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So now I'm going to show you a case of a patient

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who has an acute stroke with good collaterals. These are

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images of an 89 year old female who has atrial fibrillation probably

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through a clot

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on that basis.

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She had acute left-sided weakness. We're gonna

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look in the right MCA territory. This is the non contrast CT.

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Don't really see much in the way of the right MCA stem.

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And insular ribbon looks good. Basal. Ganglia

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look pretty good. Maybe there's minimal hypodensity non-contrast.

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CT is pretty unremarkable. Although has

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extensive white matter changes.

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So we are going to

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do the CTA of the head and neck and we're

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going to take a quick look at head and

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neck vessels.

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the neck

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just go through quickly, but there's not much of the Carotid bifurcations wasn't

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much going on in the arch.

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Virtual arteries aren't that remarkable don't see

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that much going on. I'm not really looking for that. When I

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look at the head I can see on this coronal image. The MCA

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stem is cut off, you know, so she's got out the romance

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disease. It's not that bad. It's probably the afib

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that's causing her acute stroke. So we're gonna

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look at the axial mips. And here's the

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MCA stem cut off and you can see the collaterals or

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approximately the same as the contralateral side.

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And you can see some collateralization from the right PCA

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territory going to the MCA some peel collaterals.

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It's a nice example of that.

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And left MCA looks fine.

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ACA is like fine. So it's really that.

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Right MCA stem and we'll take a look at the coronals.

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same findings

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MCA stem cut off good collaterals

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some collateralization from the PCA to

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the MCA

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And just so you can see what this looks like on the raw data.

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again, the vessels in the neck will just go through those quickly

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so you can see them but

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The right carotid bifurcation, you know

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not very exciting a little calcification. Probably not

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the cause as we said it's probably our afib, so

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we just follow that right carotid up again a little etheroma's disease

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in the

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right carotid siphon not that exciting.

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And then here's the cutoff so you

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can see there's the cutoff and then here the

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collaterals.

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So you can see the vessels going up in the

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civilian Fisher and up over the cerebral convexity are very similar

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to the contralateral side. There's a little better windowing and

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then I said I was look at CTA Source images

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to see if I can, you know see an infarct better

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than I could see it on the non-contrast CT and even

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on the CTA Source images. Everything looks pretty good here. Maybe there's a

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little cut off of that posterior.

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lentiform nucleus, but otherwise

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things look pretty good. So I'm thinking

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that you know, this is patient is going

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to do pretty well.

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So this patient also had some

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CT perfusion, which we're going to get into later, but I'm

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just going to show you.

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one

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slice from the CT perfusion

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And on the CT profusion, they basically threshold

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so anything with a

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CBF of less than 30 CCs is considered the infarct core

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which is here and this red and basically in

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Far core was slack to be three CC so great collateral

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small infarct core and then they threshold

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the T-Max at greater than six seconds for a

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number tissue at risk of infarction, and there's a lot of tissue

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at risk of infarction. So it's a good collateral early

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on

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Small core good candidate for thrombolysis. So

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this patient went to thrombolysis and

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then follow up CT shows

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this finding so follow-up CT.

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You go up through the head and what we see is some mild hypertensity in

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the right posterior pucane and just where we saw that abnormally on

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CTA Source images.

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And that's just contrast staining contrast staining usually goes

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into the core of the infer and I don't see hypodensity anywhere

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else. But basically this is a really

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small in far and a nice

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outcome with early thrombolysis

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in a patient who had good collaterals.