0:00

So, these are images of a 50-year-old female

0:03

who had aphasia and right hemiparesis,

0:05

and was imaged within a few hours of symptom onset.

0:10

This is just a non-contrast CT.

0:12

And we can see a hyperdense vessel.

0:15

The top of the ICA going into

0:17

maybe the A1 segment and the left MCA segment,

0:21

and we can already see some loss grey-white differentiation

0:26

and hypoattenuation.

0:27

We'll look at the thicker sections.

0:28

That makes it a little bit easier.

0:30

Suggestion that there's...

0:32

you know, even at a few hours,

0:33

there's already edema, some effacement of sulci,

0:38

some loss grey-white differentiation.

0:41

The patient got a CTA,

0:43

and we'll just look at the CTA.

0:46

There's a left common carotid artery,

0:49

and we have internal external bifurcation.

0:52

Looks fine.

0:55

Internal looks pretty good.

0:58

Follow it all the way up,

0:59

a little calcification in the cavernous ICA,

1:03

paraclinoid ICA,

1:05

and then what happens is we lose the carotid.

1:09

So, you've got clot in the distal ICA,

1:13

and then extending into the A1 and M1 segments.

1:19

And when we look at the CTA source images,

1:22

you can see that that whole MCA territory

1:24

is not being perfused.

1:26

You don't see many collaterals.

1:27

When we look at the MIP of the CTA,

1:30

again, there's the clot in the ICA, ACA,

1:34

and MCA lesion,

1:35

and there are not really many

1:39

collaterals in that region.

1:41

The patient shortly afterwards got an MRI.

1:47

And here are the DWI images showing

1:50

basically restricted diffusion throughout

1:53

the whole MCA territory.

1:55

Again, you can already see the little mass effect.

2:00

There's also involvement of the anterior

2:02

cerebral artery territory.

2:04

Remember, there was also clot in the A1.

2:07

So, that's the DWI.

2:12

You always have to check the ADC, too,

2:14

to make sure that it's low signal.

2:16

And it is low signal here.

2:18

Sometimes hyperintensity on DWI

2:21

is from the T2 component

2:22

and not from the diffusion component.

2:25

But anyway, if it's low on ADC,

2:28

it's true stroke.

2:29

We kind of knew that in this case, anyway.

2:31

And then when we look at the FLAIR images,

2:34

we can see that there's early breakdown

2:37

of the blood brain barrier.

2:38

There's already a lot of FLAIR hyperintensity

2:41

at only a few hours, which is unusual.

2:44

And we see a few collateral vessels,

2:47

but not that many, which goes along

2:49

with the poor collaterals on CTA.

2:54

On susceptibility,

2:55

we can again see marked blooming in

2:58

the region of the ICA and proximal A1 and M1

3:02

consistent with clot.

3:04

So, this is a patient who had poor collaterals,

3:08

rapid growth for infarct,

3:10

early breakdown of the blood brain barrier

3:12

and FLAIR images.

3:13

The lack of collaterals correlates

3:15

with the lack of collaterals on the CTA.

3:17

The gradient echo shows where the clot is,

3:20

just as we could see it on the CTA.

3:22

And the DWI defines the whole infarct core.

3:26

This patient was not a candidate for

3:28

thrombolysis, and, as you'd expect,

3:32

follow up images.

3:33

This follow-up head CT a couple of days later,

3:37

continued to show infarction

3:40

of the whole MCA territory.

3:41

You can see swelling.

3:43

A lot of swelling and effacement

3:45

of the basilar cisterns at this point.

3:46

There was also some involvement of

3:48

the right ACA territory as well.