Middle and anterior cerebral artery infarction with hemorrhagic transformation
Presentation
Known multiple sclerosis presents with right-sided hemiplegia and dysarthria.
Patient Data
Large left frontal and temporo-parietal cortical and subcortical areas of abnormal signal intensity demonstrate high signals on T2 and FLAIR sequences and hypointense signals on T1, as well as diffusion restriction on DWI with an area of blooming artifact on GRE. A marked mass is seen in the form of effacement of overlying cortical sulci, compression of the left lateral ventricle, and a midline shift of about 10mm. This is in keeping with a subacute infarction with hemorrhagic transformation.
MRA reveals marked attenuation of the left anterior cerebral artery and moderate attenuation of the left internal carotid, as well as the left middle cerebral artery, which is still patent.
Multiple periventricular and subcortical white matter high-signal intensity foci at the right cerebellar hemisphere, corpus callosum, and brain stem denote multiple sclerosis.
Four days later, a CT was done, showing left fronto-parietal hypoattenuation with loss of grey-white matter differentiation extending to the left basal ganglia and a mass effect in the form of ipsilateral ventricular compression and midline shift to the right. This is in keeping with a subacute middle cerebral artery territory infarction.
Hyperdense area in the left basal ganglia as well as linear hyperdensities in the left frontoparietal area, suspecting hemorrhagic transformation, subtype parenchymal hematoma type 1.
The patient underwent an emergency decompressive craniectomy.
The skull bone flap overlies the left lower quadrant of the anterior abdominal wall.
Case Discussion
Multiple sclerosis increases the risk of developing an acute cerebral infarction. This example demonstrates hemorrhagic transformation in a subacute middle and anterior cerebral artery infarction.
Malignant hemispheric infarction is a massive ischemic stroke resulting in significant cerebral edema with brain parenchymal shifts and herniation. Patients with a malignant hemispheric infarction are at an increased risk of developing hemorrhagic transformation, and a prophylactic craniectomy is often performed to reduce mortality.
This patient underwent an emergency decompressive craniectomy with bone flap preservation on the anterior abdominal wall. The bone flap can also be implanted in the peritoneal cavity or frozen for possible cranioplasty once the edema subsides.
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