Differentiating between Hemorrhagic Infarct and Parenchymal Intracerebral Hemorrhage

Figure 5

69-year-old man with atrial fibrillation on warfarin, he presented with a 2-day history of left hemiparesis and neglect. (a) Initial axial unenhanced CT images show hemorrhage in the right basal ganglia, involving the right caudate head, unusual for ICH. Stage IIH d1 [1]. Warfarin was stopped and anticoagulation was reversed. (b) Axial unenhanced CT images 10 days later show further extension of hematoma with the surrounding hypodensity extending out to the cortex. (c) Axial unenhanced CT images 1 month after stroke show an extensive area of hypoattenuation in the right MCA territory. There is also an area of low attenuation more posteriorly (thin arrow), not evident on the previous CT and separate from the initial stroke, raising the possibility of a new subacute infarct since the first stroke. (d) Axial T2-weighted MR images 3 months after stroke show the posterior temporal infarct evident on the last CT scan more clearly, suggestive of bland infarction in that region. The cessation of warfarin after the first stroke probably contributed to this cardioembolic stroke. (e) On reviewing the initial CT images, a dense right middle cerebral artery sign is present on the coronal view (but not axial), further suggesting the first stroke is a hemorrhagic infarct rather than a hemorrhagic stroke.