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67 yo Male

67 yo Male. Clinical History: Presented to ED with left facial droop and left sided weakness PMH: Left ventral medullary infarct 10/03 HTN DM Epilepsy since childhood Meds: ASA, Statin, Dilantin, Insulin. CT. R/O hemorrhage R/O stroke mimics – tumor, abscess, aneurysm

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67 yo Male

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  1. 67 yo Male • Clinical History: • Presented to ED with left facial droop and left sided weakness • PMH: • Left ventral medullary infarct 10/03 • HTN • DM • Epilepsy since childhood • Meds: ASA, Statin, Dilantin, Insulin

  2. CT • R/O hemorrhage • R/O stroke mimics – tumor, abscess, aneurysm • Look for early signs of infarction • Hyperdense artery sign • Subtle hypodensity (cytotoxic edema) • Loss of gray/white differentiation • Insular ribbon sign • Swelling/Sulcal effacement

  3. CT • Large area of hypodensity in right insular and temporal/parietal regions • Loss of gray/white matter differentiation • Sulcal effacement • No hemorrhage or mass • No hydrocephalus or midline shift

  4. T2 FLAIR • Large area of signal abnormality in right MCA territory • No mass or extra-axial collection

  5. DWI • Increased signal intensity in right MCA territory

  6. TOF MRA • Abrupt termination of right MCA • Mild atherosclerotic narrowing of proximal right internal carotid • No other major arterial occlusion, aneurysm, or vascular malformation

  7. Diagnosis • Large Right Middle Cerebral Artery Infarct

  8. Hospital Course • HD#2 • Decreased mental status • Interval increase in edema seen on CT • HD#4 • Questionable aspiration • Barium swallow study performed • NG tube placed

  9. References: • Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute Stroke.A Report of the Stroke Council, American Heart Association (1997) • UVA Radiology Website • ACR Code: 174.781 • Maria M. Meussling

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