Case of the Month, May 2018

Submitted by  Ricky Kaneshiro, MD, and Thomas Learch, MD.


A 51-year-old female with a history of bipolar disorder presents to the E.D. after waking up with acute onset left sided weakness, nausea and vomiting. Last known well was 4 hours ago. Physical exam notable for 0/5 strength in her left upper and lower extremities and a noticeable left sided facial droop.

CT of the brain was performed.

A focal hypodensity with loss of gray-white matter differentiation in the right anterior frontal lobe was noted. The deep gray matter appears normal and the gray white differentiation of the remainder of the brain was maintained.

 A more inferior slice demonstrates a linear hyperdensity in the expected area of the right middle cerebral artery.

CT angiography was subsequently done.

The angiogram demonstrated a vessel "cut off" sign of the right M1 segment of the middle cerebral artery and the A2 segment of the anterior cerebral artery.

 CT perfusion showed corresponding regions of brain parenchyma (highlighted in pink) with decreased cerebral blood flow.

The patient underwent thrombectomy of the M1 MCA thrombus.

Pre-thrombectomy arteriogram shows decreased vascularity within the right MCA and ACA vascular territories.

Arteriogram post M1 thrombectomy depicts improved vascularity within the MCA vascular territory.


Right frontal lobe acute infarct due to A2 ACA occlusion and right M1 MCA occlusion


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