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MCA stroke with calcified embolism and movement on perfusion

Case contributed by Frank Gaillard
Diagnosis certain

Presentation

Left sided neglect, dysarthria, facial droop.

Patient Data

Age: 95 years
Gender: Male

Non-contrast brain: Loss of grey-white matter differentiation involving the right precentral gyrus (M5 and M2; ASPECTS = 8). No acute hemorrhage. Periventricular white matter hypoattenuation in keeping with chronic small vessel disease.

There is a calcified hyperdensity (up to 180 HU) seen within the right Sylvian fissure.

CT Perfusion: Movement degraded. Increased MTT/Tmax and decreased CBV/CBF in the right MCA territory in the region of the right precentral gyrus. RAPID calculated volumes should be discounted.

CTA: Occlusion of an M3 branch of the superior segment of the right MCA.

Incidental note 1.2 cm spiculated mass within the right upper lobe.

These two stacks obtained at different levels are the perfusion scans and demonstrate movement during the scan accounting for the artefacts on perfusion maps and errors on RAPID automated maps. 

Established infarct within the right frontal lobe. No intracranial hemorrhage or collection. 

Case Discussion

This case demonstrates some of the dangers of relying on perfusion calculate maps in the setting of movement. Reviewing the source data is useful in this instance. 

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