Petechial hemorrhagic transformation of MCA infarct

Case contributed by Assoc Prof Frank Gaillard


Sudden onset left hemiplegia.

Patient Data

Age: 65 years
Gender: Male

CT brain (within 60 min of symptom onset)

No acute intracranial hemorrhage. Ventricles and sulcal pattern are age appropriate. Basal cisterns are unremarkable.

Area of increased mean transit time (MTT) and normal cerebral blood flow in the right frontoparietal lobes is in keeping with an area of penumbra in the right middle cerebral artery territory.

The patient went on to recieve tPA. 

MRI next day

There is a large region of cortical and subcortical T2 signal abnormality involving the right middle cerebral artery (MCA) territory, which shows diffusion restriction. This is in keeping with established infarction. There is relative sparing of the right prefrontal gyrus.

There is extensive gyriform susceptibility on the SWI sequence, slightly smaller than the infarction area, and predominantly involving the temporal lobe.


CT brain 2 weeks later

A large area of low density change in the right middle cerebral artery territory is demonstrated with prominent regions of gyriform and punctate foci of high density. No subarachnoid or extra-axial hemorrhage identified. Minimal mass-effect is exerted on the right lateral ventricle however the
midline remains central.

No new regions of ischemic change compared to the MRI. The focal low density within the left cerebellar hemisphere is again noted and unchanged from the previous imaging and is likely to represent a previous ischemic insult.

Case Discussion

Petichial hemorrhages are the most common sort of hemorrhagic transformation encountered.

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Case information

rID: 23568
Published: 24th Jun 2013
Last edited: 22nd May 2020
Inclusion in quiz mode: Included

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