Left middle cerebral artery territory stroke with haemorrhagic transformation

Case contributed by A.Prof Frank Gaillard

Presentation

Right hemiplegia and dysphasia.

Patient Data

Age: 85 years
Gender: Male

No definite evidence of acute infarct. A small region of white matter hypodensity near the left vertex (medial aspect of precentral gyrus) with preservation of grey-white matter differentiation is most likely consistent with an established infarct. Right temporal lobe hypodensity with ex-vacuo dilatation of the temporal horn of the lateral ventricle and right caudate head hypodensity are consistent with old infarcts. No haemorrhage identified. 

Hyperdensity in the left sylvian fissure suggests an acute thromboembolism.  

CT perfusion - same time

Modality: CT

There is a large region of decreased CBV and CBF in the left parietal/posterior left frontal lobes consistent with infarct core. No significant CBV/CBF mismatch to suggest penumbra.

CT brain 5 days later

Modality: CT

Hypodensity in the left frontal, temporal and parietal lobes is more markedly hypodense, but stable in distribution, consistent with evolution of the left MCA territory infarct. Hyperdensity within the infarct, consistent with haemorrhagic transformation, is increased in volume. Intraparenchymal haemorrhage in the inferior left temporal lobe measuring 26 x 18 mm has slightly increased from 23 x 16 mm. There is increased associated mass effect, characterised by effacement of left cerebral hemispheric sulci, partial effacement of the left lateral ventricle and 3 mm rightward midline shift at the level of the septum pellucidum. Hyperdense left MCA is again demonstrated. No new infarct detected. Old infarcts in the right caudate head and right temporal lobe, associated with ex vacuo dilatation of the occipital and temporal horns of right lateral ventricle, are again demonstrated. 

Case Discussion

Typical appearances of haemorrhagic transformation following a large MCA territory stroke. Between 0.5-3% of ischaemic stroke patients will undergo haemorrhagic transformation with petechial haemorrhage much more common the haematomas. Of course, there is increased risk in patients treated with thrombolysis (up to 6%). 

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Case Information

rID: 23422
Case created: 14th Jun 2013
Last edited: 17th Oct 2016
Inclusion in quiz mode: Included

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