Wk 4, Case 2 - Review

Patient History

New aphasia and right-sided facial droop.

Findings

MRI Brain:

Brain Parenchyma: Large acute left MCA territory acute infarct involving the left frontal lobe, left insula/temporal lobe, and left parietal lobe evidenced by diffusion restriction. No substantial associated FLAIR high signal. No hemorrhagic conversion. No midline shift.

Extensive periventricular and subcortical white matter T2/FLAIR hyperintensities are nonspecific but likely reflect sequela of chronic microangiopathic ischemic changes.

Perfusion imaging demonstrates a matched deficit involving the infarcted territory on CBV, CBF, Tmax, and MTT maps.

Ventricles and Sulci: Normal for age.

Extra-Axial Spaces: No extra-axial fluid collection.

Intracranial Flow-Voids: Left MCA M1 segment occlusion. Signal loss on SWI within the left distal M1 segment compatible with intraluminal thrombus. Increased conspicuity of cortical vessels over the left cerebral hemisphere compatible with slow flow phenomenon.

Orbits: Normal.

Paranasal Sinuses: Trace ethmoid mucosal thickening.

Mastoid Sinuses: Normal.

Cranium: Normal.

Extracranial Soft Tissues: Normal.

MRA Circle of Willis:

MCAs: Abrupt occlusion of the left MCA M1 segment. Flow related signal present within anterior temporal artery on the left, but remainder of MCA branches are occluded and absence of signal within distal left MCA branches. Right MCA is normal.

Intracranial ICAs: Mild irregularity along the bilateral cavernous segments, likely on the basis of atherosclerotic disease.

ACAs: Normal bilaterally.

AComm: Normal

P-Comms: Not visualized bilaterally.

Vertebral arteries: Normal to the confluence with the basilar artery.

Basilar artery: Normal.

PCAs: Normal bilaterally.

Conclusion

1. Large hyperacute left MCA territory infarct. No evidence of hemorrhagic conversion.

2. Abrupt thrombotic occlusion of the left MCA M1 segment.

3. Perfusion data indicates essentially completed left MCA distribution infarct without evidence of "at risk" brain tissue (penumbra).