MR FLAIR
Claim CME CreditPOINT OF CARE INFORMATION
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.
CME Advisory Committee Disclosure:
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.
CA0388-MR FLAIR
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CA0388-MR FLAIR
Case ReportHistory
Exam
Prior Study
1. Prior occlusion of the posterior M3 trunk off the superior division Lt MCA, which has good pial collateral preventing extension of the stroke to most of the posterior superior division perfusion zone.
2. There is acute thrombus in single artery (artery to the central sulcus). The affected perfusion zone for this artery is much smaller than its’ full (normal) perfusion territory, which indicates there has been substantial retrograde pial collateralization from the A4 (ACA) pial vessels. However, there remains a small pial collateral gap in the mid-insula and the adjacent frontoparietal opercular cortex. In this case, the affected area includes the tongue part of the primary facial motor area, which correlates with the patients presenting symptom of dysarthria.
3. The improved CT density in the venocapillary pool is a good indication that the extent of final stroke-zone will remain quite small.
MR diffusion
Both the DWI & ADC maps are positive for a small stroke in mid-insula and adjacent intrasylvian frontoparietal operculum. This matches the expected perfusion zone of the proximal part of the artery to the central sulcus vascular territory. Thus, the distal lateral cortical part of the arteries expected perfusion zone is adequately perfused by retrograde ACA (A4) pial collaterals.
Findings
MR flair
There is edema well defined positive FLAIR signal in all parts of the left cerebral stroke as defined on the MR diffusion imaging. The extent of the edema is more proiminent in the sites of dense ischemic core (i.e. the lateral lenticulostriate, the lateral orbital frontal and anterior insular perfusion zones). The FLAIR signal is abnormal but to a lesser extent in the remaining distal left MCA branches. The timeframe for all ischemic areas are well beyond the hyperacute time frame.
There is dilatation of at least one artery in the posterior trunk left superior division MCA with positive FLAIR signal. This artery was patent on the delayed post contrast CT; it is not thrombosed, but is part of the retrograde pial collateral.
There is no hemorrhagic conversion.
There is no FLAIR change in the proximal left ICA or MCA to confirm prior recanalized thrombus.
There are positive FLAIR changes in the gliosis associated with the prior right posterior insular stroke as expected.
Impression
Minimal stroke area edema on FLAIR places the stroke-age in the hyperacute timeframe.
