Right MCA infarction with thrombectomy

Case contributed by Dr Matt A. Morgan

Presentation

During admission for a separate issue, the patient developed left sided weakness, left facial droop, and dysarthria.

Patient Data

Gender: Male
CT

Initial CT

The initial CT was read as "no CT evidence of acute major territorial infarct".

The gray-white junction is intact. No intracranial hemorrhage, extracerebral fluid collection, midline shift or mass effect. 

In retrospect, possible hyperdense right MCA at M1.

MRI

Follow up MRI

Brain: There is an acute right MCA infarct involving right basal ganglia, frontal operculum, and anterior insula. Much of the MCA distribution appears spared, however.

There is T2/FLAIR hyperintensity of the right MCA branches, compatible with stroke. No hemorrhagic transformation.


Right ICA: Abrupt proximal right M1 occlusion, with no flow-related enhancement in remaining right sided middle cerebral branches. Right skull base ICA and anterior cerebral segments are otherwise patent

Left ICA: No large aneurysm or significant stenosis. Patency of the intracranial skull base segments, carotid terminus, proximal anterior and middle cerebral arteries, and visualized distal branches.
 
Vertebrobasilar: No large aneurysm or significant stenosis. Patency of the bilateral intracranial vertebral arteries, basilar artery, and visualized distal branches.

Annotated image

Annotated MRI

Annotated images

DSA (angiography)

Neuro angio

There is occlusion of the right middle cerebral artery proximal M1 segment, TICI 0.

A significant amount of the right MCA territory is filled from right ACA collaterals. The right posterior communicating artery is present. 

Post mechanical thrombectomy angiography shows revascularization of the right MCA territory however there is a persistent partially occlusive thrombus at the right MCA bifurcation extending into the inferior division resulting in delayed filling of the territory with some retrograde filling supplied by the right ACA collaterals, TICI 2B.

Final angiography again demonstrates full filling of the right MCA territory however with some sluggish and collateral flow, TICI 2B.

Annotated image

Neuro angio annotated

See annotations.

Case Discussion

Images of an acute right M1 segment MCA infarction, TICI 0 with subsequent thrombectomy and reconstitution of flow.

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Case information

rID: 53899
Case created: 13th Jun 2017
Last edited: 14th Jun 2017
Inclusion in quiz mode: Included
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