Wk 2, Case 3 - Review

Patient History

Code stroke. Weakness on the left.

Findings

CT Head:

No acute intracranial hemorrhage. No appreciable early ischemic changes. No midline shift, hydrocephalus, or herniation.

Moderate to severe chronic ischemic changes in the white matter of both cerebral hemispheres. Mild global parenchymal volume loss with prominence of the ventricles and sulci.

Vascular calcifications in the cavernous carotid and vertebral arteries on both sides.

CTA Head and Neck:

Severe narrowing or occlusion of the distal right M3 inferior division branch. No clear vascular occlusion in the distal right superior MCA division. Slight asymmetry in vascular density in the right frontal opercular region compared to the left.

No intracranial aneurysm or other vascular stenosis. Normal variant hypoplastic left P1 segment with fetal origin of the left PCA.

Three-vessel aortic arch with no great vessel origin stenosis. No carotid or vertebral stenosis on either side of the neck.

Atherosclerotic calcifications at the common carotid artery bifurcations and along the aortic arch.

Left chest wall pacemaker.

CT Perfusion:

Territorial oligemia in the inferior right MCA distribution with Tmax > 6s. Lesser degree of oligemia in the right frontal operculum at the anterior right MCA watershed with Tmax >4s.

Tmax >6.0s: 12 cc

CBF<30%: 0 cc

Mismatch volume: 12 ml

Conclusion

1. Distal right M3 inferior division branch occlusion with corresponding oligemia on CT perfusion maps. No core infarct. No early ischemic change or hemorrhage appreciable by non-contrast CT.

2. Subtle decrease in vascular density at right anterior MCA watershed with milder oligemia on perfusion.

3. Moderate parenchymal volume loss and moderate to severe chronic small vessel ischemic changes.

4. Unremarkable CTA extracranial circulation.