Neuro – Osce

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Physical examination : HR 90 / min, totally irregular : Stupor : Pupil 2 mm equal and reactive : decrease Rt. Nasolabial fold : flaccid Rt. Hemiplegia : Generalized hyporeflexia : Rt. extensor plantar response

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1. บรรยาย1. Normal bony structure and paranasal sinus 2. Tubular shape hyperdensity area along the

course of left middle cerebral artery 3. Pressure effect at left basal ganglia area upon

frontal horn of the left lateral ventricle or ill defined hypodensity area at left basal ganglia

4. Effacement of cerebral sulci / or loss of gray white difference /or loss of cerebral sulci at left fronto-temporal area

2.

• Left middle cerebral clot

• Early brain edema of left fronto – temporo – parietal area

3.

• Acute cerebral embolism of left middle cerebral artery

Imaging in acute stroke

CT early signs of ischemia

• Hypo attenuating brain tissue • obscuration of the lentiform nucleus • Insular Ribbon sign• Dense MCA sign • Hemorrhagic infarcts

Penumbra: Occlusion of the MCA with irreversibly affected or dead tissue in black and tissue at risk or penumbra in red

CT early signs

• Hypoattenuating brain tissue

• Obscuration of lentiform nucleus

• Dense MCA sign

• “Insular” ribbon sign

• Loss of sulci effacement

MCA infarction: on CT an area of hypoattenuation appearing within six hours is highly specific for irreversible ischemic brain damage

Obscuration of the lentiform nucleus or blurred basal ganglia

• Obscuration of the lentiform nucleus, also called blurred basal ganglia

Insular Ribbon sign : This refers to hypodensity and swelling of the insular cortex

Dense MCA sign

• This is a result of thrombus or embolus in the MCA

Hemorrhagic infarction

Case 1

• 57 year old woman presented to the ER with sudden onset left hemiparesis 2 hours before arriving at the ER

Answer

Description• CT brain without contrast• Soft tissue, bony structure, sinus, orbit,

mastoid- normal• Hypodensity lesion in the right

frontoparietal region• Loss of gray white differentiation/ loss of

sulci in the right frontoparietal region• Edema in the right frontoparietal region

with pressure effect on right lateral ventricle

• No midline shift

Left hyperdensedMCA sign