Presentation
Right sided weakness, history of previous stroke episode
Patient Data
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.
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.