M2 vessels. Again note that the M1 segment starts when the middle cerebral artery originates from the terminal internal carotid artery, and the M2 segments begins at the sylvian fissure.
Imaging follow up CT examination from 9:50 AM; follow up MRI (Scan 2)
Subsequent head CT imaging shows continued subtle hypodensity in the left putamen/globe pallidus regions. No acute hemorrhage.
Subsequent brain MRI demonstrates high DWI signal and low to isointense ADC signal, suggestive of an acute/subacute left lenticular nuclei infarct.


Primary teaching points:

1. Systematic head CT search patterns for acute infarcts should include scrutiny of the deep gray nuclei, particularly in the presence of an ipsilateral hyperdense vessel. The findings are very difficult to see on the original CT but evolve to become more conspicuous on the repeat exam two hours later.
2. Reinforcing lenticular nuclei anatomy.


Non-Contrast CT

On the CT from 7:30 am, which finding (which is not difficult to see) should make you scrutinize the images to find the infarct (which I think is very, very difficult to see even in retrospect)?