Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
Ultimate Learning Pass
Unlock access to our full Course Library and all self-paced Fellowships.
Noon Conference (Free)
Get access to free live lectures, every week, from top radiologists.
Case of the Week (Free)
Get a free weekly case delivered right to your inbox.
Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
Lower Extremities MRI Conference
Musculoskeletal Imaging
Emergency Imaging
PET Imaging
Pediatric Imaging
For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
Ultimate Learning Pass
Unlock access to our full Course Library and all self-paced Fellowships.
Noon Conference (Free)
Get access to free live lectures, every week, from top radiologists.
Case of the Week (Free)
Get a free weekly case delivered right to your inbox.
Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
Lower Extremities MRI Conference
Musculoskeletal Imaging
Emergency Imaging
PET Imaging
Pediatric Imaging
For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
21 topics, 34 min.
Introduction to ED Practice Cases
2 m.Wk 1, Case 1 - Practice
Wk 1, Case 1 - Review
2 m.Wk 1, Case 2 - Practice
Wk 1, Case 2 - Review
3 m.Wk 1, Case 3 - Practice
Wk 1, Case 3 - Review
11 m.Wk 1, Case 4 - Practice
Wk 1, Case 4 - Review
6 m.Wk 1, Case 5 - Practice
Wk 1, Case 5 - Review
2 m.Wk 1, Case 6 - Practice
Wk 1, Case 6 - Review
4 m.Wk 1, Case 7 - Practice
Wk 1, Case 7 - Review
2 m.Wk 1, Case 8 - Practice
Wk 1, Case 8 - Review
3 m.Wk 1, Case 9 - Practice
Wk 1, Case 9 - Review
4 m.Wk 1, Case 10 - Practice
Wk 1, Case 10 - Review
2 m.20 topics, 35 min.
Wk 2, Case 11 - Practice
Wk 2, Case 11 - Review
10 m.Wk 2, Case 12 - Practice
Wk 2, Case 12 - Review
3 m.Wk 2, Case 13 - Practice
Wk 2, Case 13 - Review
3 m.Wk 2, Case 14 - Practice
Wk 2, Case 14 - Review
2 m.Wk 2, Case 15 - Practice
Wk 2, Case 15 - Review
10 m.Wk 2, Case 16 - Practice
Wk 2, Case 16 - Review
2 m.Wk 2, Case 17 - Practice
Wk 2, Case 17 - Review
1 m.Wk 2, Case 18 - Practice
Wk 2, Case 18 - Review
2 m.Wk 2, Case 19 - Practice
Wk 2, Case 19 - Review
3 m.Wk 2, Case 20 - Practice
Wk 2, Case 20 - Review
4 m.20 topics, 40 min.
Wk 3, Case 21 - Practice
Wk 3, Case 21 - Review
8 m.Wk 3, Case 22 - Practice
Wk 3, Case 22 - Review
4 m.Wk 3, Case 23 - Practice
Wk 3, Case 23 - Review
9 m.Wk 3, Case 24 - Practice
Wk 3, Case 24 - Review
2 m.Wk 3, Case 25 - Practice
Wk 3, Case 25 - Review
6 m.Wk 3, Case 26 - Practice
Wk 3, Case 26 - Review
2 m.Wk 3, Case 27 - Practice
Wk 3, Case 27 - Review
3 m.Wk 3, Case 28 - Practice
Wk 3, Case 28 - Review
4 m.Wk 3, Case 29 - Practice
Wk 3, Case 29 - Review
3 m.Wk 3, Case 30 - Practice
Wk 3, Case 30 - Review
5 m.20 topics, 39 min.
Wk 4, Case 31 - Practice
Wk 4, Case 31- Review
2 m.Wk 4, Case 32 - Practice
Wk 4, Case 32 - Review
7 m.Wk 4, Case 33 - Practice
Wk 4, Case 33 - Review
3 m.Wk 4, Case 34 - Practice
Wk 4, Case 34 - Review
5 m.Wk 4, Case 35 - Practice
Wk 4, Case 35 - Review
5 m.Wk 4, Case 36 - Practice
Wk 4, Case 36 - Review
5 m.Wk 4, Case 37 - Practice
Wk 4, Case 37 - Review
3 m.Wk 4, Case 38 - Practice
Wk 4, Case 38 - Review
6 m.Wk 4, Case 39 - Practice
Wk 4, Case 39 - Review
3 m.Wk 4, Case 40 - Practice
Wk 4, Case 40 - Review
5 m.20 topics, 41 min.
