Presentation
Acute left-sided weakness and confusion.
Patient Data
A calcified focus in the right Sylvian cistern is suspicious for a calcified thromboembolism. Loss of grey-white matter differentiation of the right posterior temporal, insular and parietal cortex. Elsewhere, grey-white matter differentiation is preserved. Automated ASPECTS = 5.
No intra or extra-axial hemorrhage, collection or lesion. General involutional change, with periventricular white matter hypoattenuation, in keeping with prominent chronic small vessel ischemia. Multi small old bilateral basal ganglia lacuna infarcts.
CT perfusion reveals an area of hypoperfusion in the right MCA territory (Tmax greater than 6 seconds. Using the threshold of CBF <30%, there is an area of ischemic core within this region with a substantial penumbra (mismatch) volume.
CTA (only limited edge enhanced/bone window images providedemonstrates occlusion of the right inferior division of MCA at the site of calcification and a second more distal occlusion of the right superior division of MCA. Above these occlusions there is reduced vascular enhancement throughout the MCA territory.
Conclusion:
Acute right MCA territory ischemic stroke with occlusion of inferior division due to calcified thromboembolism. Sizable penumbra.
The patient went on to receive intravenous thrombolysis and was subsequently re-scanned later that same day.
Dense contrast is seen within the vasculature and dural venous sinuses.
There is a wedge-shaped region of hyperdensity within the superior division of the right MCA territory within the right middle frontal gyrus. This region demonstrates uptake on the iodine maps and there is no hyperdensity on the virtual non-contrast images.
Elsewhere there is loss of grey-white matter differentiation in other parts of the right MCA territory, particularly within the posteriorly, in keeping with evolution known right MCA infarct secondary to calcified thromboembolism.
Conclusion:
Developing right MCA territory infarct with contrast staining. No hemorrhage.
Case Discussion
This case demonstrates the utility of dual-energy imaging in the setting of post-thrombolysis intraparenchymal hyperattention. This phenomenon is most frequently seen in the setting of post-mechanical thrombectomy, however, it can also be seen in patients treated purely with intravenous thrombolysis 1.
Although often, in a given clinical context, it is possible to distinguish contrast staining from petechial hemorrhagic transformation, this is not always easy. The addition of dual-energy imaging with iodine maps (showing contrast) and virtual non-contrast images (showing images with removal of hyperdensity due to iodine) can be very helpful.
Ideally, a follow-up study 24 to 36 hours later should be obtained to confirm the diagnosis (not available in this case) as contrast staining will usually resolve quickly.
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