Bilateral Infarction Research Articles

Early use of targeted blood patch in spontaneous intracranial hypotension presenting with bilateral subdural hematomas and acute infarcts

Early use of targeted blood patch in spontaneous intracranial hypotension presenting with bilateral subdural hematomas and acute infarcts

From the right ventricle to the descending aorta: a Case Report of complex thrombotic events in a patient with nephrotic syndrome

BackgroundNephrotic syndrome is characterized by significant proteinuria, hypoalbuminemia, edema, and hyperlipidemia. Patients frequently exhibit hypercoagulability on account of endothelial dysfunction and abnormal blood coagulation function, which significantly heighten the risk of thrombus formation. Although anticoagulant therapy is crucial for preventing thrombotic events, formulating individualized anticoagulation treatment plans for these patients remains a challenge in clinical practice due to variations in renal function and the distinct metabolic characteristics of anticoagulant medications.Case IntroductionThis case report presents a 27-year-old male patient diagnosed with nephrotic syndrome. The etiological diagnosis was hepatitis B virus-associated glomerulonephritis, and the pathological diagnosis was mesangial proliferative glomerulonephritis. The patient had a relapse accompanied by bilateral pulmonary embolism and a right ventricular thrombus, and ultimately underwent thrombectomy. In the subsequent year, despite receiving adequate anticoagulation therapy with rivaroxaban, rare events of descending aortic mural thrombus and bilateral renal infarction occurred. The patient was treated with anticoagulation, endovascular exclusion with a descending aorta covered stent for the isolation of mural thrombus, and prolonged antiplatelet therapy. As of now, follow-up has shown no recurrence of thrombotic events.ConclusionThis case underscores the challenges associated with managing the hypercoagulability in patients with nephrotic syndrome and emphasizes the importance of personalized anticoagulation therapy. To improve patient outcomes, future research should focus on the selection of anticoagulant agents, dosage optimization, and monitoring strategies to enhance the safety and efficacy of anticoagulation treatment in this patient population.

Lesion Topography and Clinical Features Associated With Respiratory Failure in Patients With Medullary Infarction.

Respirator failure (RF) is a severe malignant complication in both lateral medullary infarction (LMI) and medial medullary infarction (MMI) patients. However, the differences in clinical and radiological manifestations associated with RF between patients with LMI and MMI have not been fully elucidated. A total of 435 consecutive patients with MI within 7 days of onset in our institute were retrospectively enrolled from January 2017 to January 2024. Lesions were categorized both rostral-caudally and horizontally, and clinical characteristics were collected to evaluate the correlation between them and RF that occurred within 10 days of stroke onset. Among the 435 patients, 33 patients developed RF, with 19 exhibiting LMI and 12 exhibiting MMI. Multisegment involvement was more common among LMI patients experiencing RF compared to those without (52.6%vs. 23.9%, p = 0.012). However, this difference was not observed among MMI patients. Large (n = 12, 63.2%, p = 0.014) and typical (n = 6, 31.6%, p = 0.016) lesions were more common among LMI patients with RF. In MMI patients with RF, nine (75.0%) patients had long lesions extending from the ventral to the dorsal medulla, with six of these cases involving bilateral lesions, as V-shape or heart-shape on MRI. Univariate analysis of clinical symptoms revealed that bulbar symptoms, urinary retention, and pulmonary infection were significantly more common in both the LMI and MMI groups with RF. Specific lesion patterns, such as large and typical infarctions in LMI patients or long lesions, particularly those with bilateral infarctions, as V-shape or heart-shape on MRI in MMI patients, appear to correlate with a higher incidence of RF, while clinical symptoms associated with RF are similar in LMI and MMI.

Bilateral Adrenal Infarction and Secondary Haemorrhage in Pregnancy: Implications of Factor V Leiden Heterozygosity: A Review of the Literature and a Case Report.

Adrenal haemorrhage in pregnancy is rare but can lead to significant maternal and foetal morbidity if unrecognised. We present the case of a 25-year-old woman in her second pregnancy, who was admitted at 34+4 weeks of gestation with severe abdominal pain. Despite initial unremarkable assessments, further imaging revealed a left adrenal haemorrhage, with evidence of prior right adrenal infarction, resulting in primary adrenal insufficiency. Haematological investigations later confirmed heterozygous Factor V Leiden as a likely contributing factor. This report underscores the diagnostic challenges of adrenal pathology in pregnancy, where symptoms may overlap with more common conditions. Immediate management with hydrocortisone therapy, supported by a multidisciplinary team (MDT), was employed, with a successful outcome for both mother and child following delivery by caesarean section.

Contrast-enhanced ultrasound for diagnosing testicular infarction: Findings from a retrospective cohort analysis.

