Wk 1, Case 4 - Review

Patient History

Acute-onset right hemiplegia.

Findings

CT Head:

Relative hypoattenuation along the left parietal and temporal lobes. No acute intracranial hemorrhage or abnormal extra axial fluid collection. No mass, mass effect, or midline shift.

No significant volume loss or encephalomalacia. The ventricles are normal in size and configuration. Basal cisterns are patent.

Posterior fossa is unremarkable. Calvarium, skull base, and soft tissues are unremarkable.

Orbits are symmetric and unremarkable. Mastoid air cells are clear. Visualized paranasal sinuses are clear.

CTA Head:

Arteriosclerosis of the bilateral supraclinoid portions of the internal carotid arteries, without significant narrowing.

Right middle cerebral and anterior cerebral arteries are patent. Anterior communicating arteries are patent bilaterally.

Abrupt cut off of the post bifurcation M1 segment of the left middle cerebral artery inferior division.

Right anterior cerebral artery is patent. Hypoplastic left posterior communicating artery, normal variant. Right posterior communicating artery is patent.

Visualized vertebral arteries are patent. Left dominant vertebrobasilar system. Basilar artery is normal. Bilateral posterior cerebral arteries are patent.

CTA Neck:
No dissection or aneurysm. Minimal atherosclerosis at the carotid bulbs without associated stenosis. Medialization of the right carotid artery.

Vertebral arteries are unremarkable bilaterally. Left vertebral artery is dominant.

Normal three-vessel branching aorta. Lung apices are clear. No acute osseous abnormality or suspicious osseous lesion. Mild age-appropriate degenerative changes of the cervical spine.

CTP Head:

RAPID perfusion analysis reports a CBF <30% of 0 ml, with a TMax >6s volume of 51 ml, with mismatch of 51 ml (TMax - CBF).

Conclusion

1. Perfusion mismatch in the left MCA territory, without an ischemic core.

2. Occlusion of the post bifurcation distal M1 segment inferior division of the left MCA.