Case #2

• Hypoattenuation throughout the left MCA territory with loss of gray-white differentiation and sulcal effacement
• Slight left to right midline shift without evidence of herniation
• Asymmetric increased density of the left carotid terminus and proximal left M1 segment
• Sequela of chronic ischemic microvascular disease
• Heavy atherosclerotic calcification of the cavernous carotid and intradural vertebral arteries
• Extensive mucoperiosteal thickening of the right maxillary sinus

• Left MCA territory infarct

• The MCA territory is by far the most common affected by ischemia
• The deep gray structures and insular cortex develop cytotoxic edema quicker (usually within a few hours) than the frontal, temporal, and parietal cortical gray matter because there is more developed surface cortex collateral flow, so look closely at the basal ganglia and insular cortex (e.g. insular ribbon sign, which is loss of gray-white differentiation between the insular cortex and external capsule)
• The earliest CT finding of MCA territory ischemia is a dense MCA sign (seen immediately), though this is seen in a minority of cases
• Always talk about mass effect (e.g. midline shift, herniation, hydrocephalus) and hemorrhagic conversion.

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