Post contrast head CT
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This CME activity consists of the student reviewing the video of the professor reviewing the case as well as the associated DICOM image set related to the case in question.
Learning Objectives
As a result of participation in this activity, participants should be able to:
- Provide improved patient care.
- Greater knowledge of the imaging characteristics of the patient's disease.
- Understand a better approach to interpretation of studies.
Faculty Disclosure
Mehmet Albayram, MD, Ivan Davis, MD, Mariam Hanna, MD, Anthony Mancuso, MD, Ronald Quisling, MD, Dhanashree Rajderkar, MD, Priya Sharma, MD, Roberta Slater, MD and Joann Stamm, MBA have disclosed that they have no relevant financial relationships. No one else is a position to control content have any financial relationship to disclose.
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Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/.
Continuing Medical Education Credit
Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CA0377-Post contrast head CT
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CA0377-Post contrast head CT
Case ReportHistory
Exam
Prior Study
There is focal hyperdensity in the distal basilar apex consistent with acute thrombus.
There is no discernable cytogenic edema, and certainly no obvious edema to confirm stroke outside the treatment window.
CT Perfusion
1. Short segment acute thrombus is evident on the included head CTA located in the distal basilar apex.
2. Delayed PCA filling (prolonged TTP) is related to retrograde PCA filling from the circle of Willis.
3. Chronic reduced CBV is evident in the caudal Rt. cerebellum, but no discernable hyperacute stroke is evident.
CTA of the Neck
There is a focal stenosis of the left vertebral artery origin. The stenosis measures >60%, however, there is no post stenotic dilatation nor distal vessel collapse.
CTA of the Head
Acute thrombus in the distal basilar artery apex with limited filling of the SCA perfusion zones to the rostral cerebellum and superior vermis.
There is no opacification of the superior vermic venous complex; correlate with the delayed post contrast CTA to determine whether this just a delay or venous collapse.
Findings
Post contrast head CT for venocapillary pool analysis
Intraluminal acute thrombus remains in the distal basilar artery segment and basilar apex with only partial filling of the proximal SCA’s.
At least some of the superior vermic arteries and veins reappear on the delayed post contrast CTA head. These vessels plus the relatively normal parenchymal density are consistent with functional collateral to the SCA and superior vermic arterial territories bilaterally.
No apparent focal reduction CT density within the venocapillary pool on the delayed post contrast CTA head is evident to confirm completed infarction in the rostral brain stem, the rostral cerebellum, the mid brain or the thalamus on either side. Tissue level ischemic changes, however, may still be present. Therefore MR is recommended.
Impression
2. The PCA’s and at least part of the P1 segments fill retrograde from the circle of Willis.
3. There was at least some antegrade filling of the SCA’s plus there is likely pial collateral arising from the AICA and PICA sources, which is sufficient to increase the rostral cerebellar & superior vermic CT density in the venocapillary pool to within normal limits.
4. No focal reduced CT density within the venocapillary pool is evident to confirm completed stroke in the rostral cerebellum, rostral brain stem, nor occipital poles.
Recommendations
Consider MR to evaluate for tissue ischemia that is not revealed on the CT perfusion or CT venocapillary pool and to evaluate status of intramedullary veins.
