Medical Neurology Channel Author: Chu Zhongren Reporting Expert: He Zhiyi
Professor He Zhiyi of the Department of Neurology of the First Affiliated Hospital of China Medical University shared a wonderful lecture on the theme of "Clinical Characteristics of Acute Cerebral Infarction Head MRI". Due to the large amount of content and limited space, we will split into multiple parts to explain, start the first part, the small bench moved, let's learn together...
First, let's briefly look at the blood vessels and blood supply map of the brain.
Blood supply to the brain
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Infarction of the blood supply area of the important branch of the internal carotid artery
Next, Professor He Zhiyi will share with you in the order of the anterior cerebral artery, the middle cerebral artery, and the anterior choroidal artery.
1. Infarction of the anterior cerebral artery blood supply area
【Case 1】
The patient, a 60-year-old female, was admitted to the hospital for "10 days of irregular movement of the right limb". 10 days ago, there was no precipitating weakness in the right limb, inability to stand, and relieved after 10 minutes. Recurrence the next day, followed by another recurrence, persists without remission, but can still walk. The disease does not cause dizziness, confusion and headache. Past history: Hypertension for more than 10 years. Physical examination: Shenqing is clear, and no abnormalities are found in the cranial nerve examination. Right limb muscle strength level IV. Babinski's sign (L:-, R:±).
Craniocerebral MRI shows high signals of T2 in the left frontal lobe and callosum knee
【Clinical Diagnosis】
Infarction in the blood supply area of the left anterior cerebral artery.
【Case 2】
The patient, a 57-year-old woman, was admitted to the hospital with "difficulty in eating and weakness in both lower limbs for 4 months". Since 4 months, the patient has been eating hard, does not like to talk, a burst of understanding, a bout of confusion, weakness of both lower limbs, two incontinence, no convulsions. Examination: Shenqing Yuming, double pupils and other large perfect circle, diameter ≈ 3.0mm, sensitive light response. Double upper extremity muscle strength V, double lower limb muscle strength level III. BCR（L：++，R：++），PSR（L：++，R：++）。 Hoffmann sign (L:-, R:-), Babinski sign (L:-, R:-). No abnormalities were seen on masonic movements and sensory examination.
CT of the cranial brain shows bilateral medial frontal lobe, bilateral caudate nucleus head, and anterior nucleus of the shell (as shown by a yellow arrow)
Infarction of bilateral anterior cerebral artery blood supply areas.
【Case 3】
The patient, a 59-year-old woman, was admitted to the hospital with "fever for more than 10 days and weakness of both lower limbs for 12 days". The patient had fever more than 10 days ago without obvious cause, body temperature of 38.2 ° C, 4 days later, coma, weakness of both lower limbs, incontinence. Examination: Clear-headed, normal speech. Double pupils are equally large round, ≈ 3.0 mm in diameter, the light response is sensitive, the eyes are fully moved in all directions, and there is no nystagmus. Bilateral frontal streaks and nasolabial folds are symmetrical, the soft palate and uvula are centered, the pharyngeal reflex is normal, the tongue is centered, and the neck is strongly positive. Left upper extremity proximal muscle strength V, distal muscle strength V, left lower extremity proximal muscle strength level 0, distal muscle strength level 0; right upper extremity proximal muscle strength V, distal muscle strength V; right lower extremity proximal muscle strength 0, distal muscle strength 0. Decreased muscle tone in the extremities. Both lower extremities are less painful, lightly touched, kinesthetic, positional, and vibrational.
(1, 2) On the 7th day of the disease, cranial CT showed bilateral frontal lobe hypoglue lesions. (3~9) is the 8th day of the disease brain MRI sweep + enhancement + DWI, DWI (3, 4) shows bilateral frontal lobe lesions showing high signal, right frontal lobe lesions mixed low signal, ADC plot (5) corresponding parts are low signals, indicating recent infarction foci, T2 weighted (6) is mixed high signal, T1 weighted (7) is mixed low signal, enhancement (8) shows that there is a strengthening within the lesion, FLAIR sequence (9) the corresponding part is a mixed high signal, indicating that the recent infarction and bleeding are likely. (10) Cranial MRA on the 9th day of illness suggests bilateral anterior cerebral artery A2 segment and distal vascular occlusion.
Bilateral anterior cerebral artery blood supply area infarction with bleeding.
【Commentary】
Anterior cerebral artery (ACA) area infarction is rare, and the typical clinical symptoms are the following: contralateral central hemiplegia, characterized by heavy lower limbs, light head and upper limbs, and some only central paralysis of the lower limbs. There is usually a frontal lobular ataxia. Contralateral lower extremity sensory impairment. Mild bladder and rectal sphincter disorders, manifested mainly by dysuria. Psychiatric symptoms. When one side of the anterior cerebral artery is absent, the paracentral lobules on both sides may be affected by occlusion of the anterior cerebral artery,
Paraplegia and sensory impairment of both lower extremities, often accompanied by severe urinary retention, should be distinguished from paraplegia caused by spinal cord lesions.
