Sudden onset of disturbed conscious level which progressed to coma of two days duration.
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Right hemispheric infarction with dense MCA sign and massive brain edema that leads to subfalcine and uncal herniation. There is associated hemorrhage within the pons and midbrain due to damage to the perforators arteries from the basilar artery known as duret haemorrhage. Moreover there is a focus of hemorrhage at left cingulate gyrus likely from damaged left ACA owing to subfalcine herniation.
Toxic brain oedema associated with cerebral infarction can be severe that it obliterates the basal cisterns and forces the brain to herniate through the tentorial notch (uncal herniation) and below the falx cerebri (subfalcine herniation). As a sequelae there is downward displacement of the brain stem which can lead to damage to the perforators of the basilar artery that supplies the brain stem and may progress to brain stem coning within the foramen magnum leading to death. This patient requires urgent craniectomy.