Q11613 [Neurosurgery Wiki]

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====== Q11613 ======

[[Hemorrhagic Transformation]] of Left M1 [[Ischemic Stroke]]: Multidisciplinary Management and Outcomes

Authors:
Miguel Herrera Murillo, MD; Juan Sales Llopis, MD, PhD; 

Affiliation:
Department of Neurosurgery, Hospital General Universitario Dr. Balmis, Alicante, Spain

Abstract
This [[case report]] details the management of a 55-year-old male presenting with an [[ischemic stroke]] involving the left [[middle cerebral artery]] (MCA) and subsequent [[hemorrhagic transformation]] (HT). The patient underwent stent-assisted [[angioplasty]] for left M1 stenosis and experienced post-procedural complications, including [[intraparenchymal hemorrhage]], [[intraventricular hemorrhage]] [[acute hydrocephalus]], and ventilator-associated [[pneumonia]]. A [[multidisciplinar]]y approach, involving neurology, neurosurgery, and [[critical care]] teams, enabled [[stabilization]] and transfer to a referral center for continued [[rehabilitation]]. This case highlights the complexities of managing ischemic stroke with HT and the role of timely interventions, including [[external ventricular drainage]] and tailored [[antibiotic]]s.

Introduction

Hemorrhagic transformation (HT) is one of the recognized [[ischemic stroke complications]], particularly in patients undergoing [[reperfusion]] therapies. The management of HT poses significant clinical challenges due to the risk of neurological deterioration, increased [[intracranial pressure]] (ICP), and secondary complications, such as [[infection]]. This report discusses a case of HT managed with stent-assisted angioplasty, external ventricular drainage, and comprehensive ICU care.

Case Presentation

Patient Profile:

A 55-year-old male, former [[smoker]], with a history of bilateral occupational hearing loss and hypertension managed with [[atenolol]] and [[losartan]].
Presented to the emergency department following an acute onset of right upper limb paresthesia, aphasia, and altered consciousness.

Clinical Course:

Initial Evaluation and Management:

CT and multimodal imaging suggested left M1 occlusion with [[ischemic penumbra]] ([[ASPECTS]] 10).

Emergency [[angiography]] confirmed M1 stenosis, treated with angioplasty and stent placement.

Neurological Deterioration and Hemorrhagic Transformation:

The patient developed right hemiplegia, aphasia, and decreased consciousness.
CT revealed an intraparenchymal hematoma with ventricular extension and subarachnoid hemorrhage.

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[[External Ventricular Drain for Hydrocephalus Following Intraventricular Hemorrhage]] was performed


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Intensive Care Unit Management:

Sedation with propofol and midazolam; mechanical ventilation initiated.
HT managed with ICP monitoring and controlled hypertension.
Ventilator-associated pneumonia by Enterobacter cloacae and Serratia marcescens treated with meropenem and ceftolozane/tazobactam.
Percutaneous tracheostomy was performed for prolonged respiratory support.
Neuroimaging Findings:

Serial CT scans demonstrated resolving hematoma and ventricular hemorrhage, with no new ischemic lesions.

{{:pasted:20241204-091005.png?400}}

The EVD was removed after confirming stable ventricular size.
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Discussion

Hemorrhagic transformation of ischemic stroke represents a critical event requiring coordinated management. In this case, stent-assisted angioplasty successfully addressed the underlying vascular stenosis but was followed by HT, necessitating surgical and critical care interventions.
Key management strategies included:

Prompt recognition and surgical management of hydrocephalus with EVD placement.
Strict ICP monitoring and permissive hypertension to maintain cerebral perfusion pressure.
Multidisciplinary collaboration for managing respiratory complications, including ventilator-associated pneumonia and subsequent tracheostomy.
This case underscores the importance of early recognition, aggressive management, and individualized care for ischemic stroke complicated by HT.
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Conclusion
This case highlights the challenges and complexities of managing ischemic stroke with hemorrhagic transformation. Successful outcomes hinge on early diagnosis, a multidisciplinary approach, and tailored therapeutic strategies. Future research should focus on refining intervention protocols to minimize complications in similar clinical scenarios.

Key Points
Challenges: HT, acute hydrocephalus, and infection in a critical care setting.
Interventions: Angioplasty with stenting, EVD placement, and targeted antimicrobial therapy.
Outcomes: Neurological stabilization and successful transition to rehabilitation.

Conflicts of Interest: None declared.

Funding: No external funding was received.

Ethics Approval: Informed consent was obtained from the patient for the publication of this case report.