État criblé with acute right middle cerebal artery infarct

Case contributed by Dr Hoe Han Guan

Presentation

Left sided body weakness with chronic loss of memory.

Patient Data

Age: 70 years
Gender: Male

Well defined hypodense foci at the heads of bilateral caudate nuclei, bilateral thalami and bilateral lentiform nuclei.

Symmetrical and diffuse periventricular hypodensities may represent small vessel disease.

No acute intracranial bleed.

Abnormal signal intensity at the right parieto-temporal lobes (including the right motor cortex), which involves both grey and white matter. It shows low signal intensity on T1WI and high signal intensity on both T2WI and FLAIR sequences. This corresponding abnormal signal intensity area shows restricted diffusion on DWI/ADC map.

Three smaller foci at the left centrum semiovale and left corona radiata which also show restricted diffusion, representing another three acute lacunar infarcts.

A few foci of blooming artefacts within the right parieto-temporal lobe are in keeping with microhemorrhage.

A few gyriform-like curvilinear hyperintensity on T1WI at the right temporal lobe may represent cortical laminar necrosis

Bilateral lentiform nuclei demonstrate innumerable dilated perivascular space. This appearance is known as état criblé.  A few chronic lacunar infarcts at bilateral caudate nucleus, thalami and lentiform nuclei.

Periventricular deep white matter hyperintensities on T2WI/FLAIR sequences may represent small vessel ischemia.

MR angiogram (time of flight) of circle of Willis shows normal flow signal intensities in anterior and posterior circulation. Right fetal posterior communicating artery with hypoplastic of P1 segment of right PCA.

Case Discussion

MR feature are in keeping with right middle cerebral artery territory acute infarction.

The typical appearance of symmetrical innumerable dilated perivascular spaces in basal ganglia (état criblé) should be differentiated from état lacunaire.

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