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Fig. 5.20 Cerebral infarction is not readily identified before 12 hours duration. This scan demonstrates a hyperdense middle cerebral artery due to vessel thrombosis. A later scan confirmed infarction of the middle cerebral artery territory. A further early sign of infarction is loss of differentiation between grey and white matter.

Fig. 5.20 Cerebral infarction is not readily identified before 12 hours duration. This scan demonstrates a hyperdense middle cerebral artery due to vessel thrombosis. A later scan confirmed infarction of the middle cerebral artery territory. A further early sign of infarction is loss of differentiation between grey and white matter.

Fig. 5.22 Mature infarct in the territory of the left middle cerebral artery. Mature infarction is of lower density (darker black) than acute infarction.

The hallmark of ischaemia is a wedge-shaped low-density areas of affected brain which reaches the cortical surface. Middle cerebral artery infarction spares the thalamus. Mass effect is not uncommonly seen in the first week with sulcal effacement, ventricular and cisternal compression.

It is important to appreciate the territory supplied by the cerebral arteries as this enables confident diagnosis and helps distinguish infarction from space-occupying lesions. Space-occupying lesions cross arterial territories while infarction is limited by them. Infarction in the territory of the middle cerebral artery (hemiparesis) and the posterior cerebral artery (see Fig. 5.21) (producing homonymous hemianopia) are the more commonly affected arteries. The anterior cerebral artery territory is rarely affected partly due to good collateral supply from the anterior communicating artery. On CT an area of mature infarction is of reduced density and appears darker than acute infarction (Fig. 5.22).

58-year-old female.

Admitted following road traffic accident and minor head injury (Fig. 5.23). Normal physical examination.

No fracture could be seen on the film and the patient was discharged from accident and emergency.

■ What is the radiological abnormality on the plain film of the skull?

■ Suggest two possible differential diagnoses.

■ What radiological investigation would you want to request next?

Fig. 5.23 Quiz case.

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