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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 an increase in the geographic extent of the edema with mass effect causing subfalcine herniation.  The herniation has produced compression of the bilateral anterior cerebral arteries.   NOTE:  now this lesion includes the medial frontal lobe and head of the caudate nucleus - which are in the anterior cerebral artery territory.
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MPX1634_synpic58261: There is an increase in the geographic extent of the edema with mass effect causing subfalcine herniation. The herniation has produced compression of the bilateral anterior cerebral arteries. NOTE: now this lesion includes 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 an increase in the geographic extent of the edema with mass effect causing subfalcine herniation.  The herniation has produced compression of the bilateral anterior cerebral arteries.   NOTE:  now this lesion includes 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_synpic58261: There is an increase in the geographic extent of the edema with mass effect causing subfalcine herniation. The herniation has produced compression of the bilateral anterior cerebral arteries. NOTE: now this lesion includes 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.