Ischemic stroke

Case contributed by Hugo Neves (RT)


Admitted with temporary aphasia and dysarthria for three hours.

Patient Data

Age: 65
Gender: Male

First CT Scan - ER three hours after symptoms onset

There is a loss of insular ribbon sign on right side indicating an early sign of ischemic stroke. 

It is important to remember that the cortex, like on insular ribbon, has a poor collateral supply and for this reason is more vulnerable. 

The patient progressed with left hemiplegia, aphasia and labial commissure deviation to the right side.

The second CT scan shows an extension of hypoattenuating ischaemic area and the hyperdense MCA sign, which has been associated with a poor outcome.


Second CT - three hours after the first scan

There is an extension of the hypoattenuating area indicating an acute ischemic stroke on right MCA territory, with no evidence of midline shift, herniation or hemorrhagic transformation. There is increased attenuation of the proximal portion of the right MCA and it is compatible with thrombosis of the M1 segment. 

With time the hypo-attenuation and swelling become more marked resulting in significant mass effect. This is a major cause of secondary damage in large infarcts. 


Third CT - two days after admission

A huge right MCA territory infarction has evolved with midline shift and subfalcine herniation.


Fourth CT - five days after admission

Ischemic stroke evolution and management with a decompressive craniectomy. Remaining midline shift with subfalcine and uncal herniation.

Case Discussion

Ischemic stroke results from a sudden cessation of adequate amounts of blood reaching parts of the brain. Ischemic strokes can be divided according to territory affected or mechanism, in this case a MCA territory infarct. 

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Case information

rID: 23669
Published: 24th Jan 2015
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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