Right middle cerebral artery ischemic stroke with hemorrhagic transformation
Presentation
Disoriented with sudden onset of left sided weakness, GCS 6/15 at the time of presentation to ER.
Patient Data
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 evidenced 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.
Diagnosis
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 hemorrhagic transformation into four categories 1:
- hemorrhagic infarction type 1 (HT-1): small petechiae along the margin of infarct
- hemorrhagic infarction type 2 (HT-2): confluent petechiae within infarct without space occupying effect
- parenchymal hematoma type 1 (PH-1): hematoma 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
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