Bilateral hyperacute middle cerebral artery territory infarcts

Case contributed by Keshaw Kumar
Diagnosis certain


Loss of consciousness.

Patient Data

Age: 70 years
Gender: Male

Left middle cerebral (M1 segment) and intracranial internal carotid arteries appear hyperdense, likely representing thrombus, with subtle loss of grey-white matter differentiation in left insula.

Suggestive of left MCA territory hyperacute infarct.

Extensive bilateral diffusion restriction in bilateral cerebral hemispheres, mildly extending into the basal ganglia in the territory of the middle cerebral arteries. There is sparing of the thalamus. Few small patchy areas of T2W/FLAIR hyperintensity in the bilateral cerebral hemisphere. A few small patchy areas of blooming on SWI with the corresponding hyperintensity on phase images, likely represent early hemorrhagic transformation. On T2W images, there is a loss of flow void in the left ICA and MCA, which likely represents a thrombus.

Suggestive of bilateral MCA territory hyperacute infarcts with early hemorrhagic transformation.

Neck & Brain angiography


There is non-opacification of bilateral middle cerebral arteries and left distal internal carotid artery, consistent with thrombosis.

There is also non-visualization of the left external carotid artery, likely due to partially calcified atherosclerotic plaque causing near-complete luminal narrowing just after its origin from the common carotid artery.

Case Discussion

Bilateral simultaneous MCA territory infarcts are uncommon with poor patient outcomes.

Co-author: Dr Saket Ballabh, Consultant radiologist

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