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Images in Neurology |

Ultra Hyperacute Magnetic Resonance Findings in Reperfusion Hemorrhage

Jordan Samuels, MD1; Miral Jhaveri, MD2; James J. Conners, MD1; Shawna Cutting, MD1; Shyam Prabhakaran, MD, MS3; Vivien H. Lee, MD1
[+] Author Affiliations
1Section of Stroke, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
2Department of Radiology, Rush University Medical Center, Chicago, Illinois
3Department of Neurology, Northwestern University, Chicago, Illinois
JAMA Neurol. 2014;71(3):364-365. doi:10.1001/jamaneurol.2013.131.
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A 75-year-old woman with a history of paroxysmal atrial fibrillation and aspirin therapy presented with global aphasia, left gaze deviation, and right hemiplegia. She was last seen without acute symptoms 10 hours before this examination. She had a score of 21 on the National Institutes of Health Stroke Scale (a clinical assessment tool to quantitatively measure neurologic deficit related to stroke), and her blood pressure was 130/84 mm Hg. A computed tomographic (CT) brain scan (at 9:29 am) showed early infarct changes in the left middle cerebral artery territory, and a CT angiogram showed a left M1 occlusion (Figure 1). Magnetic resonance imaging (MRI) of the brain (at 4:24 pm) showed a new hemorrhage that expanded during the MRI scan with increasing mass effect and midline shift (Figure 2). Gradient echo (GRE) showed an isointense/hyperintense mass without a hypointense rim. Magnetic resonance angiography of the head indicated recanalization of the left M1 segment. After the patient was returned to the ward (at 5:30 pm), clinical deterioration was noted with coma and extensor posturing. Her blood pressure was 218/91 mm Hg, and her pulse was 120 beats/min. A CT scan of the brain confirmed intracerebral hemorrhage (ICH). The patient’s condition progressed to brain death by the next day.

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Figure 1.
Computed Tomography (CT) Brain Scan (9:29 am)

Subtle hypodensity was present in the left insular ribbon and lentiform nucleus with mild effacement of the left lateral ventricle, consistent with an early infarct (double arrowheads) (A). Computed tomographic perfusion and a CT angiogram of the head (11:19 am) demonstrated left middle cerebral artery deep zone of infarct (red) surrounded by an area of penumbra (green) (B) and left M1 occlusion (arrowhead) (C).

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Figure 2.
Magnetic Resonance Images Shown in Temporal Sequence of Acquisition With Expanding Hemorrhage (Double Arrowheads) and Progressive Mass Effect and Worsening Midline Shift

A T1-weighted image (4:24 pm) showed subtle hypointensity in the left lentiform nucleus with mild effacement of the anterior horn of the left lateral ventricle (A). A diffusion-weighted image (4:27 pm) showed an area of restricted diffusion in the left subcortical region confirming an acute infarct (B). T1-based source images for magnetic resonance angiography (4:32 pm) showed a hypointense mass with a significant increase in midline shift (C). Fluid-attenuated inversion recovery (5:06 pm) showed continued expansion of the hyperintense mass (D). Gradient echo (5:09 pm) showed a heterogeneous isointense/hyperintense mass without a hypointense rim (E). A computed tomography brain scan (8:06 pm) confirmed a large hemorrhage with herniation (F).

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