Back to Transcapillary Case 05 - Hyperacute Stroke

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Case Notes

History

47 yo female who presents with right  sided acute weakness. Hx: cocaine abuse and an unruptured right MCA aneurysm.

Exam

Prior Study

Noncontrast CT head
Given the history of cocaine abuse and hypertension, there is substantial global brain atrophy for chronological age, plus end-artery type of completed lacunar infarctions.

MRA of the neck
Normal MRA of the neck without vascular stenoses nor dissection.

MRA of the head
Right MCA bifurcation saccular aneurysm, as above.
Suspicious evidence of distal left MCA and PCA vasospasm plus minimal delay in filling rate, which are consistent with cocaine related distal arterial vasospasm. Otherwise, negative head MRA for arterial occlusion or dissection.

Noncontrast T1-w MR
There are a myriad of the lacunar-type strokes affecting terminal arteries in the centrum semiovale and the corona radiata bilaterally. There are multicentric lacunar-type strokes in the lenticulostriate perforators, the thalamic perforators, and the brainstem perforators bilaterally. The lacunes follow the Virchow-Robin spaces; they are tubular in shape characteristic of end-artery types of ischemia. This is evident in this case of chronic vasospasm and ithe CNS angiits cases, as well. All the changes appear chronic and there is global brain injury, as well. With the history of drug abuse these findings are consistent with terminal artery ischemic effects of vasoactive drugs (i.e. cocaine and metamphetamines, etc.) or occasionally with microembolization of the foreign body material from IV drug use. 
There is some T1-w signal increase deep to the left insula, which represents chronic lower grade oligemic effects likely with microhemorrhage; this does not represent laminar necrosis.

MR diffusion
Multicentric completed end-artery strokes, as described previously. MR diffusion is negative are any recent infarctions.

Dicom

 
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Findings

MR T2-w or Flair

There is prominence of the Virchow-Robin spaces surrounding the cerebral perforatoring arteries or around the deep medullary veins, as often seen in the moyamoya vasculopathy.

There is increased T2 or flair signal following the Virchow-Robin spaces surrounding the cerebral penetrating white matter arteries or around the deep medullary veins, as often seen CNS angiitis and CNS microembolization.

There is minimally abnormal FLAIR in any site of positive diffusion imaging (implying stroke timeframe is recent <6 hours).

Given both the MR flair and the turbo spin-echo T2 are positive the ischemic event is beyond 8 hours

There is positive FLAIR in an arterial or dural sinus wall or lumen indicating the presence of residual acute thrombus.

Assess the T2 MR for optic hydrops (often requires multiplanar reformations).

There is evidence of early brain swelling or hemorrhage sufficient to produce evidence of brain shift and/or herniation.

There is evidence of early subependymal edema plus mild venticulomegaly indicating early stage of hydrocephalus.

Other

No other abnormalities are noted.