Patient with the right sided body weakness . More slices helps with visualizing the lesion. What is the diagnosis?

Dear friend, I’m very sorry, but that tiny hypodensity is NOT a basal ganglia lacunar infarction as you and @whitfieldlewis6 stated. It’s a harmless enalrged perivascular space in a typical location (the lateral branch of the anterior commissure), a very common incidental finding

@whitfieldlewis6 U were able to conclude it's a perivascular space in a typical location just from a CT slice? Laughable

@whitfieldlewis6 My friend @DrAyubaD , not from a CT slice, but from the whole set of thin CT slices of the whole brain you kindly provided 😊. Btw, this is what we all do in daily clinical practice (we do not ask for MRI to diagnose a PVS, especially in that super typical location 🤷🏼‍♂️)

My point is ; you can add your views on what you think the diagnosis is for a lesion in that location and give possible differentials and teaching points without trying to make the post author look stupid . @whitfieldlewis6 gave his opinion on the case which is a possibility and u also gave urs which is also possibility, We all learn and move forward . I am here to learn from you .

@whitfieldlewis6 I NEVER said anyone is “stupid”. I never do that, it’s not the aim of my posts. I just said what I do think that hypodensity is, and dozens of “brain specialists” think the same. When findings are so obvious, IMO we have the “obligation” to tell it clearly, otherwise the teaching

@whitfieldlewis6 aim of the post fades away. Not in every situation the “politically correct method is a value: we need to learn to speak clearly in our reports, whenever possible. Otherwise we as (neuro)rads will be easily substituted by AI listing all the possible diagnoses as of the same value

Gentlemen, we got him! It’s a lateral putamen infarction it seems 👇🏾

Exactly 👍👍👍. I knew the first clips didn’t do justice

lol. It was tough. I was looking at the contrast in the study trying to find an LVO instead of focusing on an actual infarction on the Brain. Good case.

Age, prior history, and any follow-up MRI would help. I agree, a prominent perivascular space cannot be reliably distinguished from a lacunar infarct on CT/CTA. There is no clear additional white matter disease, and no definite atherosclerotic disease, though the window provided is not really adequate for vascular evaluation. If the patient is young/lets say younger than 50 with no relevant past medical history, this is most consistent with a prominent perivascular space. MRI is still reasonable to exclude infarct given the right-sided deficit. If older, or if there is hypertension, diabetes, or similar risk factors, and CT/CTA are negative, my differential is age-indeterminate infarct versus prominent perivascular space. I would not call this an infarct with certainty on imaging alone. IMO with a negative CT/CTA, management should be guided by the neurologist’s clinical assessment. I hope no neurologist is making a treatment decision based on this study alone. Please educate me if not the case. Recent radiology posts have reminded me that everything is about clicks and engagement. Would not surprise me if some or many of the recent confrontational posts I am seeing are just to increase engagement. This is not related to your posts @DrAyudaD

The information provided above are the only ones at my disposal. Like I said the CT findings may not represent what the clinicians wrote down but that's not a huge problem of mine

It can hardly be the lacunar infarction that is shown. That wouldn't fit the clinical picture.

The clinical history above is just what was written in the request form. The findings says otherwise

I just can't seem to convince the radiologists at the center where I currently work that thin slices yield more information than 4mm reconstructions. They’re afraid they’ll have to look at more images—don’t laugh, that’s actually what one of them said.

@DrAyubaD By default, we reformat brain CT scan at 5 and 2 mm thick slices, then we have the whole set of 0.5-0.6 mm thick slices for reconstructions in any other plane. That said,: 1️⃣I recommend against looking at submillimetric slices2️⃣ that one is a perivascular space, not an ischemia🤓

@DrAyubaD How can you be so sure that this is a perivascular space? It doesn’t have the typical sharp and ovoid or round configuration. Even on an MRI one cannot always make a reliable distinction. But apparently you are able to do so on a CT of the brain. Miraculous.

@DrAyubaD Dear @BumblebeeJoe ,WE are sure (lots of neuroads and stroke neurologists saying the same) just because this is our job (btw, location and shape are absolutely the usual ones)and we have seen tons of “cases” like this one🤷🏼‍♂️. If we’d need an MRI to confirm every PVS seen at CT, 🤦🏼‍♂️

@DrAyubaD “It doesn’t have the typical rounded or ovoid configuration” … 🤔

@DrAyubaD Ah... You took the slides that suits you...

Anyone adding perspectives into my posts that doesn't sound like a genuine contribution will be blocked permanently from accessing my posts . If u have any observation or contribution please feel free to add but don't move ahead of yourself trying to assume things I didn't say. Before concluding that lesion is a perivascular space u must prove beyond doubt that it is and not a chronic lacunar infarct and you must do it professionally and not in a condescending manner . No matter who you are I will block from my space . Thank you for your attention to this matter. Yours sincerely.

Whether it’s a PVS or a chronic lacunar infarct is irrelevant, Probably the former given lack of WM dz otherwise, but not clinically relevant at the moment so bury it in the findings and move on.