Case Notes
History
71 year old male presenting with acute onset slurred or muffled speech, no weakness, was able to understand speech, with no loss of consciousness.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
Head CT1. Hyperacute very focal intraluminal thrombus in a single mid insular M3 branch off the superior division Lt. MCA; stroke-age would likely be hyperacute.
CT perfusion…
1. Focal area of minimally reduced CBV and CT density within the venocapillary pool in the mid left insula. This matches the territory of the acute branch thrombus on the noncontrast head CT.
2. The wider area of both prolonged TTP/MTT (compared to the CT) suggests that there is additional thrombus in the more proximal M3 trunk that is not currently hyperdense on CT.