Precedence of Parenchymal Enhancement on CT Angiography to a Fatal Duret Hemorrhage
A 66-year-old man was admitted to the emergency department with a 3-day history of progressive headache, nausea and vomiting. He had been in a bed-ridden state with a bilateral posterior cerebral arterial infarction due to cardioembolism. He had taken aspirin (100 mg/day) and warfarin (4-5 mg/day) as well as hypertension medications. Physical examination revealed no definite neurologic deficits except for cognitive defects and bilateral medial hemianopsia. Both of his legs were slightly weak due to disuse atrophy. His vital signs were stable. Laboratory investigations revealed a coagulation abnormality with a prolongation of prothrombine time (33.3 sec), prothrombine time international normalized ratio (3.14), and activated partial thromboplastin time (37 sec). Brain CT on admission revealed left-side tentorial acute SDH and bilateral hemispheric chronic SDH, as well as a transtentorial downward herniation of the uncus with signs of increased intracranial pressure, such as sulcal obliteration and sylvian fissure obliteration (). The brain stem was unremarkable (). CTA was acquired with precontrast and arterial phase 2 hours after the initial CT for the evaluation of stroke risk. CTA revealed a prominent, wedge-shaped, enhancing lesion in the ventral pontomesencephalic area arterial phase (). During the first hospital day, his mental state rapidly decreased to stupor with pupil dilation and impaired light reflex. Subsequent brain CT revealed a small, acute hemorrhage in the tegmentum of the pontomesencephalic junction area and an increase in the amount of tentorial SDH (). After the coagulation abnormality was corrected to normal with the administration of fresh frozen plasma, the chronic SDH was operated with trephination as usual. After the operation, the patient was still in a stupor with pupil dilation and impaired light reflex. A postoperative brain CT revealed a large pontine and midbrain hemorrhage with an intraventricular hemorrhage (). He remained in a vegetative state for approximately 2 years and died due to respiratory distress.