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NEUROIMAGE
Year : 2022  |  Volume : 70  |  Issue : 2  |  Page : 816-817

Beware of Brain Pearl—Virtually Missed a Large Vessel Occlusion Guided by CT Perfusion


Department of Neurosciences, Medanta The Medicity, Gurugram, Haryana, India

Date of Submission02-Jan-2020
Date of Decision09-Feb-2020
Date of Acceptance09-Feb-2020
Date of Web Publication3-May-2022

Correspondence Address:
Dr. Gaurav Goel
Department of Neurosciences, Medanta The Medicity, Gurugram - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.344606

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How to cite this article:
Mahajan A, Goel G, Banga V, Chatterjee A. Beware of Brain Pearl—Virtually Missed a Large Vessel Occlusion Guided by CT Perfusion. Neurol India 2022;70:816-7

How to cite this URL:
Mahajan A, Goel G, Banga V, Chatterjee A. Beware of Brain Pearl—Virtually Missed a Large Vessel Occlusion Guided by CT Perfusion. Neurol India [serial online] 2022 [cited 2022 Jun 25];70:816-7. Available from: https://www.neurologyindia.com/text.asp?2022/70/2/816/344606





  Case Description Top


A 54-year-old male with a history of type 2 diabetes mellitus, hypertension, and severe calcific aortic stenosis presented with left-sided hemiparesis and facial palsy during the coronary angiography. His initial National Institutes of Health Stroke Scale (NIHSS) score was 9. Non-contrast computed tomography (NCCT) of the head was performed which showed no infarct and small calcified hyperdensity or “brain pearl” in the right proximal middle cerebral artery (MCA) region [Figure 1]a. Intravenous tissue plasminogen activator was immediately initiated. CT angiography (CTA) of the head and neck was performed which showed no major vessel occlusion with an apparent normal filling of distal MCA vessels and a calcified hyperdensity in the M1 segment which was thought to be extraluminal [Figure 1]b. CT perfusion (CTP) showed large penumbra in the right MCA territory suspected of large vessel occlusion which did not correspond to CTA findings [Figure 1]c, [Figure 1]d, [Figure 1]e. The patient had no improvement in his symptoms and, thus, he was emergently shifted for angiography and tentatively planned for mechanical thrombectomy. Right internal carotid artery (ICA) injection confirmed the right MCA (M1 segment) occlusion which was masked by the calcified brain pearl and retrograde leptomeningeal collaterals on CTA [Figure 2]a. Mechanical thrombectomy was performed resulting in thrombolysis in cerebral infarction (TICI) score of 2c [Figure 2]b. The patient's neurologic examination improved significantly the following thrombectomy with minimal residual left hemiparesis. NCCT head after 24 h showed no infarct and few calcific hyperdensities distally in the MCA territory suggestive of thromboembolism [Figure 2]c and [Figure 2]d. Calcific emboli from aortic stenosis, aortic arch atherosclerosis, and mitral valve calcification are the uncommon recognized cause of ischemic stroke which can create pseudopatency of the vessel on CTA. Calcified thrombus is usually isodense to the iodine contrast which can simulate the vessel patency.[1] In our case, the likely source of the calcified embolus was his calcific aortic stenosis. There are few cases described in the literature regarding the pseudopatency of the vessel in case of calcific emboli which was guided by digital subtraction angiography, multiphase CTA, and magnetic resonance imaging.[1],[2],[3] In our case, CTP detected the major vessel occlusion in cases of calcified thrombus which potentially created a pseudopatency of the vessel.
Figure 1: Non-contrast computed tomography (NCCT) of the head showed a hyperdens ity (arrow) in the right middle cerebral artery (MCA) region (a). CT angiography (CTA) showed calcific thrombus (arrow) in the M1 segment of MCA with normal opacification of distal MCA branches creating pseudopatency (b). CT Perfusion showed large mismatch deficit in right MCA territory (c–e)

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Figure 2: Catheter angiography (Right ICA injection) showed right MCA occlusion (arrow) (a). TICI 2c recanalization was achieved on control angiogram after mechanical thrombectomy (b). NCCT of the head done after 24 h showed no infarct and calcific hyperdensity in right MCA territory (arrows) (c and d)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Yogendrakumar V, Patro S, Dowlatshahi D, Stotts G, Iancu D. Calcified embolus mimics patent middle cerebral artery on CT angiogram. Pract Neurol 2017;17:307-9.  Back to cited text no. 1
    
2.
Uneda A, Kanda T, Suzuki K, Hirashita K, Yunoki M, Yoshino K. Acute cerebral artery occlusion by a calcified embolus with false patency sign on computed tomographic angiography. J Stroke Cerebrovasc Dis 2017;26:5-7.  Back to cited text no. 2
    
3.
Power S, McEvoy SH, Cunningham J, Ti JP, Looby S, O'Hare A, et al. Value of CT angiography in anterior circulation large vessel occlusive stroke: Imaging findings, pearls, and pitfalls. Eur J Radiol 2015;84:1333-44.  Back to cited text no. 3
    


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