Ipsilateral parenchymal hemorrhage after hemicraniectomy in a patient suffering from malignant middle cerebral artery infarction.

INTRODUCTION

Early hemicraniectomy reduces mortality in malignant middle cerebral artery (MCA) infarctions to 16%, although the benefit on functional outcome is still unclear. We treat patients with malignant MCA infarction younger than 60 years. Epidural or subgaleal hemorrhages are relatively common complications. Only 1 trial described parenchymal hemorrhage as a complication of hemicraniectomy.

CASE REPORT: A 55-year-old man was admitted to our stroke unit with right-sided hemiparesis and aphasia. NIHSS was 18; GCS, 3. The initial CT showed hypoattenuation in the basal ganglia and the insular ribbon on the left side. CT-angiography showed M1 occlusion. Despite thrombolysis with rtPA in the 3-hour time window, no recanalization was achieved. We performed early hemicraniectomy. Additionally, we started mild hypothermia and deep sedation to prevent increasing cerebral edema. Control CT on day 2 showed intracerebral hemorrhage and an obstructive hydrocephalus because of intraventricular blood. To avoid herniation, the patient received an extraventricular drainage (EVD). Thereafter, the intracerebral pressure remained stable. The patient was discharged, with a NIHSS of 18 and GCS of 10.

CONCLUSION

The reported patient is the first in the literature that suffered from deep hemorrhage after hemicraniectomy. Hemorrhagic transformation might be a risk factor for clinically relevant hemorrhage after hemicraniectomy.