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.
Subtle wedge-shaped hypodensity in the left inferomedial cerebellum (see axial image too), suspicious for acute infarct.
Deep gray nuclei: Preserved
Hyperdense vessels: None


Case Discussion:
Systematic review of the parenchyma on stroke window accentuating the cortex may reveal a subtle left inferomedial cerebellar hypodensity, suspicious for acute infarct (axial).


Imaging follow up MRI (Scan 2)
Subsequent brain MRI reveals acute/subacute infarcts of the left inferomedial cerebellum, left dorsolateral cervicomedullary junction, and left parietal cortex with high DWI signal (1 ,2) and low/isointense ADC signal (1, 2)
The left dorsolateral cervicomedullary junction infarct remains occult on CT despite retrospective review. The small left parietal lobe cortical infarct would be very difficult to discern prospectively on CT, though may be questioned if there is a clinical history of right-sided sensory symptoms given slight involvement of the left postcentral gyrus posteriorly.

Brief recall: The left inferior cerebellar infarcts are located below the level of the cerebral peduncles. Which vasculature territory is involved? (Answer at end.)
a) Anterior inferior cerebellar artery (AICA)
b) Posterior inferior cerebellar artery (PICA)
c) Superior cerebellar artery (SCA)


Primary teaching points:
1. Review of subtle and occult infarcts on CT examination, readily discernible with follow-up MRI.
2. Brief review of cerebellar vascular territories.
a) Recall that middle cerebellar peduncles are supplied by AICA.
b) Cerebellum superior to the middle cerebellar peduncles is supplied by SCA.
c) Cerebellum inferior to the middle cerebellar peduncles is supplied by PICA.
d) Note on imaging that the middle cerebellar peduncles are anterior to the cerebellar parenchyma.
3. The answer is B, posterior inferior cerebellar artery.


Non-Contrast CT

Which vessel is responsible for the cerebellar infarct?