Bilateral Middle Cerebral Artery

Cerebrovascular Accidents and

Hemorrhagic Transformations.
Abstract
Middle Cerebral Artery (MCA) ischemic strokes are the most common locations
for cerebrovascular accidents (CVA). They usually arise from thrombosis in the
artery leading to hypoxia and eventual ischemia. The MCA divides into two
divisions the superior and inferior, they supply roughly 2/3 of the lateral
surfaces and the temporal lobes left and right respectfully. Ischemia in these
regions can result in various motor and sensory deficits.
Haemorrhagic transformation is a frequent consequence of thrombolytic therapy
of ischemic strokes. Once the brain tissue is subject to tissue ischemia is loses its
ability to retain blood efficiently, therefore after thrombolytic treatment rapid
reperfusion can lead to a hemorrhagic transformation/conversion.
The following discussion follows a patient who has had bilateral CVAs and
hemorrhagic transformation and the ability to distinguish this from
subarachnoid hemorrhage.

Learning Points
MCA ischemia can cause contralateral facial and upper extremity
hemiparesis plus speech and sensory deficits.
Thrombolytic treatment can lead to reperfusion resulting in hemorrhagic
transformation of ischemic strokes.

Case Report
A 49 year old African American woman with past medical history of
hypertension (HTN), asthma, venous thromboembolism (VTE) located in her leg
in 2013 for which she completed anticoagulation therapy and previous stoke in
1992. She presented to the ER with left sided facial droop. She said that she
woke up that morning with the left sided facial droop, however denies any
headache, vision problems, tingling, numbness, pins and needles on the face and
any drooling. She has no other complaints and denies chest pain, abdominal pain,
nausea, vomiting, constipation, diarrhea or any urinary irregularities.

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She doesnt have any past surgical history. She denied hyperacusis or loss of
taste or any preceding viral syndrome.
The patient denied any smoking or alcohol intake, however does have a
significant history of heroine use for which she is currently on methadone 40mg
daily for the past 3 months. She was also taking Hydrochlorothiazide (HCTZ)
At presentation she had facial asymmetry on the left side, 4/5 strength in the left
upper arm, and 5/5 in the right upper arm, lower limb reflexes 3+ globally.
(Insert any vitals)
Patient was then admitted to the ward for further evaluation and monitoring, she
was put on fall risk and aspiration risk. Cardiac enzymes, EKG, 2D echo and
carotid Doppler were ordered and she was put on aspirin 325mg, Zocor 40mg,
and continued methadone to avoid any withdrawal symptoms. DVT prophylaxis
was also initiated.
The patient was aware of her surrounding and passes MMSE and was also able to
follow commands.
On examination there was a slight positive pronator drift noticed on the left side
and Babinski sign was positive on the left side also.
The patient suffered a seizure, and was treated and sent for a head CT.
(Insert image?)
The results of the CT showed a new acute infarct in the left frontoparietal lobe
plus Developing acute to subacute infarct in the right parietal lobe with new
hemorrhagic transformation versus small subarachnoid hemorrhage. (wording)
Patients labs were reviewed and she was transferred to ICU, she was given Ted
Hose due to her history of DVT she was also started on Keppra 1g m BID.
She also developed left lung pneumonia due to complete atelectasis of the left
lung due to mucus plugging, along with left maxillary sinusitis, she was given
mucomyst for the plugging. Status post tracheostomy and G-tube placement
showed leucocytosis.
Mechanical ventilation was continued, given IV decadron and antibiotic coverage
for pneumonia and empiric antifungal coverage whilst pending blood cultures
were being done.
Having stabilized the patient she was transferred to a chronic ventilator hospital

Discussion