Wk 2, Case 4 - Review

Patient History

73-year-old man with acute-onset left-sided weakness.

Findings

CT Head:

Subtle loss of gray-white differentiation involving the right basal ganglia including potentially the caudate head and insula. Questionable hypoattenuation that may involve the anterior right temporal lobe. No acute intracranial hemorrhage. No midline shift.

Slight asymmetric hyperdensity of a proximal right M2 branch.

Ventricles and sulci normal in size and configuration for age. No extra-axial collection. Cerebellar tonsils are normally positioned. Sella is not expanded.

Visualized paranasal sinuses are well-aerated. Mastoids are well-aerated. Calvarium is intact. Orbits are normal in appearance. Vascular calcifications at the skull base.

CTA Head:

Right ICA:

Non-opacification of the petrous, cavernous, paraclinoid and supraclinoid segments of right ICA with reconstitution of flow at the communicating segments of right ICA.

Non-opacification of the distal M1 and M2 segments of the right middle cerebral artery. Reconstitution of flow distally but decreased opacification of cortical segments of the right MCA.

A1 and A2 segments of the right anterior cerebral artery are patent (reconstitution of flow) but are slightly narrowed compared to the left side.

Left ICA:

Petrous, cavernous, paraclinoid, supraclinoid segments of the left ICA are patent.

M1 and M2 segments of the middle cerebral artery are patent.

A1 and A2 segments of left anterior cerebral artery are patent. Anterior communicating artery is patent.

Vertebrobasilar circulation:

Left V4 segment is patent. PICA termination of the right vertebral artery. Right superior cerebellar artery is poorly opacified.

Basilar artery is patent. Multifocal high-grade stenosis or occlusion of the right P1 and P2 segments. Left posterior cerebral artery is patent and normal in caliber.

CTA Neck:

Normal three-vessel branching pattern of the aortic arch. 1.5 cm thrombus within the aorta at the origin of the brachiocephalic artery. Origins of the common carotid arteries and vertebral arteries are patent.

Nonopacification of cervical segments of the right internal carotid artery from the origin. Small calcified atherosclerotic plaques near the right carotid bulb.

Cervical segments of the left internal carotid artery are patent.

External carotid arteries are patent.

Cervical segments of the vertebral arteries are patent.

No evidence of aneurysmal dilatation, luminal narrowing, or dissection of the vasculature of the neck.

CTP Head:

Contrast inflow and outflow curves have a normal appearance. No significant translation in the X, Y, or Z planes during image acquisition.

T-Max/MTT: Increased, delayed perfusion to the right frontal, temporal, parietal lobes, corresponding to the right MCA territory as well as in the right PCA territory and right cerebellar hemisphere.

CBF: Moderately decreased CBF in the right parietal temporal lobe (lesser extent compared to MTT abnormality), corresponding to the right MCA territory.

CBV: Small areas of decreased CBV predominantly in the right basal ganglia and anterior temporal lobe (lesser extent compared to CBF and T-max abnormality), corresponding to the right MCA territory.

Tmax >6 sec: 199 mL

CBF <30%: 41 mL

Mismatch volume: 158 mL

Mismatch ratio: 4.9

Conclusion

1. Evolving acute right MCA territory infarction with occlusion of the distal M1 and M2 segments of the right MCA.

2. Large perfusion mismatch/ischemic penumbra within the right MCA territory, right PCA territory, and right cerebellar hemisphere measuring approximately 158 mL. Smaller core infarcts within the right basal ganglia and anterior temporal lobe measuring approximately 41 mL.

3. Multifocal high-grade stenosis or occlusion of the right posterior cerebral artery. Nonopacification of the distal right V4 segment and superior cerebellar artery, which may contribute to the ischemic penumbra in the posterior fossa.

4. Nonopacification of right ICA at the origin involving the cervical, petrous, cavernous, paraclinoid and supraclinoid segments with reconstitution of flow at the communicating segments of right ICA. Large thrombus in the aorta near the origin of the brachiocephalic artery, which may have contributed to distal thrombosis of the right carotid artery.