Stroke progression

Case contributed by Ettie Ben-Shabat
Diagnosis certain

Presentation

Woke up with right hemiplegia and speech disturbance

Patient Data

Age: 35 years
Gender: Male

Initial imaging

ct

Hyperdense left middle cerebral artery sign is visible, with a clot in the M1 segment. Grey-white matter differentiation is grossly preserved. No established cortical infarct. 

Large perfusion mismatch (103ml 72%) and a small infarct core (40ml - 28%).

This individual proceeded to receive thrombolysis and underwent an endovascular clot retrieval.

Post clot retrieval

ct

Following endovascular clot retrieval, focal areas of grey-white matter differentiation loss are present within the left frontal lobe, and insular region. These areas correspond to the areas of reduced cerebral blood flow and increased time to peak. Overall compatible with acute cerebral infarct.

High-density material within the left basal ganglia is present.  Mass effect is present and evident by effacement of the left cerebral sulci and lateral ventricle. No significant midline shift is observed.  

Perfusion mismatch 89 ml with infarct core of 44 ml.

It was decided that this individual should undergo a second endovascular clot retrieval.

Post 2nd clot retrieval

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Day 1 post stroke, thrombolysis and 2 x clot retrievals.

Evolution of left MCA territory infarction with further loss of grey-white matter differentiation and increase extent of hypodensity. 

Marked cytotoxic edema associated with increased midline shift (8mm) and left uncal herniation. The left lateral ventricle is almost entirely compressed and new dilatation of the right lateral ventricle temporal horn is in keeping with evolving hydrocephalus.  

Hyperdense foci within the region of infarction favor contrast staining and are decreasing in density compared to the previous scan.

The patient went on to receive an emergency decompressive craniectomy.

Day 3

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Day 3 post-stroke, and one day after emergency decompressive craniectomy.

Expected evolution of the known large left MCA territory infarct, with marked surrounding edema, which results in near-complete effacement of the left lateral ventricle. Reduced uncal herniation and subfalcine herniation to the right following a decompressive craniectomy. Midline shift is currently measuring 4 mm.

New left parafalcine subdural hemorrhage measuring 6 mm in maximal diameter, with an extension over the left tentorium cerebellar. Hyperdense left extra-axial collection in the region of the left craniectomy consistent with postoperative blood, with multiple subcutaneous gas locules.

Further reduction in left basal ganglia hyperdensity, most in keeping with contrast staining from the recent endovascular clot retrieval. No new loss of grey-white matter differentiation.

Day 30

ct

Left hemicraniectomy with marked cytotoxic edema within the left fronto-parieto-temporal lobe and basal ganglia, which herniates through the craniectomy. 

Heterogeneous low density extra-axial collection overlying the herniated brain in keeping with a seroma/hygroma.

There is a stable degree of vasogenic edema with no new intracranial hemorrhage, midline shift or hydrocephalus. Moderate vacuo dilatation of the left lateral ventricle.

Day 84

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Day 84 post-stroke

Extensive encephalomalacia of left MCA territory brain involving the left middle and inferior frontal lobe gyri, most of the parietal lobe and most of the temporal lobe superior and middle gyri with preservation of the temporal pole. 

There is interval reduction in the degree of residual parenchymal swelling and decreased bulging of the left cerebral convexity dura through the craniectomy defect.  Persistent but decreased herniation of left inferior temporal lobe gyrus parenchyma over the residual left parietal bone.

Mild to moderate increase in size of the extradural CSF fluid collection which measures 2.4 cm depth by 17.8 cm craniocaudal by 15.8 cm anterior-posterior. 

Case Discussion

Thrombolysis and thrombectomy have become important treatment options for stroke care1. Yet, the success of these treatments may vary across individuals. In this case, the lesion progressed to a malignant stroke. Lesion extension occurred despite:

  • thrombolysis
  • two retrievals of a proximal clot
  •  young age and,
  • presentation to the hospital within a treatable time window.

By viewing early brain images, rehabilitation clinicians can evaluate treatment outcomes and residual lesions. The scan from day 1 post-stroke, provides the first evidence that the lesion progressed to a large MCA infarct. The scan also shows evidence of swelling, uncal herniation and a small bleed.

Knowledge of the exact location and extent of the lesion can further aid rehabilitation clinicians in prognostication. The impacted anatomical structures can be viewed clearly on the scan from day 3. The images show that the lesion engulfed the IFG, hence causing persistent expressive aphasia. The images also show preserved medial motor cortices, with affected lateral cortices. This explains the functional recovery of mobility, but the lack of meaningful hand function recovery. 

This case demonstrates that brain images can assist prognostication and formation of treatment goals, well before the person is able to engage in active rehabilitation.

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