Wk 1, Case 3 - Review

Patient History

A 65-year-old female with a history of recently diagnosed metastatic breast cancer presents with acute onset of left-sided weakness. Clinical examination is notable for right gaze deviation, left hemineglect, and left hemiparesis.

Findings

CT Head:

There is focal hypoattenuation in the lateral right frontal lobe measuring approximately 3.3 cm. There is associated locoregional sulcal effacement. No intracranial hemorrhage or midline shift is present. There is no hydrocephalus. The basal cisterns are patent. The calvarium is intact. Paranasal sinuses and mastoid air cells are clear.

CTA Head:

There is an abrupt cutoff of the right superior M2 segment. The remaining vessels of the circle of Willis are widely patent. An aneurysm is seen arising from the right anterior cerebral artery measuring 4.8 mm with a 2 mm neck. There is an azygos anterior cerebral artery.

CTA Neck:

There is no evidence of dissection or aneurysm. There is mild atherosclerosis at the carotid bulbs without associated stenosis. The vertebral arteries are unremarkable bilaterally. The left vertebral artery is dominant.

There is calcified and noncalcified atherosclerosis of aortic arch and proximal left subclavian artery. Mild emphysematous changes are noted within the lung apices. There is no acute osseous abnormality or suspicious osseous lesion. There are mild age-appropriate degenerative changes of the cervical spine.

CTP Head:

In the lateral right frontal lobe there is an area of perfusion abnormality corresponding with the finding on noncontrast CT. The volume of increased time to maximum greater than 6 seconds is 36 mL, with corresponding area of decreased cerebral blood flow of less than 30% measuring 5 mL. This gives a mismatch volume of 31 mL with a mismatch ratio of 7.2. No other perfusion abnormality seen.

Conclusion

1. Hypoattenuation with local sulcal effacement in the right frontal lobe suggestive of recent infarct within the superior right MCA distribution. No hemorrhage or midline shift.

2. Occlusion of the right superior M2 segment corresponding with the acute to subacute infarct seen in the right frontal lobe. Associated perfusion defect with significant mismatch volume suggesting mostly reversible infarct.

3. 4.8 mm right anterior cerebral artery aneurysm.