Presentation
The patient presented with a right-sided weakness for 7 days. Long-standing history of hypertension.
Patient Data
T1 isointense and T2/FLAIR hyperintense signals are seen in the left occipito-parietal and frontal lobe showing gyral enhancement on post-contrast T1 images associated with sulcal effacement and surrounding edema. There is no intra or extra-axial mass lesion seen. No mass effect or midline shift is seen.
Case Discussion
Non-enhanced CT scan is the initial step to rule out any hemorrhage in ischemic stroke but if a patient presents 1 week later, MRI with contrast is helpful in diagnosing the stage of ischemic stroke like in this case. Rule of 3s for enhancement:
- starts in 3 days
- peaks in 3 weeks
- gone by 3 months
The mass effect also occurs in ischemic stroke and peaks at 3-5 days and gradually abates. Therefore, a fairly unique feature in subacute infarct is that it enhances but creates little mass effect.
Further MRI sequences i.e DWI and ADC are helpful in hyperacute ischemic stroke. Acute infarcts demonstrate high-signal on DWI within a few minutes after the stroke and leasts for at least 2 weeks. Restricted diffusion without a bright signal on FLAIR should make you think hyperacute (< 6 hours).
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