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Images in Neurology
May 2012

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

Arch Neurol. 2012;69(5):666. doi:10.1001/archneurol.2011.2327

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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