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The Insular Ribbon Sign

PCA Territory loss of Grey White - Look out For

PCA territory infarct can be subtle on non-contrast CT of the head. Make sure you look in this vascular territory and strutinize the grey white differentiation in all vascular territories, including the PCA and the ACA. 

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 clot would within the stent retriever and can get be pushed against the intimal wall as the stent opens. 

Gaze Deviation

Gaze deviation is ipsilateral (ie. same side) as the ischemic brain hemisphere. Eyes point towards the affected side. 

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 clot 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. 

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