Presentation
Witnessed onset of aphasia and right sided weakness; NIHSS 22.
Patient Data
Unenhanced CT (approximately 70 mins from onset): hyperdensity at the distal left M1 / MCA bifurcation. Subtle hypoattenuation of the left insular and frontal opercular cortex; ASPECTS 8. Gliosis at old right PCA infarct. No hemorrhage or mass.
Angiogram (recall, approximately 120 mins from onset): distal left M1 / posterior M2 occlusion. Good collaterals. No significant proximal carotid disease (not uploaded).
Perfusion defect on TTP involving M1-M6 regions. Relative preservation of ganglionic cortex rCBV, but reduced in M4-M6. Using thresholds of rCBV -32%, TTP +4.3 s estimated penumbra was 165 mL, estimated core 65 mL, mismatch ratio 2.5.
Onset to skin puncture <180 minutes.
No LVO present at time of angio; IV tPA was administered after the initial CT head with interval dissolution of the thrombus. Some residual clot noted in distal parietal MCA cortical branches.
TICI 2c.
Case Discussion
An interesting case demonstrating the territory at risk in a saddle MCA bifurcation infarct on perfusion imaging, as well as the effect of thrombolysis therapy on more distal thrombi. Following the tPA the patient's NIHSS reduced from 22 to 5 with some residual right limb weakness and dysphasia.
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