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This is a case of an MCA stroke,
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and we're going to talk mostly about the MR findings,
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but I'm going to show you the CT and CTA first.
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So, this patient came in with acute right-sided
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weakness and aphasia.
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Non-contrast CT,
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you can see the hyperdense MCA sign.
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Don't see too much else on the non-contrast CT,
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except some, maybe chronic ischemic changes,
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maybe a little asymmetry in the left
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basal ganglia.
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That was the CT.
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He got a CTA.
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You can see the CTA on the left side,
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left common carotid.
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Internal.
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You can see there's a severe stenosis
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at the origin of the internal
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with complex plaque.
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Follow the internal up,
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there's also some atheromatous disease
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in the carotid siphon with some stenosis.
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And then we get to the MCA stem,
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and you can see right
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where we saw that hyperdensity,
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there's a cutoff going into the bifurcation.
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They're pretty decent collaterals here,
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but there had been some delay when the patient
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was transferred from the outside hospital.
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Patient didn't get CT perfusion maps,
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so we got an MRA.
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Just showing you again the maximal intensity
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projection images where there's an MCA stem embolus
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and pretty good collaterals.
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Patient got to our hospital,
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and a couple hours later, we got the MR.
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And you can see on the diffusion
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weighted images that there's restricted diffusion
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in the lateral aspect of the left lentiform nucleus,
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and then higher up,
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and goes up into the corona radiata.
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So pretty small core,
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that's going to be much less than 70 ccs.
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We can look at the FLAIR images,
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and here's the clot.
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It's bright on FLAIR,
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you can see the hyperintense vessels suggesting
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slow flow and good collaterals.
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We don't see any breakdown of the
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blood brain barrier yet.
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There's no FLAIR hyperintensity.
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And this is just a little
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old infarct in the corona radiata there,
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but not much else.
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So, FLAIR is suggesting they're good collaterals.
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It correlates with what we saw in CTA.
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And we can also look at the swan.
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Swan SWI just depends on what vendor you use.
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And you can see on the swan images,
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you can see there is blooming,
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consistent with the clot and the distal MCA,
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then going into the proximal N2 branches.
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So, this was a nice example of DWI showing the core,
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being the best method of identifying the core.
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The FLAIR showing the good collaterals,
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which matched for the CTA,
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and the gradient echo showing exactly where the clot is.
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With a small infarct core and
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with good collaterals,
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the patient was considered a good
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candidate for thrombolysis.
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Here's the angiogram showing the ICA
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and then the MCA stem cut off.
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And they were able to open up the vessel
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and restore complete circulation.
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And follow up head CT showed pretty much what
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we had seen on DWI, maybe a little bit larger.
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The core involving the lymph form nucleus
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and extending up into the corona radiata.
Pamela W Schaefer, MD, FACR
Professor of Radiology, Vice Chair of Education
Massachusetts General Hospital
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