Case Notes
History
76 year old male presenting with acute slurred speech, left sided weakness, and left facial droop.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.
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.
Prior Study
CT Head1. Hyperacute thrombus in M1 and M2 segments of the Rt. MCA
2. The post-ischemic stroke changes affect the Rt. orbitofrontal artery, the rostral lateral lenticulate perforators, and the anterior portion of the intrasylvian MCA superior-division branch perfusion zones; these involved areas are likely beyond the IV treatment window.
3. The posterior M3 sylvian arterial perfusions zone may have some post ischemic changes, but likely are at least partially spared by pial collateral. The same is true for most of the lateral cortex.
CT Perfusion
CT perfusion evidence of prolonged filling rate (prolonged TTP/MTT) affecting mainly the Rt. lateral orbitofrontal perfusion zone with lesser post ischemic changes in the Rt. lateral basal ganglia (lateral lenticulostriate perforator perfusion zone) and the anterior insular M3 perfusion zones. However, the CBV is only minimally reduced in most areas and is only partially reduced in the right orbitofrontal artery perfusion zone indicating at least reasonable retrograde pial collateralization in most of the area included in the prolonged TTP zone.