Presentation
Patient was found at home with aphasia, right sided neglect and mild right sided weakness.
Patient Data
Ill-defined regions of intermediate hypodensity on the left posterior frontal and parietal region.
Small old right frontal infarction.
Mild periventricular hypoattenuation in keeping with chronic small vessels ischemia.
Perfusion imaging is in keeping with an established infarct with match prolongation on TMax and decreased rCBF. No convincing penumbra.
MRI performed two weeks after the CT scan.
Elevated signal on the FLAIR and T2. There is edema involving the cortex and subcortical white matter of the left parietal lobe, corresponding to the the area of ischemia demonstrated on the CT scan.
Scattered T2 white matter hyperintense foci giving a degree of mild ischemia.
There are also multiple old infarcts that are small in the cerebellar hemispheres bilaterally and ischemic change in the pons.
Case Discussion
Rehabilitation notes
Large part of the penumbra seen on the CT perfusion images underwent infarction as seen on the FLAIR images taken two weeks later.
The main lesion involves the left inferior parietal lobe including the supramarginal and angular gyri, and the posterior part of the superior temporal gyrus. The lesion affects both the grey matter and its underlying white matter. The functional networks most likely to be affected are the Central Executive Network 1 and the Default Mode Network 2.
Brain health is also compromised with: 1) a previously undetected right frontal lesion, 2) white matter disease seen on the FLAIR images, and 3) multiple small old lesions of the cerebellum and pons seen on the T2 posterior fossa images.
Motor function and neglect recovered well, whilst the recovery of dysphasia was limited. Recovery was impeded by additional cognitive issues (impaired processing speed, planning and organization, basic mathematical skills, immediate visual memory and fluctuating attention and concentration). The cognitive issues could be attributed to both the affected networks and reduced brain health.
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