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.
Samuels J, Jhaveri M, Conners JJ, Cutting S, Prabhakaran S, Lee VH. Ultra Hyperacute Magnetic Resonance Findings in Reperfusion Hemorrhage. JAMA Neurol. 2014;71(3):364-365. doi:10.1001/jamaneurol.2013.131