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Okay, I'd like to show you this

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case of stroke with dissection.

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This is a patient who had a week-long history

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of weakness and right-sided facial droop that

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progressed, and this is the noncontrast CT,

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and you can see the hyperdense vessel sign that

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we talked about before in the MCA stem, and you

0:22

can see a subacute stroke involving the basal

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ganglia and the left anterior temporal lobe.

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and extending up into the left frontal

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lobe, and you can see there's some

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mass effect on the right lateral

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ventricle, and there's no hemorrhage

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and the rest of the brain looks normal.

0:38

And now we're going to look

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at what caused the stroke.

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So again, I'm going to look at my, um,

0:43

coronal and axial MIPs, and I'm going to

0:45

start with the coronal MIPs here, and ICA.

0:50

And you can see that the bifurcation looks

0:52

normal, but then it looks really weird here.

0:55

It looks like there's incremental

0:56

thrombus and flap and some narrowing.

0:59

So we're going to want to look

1:00

closely at that on the source

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images, but also the right ICA box.

1:06

It's big here and it doesn't quite look normal,

1:10

so we're going to get a better look at that.

1:12

And the irregularities look,

1:14

um, slightly irregular.

1:16

There's a little clot on the right.

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So we're looking at a patient who

1:20

may have multiple dissections.

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Let's look at the sagittal images.

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Here's the left side again.

1:28

You can see it's irregular and there's

1:30

probably intraluminal thrombus.

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And the right side has a pseudoaneurysm,

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that's a common sign of carotid dissections,

1:41

there's a little irregularity above that.

1:44

Those are my thoughts on the vessels, so

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let's take a look at the axial images.

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We're just going to follow the left

1:50

common carotid artery up, so here's

1:52

the left common carotid artery.

1:54

And we get up to the bifurcation looks normal.

2:00

This is a relatively young patient,

2:02

doesn't really have atherosclerotic disease.

2:05

And then we note that the vessel gets a

2:08

little bit larger and there's a little

2:10

subaneurysm and maybe some intraluminal clot.

2:18

It's a string sign at the skull

2:19

base, and then it's occluded,

2:22

reconstituted, it's still a string sign.

2:25

And then when you get up intracranially,

2:27

there's a cutoff because there's an MCA thrombus,

2:30

which we just saw on the noncontrast head CT.

2:34

So this patient has a left carotid

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dissection with an embolus to the left MCA.

2:42

And then on the right side, you can see it

2:46

looks pretty normal, internal carotid artery.

2:52

And then there's that double lumen

2:53

sign because there's a pseudoaneurysm

2:56

that we saw on the MIP images.

2:59

And then there's a little irregularity

3:01

in the skull base, so it basically

3:02

has bilateral carotid dissections.

3:07

Then on the left vertebral artery,

3:09

we're going to follow that up.

3:12

You can see a little tiny irregularity there.

3:15

And then the right vertebral

3:16

artery, follow that up.

3:20

And that looks okay until you get

3:24

to the B3 segment, which is the

3:28

part that goes around C1 and C2.

3:30

And you can see that's irregular,

3:32

probably a little intraluminal thrombus.

3:37

Dissections in basically the bilateral common

3:40

carotid arteries and the right vertebral artery,

3:43

then a big MCA stroke, as we said, and then

3:46

the left vertebral artery slightly irregular.

3:48

So this patient does not carry the diagnosis

3:53

of a specific collagen vascular disease, but

3:57

my guess is has an underlying collagen vascular

4:00

disease, perhaps fibromuscular dysplasia.