Loss of insular ribbon - sign of early MCA infarction

Case contributed by Nafisa Shakir Batta
Diagnosis certain


Right sided weakness, history of previous stroke episode

Patient Data

Age: 70 years
Gender: Male

CT immediately from triage


CT reveals a subtle hypodensity at the left insular cortex, with preserved attenuation of the lentiform nucleus. An older subacute infarct is evident at the right posterior perirolandic region of parietal cortex.

2 hours post thrombolysis


Post thrombolysis delayed two-hour scans showed a more mature infarct in the left perisylvian cortex, clearly depicting the 'loss of insular ribbon sign. Also notable is the straightening of the Sylvian sulcus, which may be seen occasionally.

Corroborative MRI confirms the restriction of diffusion in the left insular cortex. The right subacute infarct shows minimal persistent bright signal on DWI.

Case Discussion

Loss of insular ribbon sign denotes loss of grey white matter distinction at the insular cortex secondary to edema due to an ischemic insult. This is an early sign of MCA infarction and should be looked for intently in the clinical setting of stroke.

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