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: None
Hydrocephalus: Diffuse ventriculomegaly, though the temporal horns of the lateral ventricles and the third ventricle do not appear enlarged, overall suggesting diffuse parenchymal volume loss.
Herniation: None
Gray-white differentiation/wedge-shaped hypodensity/cortical involvement: No. There is no acute transcortical infarct seen though there are numerous hypodense foci in the paraventricular white matter, age-indeterminate in the absence of prior imaging, though likely reflecting chronic small vessel disease.
Deep gray nuclei: Small left thalamic hypodensity, age indeterminate though concerning for acute infarct given the clinical history.
Hyperdense vessels: None.

Case Discussion:
1. Immediately visible on 'stroke' window are numerous hypodense foci in the supratentorial white matter, though careful review reveals no definite signs of an acute cortical infarction (i.e. focal cortical hypodensity).
2. After careful review of the cortex and gray-white matter junctions, a thorough assessment of the deep gray nuclei should be performed, especially given this clinical history. Here a left thalamic hypodensity should be apparent.
Brief review of the white matter tract and deep gray nuclei terminology:
Basal ganglia: Caudate, putamen, globus pallidus, subthalamic nucleus*, substantia nigra* (*not well visualized with CT)
Lentiform nuclei: Putamen, globus pallidus
Striatum: Caudate, putamen, globus pallidus
Gangliocapsular, lenticulocapsule, striatocapsular: Respective deep grey nuclei and involvement of the white matter capsular tracts (e.g. internal and/or external capsule)
Thalamus: Again, this is separate deep grey structure from the above. The thalamus relays sensory and motor signals to the cerebral cortex so infarcts here can have sensory and motor consequences. The thalamus also helps regulate consciousness and sleep.

Imaging follow up MRI (Scan 2)
Subsequent review of the MRI reveals an acute/subacute left thalamic infarct (high DWI signal, low to isointense ADC signal). In addition, scattered and confluent foci of T2 prolongation in the supratentorial white matter likely reflects chronic small vessel ischemia, marked in extent.

Primary teaching points:

1. Scrutiny of the deep grey nuclei is essential for detecting small vessel lacunar infarcts. MRI remains more sensitive for detecting deep grey nuclei and brainstem infarcts compared to CT.
2. Review of select deep grey nuclei anatomy and terminology


Non-Contrast CT

Is the following statement True or False? Complete hemiparesis requires infarct involving the entire motor cortex.