Left middle cerebral artery infarct. Assess stroke evolution.Additional clinical history from the electronic medical record: Past medical history of hypertension and daily heroin use, who initially presented to ED with 1 week history of vaginal bleed. Evaluated by Gynecology, had exploratory laparotomy with radical hysterectomy due to concern of invasive cervical carcinoma. Procedure Lasted ~6-7 hours with an estimated blood loss of 800 mL but no reported hypotensive event during surgery. Patient was neurologically intact before procedure. After extubation, the patient was noticed to be persistently lethargic, mute and not moving her right side. A stroke code was activated. Initial neurological evaluation remarkable for right side paralysis (0/5), mute patient with left gaze deviation and not blinking to threat on right side. BRAIN MRI:The left middle cerebral artery territory infarct is now more extensive compared to the previous MRI with more anterior left frontal extension, now involving the left frontal operculum, and more posterior-inferior extension into the left temporal lobe. There is also new diffusion restriction along the posterior left insular cortex. There is a gyriform susceptibility are present within these areas of infarct representing petechial hemorrhage. Though these infarcts are increased/new on diffusion-weighted imaging and T1/T2 sequences, retrospectively there was very subtle hypointensity on the ADC maps of the baseline examination. Also, they are associated with edema and increased T2 signal, which are findings that typically take few days to develop (subacute). The component of the infarct along the left central sulcus and in the left parietal lobe shows expected evolution with gyriform susceptibility effect and intrinsic T1 hyperintensity reflecting blood products. Also, the infarction in the head of the left caudate nucleus is evolved. Post contrast images show expected gyriform contrast enhancement compatible with subacute infarct. Of note, the peripheral margins of the current left MCA territory infarct are suggested of watershed etiology. The infarcts are associated with mild mass-effect especially on the left lateral ventricle but no significant midline shift and no brain herniation. There is no new diffusion restriction outside the left middle cerebral artery territory. Punctate foci of susceptibility effect in the central pons and the anterior left subinsular region remain unchanged without associated edema. T2/FLAIR hyperintensity centrally within the pons is unchanged and probably represent chronic microvascular ischemia. Similarly, the other foci of deep and periventricular white-matter T2 FLAIR hyperintensity, especially parietal, are unchanged and probably represent chronic microvessel ischemia. There is incidental right cerebellar developmental venous anomaly.There is no destructive skull lesion. There is no gross orbital abnormality.Dynamic, susceptibility-weighted, contrast-enhanced MR perfusion was also performed but is limited by motion. The color coded maps show expected increased MTT correlating with area of infarcts, more pronounced in the previously recognized areas of infarct, and less so in the newly seen areas, with corresponding decreased CBV and CBF. CBF appears slightly increased in the non-infarcted posterior frontal and parietal lobes as well as the anterior left temporal lobe in the left MCA territory.HEAD MRA:The short segment lack of flow-related signal involving the region of the left middle cerebral artery has not changed. There is attenuated flow-related signal in the distal left middle cerebral artery and its major branches, also without significant change. The right anterior cerebral artery continues to be smaller than the left though without focal stenosis, which is likely developmental. Otherwise, there is no significant intracranial stenosis. Of note, the ACOM and PCOM's are not well visualized.
1.The left middle cerebral artery infarct is more extensive now when compared to baseline but is already showing signs suggestive of being subacute on today's examination. Areas of gyriform blood products are present within the infarct which is also associated with mild mass-effect but no brain herniation.2.Unchanged short segment of near occlusion involving the proximal left middle cerebral artery with attenuated downstream flow. No other significant intracranial focal arterial stenosis.3.Perfusion imaging suggests relative mild increased CBF in areas of currently noninfarcted left MCA territory, as to be expected.