Wk 5, Case 41 - Practice
Wk 5, Case 41 - Review
6 m.Wk 5, Case 42 - Practice
Wk 5, Case 42 - Review
8 m.Wk 5, Case 43 - Practice
Wk 5, Case 43 - Review
2 m.Wk 5, Case 44 - Practice
Wk 5, Case 44 - Review
3 m.Wk 5, Case 45 - Practice
Wk 5, Case 45 - Review
7 m.Wk 5, Case 46 - Practice
Wk 5, Case 46 - Review
3 m.Wk 5, Case 47 - Practice
Wk 5, Case 47 - Review
2 m.Wk 5, Case 48 - Practice
Wk 5, Case 48 - Review
6 m.Wk 5, Case 49 - Practice
Wk 5, Case 49 - Review
4 m.Wk 5, Case 50 - Practice
Wk 5, Case 50 - Review
6 m.Interactive Transcript
Report
CT PERFUSION STROKE PROTOCOL W/WO IV CONTRAST, CTA NECK W/WO IV CONTRAST
INDICATION: stroke, word finding difficulties, confused, expressive aphasia
TECHNIQUE: Multiple-row detector helical CT examination of the head without intravenous contrast. Postintravenous contrast images were obtained through the head per standard CTA/CT Perfusion protocol. Multiplanar reformatted, MIP, and volume rendered images were generated from the CT dataset.
COMPARISON: None available
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Loss of gray-white differentiation with focal low-attenuation in the left insular cortex, left frontal operculum with additional involvement of the left putamen and external capsule compatible with a left MCA infarct. No CT evidence for acute intracranial hemorrhage. Remainder of the gray-white differentiation is grossly preserved.
Orbital contents are unremarkable. Paranasal sinuses are clear. Calvarium is intact. There is a small osteoma of the inner table of the right frontal bone. No mastoid effusions.
CT PERFUSION: Rapid CT perfusion software demonstrates a focal area of decreased cerebral blood volume with slightly greater area of time to maximum within the left frontal lobe and insular cortex corresponding to the acute infarct. Reported mismatch
volume is 2 mL with Tmax greater than 6 seconds volume of 6 cc and CBF less than 30% volume of 4 cc.
The Siemens perfusion imaging demonstrates slightly greater elevated time to maximum, mean transit time and time to drain within the left anterior corona radiata that does not demonstrate decreased cerebral blood volume which may indicate at risk ischemic tissue. Otherwise a relatively matched defect is seen. Remainder of the vascular territories demonstrate symmetric perfusion.
CTA:
Severe 4 mm short segment critical narrowing of a proximal left M2 anterior branch (Key Image 2).
There appears to be robust opacification distally of this segment with relative symmetric vascularity within the MCA branches bilaterally. There is also occlusion of one superiorly oriented early sylvian branch seen best on Key Image 3.
As seen best on Key Image 4 there is a clot identified in the upward vertically oriented sylvian segment of one anterior left middle cerebral artery branch. A more medial branch shows gradual tapering.
Slightly smaller caliber of the left petro cavernous ICA compared to the contralateral side. There is early venous filling within the right cavernous sinus which slightly limits evaluation.
Trifurcated anterior cerebral artery anatomical variation. The vessels appear widely patent. The right MCA branches are patent. The bilateral posterior cerebral arteries as well as the basilar artery and intracranial vertebral arteries are patent. No significant flow-limiting stenosis or aneurysm is seen.
There is a very subtle luminal irregularity left distal cervical ICA. The bilateral common carotid and cervical internal carotid arteries are otherwise widely patent. The extracranial vertebral arteries are patent. Suboptimal evaluation at the origin of the left T1 segment from venous contamination.
NON-VASCULAR:
Enhancing 1.2 x 1.0 cm exophytic right thyroid gland nodule posteriorly. Visualized lung apices are clear. Remainder of the soft tissues of the head and neck are normal. Osseous structures are intact.
IMPRESSION:
Loss of gray-white differentiation and focal attenuation in the left insular cortex and left frontal operculum compatible with acute left MCA infarct. Critical narrowing short segment narrowing of a proximal left M2 branch with robust opacification distally and symmetric MCA vascularity. In addition there is a focal area of nonopacification in one anterior left sylvian branch measuring 5.5 mm compatible with a thrombus. A more medial and anterior branch shows gradual tapering suggestive of occlusion. Both of these are best seen on Key Image 4.
Rapid perfusion imaging demonstrates a relatively matched defect with a small mismatch volume = 2 mL compatible with small focal area of at risk ischemic tissue in the left anterior corona radiata on the Siemens data.
Circle of Willis and major branches are otherwise widely patent. Patent cervical carotid and intracranial vertebral arteries. Subtle luminal irregularity of the left distal cervical ICA, consider fibromuscular dysplasia.
Enhancing 1.2 cm exophytic right thyroid gland nodule. Further evaluation with ultrasound is suggested.
Key Images
Faculty
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
Tags
Vascular
Perfusion
Neuroradiology
CTP
CT
Brain
© 2024 Medality. All Rights Reserved.