Presentation
Right side weakness. History of recent MVA. Rule out acute intracranial process.
Patient Data
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Normal appearance of the cerebellar and cerebral parenchyma, adequate cerebral grey-white matter differentiation.
The ventricles are of normal size and shape. The brain stem is grossly normal.
Absence of intracranial hemorrhage, parenchymal distortion or shift of the midline structures.
The left ICA below the base of the skull is hyperdense, presumably representing thrombus.
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On all sequences, it is clear that no flow is observed within the left internal carotid artery from the base of the skull to the cavernous sinus region. The MRI images showed flow within the left anterior and middle cerebral arteries which fill via the anterior communicating artery.
The MR angiogram of the intracranial circulation shows some, irregular flow in the petrous portion of the left internal carotid artery however most of the hypersignal noted in this region is "shine through" from the actual clot.
These studies are compatible with left internal carotid artery dissection. There is no evidence of acute infarct. MRA with gadolinium recommended and MR perfusion studies.
The MR angiogram of the extracranial arterial circulation shows a 1cm stump and then no further flow in the left internal carotid artery. The other arteries are of normal flow and caliber.
These studies are compatible with left internal carotid artery dissection. There is no evidence of acute infarct.
Patient was managed with aspirin.
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Persistent occlusion of the left ICA from above its origin to the skull base with no evidence of recanalization.
Case Discussion
The case was contributed by Dr Raquel Del Carpio-O'donovan, Professor of Radiology, Neurology, Neurosurgery at McGill University.