Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review

• Published in: Surgical neurology international Vol. 12; p. 105
• Main Authors: Moughal, Saad, Uberti, Micaela, Al-Mousa, Alaa, Al-Dwairy, Salem, Shtaya, Anan, Pereira, Erlick
• Format: Journal Article
• Language: English
• Published: United States Scientific Scholar 17.03.2021
• Subjects: Case Report; Decompressive craniectomy; Malignant middle cerebral artery infarction; Subdural hematoma
• ISSN: 2229-5097; 2152-7806; 2152-7806
• DOI: 10.25259/SNI_838_2020

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. 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. SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.