Presentation
Presented with sudden left sided body weakness and slurred speech for 1 day.
Patient Data
No intracranial bleed. Areas of ill-defined hypodensity with loss of grey white matter differentiation are seen at the right fronto-temporal region, right insular cortex, posterior limb of right internal capsule, right lentiform nucleus, body of right caudate nucleus and right corona radiata. Associated with dense right MCA sign, loss of right insular ribbon sign and disappearing right basal ganglia sign.
There is mild mass effect onto the right lateral ventricle, right Sylvian fissure and effacement of the adjacent cerebral sulci. No midline shift. Mild prominent left lateral ventricle. Basal cisterns and rest of CSF space are not effaced.
Incidental finding of left scalp heterogeneous hypodense lesion in the left fronto-temporal region, likely benign in nature.
Long segment non-opacification at the right M1 and right M2 with paucity at the right M3 and right M4, suggestive of thrombosis.
The previously seen areas of ill-defined hypodensities at the right fronto-temporal region, right insular cortex, posterior limb of right internal capsule, right lentiform nucleus, body of right caudate nucleus and right corona radiata have become more conspicuous. No hyperdensities within to suggest hemorrhagic transformation. It is causing mass effect onto the right lateral ventricle with compensatory dilatation of the left lateral ventricle.
Right dense MCA sign has become less dense as compared to previous study.
Conclusion:
Evolving acute right MCA territory infarction with mass effect. No CT evidence of hemorrhagic transformation.
Case Discussion
This is a case of acute right middle cerebral artery (MCA) territory infarct caused by total occlusion of right M1 and M2.
MCA infarct is the most common type of infarct as compared to ACA and PCA territory infarcts. Findings in hyperacute or acute MCA territory infarct could be very subtle. It is important to look for early sign of middle cerebral artery thrombosis, such as dense MCA sign, loss of the insular ribbon sign and disappearing basal ganglia sign. DWI/ ADC map and FLAIR sequence in MRI is also very helpful to detect recent infarct.
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