Case Images
Case Notes
History
79 year old female presenting with sudden onset symptoms including Rt. facial droop, Rt. side weakness; the patient was nonverbal nor following commands; there is known history of secondary diabetes with hyperlipidemia.Exam
Purpose
1. Define sites of any and all arterial thromboses or flow-limiting, high-grade stenosis, or tandem stenoses with lesser degrees of luminal narrowing, but are included within the same arterial circuit;
2. Characterize the features of the stenotic/occluded arterial segment (NASCET, assess length of stenosis/occlusion, intimal dehiscence, atherosclerotic vs inflammatory basis, etc.);
3. Determine whether there is effective collateral around any occluded segment;
4. Assess the presence of effective EC-IC collateral in cases of extradural ICA occlusion.
Prior Study
CT Head1. Acute thrombus is present in the proximal Lt. M1 & M2 segments of the MCA.
2. Early stroke findings are evident in the rostral portions of the Lt. lateral lenticulostriate perforator, the Lt. orbitofrontal, and the Lt. MCA arterial perfusion zones.
3. The stroke timeline in all the affected areas are similar, and all are likely to have occurred within the stroke treatment window.
CT Perfusion
1. There is prolongation of the TTP & reduced CBV/CBF in the superior division Lt. MCA are consistent with post ischemic parenchymal injury. There is focal, marked, reduction (likely within the dense ischemic core) within the perfusion zones of the Lt. lateral lenticulostriate perforators and the rostral left M3 anterior insular territory. There is post ischemic change likely affecting white matter deep to Broca’s area, premotor cortex and primary motor cortex (especially in facial portion). These areas of involvement appear to match the included clinical symptoms.
2. There is partial reduction of CBV and CBF are evident in the lateral orbitofrontal artery territory and in the lateral cortex (superior division MCA) imply ischemic penumbra, but is protected to some degree by pial collateralization.
CTA Neck
1. Rt. proximal ICA stenosis in the 50-60% range, but on side opposite the stroke. This stenosis plus hypoplastic P-coms are likely to reduce circle of Willis collateral availability to the Lt MCA region, especially in the context of a known hyperacute Lt M1/2 thrombosis.
2. Suspicious nodule in the left thyroid.
Dicom
Findings
| Low Neck Evaluation (Aorta, Brachiocephalic, Proximal Common Carotid (CCA) & Proximal Vertebral Arteries) | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of aortic arch dissection or other abnormality. |
No | NA |
|
There is evidence of occlusion of brachiocephalic arteries. |
No | NA |
|
There is evidence of stenosis of brachiocephalic arteries. |
No | NA |
|
There is evidence of occlusion at the origin of a carotid artery. |
No | NA |
|
If there evidence of stenosis at the origin or the cervical segment of either common carotid artery. |
No | NA |
|
Given a CCA is occluded, are the vertebral to occipital branch of the external carotid artery (EAC) collateral arcades functional. |
No | NA |
|
There is evidence of occlusion in the proximal segment of a vertebral artery. |
No | NA |
|
There is evidence of stenosis in the cervical segment of either vertebral artery. |
No | NA |
| Upper Cervical Neck & Intracranial/Extradural Evaluation for Carotid & Vertebral Arteries | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of occlusion at the carotid bifurcation including proximal ICA or ECA or both. |
No | NA |
|
There is evidence of some degree of stenoses within either the carotid or the vertebral arteries, but these are in the range of 50% or less by NASCET standards. |
No | NA |
|
There is carotid bifurcation of carotid origin (ICA or ECA) stenosis exceeding 60% by NASCET and physiologic criteria. |
Yes | NA |
|
There is carotid bifurcation or carotid origin (ICA or ECA) stenosis exceeding 70% by NASCET and physiologic (post stenotic dilatation and/or partial luminal collapse beyond the stenosis) criteria. |
No | NA |
|
There is intimal stenotic web within an area of carotid stenosis. |
No | NA |
|
There is intimal ulceration or intimal dehiscence in the area of carotid plaque. |
Yes | NA |
|
There is intraluminal soft clot in the area of carotid plaque. |
No | NA |
|
There is evidence of occlusion/high grade stenosis of high cervical ICA or vertebral arteries. |
No | NA |
|
Given there is an ICA occluded are there functional EC-IC collateral? |
No | NA |
|
There is dissection of high cervical ICA. |
No | NA |
|
There is dissection of mid or high cervical vertebral artery. |
No | NA |
|
There is FMD (fibromuscular dysplasia) of high cervical ICA. |
No | NA |
|
There is FMD of the high cervical vertebral artery & its’ dural penetration. |
No | NA |
|
There is pseudoaneurysm of high cervical ICA. |
No | NA |
|
There is stenosis/occlusion of the ICA in its intracranial-extradural segment. |
No | NA |
|
There is stenosis/occlusion of the high cervical carotid or vertebral artery at the skull base. |
No | NA |
|
There is focal occlusion of the ICA or the vertebral at the dural ring. |
No | NA |
|
There is thrombosis of internal jugular or other large neck veins. |
No | NA |
| Other | Correct Answer | Your Answer |
|---|---|---|
|
Other findings are present more consistent with a diagnosis other than stroke. |
No | NA |
Impression
Expert Answer
There is stenosis of a proximal carotid or vertebral artery in the neck but it is not likely flow limiting.
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Continue with the rest of the stroke-protocol series.
Your Answer
Acuity
Expert Answer
Emergent: non-routine communication required immediately or within 30 minutes
