6.1.1 Clinical Presentation

A 39-year-old woman developed left hemiparesis while driving. Her father noted she was also confused. The patient was transferred to the emergency department via ambulance, presenting 50 minutes following symptom onset.

Examination revealed expressive dysphasia, dense left hemiparesis, and severe neglect. She was noted to be ambidextrous. The patient had no significant past medical history and was on no medication.

6.1.2 Imaging Workup and Investigations

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  Noncontrast computed tomography (NCCT) was performed at 1 hour. This demonstrated hypodensity involving grey and white matter in the right lenticulostriate territories and temporal lobe, ASPECTS score 6. Right M1 linear density was suggestive of acute thrombus (Fig. 6.1).

  
  
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  Perfusion maps showed increased mean transit time (MTT) throughout the entire right middle cerebral artery (MCA) territory, with decreased cerebral blood volume (CBV), consistent with core infarction in the right lateral lenticulostriate territories, right temporal lobe, and paracentral gyri (Fig. 6.2).

  
  
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  CT angiography revealed a right internal carotid artery dissection causing total occlusion from the level of the axis to the petrous portion of the intracranial carotid artery. Right M1 segment occlusion was confirmed.

  
  
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  MRI demonstrated a large area of diffusion restriction (approximately 180 cc) involving the right MCA territory (Fig. 6.3).

  

  

  

6.1.3 Diagnosis

M1 segment occlusion and right internal carotid artery dissection (Fig. 6.3).

6.1.4 Treatment

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  Given the large volume core infarct, the patient was treated medically with aspirin and statin alone. She also received intensive physical, occupational, and speech therapy.

6.1.5 Outcome

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  She made moderate improvements in dysphasia and mild in weakness. Rankin disability score was 4 on discharge.

  
  
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  Following discharge, the patient had a residual left-sided dyspraxia, weakness, and mild cognitive impairment. Her recovery was complicated by the development of secondary generalized tonic/clonic seizures.

  
  
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  Follow-up MRI revealed established right MCA infarct with extensive encephalomalacia and cavitation (Fig. 6.4). New infarction was also noted in the posterior limb of the right internal capsule.

  

6.2.1 Clinical Presentation

A 73-year-old man developed sudden-onset expressive dysphasia and right hemiparesis following admission the previous night with new-onset atrial fibrillation. He had been last seen well 3 hours 30 minutes prior.

His past history included ischemic heart disease, treated with a cardiac stent, dyslipidemia, hypertension, and chronic airways disease.

6.2.2 Imaging Workup and Investigations

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  NCCT performed 2 hours 20 minutes following presentation (5 hours 50 minutes following last known well time) showed no established infarct, ASPECTS score 10 (Fig. 6.5a).

  
  
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  CTA demonstrated left M1 segment occlusion (Fig. 6.5b).

  
  
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  Perfusion imaging revealed a large region of left MCA territory ischemia, highlighted with increased MTT. CBV maps indicated only a small region of core infarction (Fig. 6.5c, d).

  
  
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  MRI imaging was performed to confirm a small infarct core prior to determining the treatment course. MRI demonstrated restricted diffusion, consistent with core infarct of less than 10 cc involving the left corona radiata, left caudate body, and possibly the posterior limb of the internal capsule (Fig. 6.6).