Presentation
During admission for a separate issue, the patient developed left sided weakness, left facial droop, and dysarthria.
Patient Data
The initial CT was read as "no CT evidence of acute major territorial infarct".
The gray-white junction is intact. No intracranial hemorrhage, extracerebral fluid collection, midline shift or mass effect.
In retrospect, possible hyperdense right MCA at M1.
Brain: There is an acute right MCA infarct involving right basal ganglia, frontal operculum, and anterior insula. Much of the MCA distribution appears spared, however.
There is T2/FLAIR hyperintensity of the right MCA branches, compatible with stroke. No hemorrhagic transformation.
Right ICA: Abrupt proximal right M1 occlusion, with no flow-related enhancement in remaining right sided middle cerebral branches. Right skull base ICA and anterior cerebral segments are otherwise patent
Left ICA: No large aneurysm or significant stenosis. Patency of the intracranial skull base segments, carotid terminus, proximal anterior and middle cerebral arteries, and visualized distal branches.
Vertebrobasilar: No large aneurysm or significant stenosis. Patency of the bilateral intracranial vertebral arteries, basilar artery, and visualized distal branches.
Annotated images:
- DWI and ADC map: the red circle outlines the area of restricted diffusion in the deep right gray matter, compatible with an acute infarct
- FLAIR: subtle T2 hyperintensity in the right deep gray matter and hyperintensity of right MCA branches
- MRA: abrupt cut-off at M1 on the axial TOF MRAN
- MRA: no hyperintensity in the right MCA branches;
- MRA: abrupt cut-off at M1 on the TOF MRA - coronal reconstruction
There is occlusion of the right middle cerebral artery proximal M1 segment, TICI 0.
A significant amount of the right MCA territory is filled from right ACA collaterals. The right posterior communicating artery is present.
Post mechanical thrombectomy angiography shows revascularization of the right MCA territory however there is a persistent partially occlusive thrombus at the right MCA bifurcation extending into the inferior division resulting in delayed filling of the territory with some retrograde filling supplied by the right ACA collaterals, TICI 2B.
Final angiography again demonstrates full filling of the right MCA territory however with some sluggish and collateral flow, TICI 2B.
Image 1: abrupt cut-off at M1 on the TOF MRA coronal reconstruction
Image 2: occlusion of the M1 segment of the middle cerebral artery. Anterior cerebral artery is normal.
Image 3: on the lateral projection the ACA and its branches fill promptly as well as a few feeder arteries to the basal ganglia that arise from the ACA. The MCA and its branches are absent.
Image 4: early reconstitution of flow in the MCA after thrombectomy
Images 5 and 6: late reconstitution of flow after thrombectomy. The small red arrow points to a filling defect in M1, compatible with a small amount of residual thrombus
Case Discussion
Images of an acute right M1 segment MCA infarction, TICI 0 with subsequent thrombectomy and reconstitution of flow.
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