Cerebral Misery Perfusion
The patient presented with acute onset right-sided weakness and slurred speech. MRI was performed, revealing a subtle diffusion restriction (panel B) with a large perfusion defect (panel C) and venous prominence on susceptibility weighted imaging in the area of perfusion defect to indicate stage II hemodynamic failure, or cerebral misery perfusion, which is the final physiological change before irreversible ischemia (Panel D). At emergency neurointervention, angiography revealed a long segment of severe narrowing in the cervical left internal carotid artery caused by acute dissection (arrowheads, Panel A). After stenting, the artery was restored to wide patency (Panel E) and repeat MRI 26 hours later showed resolution of the prior left cerebral misery perfusion (Panels G, H) and minimal enlargement of the left caudate infarct to involve the anterior putamen (Panel F). This case illustrates the utility of susceptibility weighted imaging as part of an MRI exam to provide imaging evidence of brain tissue in stage II hemodynamic failure, elevating the urgency of intervention and improving patient care.