Case - Ischemia Detected Only on MR Perfusion (Case 2)
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So, these are images of a 71-year-old male
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with right sided weakness and aphasia.
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And we started out with a head CT
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and looked pretty normal.
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Didn't see a dense MCA vessel sign.
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Basal ganglia looked good,
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insula looked good.
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He has some chronic white matter changes.
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We got a CTA.
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Unfortunately, I don't have MIP images,
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but you can see on these MIPs that I made
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that the left MCA looks normal.
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The right MCA looks normal.
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There were pretty symmetric collaterals.
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Didn't really see much on the CTA.
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Was, you know, wondering what was going on
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with his weakness.
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So, we got a DWI image and perfusion image.
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And here's the DWI.
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And there was a little tiny infarct in the left cerebellum.
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The rest of it was red as normal.
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There's probably another tiny little infarct here,
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but, you know, she's got these small infarcts.
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The MRA looked normal.
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So, you know,
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what's going on as symptoms are kind of worse
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than what we're seeing on the DWI.
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And then, here's the time to peak map.
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And you can see that there's prolonged time
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to peak in the left temporal lobe
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and the occipital lobe,
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and going up into the parietal lobe.
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So, essentially,
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he has an embolus that just wasn't seen on CTA.
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But now we know what's causing his symptoms.
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He was given appropriate medications.
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His blood pressure was kept up
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to try to perfuse that area.
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So, the perfusion map was really helpful here
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in identifying an ischemic area that wasn't really
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seen on the CT, the CTA, the DWI,
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or the FLAIR images.
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Here are the FLAIR images,
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which really motion degraded
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and weren't very helpful.
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We got follow-up DWI for that patient,
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and you can see now there is some small areas
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of infarction in the left temporal lobe
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and the left peritro white matter.
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But much of that abnormality on the time to peak map
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shown here was spared with appropriate therapy.
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So, again,
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the perfusion map was really instrumental in
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identifying that area of ischemia
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and maximizing therapy.
Pamela W Schaefer, MD, FACR
Professor of Radiology, Vice Chair of Education
Massachusetts General Hospital
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