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Case Notes
History
59 year old male with COPD who developed tachycardia requiring therapy. Two days later he developed Rt. sided weakness, pupillary dysfunction, and slurred speech. Shortly thereafter, he became somnolent and unresponsive.Exam
Head MR Diffusion Sequences (with DWI & ADC maps)
Purpose
1. To use the diffusion maps (DWI & 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 & 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 CTA1. Markedly reduced CT density in the venocapillary pool within the left pons, both rostral cerebellar hemispheres, most of the left caudal cerebellar hemisphere, and the deep portion of the right cerebellar hemisphere. These areas are all included in the dense ischemic core.
2. There is a very recent left deep cerebellar reperfusion hemorrhage, which when combined with the stroke-related brain swelling, has produced mass effect with early upward transtentorial herniation.
3. Lack of venous egress in the left cerebellum is indicative of venous collapse, and is likely the basis for the left cerebellar hemorrhage.
4. Old infarct in the left P3 PCA perfusion zone.
