Case Notes
History
36 yo female with 2 week history of intermittent weakness on both sides, numbness epsodes lasting 4 hours & word finding difficulty.Exam
MR T2-w or flair
Prior Study
CT HeadNegative study for acute arterial or venous occlusion. But, there is focal mural wall calcification in the subclinoidal right ICA with the potential for causing a flow-limitng stenosis.
There is a small completed lacunar infarct in the left caudate head.
The combination of a completed stroke and mild global atrophy and prominent basal ganglia calcificiation suggests the presence of underlying vasculopathy.
CT Perfusion
CT perfusion and CTA evidence of moyamoya disease with expected alteration of blood flow, as above.
Small completed infarct in the left caudate head.
CTA neck
Arterial vascular changes consistent with moyamoya disease.
Focal vascular calcification in the extradural ICA segment on the right producing a flow-limiting stenosis.
CTA head
1. Evidence of moyamoya disease vasculopathy
2. There is a prior small completed lacunar stroke in the left caudate head.
3. There is delayed filling of distal MCA pial arteries on the right
Post contrast CT head
1. The brain CT density within the venocapillary pool is essentially normal, despite the delayed pial filling in the right MCA on the CTA head.
2. There are two small areas of persistent oligemia in the caudate head on the left and basifrontal white matter on the right. Both are likely sites of previous ischemic injury.
3. The classic features of moyamoya disease are again evident.
T1-w MR pre and post contrast
1. The vasculopathy of moyamoya disease are evident on both the pre and post contrast T1-w sequences.
2. Two sites of chronic lacunar stroke are evident. One seen in the left caudate head was also seen on the prior post contrast head CT. The second is a very small lacunar stroke in the right caudate head adjacent to the frontal horn.
3. There is no contrast leak to suggest post ischemic dysautoregulation.
MR diffusion
Negative MR diffusion with no acute stroke. Small caudate head lacunes are evident on the Bo sequence.