Age: 55
Sex: Male
Indication: Recent stroke, worsening clinical exam
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Case #9
Findings
- Extensive hypoattenuation and loss of gray-white differentiation throughout the right MCA and bilateral ACA territories with smaller hypodense areas in the bilateral PCA territories, the right cerebral peduncle, and in the right greater than left cerebellar hemispheres
- Substantial right to left midline shift with diffuse cerebral sulcal effacement, subfalcine herniation, downward transtentorial herniation, and slight inferior descent of the cerebellar tonsils through the foramen magnum. Linear hyperdensity in the left hemipons
- Enlargement of the atrium and temporal horn of the left lateral ventricle with surrounding hypodensity in the periventricular white matter
- Sequela of right hemicraniectomy with brain parenchyma herniating slightly through the operative defect and small volume hemorrhage and gas in the surgical epidural space
- Remote appearing left basal ganglia infarct
- Frothy secretions and fluid levels in the paranasal sinuses. Secretions layering in the nasopharynx
Diagnosis
- Downward transtentorial herniation with Duret hemorrhage and obstructive hydrocephalus
- Multiterritorial ischemia
Sample Report
Evolving multiterritorial ischemia involving the right MCA and bilateral ACA territories with smaller areas of likely acute/early subacute ischemia in the bilateral PCA territories, the right cerebral peduncle, and in the right greater than left cerebellar hemispheres.
Despite changes of right hemicraniectomy, there is associated 20 mm right to left midline shift with diffuse cerebral sulcal effacement, right subfalcine herniation, downward transtentorial herniation, and slight inferior descent of the cerebellar tonsils through the foramen magnum. Linear hyperdensity in the left hemipons is consistent with Duret hemorrhage. Findings concerning for associated left lateral ventricular entrapment with transependymal flow of CSF.
Small volume hemorrhage and gas in the surgical epidural space associated with the right hemicraniectomy.
Remote appearing left basal ganglia lacunar infarct.
Frothy secretions and fluid levels in the paranasal sinuses. Secretions layering in the nasopharynx. These findings like relate to the patient’s intubated status.
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