Right middle cerebral artery ischaemic stroke with hemorrhagic transformation

Case contributed by Dr Subash Thapa


Disoriented with sudden onset of left sided weakness, GCS 6/15 at the time of presentation to ER.

Patient Data

Age: 72 years
Gender: Male

There is a large, ill-defined hypo-attenuating area with loss of gray-white matter differentiation involving the right cerebral hemisphere with an irregular hyper-attenuating area of blood density within and also extending to the right lateral ventricle. Right proximal MCA is hyper-attenuated: “Hyperdense MCA”.

The significant mass effect is evidence by the effacement of the ipsilateral Sylvian fissure, adjacent cortical sulci, lateral ventricle with midline shift toward the contralateral side.  Subfalcine herniation also noted.

Annotated image showing hyperdense MCA sign and subfalcine herniation. 


Right MCA territory infarction with hemorrhagic transformation (dense hematoma >30% with space occupying effect with evidence of intraventricular extension - parenchymal hematoma type 2).

Case Discussion

Hemorrhagic transformation is due to the permeability disruption of the blood-brain barrier by matrix metalloproteinases and free radical pathway during ischemia and reperfusion.

According to the imaging, European Cooperative Acute Stroke Study trialists classified haemorrhagic transformation into four categories 1:

  • haemorrhagic infarction type 1 (HT-1): small petechiae along the margin of infarct
  • haemorrhagic infarction type 2 (HT-2): confluent petechiae within infarct without space occupying effect
  • parenchymal hematoma type 1 (PH-1): haematoma  30% or less with some space occupying effect
  • parenchymal hematoma type 2 (PH-2): dense hematoma >30% with space occupying effect or any hemorrhagic lesion outside the infarcted area

PlayAdd to Share

Case information

rID: 40235
Published: 14th Oct 2015
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

Updating… Please wait.

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.