Clinically, for sudden hemiplegia or monoliplegia dominated by the lower limbs, mental symptoms based on hypowill and apathy, or urinary incontinence and frequent urination, the possibility of infarction in the ACA area should be considered, especially bilateral anterior cerebral artery occlusion, and the CRANI examination should be improved in time to avoid misdiagnosis.
2. Deep perforation of the anterior cerebral artery - Heubner recurrent artery blood supply area infarction
【Case】
The patient, a 54-year-old male, was admitted to the hospital with "headache and head fan for 2 days". Headache for 2 days, head confusion, no vomiting, no fever. The right upper and lower limbs are clumsy. Past history: cerebral infarction 1 year ago, no sequelae. Physical examination: Shenqing is clear, no abnormalities are found in the cranial nerve examination, there is no paralysis of the limbs, the neck is strong and negative, and no abnormalities are found in the residual neurology examination.
1: The high signal (red arrow) in the left basal ganglia area weighted by CRB2 shows the old lesion, and the high signal (yellow arrow) in the right caudate nucleus head and the anterior part of the shell nucleus shows the fresh lesion. 2: FlaIR right side caudal nucleus head and shell nucleus anterior high signal (yellow arrow), left side basal node area low signal (red arrow). 3: Schematic diagram of Heubner recurrent artery blood supply area infarction, dark area showing Heubner recurrent artery blood supply area.
Heubner returns to the arterial supply area of infarction.
In 1872, Heubner first described the Heubner recurrent artery of Heubner (RAH), the main branches are olfactory branch, frontal branch, prependromal perforatum, lateral fissure branch, respectively to the olfactory triangle, frontal orbital gyrus, anterior perforatum and temporal lobe medial cortex, the supply area is the inner orbital cortex, the anterior ventral part of the striatum (caudate nucleus head, anterior shell nucleus, the lateral tip of the glomerular globus palette) and the forelimbs of the medial capsule, as shown in the figure.
The typical symptoms of RAH injury or occlusion are mainly paralysis of the central facial muscles, palate muscles, and tongue muscles on the contralateral side of the lesion, paralysis of upper motor neurons dominated by the upper limbs, and ataxia of the frontal lobe, and cognitive dysfunction can also occur.
When there is contralateral central facial tongue palsy and upper motor neuron paralysis dominated by the upper motor neurons, combined with the brain MRI manifestations, that is, the infarction of the head, shell nucleus, and lateral globule globule of the caudate nucleus with varying ranges, the possibility of infarction in the blood supply area of the Heubner return artery should be thought.
3. Infarction in the middle cerebral artery blood supply area
The patient, a 59-year-old woman, was admitted to the hospital for "poor movement of the right limb and inability to speak for 3 days". 3 days ago, the patient suddenly appeared to be immobile on the right side of the limb without obvious precipitating, completely unable to move, unable to speak, accompanied by difficulty eating. 6 hours after illness, cranial CT examination is shown in the figure below, and symptomatic treatment (unthrombolytic) is not seen and transferred to the hospital. With a history of hypertension for more than 10 years, the highest blood pressure is 220/90mmHg. Examination: drowsiness, motor aphasia, poor physical examination, bilateral pupils and other large right circles, sensitive to light, both eyes staring to the left,The right nasolabial fold becomes shallow, the tongue cannot be extended, the right limb muscle strength level 0, the left limb can move autonomously, Babinski sign (L-, R:+), sensory examination and mutual assistance examination can not cooperate.
1: Cranial CT 6 hours after onset shows elevated left middle cerebral artery density. 2. 3: Cranial CT 6 hours after onset shows a local decrease in density in the left temporal parietal lobe, blurred cortical edges, and loss of the cerebral sulcus. The lesion site is shown by a yellow arrow.
Infarction in the blood supply area of the left middle cerebral artery.
The patient, a 67-year-old male, was admitted to the hospital with "recurrent left limb weakness for half a month and aggravation for 1 day". The patient began to have recurrent left limb weakness half a month ago, which remissioned within 30 minutes, and there were no abnormalities in the head CT. 3 days ago due to urinary incontinence, confusion, into the local hospital for treatment, the condition gradually worsened, 1 day ago suddenly left limb weakness does not alleviate, can not walk, accompanied by unclear speech. Past history: diabetes mellitus for 1 year, hypertension for half a year, cerebral infarction in 2001, no sequelae. Physical examination: clear consciousness, dysarthria, left central facial paralysis, left upper extremity muscle strength grade III, left lower extremity muscle strength grade II. Babinski sign (L:+, R:-).
