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Case study

Radiology Rotate 1 Group 4

Case information

• Case : A women age 63 years old with underlying disease of hypertension (loss follow up since 2545 and poor control) Nakornnayok-based

• Chief complaint : fell off a motor bicycle 10 hours prior to admission

Present illness

10 hours prior to admission, the witness

said that the patient rode a motor bicycle 1 meter

away then suddenly fell off the motor bicycle

with her face down. There was only a wound on

her face. After 30 minutes, she was not alert,

moved her extremities less but still could walk

with others help and could not correspond to

question so the cousin brought her to hospital.

Past history

Underlying disease of hypertension (loss follow up since 2545 and poor control ) - No current medication

- No drug or food allergy - Not smoking - Not drinking alcohol Family history :

- No history of genetic disease in the family

Physical Examination

• V/S : BT 38.8⁰c RR 24/min PR 80/min

BP 125/85 mmHg

• GA : An Elderly female, drowsiness

• HEENT : Not pale conjunctiva, anicteric

sclera, Multiple abrasion wound with

contusion at face

Physical Examination

• CVS : Normal S1S2 ,No murmur

• RS : Clear both lung

• ABD : Soft, not tender, normoactive bowel

sound

• EXT : No pitting edema, capillary refill<2

secs

Physical Examination

• Neuro : E4M6V5, poor co-operate,

pupil Right 3 mm. RTL Left 3 mm. RTL

no optic disc herniation

Orientation to time, place, person

Neglect left side

Motor power

Physical Examination

Neuro :Sensory - can’t be evaluated

CN III,IV,VII - full EOM

CN VII - no facial palsy

CN XII - no deviation of tongue

Deep tendon reflex

3+ left extremities

2+ right extremities

Problem lists

• History of head trauma with multiple abrasion

wound with contusion at face

• Left hemi-paralysis

• Left hemineglect

Differential diagnosis

• Intracranial hemorrhage

• Acute ischemic stroke

Provisional diagnosis

Intracranial hemorrhage

Lab investigation

BUN 9.9 (7-18) mg/dL

Cr 0.68 (0.6-1.3) mg/dL

Sodium 137 (135-145) mmol/L

Potassium 3.55 (3.5-5.1) mmol/L

Chloride 98.2 (98-107) mmol/L

Bicarbonate 27.8 (22-29) mmol/L

Lab investigation Hb 14.2 (12-16) g/dL

Hct 41.9 (36-47) %

MCV 83.3 (80-95) fL

RDW 13.2 (12-14) %

Wbc (x103) 11.67 (4-10) /mm3

Neutophil 80.4 (40-72) %

Lymphocyte 14 (18-49) %

Monocyte 4.4 (2-9) %

Eosinophil 0.9 (0-8) %

Basophil 0.3 (0-2) %

Platelet(x103) 274 (140-450) /mm3

Lab investigation

PT 12 (9.5-13.5) secs

PTT 23.9 (21.5-29.1)secs

INR 1.02

C-spine Lateral view

• C-spine lateral view

• Loss of lordotic

• Osteopenia and osteophytosis at c3-c4

• Not all C-spine fracture

• No soft tissue swelling

Approach film

Skull AP, Lateral

• Pain film Skull AP, Lateral

• No Skull fracture, osteoblastic, osteolytic bony

destruction

Approach film

CT Brain Non contrast 28-12-57(9.05)

CT Brain non-contrast 28-12-57(12:44)

CT brain non-contrast 29-12-57

• CT Brain non contrast of woman 63 years

• Hypodensity lesion at right fronto – parieto –

temporal lobe

• Wedge shape

• Sulcal effacement

• No mass effect

• Bilateral calcification at choroid plexus at third

ventricle

Approach film

Conclusion

• Acute ischemic stroke

A women age 63 years old with underlying

disease of poor control hypertension with left

hemi-paralysis and left hemineglect 10 hr PTA.

