MR T2 and 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.
CA0755-MR T2 and FLAIR
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CA0755-MR T2 and FLAIR
Case ReportExam
Prior Study
Given the history of cocaine abuse and hypertension, there is substantial global brain atrophy for chronological age, plus end-artery type of completed lacunar infarctions.
MRA of the neck
Normal MRA of the neck without vascular stenoses nor dissection.
MRA of the head
Right MCA bifurcation saccular aneurysm, as above.
Suspicious evidence of distal left MCA and PCA vasospasm plus minimal delay in filling rate, which are consistent with cocaine related distal arterial vasospasm. Otherwise, negative head MRA for arterial occlusion or dissection
Noncontrast T1-w MR
There are a myriad of the lacunar-type strokes affecting terminal arteries in the centrum semiovale and the corona radiata bilaterally. There are multicentric lacunar-type strokes in the lenticulostriate perforators, the thalamic perforators, and the brainstem perforators bilaterally. The lacunes follow the Virchow-Robin spaces; they are tubular in shape characteristic of end-artery types of ischemia. This is evident in this case of chronic vasospasm and ithe CNS angiits cases, as well. All the changes appear chronic and there is global brain injury, as well. With the history of drug abuse these findings are consistent with terminal artery ischemic effects of vasoactive drugs (i.e. cocaine and metamphetamines, etc.) or occasionally with microembolization of the foreign body material from IV drug use.
There is some T1-w signal increase deep to the left insula, which represents chronic lower grade oligemic effects likely with microhemorrhage; this does not represent laminar necrosis.
MR diffusion
Multicentric completed end-artery strokes, as described previously. MR diffusion is negative are any recent infarctions.
Findings
MR T2-w and MR flair
The MR flair demonstrates increase signal along the margins of all the end-artery strokes seen on previous imaging sequences. The pattern of this post ischemic injury follows the Virchow-Robin spaces indicating a transcapillary end-artery type of vascular injury.
The coronal T2-w sequence illustrates how these infarctions are tubular in nature and follow the course of penetrating and perforating arteries within the Virchow-Robin spaces. This is an important observation in order to place the stroke type into the transcapillary category. This moves the differential diagnosis into disorders of small vessel disease including primary and secondary CNS angiitis, vasoactive drug abuse (as in this case), malignant hypertension (as in this case), and microembolization.
Impression
Recommendations
Proceed to the summary video and case report to view all of the imaging findings in this case plus the "Lessons to be learned" from this specific instructional case.
