Wk 1, Case 2 - Review

Patient History

A 73-year-old male presents to the emergency department with left extremity weakness. The patient was last known to be well 13 hours prior.

Findings

CT Head:

Subtle hypoattenuation of the right insular cortex. Hyperdensity is visualized in the M1 segment of the right middle cerebral artery.

No acute intracranial hemorrhage or abnormal extra-axial fluid collection. No mass effect or midline shift. Ventricles and sulci are normal for stated age. Basal cisterns are patent. Posterior fossa is unremarkable. Arteriosclerosis of the bilateral intracranial portions of the internal carotid artery.

Bilateral lens extractions. Otherwise orbits are unremarkable. Mild mucosal thickening in the left posterior maxillary sinus. Trace effusion in the left mastoid air cells without evidence of bony erosion.

CTP Head:

Findings compatible with penumbra within the temporal lobe with large volume of tissue at risk. No ischemic core is identified within the definition of CBF less than 30%. However, there is 12 ml of ischemic core with CBF less than 38%.

RAPID perfusion analysis reports a CBF <30% of 0 ml, a Tmax >6s volume of 142 ml, and a mismatch of 142 ml (TMax - CBF).

CTA Head:

The right ICA has atherosclerotic calcifications of the petrocavernous and supraclinoid portions. There is an abrupt cut off at the M1 level of the right MCA with a paucity of filling of the distal branches of the right MCA. The right ACA is patent. The right anterior communicating artery is patent.

There is occlusion of the left intracranial ICA. There is reconstitution of the left ACA and MCA through the right anterior communicating artery. The right ACA is patent. The left MCA is patent.

Bilateral posterior communicating arteries are visualized.

Bilateral vertebral arteries and cerebellar arteries are patent. Bilateral posterior cerebral arteries are patent. There is asymmetric narrowing of the third and fourth segments of the left posterior cerebral artery when compared to the right.

CTA Neck:

Conventional three vessel aorta. Port in right chest wall with catheter visualized in the SVC. The catheter tip is not visualized. Coronary artery calcifications. Atherosclerosis of the thoracic aorta.

Bilateral subclavian arteries are patent.

Mild scattered atherosclerosis of the bilateral common carotid arteries. A stent is visualized in the cervical portion of the right internal carotid artery, just distal to the carotid bifurcation. Stent appears patent.

There is complete occlusion of the left internal carotid artery by atherosclerotic plaque. There is associated narrowing of the ostium of the external carotid artery, measuring approximately 3 mm at its origin with poststenotic dilation.

The left vertebral artery arises directly from the aorta. The right vertebral artery originates in the expected region of the right subclavian artery. Coarse calcifications in the origin of the right vertebral artery.

No asymmetric soft tissue thickening in the nasopharynx, oropharynx, oral cavity, tongue or larynx. Multiple missing teeth.

No pathologically enlarged lymph nodes in the neck or visualized mediastinum.

The parotid and submandibular glands are unremarkable.

The thyroid gland is unremarkable.

Emphysematous changes of the bilateral lungs. Small bilateral pleural effusions. Median sternotomy wires.

Straightening of the expected lordosis of the cervical spine. Craniocervical junction is intact.

Moderate to severe multilevel degenerative changes of the cervical spine, including multilevel intervertebral disc space height loss, and osteophytosis:

C2-C3: Left facet and uncovertebral hypertrophy with at least moderate narrowing of the left neural foramen.

C3-C4: Bilateral uncovertebral and facet hypertrophy with severe right and moderate left neural foraminal narrowing. Posterior osteophyte formation with mass effect on the posterior longitudinal ligament, causing mild mass effect on the ventral thecal sac.

C4-C5: Facet and uncovertebral joint hypertrophy with severe narrowing of the left neural foramen and mild narrowing of the right neural foramen. Posterior osteophyte formation with mild mass effect on the ventral thecal sac.

C5-C6: Primarily uncovertebral joint hypertrophy with moderate narrowing of the bilateral foramina. Posterior osteophyte formation with moderate mass effect on the ventral thecal sac.

C6-C7: Uncovertebral and facet hypertrophy with severe narrowing of the left neural foramina. Uncovertebral hypertrophy with moderate narrowing of the right neural foramen. Posterior osteophyte formation with mild mass effect on the ventral thecal sac.

C7-T1: Bilateral facet hypertrophy with moderate narrowing of the left and mild narrowing of the right neural foramen.

Conclusion

1. Acute infarct within the right middle cerebral artery territory; ASPECTS 9 (insula). No acute intracranial hemorrhage.

2. Abrupt occlusion of the right M1 segment of the MCA.

3. Perfusion mismatch in the right MCA distribution, with a large volume of penumbra.

4. Patent right internal carotid artery stent.

5.Occlusion of the left internal carotid artery, with reconstitution of the left ACA and MCA through the circle of Willis.