Subacute stroke

Case contributed by A.Prof Frank Gaillard

Presentation

Homonymous hemianopia and right arm weakness.

Patient Data

Age: 40 years
Gender: Male
Modality: CT

Moderately extensive grey and white matter hypodensity involving the left medial temporal lobe and occipital lobe, within PCA territory. Hypodensity extends into the left inferior parietal white matter. Moderate mass effect. Local sulcal effacement. Left uncal herniation with early mass effect on the midbrain. 5 mm midline shift to the right at the level foramina of Munro. Effacement of lateral ventricles. Left frontal and parietal generalised sulcal effacement also seen. No acute haemorrhage.

CONCLUSION:

Moderately large left PCA territory acute infarct involving temporal and occipital lobes. No acute haemorrhage seen.

Modality: MRI

There is extensive low T1 with corresponding high T2 signal intensity seen corresponding to the distribution of the left PCA territory (with involvement of the grey matter/cortex) including the left MCA/PCA cortical border zone superiorly (parietal lobe) and the left thalamus. Regions of lower T2/FLAIR signal intensity corresponding to loss of signal on the susceptibility sequence obtained is most compatible with foci of microhaemorrhages within the region.

Affected areas demonstrates pronounced gyriform enhancement. Presence of gyriform enhancement in the small region of T2 hyperintensity in the right parietal occipital lobe, as well as a tiny cortical focus in the right superior frontal gyrus adjacent to the precentral sulcus, documents the presence of further smaller regions of subacute ischaemia in the right hemisphere. 

Normal MRA. In particular, the left PCA appears patent. Remainder of the brain is unremarkable.

CONCLUSION:

The morphology of the contrast enhancements confirms the diagnosis of subacute infarction. This involves the entire left PCA territory, as well as a moderate region in the posterior left MCA territory, and contralateral hemisphere involvement abutting the right precentral sulcus and the right parieto-occipital lobe. Involvement of at bilateral MCA and PCA vascular territories suggests a central embolic source.

Case Discussion

Missed cerebral infarcts, those where the first imaging is in the subacute phase, can sometimes appear unusual and mimic tumours or infections. Identifying that the abnormality is confined to a vascular territory is the most useful clue. Depending on the age, and/or presence of microhaemorrhages, diffusion and perfusion may be of limited use. 

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Case Information

rID: 43386
Case created: 8th Mar 2016
Last edited: 18th Apr 2016
Inclusion in quiz mode: Included

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