Bilateral MCA territory stroke complicated by vertebral artery occlusion and pulmonary embolism
Presentation
Known dementia. Caregiver noticed new unresponsiveness, GCS 4 upon presentation. ?Intracranial bleeding
Patient Data
A nonctontrast study was requested first, which was supplemented by a single phase CTA after review of the images.
The CT shows hyperdense MCA on both sides (which makes it paradoxically harder to notice), the abnomal density is striking if you compare this to the basilar artery.
Similarly, the homogeneous cortical hypodensity of almost the whole MCA (and ACA) territory on both sides is not as striking as it should be because of the symmetry - compare it to the posterior circulation territory.
CTA confirms extensive ICA-MCA occlusion on the right and short segment M1 MCA occlusion on the left with distal collateral filling. Simultaneously there is a long segment extracranial vertebral artery occlusion on the right. Likely floating thrombus in the left proximal ECA.
Nasopharyngeal airway tube in situ.
Partially depicted extensive pulmonary arterial embolism and resultant infarction in the left lower lobe (lung window recon not shown) further complicate the already dismal prognosis.
Case Discussion
Considering the clinical picture and extensive comorbidities best supportive care was commenced.