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: Preserved
Deep gray nuclei: Subtle hypodensity in the right thalamic/posterior limb of the internal capsule.
Hyperdense vessels: None


Case Discussion:
Upon careful scrutiny of the deep gray nuclei, note is made of a very subtle hypodensity near the right thalamus/posterior limb of the right internal capsule, suspicious for an acute infarct. The posterior limb of the internal capsule contains motor function within the corticospinal tract anteriorly and specialized sensory tracts posteriorly. The infarct is in close proximity to the lateral thalamus.

Imaging follow up MRI (Scan 2)
Subsequent MRI imaging demonstrates an acute/subacute infarct centered in the right dorsolateral thalamus and slight involvement of the posterior limb of the internal capsule infarct (high DWI, low/isointense ADC signal).
A brief review of the deep gray nuclei and capsular vascular anatomy may be helpful when determining the vascular regions involved. In general, the anterior circulation (internal carotid artery, anterior cerebral artery, middle cerebral artery) supplies the striatocapsular regions (caudate, putamen, globus pallidus, external capsule, and internal capsule components [anterior limb, genu, posterior limb]). The posterior limb of the internal capsule is supplied by the anterior choroidal artery, a branch of the terminal internal carotid artery.
The thalami are the exception, and are supplied by the posterior cerebral arteries. Of note, the presence of bilateral thalamic infarcts may raise suspicion for variant anatomy, particularly the artery of Percheron morphology. Other considerations for bilateral thalamic infarcts include a venous infarct or rare infarct mimics such as an infiltrating glioma and lymphoma.

Primary teaching points:
1. Review of a subtle right thalamic and posterior limb of the internal capsule infarct.
2. Anatomic review of the striatocapsular and thalamic regions.
3. Broad overview of the arterial vascular territories supplying the deep gray nuclei.
4. Bilateral thalamic infarct differential considerations, including variant arterial anatomy or venous etiology.


Non-Contrast CT

Is this an anterior or posterior circulation infarct?