Presentation
Dense right hemiplegia and slurred speech. Associated seizures and altered level of consciousness.
Patient Data
Findings:
Asymmetrical hyperdense left MCA, A1 ACA and left terminal ICA involving the supraclinoid, ophthalmic and cavernous segment suggestive of large vessel thromboembolism.
Grey-white matter differentiation loss and generalized hypoattenuation of the left ACA and MCA vascular territory. Cytotoxic edema secondary to established ACA and MCA territory infarct.
No macroscopic hemorrhagic transformation.
The left cerebral uncal process overhangs the left falx cerebelli concerning for early uncal herniation.
Summary:
Established left MCA and ACA vascular territory cerebral infarction with cytotoxic edema, mass effect and early left uncal herniation.
Hyperdense left intracranial ICA, MCA (to mid M1) and ACA A1 segment suggestive of acute thromboembolism.
No hemorrhagic transformation.
Case Discussion
This patient was transferred to ICU from a rural hospital with a left sided ischemic stroke. Endovascular clot retrieval was not feasible due to inability to facilitate interhospital transfer within necessary timeframe. Decision made to thrombolyse with tenecteplase.
The hyperdensity of the involved vessels is due to the thrombus having previously formed and contracted, either within the heart or carotid bulb, prior to embolizing and occluding the left ICA.
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