A 45 year old woman developed the abrupt onset of a left hemiplegia, right gaze preference and left visual field loss. Her EKG showed atrial fibrillation.
Axial CT scans. (Left) Day 2; (Right) Day 4. Note the large infarction in the distribution of the right middle and posterior cerebral arteries. As the PCA territory is darker, this infarction is several days older than the MCA. There also may be a small hemorrhagic transformation deep in the basal ganglia.
In a patient this age, this is typically a lethal lesion. As the stroke is so large, as it swells, intracranial pressure increases, ultimately resulting in herniation and death. To prevent herniation intracranially, a hemicraniectomy can be performed (right image) where the a skull flap is removed. Hence, the brain can swell and herniate extracranially. Note on the right image, the herniation of brain through the surgical opening. This procedure is most appropriate to consider with right sided lesions (i.e., primary language area unaffected) and in patients with very large strokes.
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