1-3: Case 2 patients who had episodic left lower extremity weakness half a month before the onset of the disease did not see any abnormalities in cranial CT. 4. 5: Ct of the cranial brain in case 2 patient 1 day after the onset of illness shows large low-density foci on the right front, temporal and parietal lobes (as shown by yellow arrows)
Infarction of the blood supply area of the right middle cerebral artery.
The patient, a 16-year-old male, was admitted to the hospital with "headache for 8 days and poor movement of the left limb for 6 days". Past health. Physical examination: clear consciousness, slurred speech, left central facial parietal paralysis, left upper extremity muscle strength grade 0, left lower extremity muscle strength grade IV., Babinski's sign (L:+, R:-).
1-3: Cerebral MRI shows right-sided caudate nucleus, shell nucleus, and globule globus globus infarction (as shown by yellow arrows); 4: Cerebrovascular CTA shows luminal stenosis of the M1 segment of the right middle cerebral artery (bean vein artery originates from M1 segment, as shown by yellow arrows); bilateral anterior cerebral artery trunk and branches are well developed, and no stenosis and dilation are seen.
Infarction of the blood supply area of the right middle cerebral artery, the bean vein artery.
【Case 4】
The patient, a 76-year-old woman, was admitted to the hospital with "numbness in the left limb and inability to speak for 17 days". The patient suddenly appeared numbness in the left limb and inability to speak without obvious cause 17 days ago, accompanied by difficulty swallowing, drinking water, coughing, and strong crying and laughter. Examination body: clear consciousness, unable to speak, strong smile face. The double pupil is equal to the large perfect circle, 3.0 mm in diameter, and the light response is sensitive. The eyes move adequately in all directions without eye shock. Bilateral frontal striae and nasolabial fold symmetry, presence of pharyngeal reflex, strong negative neck, and limb muscle strength grade III. BCR（L：++，R：++），TCR（L：++，R：++）PSR（L：++，R：++），ASR（L：++，R：++）。 Babinski's sign (L:-, R:-). Depth of sensation, freemasonry exercise examination can not be cooperated.
Cranial CT shows bilateral ischemic infarction foci in the middle cerebral artery supply area (shown by a yellow arrow).
Infarction of the blood supply area of the bilateral middle cerebral artery, pseudobulbar palsy.
Anatomically , the medial bean vein artery supplies the anterior part of the shell nucleus, the lateral part of the globus pals, the knee of the medial capsule, the anterior nucleus of the thalamus and the lateral nucleus, and the lateral bean vein artery supplies the external capsule, the nucleus of the shell, the globus globus, the anterior 3/5 of the posterior extremity of the internal capsule, and the caudate nucleus.
Infarction of the deep middle cerebral artery is caused by occlusion of the bean-veined arteries and often manifests as a lacunar infarction syndrome. Superficial infarction is caused by M2 segment involvement, with Occlusion of the upper M2 segment often resulting in large-scale infarction of the anterior cortex and subcortical of the frontal and parietal lobes, and Occlusion of the lower M2 segment leading to temporal and parietal infarction.
4. Anterior choroidal artery infarction
The patient, a 50-year-old woman, was admitted to the hospital with "head fan and unclear vision for 1 month". Past History: (-). Physical examination: Shenqing Yuming, right central facial paralysis, right deviation of the tongue, no paralysis of the limbs, strong negative neck, Babinski sign (L:-, R:+), hemogenous hemianopia on the right side of both eyes.
1. 2: CT of the cranial brain shows a long strip of low-density lesions in the hind limbs of the left inner capsule (as shown by a yellow arrow).
3: Left anterior choroidal artery blood supply area.
4. 5: Visual field illustration of hemitropic hemianopia on the right side of both eyes.
Infarction of the anterior choroidal artery blood supply area.
Anterior choroidal artery (AChA) area infarction was first reported by Fox et al. in 1925, AChA is characterized by long stroke, fine lumen, wide blood supply range, branch lack of collateral circulation, once occluded, especially striatic in vivo cyst artery occlusion will cause typical "three bias" symptoms (hemian hemianopia of the contralateral field of the lesion, contralateral hemiplegia and hemisesthesia), can be considered as narrow AChA infarction.
When clinical examination finds typical "three partial" symptoms, that is, hemistropic hemianopia, contralateral hemiplegia and hemisesthesia disorder on the contralateral field of the lesion, to think of the possibility of infarction in the anterior choroidal artery blood supply area, it is necessary to perform cranial CT or cranial MRI examination to confirm the diagnosis, and the above clinical manifestations are of great help for judging the site of infarction in the brain.
Source: Panda Radiation
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