0:00

This is a case of an MCA stroke,

0:02

and we're going to talk mostly about the MR findings,

0:06

but I'm going to show you the CT and CTA first.

0:08

So, this patient came in with acute right-sided

0:12

weakness and aphasia.

0:13

Non-contrast CT,

0:14

you can see the hyperdense MCA sign.

0:18

Don't see too much else on the non-contrast CT,

0:21

except some, maybe chronic ischemic changes,

0:24

maybe a little asymmetry in the left

0:27

basal ganglia.

0:28

That was the CT.

0:30

He got a CTA.

0:34

You can see the CTA on the left side,

0:36

left common carotid.

0:40

Internal.

0:41

You can see there's a severe stenosis

0:43

at the origin of the internal

0:44

with complex plaque.

0:47

Follow the internal up,

0:49

there's also some atheromatous disease

0:51

in the carotid siphon with some stenosis.

0:54

And then we get to the MCA stem,

0:56

and you can see right

0:57

where we saw that hyperdensity,

0:59

there's a cutoff going into the bifurcation.

1:02

They're pretty decent collaterals here,

1:05

but there had been some delay when the patient

1:07

was transferred from the outside hospital.

1:09

Patient didn't get CT perfusion maps,

1:12

so we got an MRA.

1:14

Just showing you again the maximal intensity

1:16

projection images where there's an MCA stem embolus

1:19

and pretty good collaterals.

1:21

Patient got to our hospital,

1:23

and a couple hours later, we got the MR.

1:26

And you can see on the diffusion

1:29

weighted images that there's restricted diffusion

1:33

in the lateral aspect of the left lentiform nucleus,

1:37

and then higher up,

1:38

and goes up into the corona radiata.

1:41

So pretty small core,

1:43

that's going to be much less than 70 ccs.

1:46

We can look at the FLAIR images,

1:50

and here's the clot.

1:53

It's bright on FLAIR,

1:54

you can see the hyperintense vessels suggesting

1:58

slow flow and good collaterals.

1:59

We don't see any breakdown of the

2:01

blood brain barrier yet.

2:02

There's no FLAIR hyperintensity.

2:04

And this is just a little

2:06

old infarct in the corona radiata there,

2:09

but not much else.

2:11

So, FLAIR is suggesting they're good collaterals.

2:13

It correlates with what we saw in CTA.

2:16

And we can also look at the swan.

2:19

Swan SWI just depends on what vendor you use.

2:22

And you can see on the swan images,

2:24

you can see there is blooming,

2:26

consistent with the clot and the distal MCA,

2:29

then going into the proximal N2 branches.

2:33

So, this was a nice example of DWI showing the core,

2:39

being the best method of identifying the core.

2:42

The FLAIR showing the good collaterals,

2:44

which matched for the CTA,

2:46

and the gradient echo showing exactly where the clot is.

2:50

With a small infarct core and

2:52

with good collaterals,

2:53

the patient was considered a good

2:55

candidate for thrombolysis.

2:57

Here's the angiogram showing the ICA

3:01

and then the MCA stem cut off.

3:03

And they were able to open up the vessel

3:07

and restore complete circulation.

3:11

And follow up head CT showed pretty much what

3:16

we had seen on DWI, maybe a little bit larger.

3:19

The core involving the lymph form nucleus

3:21

and extending up into the corona radiata.