Presentation
Left hemiplegia
Patient Data
The right middle cerebral artery is hyperdense and there is subtle blurring and swelling of the cortex in the MCA territory.
CTA demonstrates occlusion of the M1 segment on the right.
MRI demonstrates infarction of the inferior division of the MCA territory on the right as well as the right ACA territory. The basal ganglia are also infarcted due to occlusion of the lenticulostriate perforators.
The regions seen to demonstrate restricted diffusion on DWI have become well demarcated and hypodense. Significant mass effect is now present with midline shift and obstruction of outflow of the left lateral ventricle. There is petichial hemorrhagic transformation involving the right lentiform nucleus.
A decompressive craniectomy has been performed with some improvement in the degree of midline shift. An extradural collection is present.
Swelling is abating and parts of the infarcted tissue have almost returned to normal density - so called fogging phenomenon.
Negative mass effect is now present with concavity of the decompressive craniectomy site.
Case Discussion
This case demonstrates typical progression of a very large infarct treated with decompressive craniectomy, often a life saving maneuverer.
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