MCA infarct with CT perfusion and clot retrieval

Case contributed by Dr Andrew Dixon

Presentation

Sudden onset left weakness 40 minutes ago.

Patient Data

Age: 60
Gender: Male

Right distal ICA and M1 segment MCA thrombosis seen on CTA without obvious features of infarction on the non-contrast CT but with evidence of a large area of abnormal perfusion (Tmax>6s, estimated volume 221ml) and small infarct core (CBF<30%, estimated volume 1.2ml) giving an estimated ischaemic penumbra of 220ml. The patient proceeded to the angiography suit for clot retrieval. 

DSA (angiography)

1 hour after intial CT

Prior to clot retrieval right ICA injection revealed near complete occlusion of the right distal ICA with no flow into the right MCA. After partial clot retrieval flow is restored within the distal ICA and M1 portion of the right MCA with a short segment M2 branch thrombosis remaining present but with good retrograde flow beyond the occlusion. 

The retrieved clot.

MRI

6 days after clot retrieval

MRI 6 days post partially successful clot retrieval showing only small foci of right MCA territory infarction which is substantially smaller than the initial at risk brain seen on CT perfusion prior to clot removal. Unfortunately, the most prominent area of infarction is within the right pre-central gyrus at the hand bump and therefore likely to produce a neurological deficit. 

Case Discussion

An example of a hyperacute MCA territory infarct with substantial ischaemic penumbra determined on CT perfusion and good result post clot retrieval. 

With thanks to Dr Anthony Kam and Dr Anoop Madan. 

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Case information

rID: 44272
Case created: 14th Apr 2016
Last edited: 6th Aug 2016
Inclusion in quiz mode: Included

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