MCA infarct (with perfusion)

Case contributed by A.Prof Frank Gaillard

Presentation

Right hemiparesis.

Patient Data

Age: 83
Gender: Female
CT

There is subtle loss of grey-white differentiation in the left basal ganglia and the insular ribbon. Branching calcific density at left M1 extending past bifurcation. No intracranial haemorrhage. No hydrocephalus or suspicious osseous lesions.

CT

CT perfusion and CT angiogram

 

CT perfusion:

Large region of increased TMax/MTT with smaller region of reduced CBV/CBF in the left MCA territory.

CT angiogram:

The M1 on the right opacifies but no flow is seen distal to this. This is consistent with an occlusion at the level of the bifurcation.

The markedly calcific distal M1 presumably represents heavily calcified plaque and a preexisting stenosis that has now been complicated by thromboembolism.

Calcific plaque present at the carotid bifurcation bilaterally, causing up to 50% stenosis of the proximal right ICA but no high-grade stenosis of the proximal left ICA.

Densely calcified left subclavian artery, probably occluded. The small left vertebral artery probably fills retrogradely. Right vertebral artery is large calibre with no focal stenosis.

No aneurysm or vascular malformation. No evidence of dissection.

Conclusion:

Occlusion of the left MCA from bifurcation, likely at the site of pre-existing stenosis from calcific plaque. Perfusion study is consistent with an established infarct core in the left MCA territory, although with a larger surrounding ischaemic penumbra.

Case Discussion

Identification of an ischaemic penumbra is critical in identifying the group of patients which can benefit from reperfusion therapy (iv tPA or clot retrieval). 

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Case information

rID: 35544
Case created: 10th Apr 2015
Last edited: 30th Aug 2016
Inclusion in quiz mode: Included

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