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.
Subtle loss of gray-white matter differentiation in the left subinsular region.
Deep gray nuclei: Subtle hypodensity of the left lentiform nuclei (putamen and globus pallidus).
Hyperdense vessels: Yes. Markedly hyperdense left middle cerebral artery distal M1 and M2 segments.

Case Discussion:
1. Meticulous review of the axial imaging on stroke window should reveal loss of the left subinsular white matter and hypoattenuation in the left lentiform nuclei, suspicious for acute infarct.
2. On the brain or stroke window, you may have also noticed the hyperdense left middle cerebral artery: the M2 segment starts at the margin of the sylvian fissure, and ends at the parietal operculum, where the M3 segment begins.
3. Coronal imaging can also be helpful for determining if a vessel is hyperdense by comparing to the contralateral side, and here you can see portions of the left middle cerebral artery are dense in the distal M1 before it reaches the sylvian fissure and becomes M2.


Imaging follow up CT (Scan 2)
Subsequent follow up CT demonstrates increased hypoattenuation in the left frontoparietal parenchyma and left striatum, corresponding to the left middle cerebral artery M2 superior/inferior divisions and left lenticulostriate arteries respectively. Regions of linear hyperattenuation within the infarct likely reflect hyperdense vessels and preserved cortical densities; no definite acute intracranial hemorrhage.
Note the increased medialization of the left uncus relative to the cerebellar tentorium, sometimes best seen on coronal (Scan 1, Scan 2). There is also increased edema and mass effect including the left caudate partially effacing the frontal and temporal horns of the left lateral ventricle. However, no midline shift or hydrocephalus.

Primary teaching points:

1. Highlighting key middle cerebral artery segments relative to anatomic landmarks. Even though the areas of infarct were small and subtle on the original scan, the extent of suspected MCA thrombus predicted a large infarct.
2. Brief introduction of medial temporaland ventricular assessment on follow-up imaging.


Non-Contrast CT

Origin of the anterior lenticulostriate artery

Where is the junction between the M1 and M2 segments of the MCA?