Case 1 - Left MCA Stroke - MRI

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

EXAM: CT head/brain without contrast. 

INDICATION: New left ICA/M1 occlusion. 

TECHNIQUE: Unenhanced axial CT images through the head/brain from the base of the skull to the vertex were obtained and reviewed. Coronal and sagittal reformats were generated from the axial data. 

COMPARISON: None 

FINDINGS: 

Hyperdense left MCA with loss of gray-white matter differentiation involving the left basal ganglia, insula, majority of the left frontal, anterior temporal, and inferior parietal lobe compatible with acute left ICA territory infarction. Complete effacement of the left sylvian fissure.

No intra or extra-axial hemorrhage identified. Ventricles and sulci appropriate for the patient's age. Basal cisterns are patent. Calvarium is intact. Minimal mucosal thickening in the ethmoid air cells bilaterally. Mastoids and middle ear cavities are clear. Orbits are symmetric and unremarkable. 

There is decreased cerebral blood flow to the entire left ICA territory with a mismatch in cerebral blood volume seen within the high left parietal lobe and anterior left occipital lobe as well as the superior left frontal lobe. These regions in the high left parietal lobe, anterior left occipital lobe, posterior temporal lobe, and superior left frontal lobe with increased cerebral blood volume represent ischemic penumbra. Core infarct zone primarily involves the majority of the left frontal lobe and anterior left temporal lobe. 

IMPRESSION: 

1. Acute left ICA infarct without evidence of hemorrhage. 

2. Small component of Ischemic penumbra in the high left parietal lobe, superior anterior left frontal lobe and a small portion of the superior left frontal lobe. Core infarct zone heavily involves the majority of the left frontal lobe and anterior left temporal lobe.

INDICATION: Concern for stroke. 

TECHNIQUE: Axial CT of the head performed without IV contrast. Coronal and sagittal reformatted images reviewed. 

COMPARISON: 5/7/2013 

FINDINGS: 

Since the prior exam, there has been evolution of small infarctions involving the left corona radiata, subinsular region, basal ganglia, and caudate body. There are stable encephalomalacia involving the anterior left frontal lobe with overlying osseous thickening, likely reflecting sequelae of prior injury. There is also small area of encephalomalacia involving the left frontal operculum, more prominent than on the prior exam. 

There is no clear evidence of acute territorial infarction, however there is new hyperattenuation within the left M1 segment, as well as a few small areas of hyperattenuation in the more distal M2 branches concerning for acute thrombus. 

No parenchymal edema or mass effect. Ventricles are normal in size for age. Periventricular hypoattenuation likely reflects sequelae of chronic microvascular ischemia. No extra-axial fluid collection. There is desiccation of the cavernous internal carotid arteries. Basal cisterns are patent. 

The calvarium shows a left frontal bone gap on series 8 image 148, likely postsurgical. Alternatively this may be from prior trauma. Mild left maxillary mucosal thickening similar to prior with asymmetrically decreased size of the left maxillary sinus. 

Mastoid air cells are clear. Extra-axial soft tissues and orbital structures are within normal limits. 

IMPRESSION: 

1. Hyperattenuation of the left M1 segment and possibly small portions of left M2 branches concerning for acute thrombus. No parenchymal changes to suggest acute infarction in the left MCA territory at this time. CTA or MRI is recommended for further evaluation. 

2. Since the prior exam in 2013, there has been evolution of multiple small left sided basal ganglia and frontal opercular infarctions. 

3. Left frontal encephalomalacia and bony irregularity related to a prior injury, unchanged since at least 2006.