Presentation
Prior right-sided MCA ischemia about 3 months earlier. Acutely developing nausea, dysarthria, complex oculomotor disturbance.
Patient Data
Age: 90 years
Gender: Female
From the case:
Malignant posterior circulation territory ischemic stroke
{"current_user":null,"step_through_annotations":true,"access":{"can_edit":false,"can_download":true,"can_toggle_annotations":true,"can_feature":false,"can_examine_pipeline_reports":false,"can_pin":false},"extraPropsURL":"/studies/115078/annotated_viewer_json?iframe=true\u0026lang=us"}
- known deeply hypodense chronic ischemic changes in the right frontal lobe, in line with the recently sustained MCA territory infarct
- subtle hyperdensity of the right PCA on the noncontrast scan, corresponding lack of contrast filling on the CTA, indicating occlusion
- patchy resultant hypodensity of the right occipital lobe is best appreciated on the CTA source images
- marked hypodensity primarily in the right hemicerebellum also seen well on the CTA source images, indicating simultaneous superior cerebellar artery territory infarction
- severe chronic small vessel ischemic changes, predominantly in the periventricular deep matter (Fazekas III.)
- likely extra-axial, vividly enhancing mass lesion in the left frontal region, virtually indistinguishable on the noncontrast scan, appearance in line with meningioma
- left frontal arachnoid cyst close to the vertex
Thrombolysis was promptly initiated, however the status of the patient continued to deteriorate.
24h later post thrombolysis
From the case:
Malignant posterior circulation territory ischemic stroke
{"current_user":null,"step_through_annotations":true,"access":{"can_edit":false,"can_download":true,"can_toggle_annotations":true,"can_feature":false,"can_examine_pipeline_reports":false,"can_pin":false},"extraPropsURL":"/studies/115075/annotated_viewer_json?iframe=true\u0026lang=us"}
The extent of ischemic changes is now clearly depicted on the non contrast scan too.
- the occipital. PCA territory involvement is limited and not expansile
- most of both cerebellar hemispheres are hypodense, individual folia can be longer appreciated due to marked vasogenic edema
- limited sparing peripherally, primarily in the left hemicerebellum, and the region of the dentate nuclei
- effacement of the fourth ventricle, as well as the extra-axial CSF spaces infratentorially, the prepontine space also becoming virtual
- descended cerebellar tonsils (see prior exam for comparison), altogether severe brainstem compression and early phase of tonsillar herniation
Case Discussion
While the potential malignant course of middle cerebral artery infarctions is well known, severe vasogenic edema and resultant brainstem compression can result in a similarly sinister disease course in infratentorial ischemic strokes.
Considering the multiple comorbidites and potential outcomes best supportive care was provided and the patient passed away a few hours later.