Presentation
History of morbid obesity and lumbar decompression surgery two weeks prior, presenting following a fall from standing while out in public and found unresponsive. Glasgow coma scale 13 on arrival (Eye opening 4/4, Verbal 4/5, Motor 5/6). Trauma activation.
Patient Data
Left middle cerebral artery territory ischemic changes are seen in the following regions: left frontal operculum (M1), left anterior temporal lobe (M2) and left insula. ASPECTS Score: 7.
There is a hyperdense vessel sign at the left middle cerebral artery distal M1 segment.
There is occlusion of the left middle cerebral artery distal M1 segment.
Intermediate (non-malignant) collateral circulation, as evidenced by asymmetrically decreased prominence/number of peripheral vessels in the left MCA territory on arterial images but opacification of these peripheral vessels on the immediate delayed images.
Neck CT angiography was normal.
The patient underwent catheter digital subtraction angiography, which confirmed acute left middle cerebral artery M1 segment occlusion. Aspiration thrombectomy was performed, achieving TICI 3 reperfusion following a single pass.
Case Discussion
The case was initially billed as possible head trauma (fall from standing). Review of the head CT showed no intracranial hemorrhage or cranial fracture. However, there was clinical suspicion for a neurologic event that caused the fall. Careful scrutiny of the noncontrast CT, albeit limited by streak artifacts, would have revealed early ischemic changes, including involvement of language areas. CTA confirmed hypoperfusion in regions of the left middle cerebral artery territory and the presence of a large vessel occlusion. NIH Stroke Scale was 9 for global aphasia and right sided weakness. The patient was not a thrombolysis candidate due to recent surgery but did undergo intra-arterial thrombectomy with technical success.
The etiology of stroke in this case was not clear, but cardioembolism is suspected based on young age, clean neck arteries, and presence of a patent foramen ovale on subsequent transthoracic echocardiogram with agitated saline (bubble study).
This case underscores the need to consider both causes and effects of traumatic events (such as fall or motor vehicle collision involving the driver) when evaluating emergency neuroimaging for the traumatized patient.
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