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Cisternostomy has shown promising results, however larger studies are needed.
In chronological order of the annotated images:
- Dense MCA sign (orange arrows segment M1-2, yellow arrow segment M2-3), loss of insular ribbon sign (blue arrows) compared to contralateral side (normal appearance, green arrow), obscuration of right lentiform nucleus (blue arrow) compared to contralateral side (normal appearance, green arrow) and frontoparietal sulcal effacement, territory of right MCA (white arrows). Note slight mass-effect on right lateral ventricle, cornu frontale et occipitale (dark red arrows).
- Demarcating right MCA territory infarct (white arrows) with cytotoxic and vasogenic edema causing subfalcine herniation (yellow arrow) and mass-effect on right lateral ventricle (red arrow).
- Two days later at the level of septum pellucidum depicts natural evolution of right MCA infarction with extensive edema and haemorrhagic transformation of different age (red arrows). Resolving subfalcine herniation and interval development of transcalvarial herniation of major parts of the right infarcted hemisphere through newly right-sided frontoparietotemporal hemicraniectomy with scant subcutaneous blood products is also illustrated (yellow arrows). Note demarcating lacunar infarction in left hemithalamus (white arrow), consistent with compression of thalamic perforating arteries from left PCA by brain herniation seen two days before.
- Chronic state of right MCA infarct with resolving edema and petechial hemorrhage, decreased transcalvarial herniation (yellow arrow) and secondary dilatation of right lateral ventricle. Note interval development of lobar hemorrhage (red arrow) in right parietal lobe, most probably due to mass-effect on craniectomy site (parietal bone edge).
- Marked concavity of brain and skin flap at the craniectomy site (yellow arrows). Subfalcine herniation to the left (red arrow), compression of both ventricles (purple arrow) and VP-shunt (white arrow) are also noted.
- Right frontoparietotemporal cranioplasty flap (blue arrows) with both intra- and extracranial air (white arrows) and moderate amount of blood products both superficially and beneath the flap (red arrows). Note resolved deviation of midline structures.
- Two subgaleal organized collections (yellow arrows) consistent with abscesses. Note interval decrease of subdural hematoma without overt cavitation (red arrow).
- Note titanium cranioplasty (white arrows) and asymmetry of mesencephalon (yellow arrows) representing right-sided Wallerian degeneration.