The Hyperdense MCA Sign - Essential Finding

The increased density of the MCA or any other intracranial vessel should be treated with suspicion for presence of thrombus. Comparison with other vessels, dural venous sinuses, history of previous contrast from another radiologic study, or delayed contrast excretion post previous administration could be consideration. Unilateral and asymmetric hyperdensity in any vessel of any size can be suggestive of presence of acute cloth and should be further investigated with a CT Angiogram CTA. 

Calcified Emboli - Imaging Sign

Look for small calcific emboli with the vessels. These could be acute or chronic but are suggestive of proximal embolic source, such as a ruptured calcified plaque. 

Diffuse Hypoxic Ischemic Injury

Diffuse loss of grey/white differentiation with presence of pseudo-subarachnoid sign, diffuse edema and loss of sulci, and tonsillar herniation through foramen magnum in keeping with diffuse hypoxic ischemic injury.

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ICA Occlusion - Look at the skull base for

Stroke Mimics - This was a Tumor!

Stroke Mimic - Not every hypoattenuation on CT is indicative of acute stroke. Given the preservation of cortical gray white in the insula, and in fact cortical expansion, this was a tumor with underlying vasogenic edema producing this appearance. 

Calcified Carotid Plaque - Source of Emboli

Calcified carotid plaques can serve as an embolic source in acute stroke. Although considered more stable than atheromateous plaque, their rupture could lead to vascular occlusion. Given their calcified nature, they are refractory to IV thrombolysis and their retrieval using interventional techniques is more challenging. Given their solid nature, it would not incorporate as a traditional cloth would within the stent retriever and can get be pushed against the intimal wall as the stent opens. 

StriatoCapsular infarct

Striatocapsular infarcts involve the striatum (ie the caudate nucleus and putamen), without involvement of the cortex secondary to either a complete or partial proximal MCA occlusion limiting flow to the lenticulostriate arteries.

Classically patients exhibit both cortical (e.g. aphasia, sensory neglect or extinction, apraxia) and subcortical (e.g. upper limb hemiparesis, dysarthria) neurological signs.

Matched Perfusion - No Ischemic Penumbra Present on CTP

 

Tmax (red) and CBV (blue) demonstrate very increased time of transit of blood, and very low blood volume in the exact same areas. This is no perfusion mismatch here and all the brain tissue has been infarcted with no pneumbra present to save.

Hemorrhagic Transformation in an Infarcted Region

Susceptibility sequences SWI demonstrate diffuse hemorrhagic change within an area of previous Infarct. With corresponding diffusion DWI restriction in the right panel.

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