Case #2

• Diffuse, confluent low attenuation with loss of gray-white differentiation in the left cerebral hemisphere involving the ACA and MCA territories
• Dense left MCA and ACA
• Left hemispheric sulcal effacement with slight left to right midline shift and slight effacement of the left lateral ventricle

• Acute left ACA and MCA territory infarct

• Dense vessel signs are immediate findings in strokes and are apparent hours before cytotoxic edema develops. While dense vessel signs are seen in a minority of cases, it is important to look for them because they may be the only clue that the patient is having an acute stroke
• Without a dense vessel sign, there is usually no evidence of an ischemic stroke on CT for several hours (even as long as 12-24 hours)
• As tissue begins to die, there is breakdown in the blood-brain barrier and edema begins to develop, which is hypodense relative to normal brain on CT
• It is important to use “stroke” windows, which are narrow high-contrast windows, when looking at head CTs to increase your sensitivity for subtle areas of edema

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