CT angiography and diffusion-perfusion MR imaging in a patient with ipsilateral reversible cerebral vasoconstriction after carotid endarterectomy

Abstract

Reversible cerebral vasoconstriction syndromes (RCVS) typically affect the bilateral medium-sized intracerebral arteries and their branches. We describe a woman with RCVS restricted to the ipsilateral hemisphere after carotid endarterectomy. Serial CT angiography proved useful in documenting vasoconstriction. Perfusion MR imaging showed hypoperfusion in the deep watershed regions of the ipsilateral cerebral arteries but relatively normal perfusion in superficial cortical regions. Diffusion MR imaging showed progressive borderzone infarcts. These novel imaging findings provide insights into the pathophysiology of stroke in RCVS.

Figures

Fig 1.

Neuroimaging findings in a 54-year-old woman with RCVS after CEA. A, CTA on day 1 shows attenuation and segmental narrowing of the left ACAs and MCAs (arrows). These abnormalities were not present on a CTA performed before the endarterectomy. B, FLAIR image from the brain MR imaging on day 1 shows multiple punctate and curvilinear hyperintensities (arrows) overlying the left cerebral hemisphere, suggesting slow blood flow within abnormally dilated arteries. C, Mean-transit-time maps from the perfusion MR imaging on day 1 (gray scale in seconds) show hypoperfusion within the left internal watershed arterial territories and relative sparing of the superficial cortical regions. D, Diffusion-weighted brain MR imaging on day 1 shows a posterior left frontal-lobe infarction, which was present before the CEA, but no new lesion. E, Repeat diffusion-weighted brain MR imaging on day 3 shows new acute infarctions developing within the previously noted regions of subcortical hypoperfusion. F, Repeat CTA performed after 2 months shows complete resolution (arrows) of the arterial vasoconstriction.