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Brain herniation from subacute cerebral infarction

Dowdy KED - MedPix (2013)

View Article: MedPix Image - MedPix Case

Affiliation: Walter Reed National Military Medical Center

ABSTRACT

Diagnosis: Brain herniation from subacute cerebral infarction

History: 23 y.o. woman who was admitted from an outside hospital after becoming unresponsive for > 1 hour. She has a PMHx of stage IV NSCLC metastatic to liver & bone, a recent hospitalization for pneumonia, and h/o PE while on anticoagulation s/p IVC filter placement, Her admission non-contrast head CT was "consistent with large right MCA embolic stroke". Two days later, she has became less responsive.

Findings: INITIAL MRI: 1. Large right MCA perfusion territory infarct, likely secondary to embolic disease given patient's history of adenocarcinoma and likely hypercoagulable state. FOLLOW-UP HEAD CT: 1. Extensive cytotoxic edema in most of the right middle cerebral artery territory, consistent with known ischemic stroke. No evidence of hemorrhage. 2. New subfalcine herniation with approximately 1 cm of right-to-left midline shift. New ischemic stroke throughout the right anterior cerebral artery territory, which may be due to vascular compression from the subfalcine herniation.

Ddx: • Ischemic stroke of right anterior cerebral artery • Hemorrhagic conversion of large right middle cerebral artery • Cytotoxic edema causing subfalcine herniation and resultant compression of right ACA

Dxhow: Clinical and Serial Imaging, MR & CT

Exam: Neurologic exam: Patient is intubated, lethargic, following simple commands intermittently when requested to move R arm, but unable to close or open eyes when requested. Opening eyes spontaneously, also moving spontaneously four extremities. GCS 11 (E4, V1, M6). MOTOR: Normal tone and bulk. Patient moved R upper limb to command, did not move lower limbs to command, although she was moving spontaneously both L and R foot. 3 beats clonus right ankle. Deep tendon reflexes R / L Brachio 3 / 2 Biceps 3 / 2 Triceps 3 / 2 Patellar 3 / 2 Suprapatellar 3 / 2 Ankle 3 / 2 Plantar response Ext / Ext Pt withdraws to pain in all extremities.

No MeSH data available.


There is a large territory of restricted diffusion in the right MCA (middle cerebral artery) consistent with intracellular cytotoxic edema from cerebral infarction.  NOTE:  this diffusion lesion spares the medial frontal lobe and head of the caudate nucleus - which are in the anterior cerebral artery territory.
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MPX1634_synpic58259: There is a large territory of restricted diffusion in the right MCA (middle cerebral artery) consistent with intracellular cytotoxic edema from cerebral infarction. NOTE: this diffusion lesion spares the medial frontal lobe and head of the caudate nucleus - which are in the anterior cerebral artery territory.


Brain herniation from subacute cerebral infarction

Dowdy KED - MedPix (2013)

There is a large territory of restricted diffusion in the right MCA (middle cerebral artery) consistent with intracellular cytotoxic edema from cerebral infarction.  NOTE:  this diffusion lesion spares the medial frontal lobe and head of the caudate nucleus - which are in the anterior cerebral artery territory.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=MPX1634&req=5

MPX1634_synpic58259: There is a large territory of restricted diffusion in the right MCA (middle cerebral artery) consistent with intracellular cytotoxic edema from cerebral infarction. NOTE: this diffusion lesion spares the medial frontal lobe and head of the caudate nucleus - which are in the anterior cerebral artery territory.

View Article: MedPix Image - MedPix Case

Affiliation: Walter Reed National Military Medical Center

ABSTRACT

Diagnosis: Brain herniation from subacute cerebral infarction

History: 23 y.o. woman who was admitted from an outside hospital after becoming unresponsive for > 1 hour. She has a PMHx of stage IV NSCLC metastatic to liver & bone, a recent hospitalization for pneumonia, and h/o PE while on anticoagulation s/p IVC filter placement, Her admission non-contrast head CT was "consistent with large right MCA embolic stroke". Two days later, she has became less responsive.

Findings: INITIAL MRI: 1. Large right MCA perfusion territory infarct, likely secondary to embolic disease given patient's history of adenocarcinoma and likely hypercoagulable state. FOLLOW-UP HEAD CT: 1. Extensive cytotoxic edema in most of the right middle cerebral artery territory, consistent with known ischemic stroke. No evidence of hemorrhage. 2. New subfalcine herniation with approximately 1 cm of right-to-left midline shift. New ischemic stroke throughout the right anterior cerebral artery territory, which may be due to vascular compression from the subfalcine herniation.

Ddx: • Ischemic stroke of right anterior cerebral artery • Hemorrhagic conversion of large right middle cerebral artery • Cytotoxic edema causing subfalcine herniation and resultant compression of right ACA

Dxhow: Clinical and Serial Imaging, MR & CT

Exam: Neurologic exam: Patient is intubated, lethargic, following simple commands intermittently when requested to move R arm, but unable to close or open eyes when requested. Opening eyes spontaneously, also moving spontaneously four extremities. GCS 11 (E4, V1, M6). MOTOR: Normal tone and bulk. Patient moved R upper limb to command, did not move lower limbs to command, although she was moving spontaneously both L and R foot. 3 beats clonus right ankle. Deep tendon reflexes R / L Brachio 3 / 2 Biceps 3 / 2 Triceps 3 / 2 Patellar 3 / 2 Suprapatellar 3 / 2 Ankle 3 / 2 Plantar response Ext / Ext Pt withdraws to pain in all extremities.

No MeSH data available.