0:00

Our next case comes with the history of stroke-like

0:03

symptoms. Okay digging further you find

0:06

that there are 63 year old patient. They have a history of hypertension on

0:09

presentation. They had a severely elevated blood

0:12

pressure at 162 over 72 their

0:15

last known well three hours ago. They presented with

0:18

left side of weakness and a left gaze deviation. It's

0:21

a little bit unusual pattern their NH Stroke Scale

0:24

was 16.

0:26

So first thing we're going to look at is the non-conhead CT.

0:30

And I'm going to describe the abnormalities without telling you the diagnosis.

0:35

So there are some subcortical why matter hypodensities in

0:38

this medial apparelandic region

0:41

and continuing to the parietal lobes. It

0:44

is really bilateral, but worse on the right side

0:47

and it continues a little bit into exhibit a Loops as

0:50

well.

0:51

I don't see definite loss of gray white differentiation.

1:00

So now we're going to move on to see that.

1:04

Okay. So again buy parietal occipital subcortical edema

1:08

now, we're going to look at the CT perfusion.

1:12

So CBF less than 30 map. There's nothing

1:15

segmented the TMax greater than six seconds. There's

1:18

nothing segmented but wait, you know, we wouldn't

1:21

stop just looking at the summary Maps. We want to look at the color

1:24

parameter Maps

1:27

as well. So here is a

1:31

The cbv map we see an asymmetry here, right?

1:36

So there's relatively high cbv in

1:39

this right parietal region.

1:42

Take a look at what the TMax shows.

1:45

The team actually is a deeper shade of blue meaning decreased TMax

1:48

in that region.

1:52

The MTT is relatively unremarkable the CBF

1:55

again shows High CBF in that region.

1:58

So so it kind of extended the right frontal

2:01

as well the right frontal and parietal region show hyper

2:04

perfusion.

2:10

Okay.

2:12

So at this point we can launch the poll

2:15

while I pull up just the next

2:18

part of the study.

2:22

Question is what is almost likely diagnosis. Is it acute MCA

2:25

infarct Subacute MCA infarc, you know science thrombosis Todd

2:28

paresis to account

2:31

for their left-sided. I mean freeza or hemiplegic migraine.

2:38

And I'll tell you the CTA was on remarkable. There's no large vessel

2:41

occlusion.

2:44

There was I suppose some greater

2:47

prominence of vessels in that hyper-perfused

2:50

area. So this just corresponds to the macrovascular manifestation.

2:53

You can see the vessels a little bit better or that

2:56

CBB is elevated.

2:59

So kind of a plurality people chose Venus sinus

3:02

thrombosis followed by hemiplegic migraine personally. The

3:05

right answer here is Todd Paris is so this is

3:08

where putting together clinical information is important to arriving at the correct

3:11

diagnosis. So they had a left-sided heme plegia

3:14

and all so left gazed

3:17

dviation and the Imaging findings. I'll

3:20

tell you the subcore article edema was

3:23

really suggested the posterior reversible encephalopathy

3:26

syndrome, and we know that as part of that syndrome we

3:29

can have seizures as part of seizures. You can have

3:32

a post ictal period where you have paralysis of

3:35

if that

3:39

area of seizure activity involved, you know

3:42

motor cortex and what have you so this is the case of Todd paralysis

3:45

following a seizure complicating poster

3:48

reversible and stuff in love with the syndrome.

3:51

The patient went on to get brain MRI that

3:54

shows the classic findings of press right? We

3:57

have vasogenic edema in this distribution that

4:00

is under the superior frontal sulci continuing

4:03

into the parietal and occipital lobes

4:06

a little bit into lateral temporal lobes as

4:09

well involving both cerebellar hemispheres. This is

4:12

flare hyperintense. In this case, you know,

4:15

we do see some areas of restricted diffusion. That's okay

4:18

as long as it's not the dominant finding that can be still compatible

4:21

with press.

4:23

There are also some findings of micro-hemorages and

4:27

some of those areas that were severely involved

4:30

and that can be a minor finding

4:33

in press so let the dominant abnormality is really

4:36

this classic distribution of azogenic Edema. That would be

4:39

most compatible with press.

4:44

Okay, so we showed major

4:47

Gengar edema in pattern compatible with press this was

4:51

treated with anti-epileptic drugs and anti-hypertensive drugs

4:54

right treatment for Price history in the underlying cause

4:57

in this case is severe hypertension.

5:00

So what is this case about?

5:02

This is stroke. Mimic. Okay, stroke mimics

5:05

present like strokes, but

5:08

it's not due to acute. Ischemia. When

5:11

you see that the summary maps on your CTP for

5:14

core infarctica tissue at risk are negative think

5:17

again think about looking

5:20

at the color maps to look for any abnormal

5:23

hyper perfusion. Okay, that could be due to

5:26

stroke and it's like seizure but also like hemiplegic migraine

5:29

and then also use

5:32

your non-conscious head CT to guide you towards any

5:35

specific diagnosis in the case of press. Sometimes you

5:38

can see subtle these organic edema already evident on the noncon has

5:41

CT, but of course MRI would be more sensitive.

5:44

So press and seizure, you know

5:47

Cedar dude other causes press without

5:50

seizure. And so and so on so forth the

5:53

most often show increase CBF early in

5:56

the disease and then decrease CBF later on so it

5:59

can be a little variable but people presenting, you know, hyperacutly they

6:03

tend to have increased CBF