Disappearing basal ganglia sign

Case contributed by Dr Nafisa Shakir Batta

Presentation

Young lady with rheumatic heart disease, presented with neurological deficit

Patient Data

Age: 27 years
Gender: Female

CT done at 4 hours, with a subsequent followup 24 hours CT

Modality: CT

CT done within 4 hours demonstrates the blurring of grey white matter differentiation at the left insular cortex, with loss of the insular ribbon, obscuration of the lentiform nucleus and abnormally hypodense left basal ganglia showing absence of normal contour ( disappearing basal ganglia sign).

CT repeated at 24 hours, (after thrombolytic therapy ) reveals more prominent hypoattenuating basal ganglia and insular cortex , as the infarct has matured.

MRI done at 24 hours from the onset of neurological symptoms.

Modality: MRI

Diffusion weighted MRI images show the bright signal in left MCA circulation territory, consistent with acute infarct.

MRA sequences in coronal and axial projections show a short segment abruption at the proximal left MCA  M2 branches , with attenuation in caliber of M2 and M3 segments , with visualisation of fewer opercular and sylvian branches of distal M3. These findings are highly suggestive of  a thromboembolic episode .

Case Discussion

An intentful look at the basal ganglia is absolutely essential on early CT scans in a patient with neurological deficit. The subtle signs of early MCA infarction are demonstrated in this case, and their careful detection can aid immensely in induction of thrombolytic therapy for it to be of timely benefit within the window period.

This case clearly delineates the early signs of MCA infarction : namely, loss of insular ribbon sign, obscured lentiform nucleus sign, and disappearing basal ganglia sign. A hyperdense MCA can be seen at times when thrombosed, but in the event of an embolic phenomenon this may not be demonstrated.

This patient had complete recovery and reversal of neurological deficit post thrombolysis.

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Case Information

rID: 24702
Case created: 5th Sep 2013
Last edited: 6th Feb 2016
Inclusion in quiz mode: Included

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