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: Possibly there is focal loss of the insular cortex on the right concerning for early acute infarct.
Deep gray nuclei: Possile right lenticular nuclei hypodensity, concerning for acute infarcts.
Hyperdense vessels: Hyperdense right middle cerebral artery M1 segment.

Case Discussion:
After assessing the imaging for hemorrhage, hydrocephalus, and herniation with a standard blood and brain windows, a prominent hyperdense right middle cerebral artery vessel should be noted. Given the clinical symptoms, careful scrutiny for any evidence of right MCA vascular territory infarction then be performed. There is a left parietal scalp hematoma, no definite calvarial fracture. Given the clinical history, an MRI would be very reasonable.

Imaging follow up CT examination at 24 hours (Scan 2)
Subsequent CT imaging 24 hours later demonstrates acute right frontal infarcts in the right middle cerebral artery vascular territory and involving the right striatum (caudate, putamen, globus pallidus). Additional acute left caudate head infarct. Mild edema and mass effect effaces the frontal horn of the right lateral ventricle. No hemorrhage or midline shift.

For this case, initially was no discernible definite cortical infarct on the intial images, though subsequent imaging demonstrates a large vascular territory infarct. In an ideal world, every infarct on an unenhanced head CT examination would be invisible or subtle. Time is brain. The objective is to suspect or detect infarcts when viable brain can still be preserved. This requires timely and accurate conveyance of relevant information to the clinical team.
Primary teaching points:

1. Subtle signs of early right middle cerebral artery vascular territory infarct.
2. Brief overview of the primary utility for initial head CT examinations when stroke is suspected.
3. Combining technical, clinical, and anatomical expertise is essential for effective head CT interpretations.


Non-Contrast CT

Combination of history and hyperdense right MCA

Findings of cortical hypodensity in the distribution of the eight MCA

What raises suspicion for infarct on presentation and initial imaging?