Subtle left middle cerebral artery territory infarct with CT perfusion

Case contributed by Dr Craig Hacking

Presentation

Acute right hemiparesis. AF.

Patient Data

Age: 77
Gender: Female

No intra- or extra-axial collection or haemorrhage demonstrated. There is subtle loss of grey-white differentiation within the left insula cortex. The left MCA is hyperdense. Ventricular size, sulcal pattern and basal cisterns all appear normal. No bony abnormality demonstrated.

Elevated MTT and TMax within the left MCA territory with normal to mildly reduced CBV and CBF in keeping with a small core and large ischaemic penumbra.

There is an abrupt occlusive filling defect within the proximal left M2 superior segment in keeping with thrombus.

Four vessel aortic arch anatomy. Common carotid and internal carotid arteries are patent with no dissection. Vertebral arteries are patent with no dissection. Left vertebral artery does not pass through the C6 transverse foramen. Fetal origin to left PCA. No aneurysms identified.

Conclusion

Occlusive thrombus within the proximal left M2 segment with subtle loss of grey-white differentiation. Perfusion imaging demonstrates large ischaemic penumbra within the left MCA territory.

Case Discussion

Subtle signs on the non contrast study. Large penumbra with little infarct core on the perfusion. CTA confirmed a thrombus in a left M2 branch.

20 minutes later a thrombus was retrieved angiographically. The patient recovered well.

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Case Information

rID: 37826
Case created: 23rd Jun 2015
Last edited: 3rd Sep 2015
Inclusion in quiz mode: Included

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