Large ischemic penumbra in the right MCA vascular territory

Case contributed by Dr Bruno Di Muzio


Stroke protocol. No further information was provided.

Patient Data

Age: 69
Gender: Female

CT Brain (Stroke) + CTA + CT Brain perfusion

No acute intracranial hemorrhage. There is linear branching hyperdensity in the region of the distal right M1 with extension into proximal M2 branches within the sylvian fissure. There is a subtle region of hypodensity affecting the corona radiata immediately superior to the right anterior limb of the internal capsule. The adjacent caudate head, insular ribbon and lentiform nuclei however remain preserved. Elsewhere, no other convincing region of developing acute/subacute cerebral infarct. 

CTA COW (aortic arch to vertex)

Heavily calcified plaque at the carotid bulb and proximal right ICA results in approximately 70% narrowing of the proximal ICA. Partially calcified atherosclerotic plaque at the left carotid bulb results in less than 50% stenosis at the proximal ICA. Minimal irregularity without significant stenosis affecting bilateral petrosal and cavernous ICAs may represent segments of atherosclerotic disease.

There is a filling defect involving the mid to distal right M1 with extension into both M2 divisions. No other filling defect or significant stenosis within the intracranial arterial circulation. No intracranial aneurysm appreciated.

The right V1 segment is of extremely narrow caliber, with the artery only visible to the level of the C5 transverse process. The right vertebral artery reconstitutes around the level of C2 with the V3 and V4 segments also demonstrating small caliber with some irregularity. The right PICA demonstrates an unremarkable origin and appearance off the right V4. The foramina transversaria are of relatively preserved diameter. Appearances are indeterminate between hypoplasia and chronic dissection of the right vertebral artery.

CT Perfusion:

There is a region of increased MTT affecting almost the entire right MCA territory. There are subtle patchy regions of reduced CBF within the right MCA territory however the appearances suggest a perfusion mismatch with ischemic penumbra.


Occluded distal right M1 with extension into the proximal M2 branches and large ischemic penumbra.

Calcified atherosclerotic plaque at the right carotid bifurcation and proximal ICA results in approximately 70% stenosis of the artery.

The patient was promptly submitted to thrombolysis treatment. With no complications and complete symptoms resolution. 


MRI Brain (after treatment)

No significant diffusion defect. No filling defect is seen in the right M1 segment. Multifocal areas of susceptibility artefact seen in both cerebral hemispheres and corpus callosum compatible with prior microhemorrhages. The axial FLAIR images demonstrate mild changes of small vessel chronic ischemic disease within the periventricular and deep white matter of cerebral hemispheres.

Case Discussion

The ischemic penumbra denotes the part of an acute ischemic stroke which is at risk of progressing to infarction, but is still salvageable if reperfused, such as happened in this case. It is usually located around an infarct core which represents the tissue which has or is going to infarct regardless of reperfusion. 

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Case information

rID: 38610
Published: 23rd Aug 2015
Last edited: 14th Aug 2019
Tag: rmh
Inclusion in quiz mode: Included

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