This study aims to evaluate the ultrasonographic features associated with testicular infarction, determine the diagnostic effectiveness of contrast-enhanced ultrasound (CEUS) in assessing the testicular vascular system, and investigate the etiological factors contributing to testicular infarction. A retrospective analysis was performed involving 12 patients with confirmed testicular infarction. Each participant underwent standard superficial ultrasound examinations, followed by CEUS. The acquired imaging data were subsequently analyzed, taking into consideration the clinical conditions preceding the imaging assessments. A total of 13 lesions were detected across the 12 patients, with 1 individual exhibiting bilateral infarcts in the left testis. Based on the CEUS imaging findings, a classification system was developed to categorize the lesions into 4 distinct types: mediastinal branch infarction, small vessel infarction, capillary infarction, and mixed testicular infarction. This classification system offers a structured approach for understanding and potentially mitigating the causes of testicular infarction. CEUS markedly improves the diagnostic accuracy for testicular infarction and serves as a crucial tool in both the diagnosis and etiological assessment of this condition.

Bilateral Basal Ganglia Region Infarction After Trauma in a Patient With Bilateral Basal Ganglia Calcification.

Bilateral Basal Ganglia Region Infarction After Trauma in a Patient With Bilateral Basal Ganglia Calcification.

Kissing balloon treatment for stenosis of the internal and external carotid artery orifice associated with moyamoya disease: illustrative case.

Moyamoya disease (MMD) is a cerebrovascular disorder that is characterized by progressive stenosis in the terminal portions of the internal carotid artery (ICA). Although a substantial number of patients with MMD exhibit stenosis of the ICA orifice (ICAO), it infrequently occurs in patients with MMD with external carotid artery orifice (ECAO) stenosis. A 48-year-old female with no past medical history presented to the authors' hospital with right hemiparesis and motor aphasia. Head magnetic resonance imaging revealed bilateral acute cerebral infarctions in the left frontal lobe, and magnetic resonance angiography demonstrated bilateral ICA terminal stenosis. Digital subtraction angiography revealed severe stenosis in the right ICAO and left ICAO and ECAO, as well as bilateral ICA terminal stenosis; therefore, the authors diagnosed this case as MMD. They first performed percutaneous transluminal angioplasty (PTA) using the kissing balloon technique (KBT) for the stenosis in the left ICAO and ECAO, followed by PTA for the right ICAO stenosis. After that, they performed bilateral direct and indirect revascularization. The authors present a rare case of MMD with stenosis of the ICAO and ECAO, which was treated with PTA using the KBT, followed by direct and indirect revascularization. Although the strategy is controversial in terms of which treatment should be performed first, this method of anterograde revascularization was a promising strategy. https://thejns.org/doi/10.3171/CASE24425.

Abstract 4119116: Percutaneous Aspiration of Mitral Valve Endocarditis using the AngioVac Device

Case Description: A 68-year-old man with end-stage renal disease on dialysis, peripheral vascular disease with metatarsal amputations, atrial fibrillation and type 1 diabetes was admitted for foot osteomyelitis secondary to MSSA bacteremia. Transesophageal echocardiogram revealed mobile mitral valve vegetations up to 1.8cm on the atrial aspect of the posterior mitral valve leaflet which prolapsed through the mitral valve during diastole. Ejection fraction was 60% and there was trivial-mild mitral regurgitation without valvular destruction or peri-annular extension into the mitral annulus. MRI brain showed bilateral cerebral and cerebellar hemispheric infarcts, consistent with acute embolic stroke. He was at high risk for both recurrent embolism and operative mortality (STS risk score 51%) due to his comorbidities and risk of hemorrhagic conversion of stroke. After shared decision making, percutaneous aspiration of the mitral vegetation was performed with AngioVac (Fig). Cerebral embolism protection devices were deployed prior to AngioVac evacuation of the mass. There was no residual mitral regurgitation and only a small vegetation strand remained (Fig). Surgical pathology confirmed MSSA endocarditis. Blood cultures remained negative, and the patient did not suffer from recurrent embolic events. The patient underwent revision metatarsal amputation and was discharged with a 6-week course of IV cefazolin. Discussion: Infective endocarditis with high embolic risk is life-threatening and challenging to treat in patients with high surgical risk. We illustrate a case of percutaneous vegetation aspiration using the AngioVac device in our patient who suffered from embolic strokes due to MSSA mitral valve endocarditis. Meta-analyses have shown clinically successful debulking in 90% of cases, with 82% of patients able to clear bacteremia with AngioVac. Although most commonly used in right-sided lesions, percutaneous debulking of left-sided endocarditis with AngioVac and cerebral protection can be considered as a treatment strategy in select patients with prohibitive surgical risk.

