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CASE 1: Imaging Continued
Case Continues...
The patient was subsequently given IV t-PA, however there was no change in her physical exam. Can anything else be done?
CT Angiogram: Given the suspected right middle cerebral artery clot, a CT angiogram was performed to evaluate the vascular system and assess the extent of the clot. A CT angiogram is a relatively non invasive test that requires a peripheral IV. Contrast is injected into a peripheral IV and timed such that imaging is performed when the contrast is predominantly located within the arterial system.
In the above images, notice the small intraluminal filling defect within the right middle cerebral artery seen on the axial images and coronal reconstruction.
CT Perfusion: Perfusion can be performed to assess how a patient is able to compensate for a stenosis/occlusion. We look at the perfusion maps to see if a particular region of brain parenchyma has delayed perfusion relative to other areas.
In this patient we can see that the territory supplied by the right MCA has delayed mean transit and decreased blood flow. The blood volume however is relatively preserved.
Digital Subtraction Angiography: The patient subsequently underwent catheter based angiography for mechanical thrombectomy. Access was gained via the right femoral artery. Catheters/wires were passed into the aortic arch, the right common carotid and subsequently the right internal carotid artery. Contrast was injected into the internal carotid artery and images of the cerberbral vasculature were obtained. Select frontal images of the right internal carotid artery injection before and after mechanical thrombectomy are displayed.
The middle cerebral artery is occluded on the image on the left and is patent after thrombectomy. This patient was able to move all 4 extremities after the procedure.
For more on Neuroimaging in the setting of stroke click Discussion
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