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: Indeterminate - linear hyperattenuation may reflect petechial hemorrhage or sparred parenchyma, though parenchymal sparing favored.
Hydrocephalus: None
Herniation: None
Gray-white differentiation/wedge-shaped hypodensity/cortical involvement: Yes.
Region 1: Loss of gray-white matter differentiation in the left frontal lobe and left insular cortex. Suspicious for acute/subacute infarct.
Region 2: Marked hypodensity in the right occipital lobe, age-indeterminate without prior imaging, though suggestive of late subacute/chronic infarct.
Deep gray nuclei: Subtle hypodensity of the left putamen.
Hyperdense vessels: Yes. Hyperdensity of the left middle cerebral artery distal M1 and proximal M2 segments relative to the contralateral side.

Case Discussion:
1. Systematic review of the 'stroke' windows should reveal a loss of gray-white matter differentiation in the left frontal lobe and insula. This loss of definition of the gray-white interface in the lateral margin of the insular cortex is called the insular ribbon sign and is an early sign of an MCA territory infarct.
2. The left frontal hypodensity also contains linear hyperdensities, indeterminate for petechial hemorrhage or spared parenchyma, though parenchymal sparing favored.
3. Scrutiny of the basal ganglia should reveal hypodensities in the left putamen.
4. Additional focal hypodensity in the right occipital lobe remains age-indeterminate in the absence of prior imaging, though is likely chronic in age given appearance and symptoms not clearly related to this region.
5. Note the hyperdense left middle cerebral artery distal M1 (pre-sylvian) and proximal M2 (sylvian) segments


Imaging follow up MRI (Scan 2)
Subsequent CT imaging 24 hours later following thrombolysis demonstrates an evolving infarct involving the left middle cerebral artery M2 superior division and left lenticulostriate vascular territories, in this case the left frontal opercular, left subinsular, and left lenticular regions.
There are hemorrhages in the anterior portion and mid portion of the left frontal infarct. No midline shift or herniation. No uncal herniation: the left uncus remains normally positioned over the left cerebellar tentorium.

Primary teaching points:

1. Reinforcing anatomy of the middle cerebellar artery
2. Reinforcing anatomy of the frontal opercular region
3. Highlight the hemorrhage and left uncus as a preface for discussions in future cases.


Non-Contrast CT

What is the most common complication associated with thrombolysis?