1. 67 yo Male  Clinical History: Presented to ED with left facial droop and left sided weakness Presented to ED with left facial droop and left sided weakness  PMH: Left ventral medullary infarct 10/03 Left ventral medullary infarct 10/03 HTN HTN DM DM Epilepsy since childhood 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 Hyperdense artery sign Subtle hypodensity (cytotoxic edema) Subtle hypodensity (cytotoxic edema) Loss of gray/white differentiation Loss of gray/white differentiation Insular ribbon signInsular ribbon sign Swelling/Sulcal effacement 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 Decreased mental status Interval increase in edema seen on CT Interval increase in edema seen on CT  HD#4 Questionable aspiration Questionable aspiration Barium swallow study performed Barium swallow study performed NG tube placed 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) Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute Stroke. A Report of the Stroke Council, American Heart Association (1997) Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute Stroke. Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute Stroke. UVA Radiology Website UVA Radiology Website  ACR Code: 174.781  Maria M. Meussling