Presentation
Hypotension, acute right hemispheric stroke syndrome (Onset 6 hours prior to imaging). Prior clinically mild stroke 6 months ago.
Patient Data
Border zone infarctions
Areas of restricted diffusion (hyperintense in DWI b=1000 and hypointense in ADC) with corresponding FLAIR hyperintensity in the right upper frontal and parietal lobes and right inferior parietal lobe.
SWI shows minor hemorrhagic transformation.
T2 SE shows hyperintensities reflexting acute and some underlying preexisting ischemic lesions.
Chronic right ICA occlusion
CT-angiogram showing a right ICA occlusion, proximal heavily calcified ICA lesion.
Small Acom, no Pcom.
A prior CT-angiogram (6 months earyler, not shown) and a prior duplex sonography (6 months earyler, not shown) confirm this to be a chronic occlusion.
Case Discussion
Typical MRI image of acute 1) posterior borderzone infarction, 2) internal borderzone infarction and 3) cortical infarctions in a patient with chronic proximal ICA occlusion.
It is important to evaluate therapeutic options in proximal ICA occlusions!
In some proximal ICA occlusions a CT-angiogram might just show a pseudoocclusion due to a high grade low flow proximal ICA stenosis - if duplex or angiogram then show residual flow, revascularization might be possible to salvage the vessel! In this case at hand, the ICA occlusion was known to be preexisting for several months.
In select patients subacute or even chronic carotid occlusions can be revascularized by endovascular treatment. In select patients with chronic carotid occlusions an EC-IC-Bypass can be performed surgically. Evaluation of those cases in neurovascular centers should be considered. In this 80y old patient those treatment options were not executed due to severe comorbidity (terminal heart insufficiency with limited life expectancy).
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