Presentation
Acute left hemiplegia. NIHSS 16.
Patient Data
Initial CT was obtained in the Mobile Stroke Unit - an ambulance equipped with a CT scanner- and demonstrates a hyperdense MCA on the right. This corresponds to a right M1 large vessel occlusion. No haemorrhage.
The patient received thrombolysis in transit and was immediately transferred to the angiography suite for endovascular clot retrieval.
The right common carotid artery was catheterised, and angiography demonstrated right sided proximal M1 occlusion.
Multiple attempts were made to retrieve the clot with recanalisation of only the proximal M1 and one of the M2 branches.
Substantial portions of the peripheral MCA territory remained devascularised. Additionally, early intense capillary blush is visible in the basal ganglia once the proximal M1 was recanalised, and these vessels demonstrate AV shunting and early opacification of the thalamostritate veins draining into the internal cerebral vein and vein of Galen. This is best seen on the final images with the internal cerebral vein opacified with contrast while the normal brain supplied by the anterior cerebral artery has only just started to reach the capillary phase.
MRI obtained the next day confirms extensive infarction of much of the MCA territory mostly sparing the territory supplied by the recanalised M2 branch (probably a middle branch of an M1 trifurcation). The basal ganglia, although reperfused, have gone on to infarct as predicted by the presence of the angiographic blush and early venous filling. Signal loss in the lentiform nucleus represents haemorrhagic transformation.
Case Discussion
This case nicely illustrates how an intense capillary blush and early venous filling during angiography, along with areas of persistent revascularisation, predicts eventual infarction. Additionally, reperfused infarcted brain is more likely to undergo haemorrhagic transformation.
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