Right middle cerebral artery territory infarct from right internal carotid artery dissection
Presentation
Sudden onset left hemiplegia 6 hours ago. Thrombolysis 3.5 hours previously.
Patient Data
Loss of grey-white differentiation in the right frontal lobe but is somewhat more preserved superiorly. Small hyperdense focus just posterior to the right caudate nucleus head. Hyperdense right M1. Mandibular screws noted.
CT Perfusion
In the inferior right frontal lobe there is reduced CBV and CBF with increased TMax indicative of a large infarct core. Superiorly in the region of the central sulcus there is an area of unmatched increased TMax and CBF, which may indicate a small area of ischemic penumbra.
CT angiogram
Normal aortic arch anatomy. Right ICA tapers abruptly and then does not opacify 17mm from its origin. Distal re-opacification of the right ICA from collateral supply. Right M1 abruptly truncates 12mm after its origin. Vertebral arteries are patent with no dissection. Normal circle of Willis anatomy.
Case Discussion
Proximal right ICA dissection with mid-right M1 occlusive thrombo-embolus results in large right MCA and ACA territory infarct with small ischemic penumbra superiorly.
New small hyperdense focus in the right basal ganglia may represent hemorrhage.
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