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We'll start with this case.

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These are images of a 70-year-old female

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with hyperlipidemia, diabetes,

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and intermittent visual loss,

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as well as left-sided headaches,

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left sensory loss and slurred speech.

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First thing I do when I look at a case is look

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at the non-contrast CT,

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as we previously discussed.

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I'm looking closely and I don't really see

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anything abnormal on the non-contrast CT.

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It looks pretty normal to me.

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So then, I'm gonna look at the vessels.

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The first thing I do when I look at the vessels

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of the neck is I look at the coronal

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and axial reconstructions.

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We're going to go through the

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coronal reconstructions.

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Basically,

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you can see that there's a severe stenosis

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in the proximal internal carotid artery.

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The right common and internal carotid arteries

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look pretty normal and the vertebral

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arteries also look normal.

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We can also look at the sagittal reconstructions

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and

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there's the left internal carotid artery.

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You can see the severe stenosis.

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Sometimes when it's really critical,

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the distal carotid artery will be collapsed.

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But the distal carotid artery looks pretty normal here.

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So now, we have to figure out why this

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patient has a severe stenosis.

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This section is focused on the neck,

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but we're going to just show the head too

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because they're connected.

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So, I'll just look at the MIPs of the head,

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and you can see there's some stenosis in

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the left MCA and the right MCA.

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There's some mild stenosis in the PCAs.

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And again,

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this is an older patient who has risk factors

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for atherosclerotic disease.

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So that's the first thing I'm thinking in my mind.

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So, let's look at the raw data and we'll start at

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the arch and we're just gonna go

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up the left carotid artery.

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You can see the common carotid

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artery looks pretty normal.

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Here's the bifurcation and there's a severe stenosis.

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Now, severe stenosis

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should be greater than 70%.

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So, what you want to do

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as far as measuring with stenosis

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is measure the stenosis,

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and this is approximately 1.2.

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And then, you want to measure...

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compared to the distal vessel and

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it's approximately 3.4, 3.7.

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So, that's going to be greater than 70%.

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So, we know it's a severe stenosis.

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Now, what's causing the stenosis here?

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Since stenosis,

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there's some calcification in the wall,

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there's some low-attenuation plaques,

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so I'm thinking it's Atheromatous disease.

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The patient has risk factors.

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You know, we get up into the head,

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you can see that there's some atheromatous

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calcifications in the bilateral carotid siphons.

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There's some narrowing.

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There's also that area of narrowing the left MCA.

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We saw some lesser foci,

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narrowing the right MCA and the bilateral PCAs.

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So, I'm thinking this is all atheromatous disease and,

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but I didn't see any,

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you know, strokes on the CTA.

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So, we're going to look in an MR.

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And, of course, diffusion-weighted imaging

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is the best way to look at strokes.

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You can see this patient has some tiny strokes.

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And as I was showing a new on the

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other image, they all line up in a line.

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And so, these are border zone strokes due to the

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severe ICA stenosis, due to atheromatous disease

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in this older patient with risk factors.