Case Notes
History
42 year old male with right sided numbness and neck pain; history of seizures and hypertension.Exam
CTA of the Head
Purpose
1. To define sites of afferent supratentorial arterial thrombosis or flow-limiting high-grade stenosis or lesser but tandem stenosis or stenosis plus incomplete circle of Willis with isolated arterial circuit;
2. To define sites of afferent infratentorial arterial thrombosis or flow-limiting high-grade stenosis;
3. To determine features of vessel wall and intimal status;
4. To assess presence of tandem stenosis or stenosis plus incompetent circle of Willis;
5. In case of ICA stenosis/occlusion is there effective EC-IC collateral;
6. Is there a watershed stroke zone affecting the usual anastomotic arterial boundary zones;
7. in case of afferent arterial block, plus an incomplete circle of Willis, is there a potential end-of the-line type of watershed stroke;
8. To assess status of retrograde pial collateral and asses for any pial collateral gap between proximal thrombus & retrograde pial collateral;
9. To assess for delayed venous egress (need to prove on post contrast CT head whether it is just delayed or is actually persistently reduced or absent).
Purpose
1. To define sites of afferent supratentorial arterial thrombosis or flow-limiting high-grade stenosis or lesser but tandem stenosis or stenosis plus incomplete circle of Willis with isolated arterial circuit;
2. To define sites of afferent infratentorial arterial thrombosis or flow-limiting high-grade stenosis;
3. To determine features of vessel wall and intimal status;
4. To assess presence of tandem stenosis or stenosis plus incompetent circle of Willis;
5. In case of ICA stenosis/occlusion is there effective EC-IC collateral;
6. Is there a watershed stroke zone affecting the usual anastomotic arterial boundary zones;
7. in case of afferent arterial block, plus an incomplete circle of Willis, is there a potential end-of the-line type of watershed stroke;
8. To assess status of retrograde pial collateral and asses for any pial collateral gap between proximal thrombus & retrograde pial collateral;
9. To assess for delayed venous egress (need to prove on post contrast CT head whether it is just delayed or is actually persistently reduced or absent).
Prior Study
Non-Contrast Head CT1. Persistent acute thrombus in the high cervical and vertical intrapetrous segments of the left cervical ICA.
2. Head was originally negative for hyperacute stroke changes. However, on the current head CT there is now evidence of hypodensity in a small area of the posterior frontal centrum semiovale and in the left splenium of the corpus callosum. There is no hemorrhagic conversion.
CT Perfusion
Limited value CT perfusion related to mistimed contrast bolus; there is prolonged TTP in the Lt. hemisphere and right ACA.
CTA of the Neck
1. The left high cervical dissected segment appears relatively the same with moderate luminal stenosis.
2. There now appears to be partial recanalization of the thrombotic segment in the ICA intrapetrous genu region. Most of the thrombus remains but some antegrade flow is evident in the mesial part of the ICA.
3. The margins of the dissected segments are irregular as expected in dissection, but there is no pseudoaneurysm, or obvious intimal web, or raised intimal flap in the dissected ICA segment.
4. There is reasonable reconstitution of blood flow beyond the thrombus from both EC-IC collateral and from recanalization and return of some antegrade blood flow despite the extension of the cervical dissection more proximally.