[Extravasation of contrast media in an acute stage of middle cerebral artery occlusion-in relation to haemorrhagic infarction (author's transl)].

Following an embolic occlusion of a major cerebral artery with peripheral migration of emboli in the early stage, cerebral haemorrhage from the recanalized perforators may occur in the infarcted zone. The following is a report of such a case. This 66-year-old-man with normotension suffered from sudden unconsciousness and left-sided paresis. On admission to our clinic five hours after onset, the patient was confused with urinary incontinence, left hemiplegia and irregular pulse. The first CT examination, which was performed immediately after admission, showed a small-sized haematoma surrounded by an obscure broad low density area in the region of the right caudate nucleus. Right carotid angiography which was performed after CT scan revealed an occlusion at the trifurcation level of the right middle cerebral artery and extravasation of contrast media from the right lenticulostriate arteries. Because of deterioration of the patient's condition, a second CT scan was done showing an extensive haematoma in the whole basal ganglionic region with ventricular rupture. An emergency decompressive craniectomy with evacuation of the haematoma was carried out with immediate postoperative improvement of the patient's condition. Judging from the mode of onset, clinical course as well as neuroradiological and preoperative findings, the pathogenesis behind the haemorrhagic infarction could be interpreted as follows: At the onset, a thromboembolic occlusion probably occurred in the right internal carotid artery with lack of sufficient collateral circulation. Before or during the first CT examination, the embolus may have migrated to the middle cerebral artery. Therefore, the reflow in the perforating arteries in the head of the caudate nucleus could have led to a haemorrhage in the infarcted area. Furthermore, the insufficiency of the lenticulostriate arteries expressed by extravasation of contrast media might be due to the high pressure reflow of the ischaemic vessels with increased permeability after further peripheral migration of the embolus. As a result, a huge and extensive haemorrhage took place in the infarcted area in the basal-ganglionic region. This phenomenon may be identical with the so-called "haemorrhagic infarction".