CT brain shows wedge shape hypodensity

lesion at right fronto – parieto – temporal lobe

Treatment

• specific treatment

Simvastatin(ZIMVA) tab 40mg po 1/2tab, 1 hs

Potassium chloride syrup 20 meq/15 ml ,30ml

po 30cc

Chloramhenicol eoint 1% ;5gm

• supportive treatment

0.9% NSS 1L

KNOWLEDGE

MCA Superior Division Infarction

MRI axial FLAIR images of Brain show an infarct involving left frontal lobe anterior to sylvian fissure. Area of involvement corresponds to left MCA Superior Division territory.

• Most common of embolic stroke.

• Result in contralateral hemiparesis affecting in

lower face and upper extremities more than

legs.

• Contralateral visual field defect predominantly

affecting in lower fields.

• Dominant hemisphere infarct is often

associated expressive aphasia.

• non-dominant infarct is associated with neglect syndrome

MCA Inferior Division Infarction

MRI axial Flair image of brain shows an infarct involving the left temporal lobe below the Sylvian fissure. Area of involvement corresponds to left MCA Inferior Division territory.

• Less commonly affected by emboli.

• Doesn’t cause any weakness or sensory loss.

• Associated with contralateral visual field

deficit predominantly affecting the upper

fields.

• Dominant hemisphere infarct is often an

associated receptive such as Wernicke's

aphasia.

• non-dominant hemisphere infarct is associated

with behavioral disturbance and impairment of

visuospatial skills like drawing, copying, dressing

MCA Distal main stem territory Infarction

CT study of Brain shows an infarct involving involving right peri sylvian cerebral cortex and adjacent insular

cortex. Right basal ganglion is spared. Area of involvement corresponds to right MCA distal main stem (superior as well as inferior division) territory.

• Involve the distribution of both superior and

inferior division.

• Embolus blocks the MCA distal main stem

after the take-off of the lenticulostriate vessels

which supply basal ganglia.

• Result in contralateral hemiplegia of lower

face and arm more than the leg, similar

distribution contralateral hemisensory loss and

a contralateral visual field deficit.

• Dominant hemisphere infarct often associated

with global aphasia that is expressive and

receptive

• non-dominant hemisphere infarct

is characterized by neglect syndrome and

impairment of visuospatial skills like drawing, copying, dressing.

MCA Proximal Stem Infarction

CT study of Brain shows an infarct involving involving left peri sylvian cerebral cortex, adjacent insular cortex and

left basal ganglia. Area of involvement corresponds to left MCA proximal main stem (superior division, inferior division as well as lenticulostriate ) territory.

• involves deeper basal ganglia in addition.

• the block has occurred at the proximal middle

cerebral artery, before the take off of lenticulo

striate perforators that supply basal ganglia.

• The major clinical difference between a

proximal and distal MCA stem occlusion is

that with a proximal lesion the leg is plegic as

well. Because the lenticulostriates are

involved, which results in infarction of the

internal capsule, which contains fibers to the leg, arm and face.

• Reference : "Neuroimaging in Neurology

by David C Preston, MD, Professor of

Neurology and Barbara E Shapiro, MD, PhD, Associate Professor of Neurology"

Take home massage

• Ischmic stroke : CT scan finding

divided in 4 stage

Take home massage

Hyperacute stage >> 50-60% normal CT scan

- hyperdense artery sign (25-50% in

noncontrast CT scan)

- hypodense of basal ganglia

- loss of gray-white differentiation

- obscuration of lentiform nucleus

- loss of insular ribbon sign

Take home massage

Acute stage >> 1-7 days

- wedge shape enlargement

- sulcal effacement

- mass effect

Take home massage

Subacute stage >> 1-8 weeks

- decrease degree of brain swelling and mass

effect

- Gyral enhancement in CECT (only in

contrast CT scan )

Take home massage

Chronic stage >> 2months – years

- cystic change

- brain atropy - encephalomalacit change