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
CTA of the neck: this part of the CTA is performed after the second bolus of contrast, and therefore has dense contrast in both the arteries and the veins related to recirculation plus twice the contrast load. The CTA neck is performed in conjunction with the delayed post contrast head CTA for assessment of the CT-density in the parenchymal venocapillary pool.
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.
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.