Post contrast head CT
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.
CA0458-Post contrast head CT
View Images
CA0458-Post contrast head CT
Case ReportHistory
Exam
Prior Study
1. Acute thrombus in Lt. intracranial primary and secondary stem components of the Lt. ICA
2. Early cytogenic edema in both Lt. ACA & MCA territories, likely stroke-age is in the 3-6 hour range.
CT Perfusion
1. CT perfusion was not obtained.
CTA of the Neck
1. There were no flow limiting stenoses in the lower and mid cervical major afferent arteries.
2. There is unexplained reduced lumen size of the upper Lt. cervical ICA likely secondary to downstream obstruction. However, the neck CTA did not include any of the intracranial/extradural parts of the left ICA.
CTA of the Head (using initial post contrast exam)
1. Likely source of the left ICA arterial obstruction is a dissection of the vertical intrapetrous ICA segment. There is no EC-IC collateralization.
2. There is complete thrombosis of both the intracranial/extradural and intradural Lt. ICA with no filling of the primary or secondary intracranial stem branches plus there is no distal pial artery filling from pial collaterals. In essence, there is no arterial circulation to the left ICA at all.
3. There is no filling of the left cortical or deep central veins. These same veins are all well seen on the normal right side. This is consistent with the venous collapse and advanced hemispheric dense ischemic core possibly to the level of acute sequestered infarction.
4. Cut-off of the opacified left P-com is indicative of incisural brain herniation on the left.
Findings
Post contrast head CT for venocapillary pool analysis
The initial post contrast head CTA demonstrates no CT density within the venocapillary pool within either the Lt ACA or MCA perfusion zones.
The delayed post contrast head CT demonstrate a minimal rise in CT density in the peripheral aspects of the left cerebral cortex, but it is nowhere near NL. The bulk of the oligemic zone shows virtually no rise (absent) in CT density indicating virtually no transcapillary blood flow.
Deep central veins show some opacification but it is minimal. Findings are consistent with little or no transcapillary blood flow and likely deep venous stasiss.
There is early downward herniation with mesial displacement of the uncus of the parahippocampal gyrus. This accounts for the amputated left P-com.
Impression
2. Only minimal peripheral pial collateralization is evident; the bulk of the Lt ICA perfusion zone is within the dense ischemic core. The addition of the virtually no venous egress to no afferent arterial input is consistent with sequestrated form of stroke, which if large enough in size typically has a very poor clinical outcome. This patient did not survive this stroke.
3. There is no current hemorrhagic conversion.
4. There is early, but definite, downward incisural herniation.
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.
