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: Yes.
Region 1: Extensive right frontal cortical hypodensity near the vertex, suspicious for acute infarct.
Region 2: Focal hypodensities in the left frontal corona radiata and left parietal centrum semiovale white matter, age indeterminate though potentially reflecting subacute/chronic infarcts.
Deep gray nuclei: Preserved
Hyperdense vessels: None


Case Discussion:
1. With utilization of an appropriate stroke window accentuating the normal cortex, a large region of right frontal cortical hypodensity would hopefully be apparent upon review of the axial series. This is most suspicious for an acute infarct, especially given the clinical history of left-sided symptoms.
2. Additional focused review of the imaging may have noted focal white matter hypodensities in the:
a) Left parietal centrum semiovale (white matter above the ventricles, appearance of 'half moons').
b) Left frontal corona radiata (white matter at the level of the ventricles).
Relevant localization anatomy review: pars marginalis, paracentral lobule, postcentral gyrus (parietal lobe), central sulcus, precentral gyrus (frontal lobe), superior frontal gyrus, superior frontal sulcus, middle frontal gyrus.


Imaging follow up CT examination at 24 hours (Scan 2)
Subsequent CT examination 24 hours later demonstrates evolving right frontal infarcts in the region of the right anterior cerebral artery and right middle cerebral artery M2 superior division vascular territories. Minimal petechial hemorrhage in the distal right ACA territory infarct. No significant mass effect. Similar left periventricular white matter hypodensities, favor chronic ischemic changes.

For vascular territory review, the anterior cerebral artery tends to supply the paramedian frontal lobe adjacent to the falx cerebri. The right frontal hypodensity more laterally is a characteristic location for the right middle cerebral artery superior M2 division vascular territory. Given the 2 differing vascular territories, an embolic etiology is favored.


Primary teaching points:

1. Reinforcing the importance of custom stroke windows for each case to best accentuate the cortical density.
2. Anatomic review of the periventricular white matter and precise frontoparietal localization.
3. Anatomic review of the anterior cerebral artery and middle cerebral artery vascular territories.


Non-Contrast CT

No change in appearance on 24 hour followup

Which imaging finding in this case argues that the left sided white matter changes are chronic and not an acute stroke?