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: None
Herniation: None
Gray-white differentiation/wedge-shaped hypodensity/cortical involvement: Yes.
Complete loss of gray-white matter differentiation in the left frontal operculum (axial, sagittal), age indeterminate, though suspicious for acute/subacute infarct.
Deep gray nuclei: Preserved.
Hyperdense vessels: None

Case Discussion:
Axial images demonstrate loss of gray-white matter differentiation in the left frontal operculum. This should be evident with a slice-by-slice approach on most windows. Given the density and absence of mass effect, an acute/subacute infarct would be favored.
For recall, the opercular region refers to parenchyma adjacent to the lateral sulcus. The operculum can be thought of as a roof 'covering' the insula. The opercular regions are sometimes better assessed with a sagittal reformats.

Imaging follow up CT (Scan 2)
Subsequent head CT several weeks later shows evolution of the infarct. Compare to the original scan, same windows. This was an evolving acute/subacute left frontal infarct in the left middle cerebral artery M2 superior division vascular territory. No acute intracranial hemorrhage.

Primary teaching points:

1. Finding infarcts in the opercular region can often be aided with sagittal reformats.
2. Brief anatomic recall of the insular and opecular regions.


Non-Contrast CT

Sagittal images can be useful for finding infarcts in which region(s)?