Presentation
Acute right hemiparesis.
Patient Data
Old left MCA infarct.
No definite acute cerebral infarction.
Subtle hypoattenuation left putamen, age indeterminate.
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CTA and CT perfusion performed with the patient's head rotated towards right (not intentional - uncooperative patient).
CTA demonstrates occlusion of right cervical ICA due to compression by calcified stylohyoid ligament. Right supraclinoid ICA non-opacified. Right MCA and ICA patent via circle of Willis.
CT perfusion demonstrates right MCA territory hypoperfusion (increased MTT, decreased CBF, normal CBV). No appreciable critical hypoperfusion (normal CBV). Of note, no acute left MCA territory perfusion abnormality to correlate with the patient's presentation (right hemiparesis - the clinical data was confirmed with the referring doctor).
Post contrast CT brain delayed phase performed with the patient's head in neutral position: The right ICA is now patent at level of stylohyoid ligament and above.
Case Discussion
CTA and CT perfusion was luckily performed with the patient's head rotated to the right (not intentional). This demonstrated occlusion of right ICA by calcified stylohyoid ligament. CTP demonstrated correlative cerebral hypoperfusion (although this did not account for the patient's apparent right hemiparesis, which was confirmed with the referring doctor).
Delayed phase post contrast CT brain was subsequently performed with the patient's head in neutral position. This demonstrated patent right ICA at and above level of calcified stylohyoid ligament.
Conclusion:
Eagle syndrome with compression of right ICA.
Acknowledgement: A/Prof Ronil Chandra (Neurointerventional Radiologist)
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