Case Notes
History
36 year old male diabetic who was found down. Patient initially was unresponsive, and later exhibited a markedly depressed level of consciousness. Patient was uncooperative on presentation and aphasic.Exam
Head MR Diffusion Sequences (with DWI and ADC maps)
Purpose
1. To use the diffusion maps (DWI and ADC) to identify sites of hyperacute stroke matching an arterial zone.
2. To determine whether the positive diffusion zone matches a primary stem arterial region, a secondary stem arterial region, a trunk/division arterial region, a major branch region; or a distal arterial cortical zone, or any combination;
3. In cases where there are more than one ischemic sites to determine whether changes could be from an extra cranial embolic site, or whether they represent proximal clot lysis and subsequent distal embolization;
4. To determine whether the areas involved fit best with an embolic event or embolic shower (could be from proximal plaque or cardiac source, etc.;
5. To determine whether the affected areas as recognizable as a watershed zone; usually in the context of currently patent major afferent arteries (ICA’ & vertebral arteries); there are often chronic extradural carotid or vertebral occlusions;
6. To determine whether the affected area(s) could represent stroke with an end of the line watershed pattern, based on the combination of occluded major afferent brain arteries plus incomplete circle of Willis plus any additional flow-limiting stenoses;
7. Evaluate the diffusion Bo sequence for hemorrhagic conversion.
Purpose
1. To use the diffusion maps (DWI and ADC) to identify sites of hyperacute stroke matching an arterial zone.
2. To determine whether the positive diffusion zone matches a primary stem arterial region, a secondary stem arterial region, a trunk/division arterial region, a major branch region; or a distal arterial cortical zone, or any combination;
3. In cases where there are more than one ischemic sites to determine whether changes could be from an extra cranial embolic site, or whether they represent proximal clot lysis and subsequent distal embolization;
4. To determine whether the areas involved fit best with an embolic event or embolic shower (could be from proximal plaque or cardiac source, etc.;
5. To determine whether the affected areas as recognizable as a watershed zone; usually in the context of currently patent major afferent arteries (ICA’ & vertebral arteries); there are often chronic extradural carotid or vertebral occlusions;
6. To determine whether the affected area(s) could represent stroke with an end of the line watershed pattern, based on the combination of occluded major afferent brain arteries plus incomplete circle of Willis plus any additional flow-limiting stenoses;
7. Evaluate the diffusion Bo sequence for hemorrhagic conversion.
Prior Study
Final Impression for Stroke CTA1. There is Lt. primary-stem ICA thrombosis affecting both the intracranial/extradural and the entire intracranial portions of the Lt. ICA. Likewise, there is very little venous opacification consistent with minimal or no transcapillary blood flow and possible deepm medullary venous collapse.
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.