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Images in Neurology |

Severe Decrease in Cerebral Blood Volume, Recanalization, and Hemorrhagic Transformation After Thrombolysis

Tae-Hee Cho, MD; Laura Mechtouff, MD; Laurent Derex, MD, PhD; Marc Hermier, MD, PhD; Norbert Nighoghossian
Arch Neurol. 2012;69(5):666. doi:10.1001/archneurol.2011.2327.
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A 70-year-old man with atrial fibrillation was admitted to our hospital for right-sided hemiplegia and aphasia (with a National Institutes of Health Stroke Scale score of 17). Imaging features are summarized in the Figure; notably, perfusion magnetic resonance imaging, using dynamic susceptibility contrast, showed a severe decrease in cerebral blood volume (CBV) within the left anterior cerebral artery territory. Intravenous thrombolysis, administered 175 minutes after the onset of symptoms, failed to improve clinical status. A thrombectomy was scheduled but was eventually cancelled after witnessing recanalization of the left anterior cerebral artery during angiography. The left middle cerebral artery had features suggestive of a chronic occlusion (extensive collateral circulation from perforators and the middle meningeal artery, and no diffusion anomaly in this territory) and was not treated. A fatal hemorrhage within the area of very low CBV occurred 12 hours after thrombolysis, with diffuse subarachnoid and intraventricular extension.

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Figure. Magnetic resonance imaging scan of diffusion lesion in the left anterior cerebral artery (ACA) territory (A), collapse of blood vessels (ie, reduction in cerebral blood volume) in the left ACA territory (B), and hypoperfusion on time-to-peak map within the left ACA and the left middle cerebral artery (MCA) territories (C). D, Angiograph showing ACA occlusion (arrow) and collateral vessels suggestive of a chronic MCA occlusion (arrowheads). E, Angiograph showing ACA recanalization (arrow). F, Follow-up computed tomographic scan.

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