Neuro_CTA_Head/Neck: 53 M, recent bilateral MCA infarcts.

CT HEAD PERFUSION WITH AND WITHOUT CONTRAST:

 

CLINICAL HISTORY: 53-year-old man with history of recent bilateral posterior division MCA infarcts, new confusion, evaluate for stroke.

 

FINDINGS:

 

BRAIN (NON-CONTRAST):

 

Parenchyma: There is loss of gray-white differentiation in the anterior right temporal lobe, which is new from prior exam. There is 

further evolution of left MCA posterior division infarct. Additionally, there is evolution of right MCA posterior division infarct, with development of mild swelling and subcortical white matter hypodensity.

 

Ventricles and extra-axial spaces: Ventricles are appropriate for age. There is a dense vessel in the lateral right MCA cistern (series 

3 images 13-11).

 

Visualized paranasal sinuses: Clear.

 

Mastoid air cells: Clear.

 

Bones: No focal abnormality.

 

Additional comment: None.

 

BRAIN (POST-CONTRAST):

 

Enhancement: There is new

 

INTRACRANIAL ANGIOGRAM:

 

Anterior circulation: There is a vessel cut off of the right inferior division M2 at its origin (series 11 images 253-251), with reconstitution of flow in MCA branches within the sylvian fissure from collaterals. Note this vessel cut off is proximal to prior inferior division M2 occlusion with subsequent larger area of perfusion deficit. No left-sided vessel occlusion or stenosis. No aneurysm.

 

Posterior circulation: No flow-limiting stenosis or aneurysm.

 

Dural venous sinuses: Patent.

 

Additional comment: None.

 

EXTRACRANIAL ANGIOGRAM:

 

Proximal great vessels: No flow-limiting stenosis or dissection.

 

Cervical vessels: No flow-limiting stenosis or dissection.

 

Additional comment: None.

 

PERFUSION:

 

There is significant Tmax delay in the majority of the right MCA territory, with smaller area of reduced CBV/CBF in the anterior temporal lobe corresponding to loss of gray-white differentiation, compatible with tissue at risk, however partially this includes previously infarcted tissue in the posterior right MCA territory.  

 

NECK:

 

Soft tissues: Unchanged calcified left preauricular lymph node. Serpiginous density in the anterior mediastinum likely relates to 

LVAD. Incompletely visualized surgical changes related to CABG. Stable scattered prominent mediastinal lymph nodes. 

 

Bones: Visualized sternotomy alignment.

 

Lung apices: 5 mm right upper lobe nodule, unchanged from 6/3/2014.

 

Additional comment: None.

  

IMPRESSION:

 

1.  Loss of gray-white differentiation in the right anterior temporal lobe with dense vessel in the lateral right MCA cistern, compatible 

with acute infarct. Evolving early subacute right posterior MCA and late subacute left MCA infarct with associated gyral enhancement. No evidence of hemorrhagic conversion.

 

2.  Occlusion of the right inferior division M2 at its origin, proximal to prior occlusion with larger amount of tissue affected.

 

3.  Perfusion mismatch, with T-Max delay to majority of right MCA territory, and smaller area of reduced CBV/CBF in the right anterior 

temporal lobe, however true tissue at risk is difficult to determine as perfusion deficit includes in part prior posterior infarct.