Unspecified cerebral artery occlusion with cerebral infarctionClinical question: l mca strokeSigns and Symptoms: L mca strokeWeakness and neglect. 60 years old male. MRI of the brainThere is diffusion restriction present involving the left insular cortex, the left middle and inferior frontal lobe gyri as well as the left parietal lobe and portions of the posterior aspect of the left temporal lobe superior temporal lobe gyrus. There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.On susceptibility imaging there are lower signal serpiginous flow-voids at the edge of the area of infarction signifying hypoxia along the watershed zone.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses demonstrate mucosal thickening in the right maxillary sinus and scattered opacities elsewhere.. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.There is a occlusion of the left middle cerebral artery distal to the left anterior temporal artery. There is some antegrade flow present along the left frontal orbital artery which appears to originate from the left anterior temporal artery.The anterior communicating artery is identified and is medium size. There is fetal origin of the posterior cerebral arteries bilaterally associated with small P1 segments. The left vertebral artery is small and predominantly supplies the left posterior inferior cerebellar artery.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no significant stenosis at the right carotid bifurcation. On the basis of NASCET criteria there is 90% stenosis at the origin of the left internal carotid artery. There is no significant stenosis along the course of the vertebral arteries. The left common carotid artery originates from a common trunk with the right common carotid artery. The right subclavian artery has an aberrant origin originating distal to the left subclavian artery. Findings suggest narrowing at the proximal right common carotid artery just distal to the origin of the left common carotid artery with approximately 50% stenosis of the right common carotid artery. The origin of the right vertebral artery is narrowed by approximately 50%. The left vertebral artery is small.
1.Subacute left middle cerebral artery territory infarction involving the left insular cortex, left inferior and middle frontal gyri and left parietal lobe as well as the left superior temporal gyrus. There is no evidence for hemorrhagic conversion at this time.2.Occlusion of the left middle cerebral artery at the M1 segment with some antegrade filling of the left anterior temporal artery to appears to be fairly large probably supplying part of the left frontal lobe and temporal lobe.3.90% stenosis at the origin of the left internal carotid artery.4.50% stenosis at the proximal right common carotid artery artery just distal to the origin of the left common carotid artery. Please note that the right subclavian artery has an aberrant origin and the right common carotid artery and left common carotid artery have a common trunk.5.50% stenosis at the origin of the right vertebral artery which is associated with a very small left vertebral artery