MCA alanı infarktı

Özet

MCA alanı infarktı, kortikal ve subkortikal dokuda erken dönemde gri-beyaz sınır silinmesi ve sulkus effasmanı olarak görünür. Kontrastsız BT kanamayı dışlar ve erken infarkt bulgularını gösterir; damar görüntüleme ise sorumlu büyük damar oklüzyonunu veya stenozunu ortaya koyar. İlk BT'de değişiklikler silik veya görünmez olabilir, bu nedenle damar alanına uyan gri-beyaz ayrım kaybı önem taşır. Alt akım evresinde kitle etkisi ve herniasyon riski artar; geniş hemisferik ödem ipsilateral ventrikülü sıkıştırıp karşı ventrikülde hidrosefale neden olabilir.

Faz ve pencere

Kontrastsız tanısal

MCA dağılımında kortikal ve subkortikal hipodensite, insular şerit veya lentiform çekirdek silinmesi, sulkus effasmanı ve ilerlemiş olguda lateral ventrikül basısı aranır. Hemorajik dönüşüm varsa infarkt içindeki yeni hiperdens kan odakları görülebilir; kontrast gerekmez.

BTA tanısal

İntrakraniyal ICA, M1 ve M2 dallarında eşlik eden oklüzyon ya da stenoz ile distal dalların opasifikasyonu değerlendirilir; CTA infarkt parankimini değil ilişkili damar lezyonunu gösterir.

Önerilen pencereler: İnme (G 40 / M 40), Beyin (G 80 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Kortikal MCA hipodensitesi — etkilenen kortekste gri madde atenüasyonu azalır ve kortikomedüller ayrım silinir.
• Gri-beyaz ayrım kaybı — etkilenen kortekste gri madde atenüasyonu azalır ve kortikomedüller sınır silinir.
• Derin perforan alan tutulumu — kaudat, lentiform çekirdek ve internal kapsülde hipodensite lentikülostriat dalların etkilenmesini gösterir.
• Sulkus effasmanı — etkilenen girusların şişmesi komşu kortikal BOS aralıklarını daraltır.
• Lateral ventrikül basısı — geniş hemisferik ödem ipsilateral frontal boynuz veya gövdeyi sıkıştırabilir.
• Kitle etkisi — genişlemiş hemisfer komşu ventrikülleri sıkıştırır ve subfalcin herniasyona yol açabilir.
• Hemorajik dönüşüm — infarkt içindeki yeni noktasal veya daha birleşik hiperdens odaklar kan ürününü düşündürür ve kontrastsız kesitlerde doğrulanır.
• Damar alanı dağılımı — lezyon çoğunlukla MCA’nın kortikal yüzey ve/veya derin perforan beslenmesine uyar; geniş infarkt veya sınır-bölge uzanımı komşu ACA/PCA kuşaklarına taşabilir.

Normalde

Karşılaştırma — hastalık yoksa veya başka bir patoloji varsa, kontrastsız BT genellikle intrakraniyal kanamanın varlığını veya yokluğunu net şekilde ayırt eder. Ayırıcı tanı — enfarktüs benzeri hipodensiteler, tümör gibi kitle lezyonları veya primer kanamalarla karışmamalı; kontrastsız BT bu farklı patolojileri birbirinden ayırır.

Ayırıcı tanı

Postiktal kortikal ödem

tek arter alanına uymayan kortikal şişme ve damar oklüzyonu olmaması infarkttan ayrılabilir.

Hipoglisemi

ani glukoz düşüşü bilinç bozukluğu, nöbet veya komaya yol açabilir ve enfarktüsle kliniği benzeyebilir; düzeltme ile semptomlar geri dönebilir.

Ensefalit

temporal veya limbik ağırlıklı ödem ve bilateral/asimetrik dağılım damar beslenme alanından farklı olabilir.

Beyin tümörü

progresif nörolojik bozukluklara ve tedaviye bağlı komplikasyonlara yol açabilir; enfarktüsün akut vasküler başlangıcından farklı seyir izler.

Eski infarkt

kronik ensefalomalazi ve doku kaybı, akut infarktın şişme ve sulkus silinmesinden farklıdır.

Tuzaklar

• Erken kontrastsız BT normal olabilir; klinik şüphe yüksekken negatif parankim bulgusunu infarkt yokluğu olarak yazma.
• Doz aşımı riski — yanlış kurulumlu CT perfüzyon yazılımları veya gereksiz tekrarlı kesitler ciddi radyasyon dozlarına yol açabilir.
• Kontrastlı CTA'da damar içi kontrastı subaraknoid kanama veya hemorajik dönüşüm sanma; aynı bölgeyi kontrastsız seriyle eşleştir.
• Eski hipodensiteyi yeni ödemle karıştırma; kronik hacim kaybı ve ventriküler çekilme akut kitle etkisinin tersine işaret eder.

Kendini dene

1. Sol lateral frontal-temporal kortekste hipodensite, insular silinme ve sağa orta hat itimi görülüyor. Hangi dağılım en iyi açıklar?

   • Sol MCA infarktı
   • Sağ PCA infarktı
   • Baziler arter infarktı
   • Sol ACA infarktı
   Cevabı göster

   Sol MCA infarktı. Lateral hemisfer korteksi ve insula MCA alanıdır; sola ait kitle etkisi orta hattı sağa iter. PCA oksipital/medial temporal, ACA medial frontal-parietal, baziler arter ise posterior dolaşım yapılarını besler.

2. Yakın zamanda kontrastlı damar işlemi geçirmemiş hastanın takip kontrastsız BT’sinde, MCA infarktı içinde yeni hiperdens odaklar ortaya çıkmış. En olası eşlik eden durum nedir?

   • Hemorajik dönüşüm
   • Kronik ensefalomalazi
   • Vazojenik kist
   • Koroid pleksus kalsifikasyonu
   Cevabı göster

   Hemorajik dönüşüm. İnfarktlı dokunun içinde yeni kan dansitesi hemorajik dönüşümle uyumludur. Ensefalomalazi hacim kaybı ve kronik hipodensite yapar; kist ve koroid kalsifikasyonu bu damar alanı içi akut kan görünümünü açıklamaz.

Kaynaklar

Bu sayfadaki 40 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 11 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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