Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, London, United Kingdom,
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, Atkinson Morley Neurosurgery Centre, St George’s, University of London, Tooting, London, United Kingdom,
- Department of General and Special Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan.
Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, Atkinson Morley Neurosurgery Centre, St George’s, University of London, Tooting, London, United Kingdom,
DOI:10.25259/SNI_838_2020Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Saad Moughal1, Micaela Uberti2, Alaa Al-Mousa3, Salem Al-Dwairy3, Anan Shtaya2, Erlick Pereira2. Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review. 17-Mar-2021;12:105
How to cite this URL: Saad Moughal1, Micaela Uberti2, Alaa Al-Mousa3, Salem Al-Dwairy3, Anan Shtaya2, Erlick Pereira2. Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review. 17-Mar-2021;12:105. Available from: https://surgicalneurologyint.com/surgicalint-articles/10646/
Background: Subacute subdural hematomas (ASDH) are only treated surgically when they cause mass effect significant enough to give symptoms. Rarely, sub-ASDH may cause enough pressure to result in a malignant middle cerebral artery (MCA) territory infarction. Decompressive craniectomy (DC) is the last resort to reduce intracranial pressure following malignant MCA infarction. Herein, we review the literature and describe a case of MCA/posterior cerebral artery (PCA) territories infarction following drainage of a sub-ASDH that was treated with DC with good outcome.
Case Description: We report a case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2.
Conclusion: SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.
Keywords: Subdural hematoma, Malignant middle cerebral artery infarction, Decompressive craniectomy
Subdural hematomas (SDH) are a well-known entity that can result from a head injury. The natural history of subdural bleeds has been described elsewhere.[
A 62-year-old male previously fit and well presented with a 1-day history of severe headache following a cycling accident that caused a head injury. There was no altered consciousness and he was neurologically intact on arrival to ED. Computer tomography (CT) of the head showed a right hemispheric acute subdural hematoma (ASDH) with no significant mass effect [
Initial computed tomography (CT) demonstrated a small right acute subdural hematoma with minimal shift (a). CT performed at re-presentation demonstrated enlarged ASDH with mass effect (b). Right malignant middle cerebral artery/posterior cerebral artery territory infarction on CT (c) and MRI (T2, d).
Raised ICP can occur after an acute SDH; hence, maintenance of cerebral perfusion pressure is central to the treatment paradigm.[
In severe head injuries, vasospasm may be aggravated by hemoglobin blood products, due to SDH or subarachnoid hemorrhage, or mechanical force through endothelin-mediated hypercontractility.[
Hyponatremia is associated with an increased risk of mortality in hospitalized patients,[
DC a life-saving procedure for treatment of refractory raised ICP, in cases of large hemispheric infarction or significant head injury.[
Malignant supratentorial infarction following SDH is rarely reported. Expanding cerebral edema, hyponatremia, and reduced cerebral blood flow contribute to malignant infarction. Postoperative brain imaging in the context of progressive neurological deficit for subacute SDH is prudent to identify this rare complication. Surgical decompression was performed quickly to prevent tentorial herniation and death and produced a good functional outcome.
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