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.
Loss of gray-white matter differentiation in the left frontal and subinsular regions.
Deep gray nuclei: Subtle hypodensity of the left putamen.
Hyperdense vessels: Yes. Hyperdensity of the left middle cerebral artery M1 and M2 segments relative to the contralateral side.


Case Discussion:
1. Although only provided axial formats, contentious review with 'stroke' window slowly slice-by-slice should reveal a loss of the gray white matter differentiation in the left frontal region. By reflex, keen eyed viewers will then interrogate the ipsilateral insula and deep gray nuclei for abnormalities to find the insular white matter and the left putamen are also hypodense. Given the clinical history, an acute/subacute infarct should be suspected.
2. Note the hyperdense left middle cerebral artery M1 and M2 segments. The M1 (pre-sylvian) segment may be difficult to discern as hyperdense, though the M2 (sylvian) segment is certainly hyperdense relative to the contralateral side.

Imaging follow up MRI 24 hours later (Scan 2)
MRI performed 24 hours later demonstrates high DWI signal, low ADC signal, and high FLAIR signal in the left middle cerebral artery and left lenticulostriate vascular territories. This is consistent with an acute infarct. For repetition, if you had diffusion restriction (high DWI, low ADC) and absence of FLAIR signal, consider a hyperacute infarct, specifically 0-6 hours in age.

Primary teaching points:
1. Repetition of middle cerebral artery M1 and M2 segments
2. Repetition between hyperacute and acute infarct on MRI


Non-Contrast CT

Which signal characteristics describe a hyperacute infarct (as opposed to an acute or chronic infarct) on MRI?