Abstract 146: Symptomatic Basilar Stenosis Presenting as Focal Tonic Posturing and Wrong Way Eyes

Introduction A common encounter for the Vascular Neurologist assessing emergent neurological complaints is recognition of stroke mimics and stroke chameleons. Unlike mimics, stroke chameleons are presentations that masquerade as an alternative neurological entity when they are truly ischemic in nature. We present a rare case of bilateral pontine infarcts masquerading as a presumptive focal tonic seizure with gaze deviation in a patient with transient decorticate posturing and wrong way eyes secondary to symptomatic basilar stenosis. Materials/Methods Case Report Results We report a case of a 77‐year‐old gentleman with a medical history of coronary artery disease, atrial fibrillation, prior liver transplant, and B‐cell lymphoma in remission who was recently discharged from an outside facility after an episode of right‐sided hemiparesis in the context of several months of kaleidoscopic‐like vision changes where electroencephalogram (EEG) showed left temporal sharp waves. Patient subsequently presented to our emergency department (ED) with fluctuating onset of alternating laterality of facial paralysis over several days and eventually left‐sided hemiparesis. On admission, magnetic resonance imaging (MRI) of the brain showed no evidence of ischemic stroke. While in the ED, the patient had a two‐minute episode of tonic flexion contraction of the left upper extremity, leftward gaze, and intact awareness, with cessation after 2 milligrams of intravenous (IV) lorazepam. He was subsequently loaded with IV lacosamide with suspicion for focal motor seizure resulting in a post‐ictal Todd's paralysis. Follow‐up vessel imaging subsequently showed a severely stenotic basilar artery with intraluminal thrombus, raising concern of brainstem hypoperfusion. EEG the following morning was normal. On day 3, given clinical concern persisted, repeat MRI Brain revealed bilateral pontine infarcts. The patient was treated with IV heparin and blood pressure support. He was ultimately discharged ambulatory with a walker with mild facial palsy. Conclusion With much attention placed on stroke mimics in clinical practice, stroke chameleons require a high index of suspicion for the prompt identification of patients presenting with acute ischemic stroke. Brainstem ischemia warrants close attention, with decorticate posturing presenting similarly to a focal tonic motor seizure and a paramedian pontine reticular formation lesion presenting with wrong way eyes (i.e. gaze deviation towards the affected limb), exhibiting high potential for misdiagnosis. This case highlights the complexities of brainstem anatomy, places focus on the variability of the presenting features of stroke and underscores the caliber clinical suspicion carries in patients with MRI‐negative strokes.

Abstract 077: Bilateral medial medullary infarction mimicking Guillain‐Barré Syndrome (GBS): Case report and qualitative systematic review

Purpose To summarize the medical literature related to the diagnosis of bilateral medial medullary infarction (MMI) mimicking GBS. Methods We identified all published case studies in five databases until February 2024. We performed a narrative synthesis to develop differential criteria on the included cases. A case report is also presented. Results We present the case of a patient with asymmetric and progressive motor weakness, bulbar dysfunction, albuminocytologic dissociation in cerebrospinal fluid (CSF), and negative brain CT scan in the acute stage. He was initially diagnosed with Guillain‐Barré Syndrome (GBS), treated with immunoglobulin without a favorable response, finally the diagnosis of MMI was made with re‐evaluation during the evolution and confirmed by brain magnetic resonance imaging. A systematic review of the literature of MMI case reports was carried out, focusing on an initial diagnosis of Guillain‐Barré Syndrome. We selected 8 studies (9 patients) of bilateral MMI with problems in the timely diagnosis and initial diagnosis of GBS. The most frequent clinical onset was respiratory problems (44.4%). The finding in CSF and nerve conduction studies were normal or negative in 60% of the cases. The delay occurred in the early stages of diagnosis in all cases. The use of immunosuppressive therapy was given in only one case. A discussion of the case report and the diagnostic challenges reported in the literature was made. Conclusion It is recommended to consider MMI for differential diagnosis in patients with symptoms of acute progressive quadriparesis and bulbar dysfunction, therefore a thorough assessment of the clinical presentation is necessary.

Abstract 392: Recurrent ischemic strokes in a patient with ITP, case report and literature review

Introduction/Purpose Immune Thrombocytopenic purpura (ITP) is an autoimmune acquired thrombocytopenia caused by autoantibodies against platelet antigens leading to platelet destruction and platelet underproduction. Patients with ITP usually have a higher risk of bleeding compared to the general population, however thrombocytopenia in ITP is not necessarily protective against thrombosis. While the exact pathophysiology of hypercoagulability in ITP is still not fully understood and not enough data in literature guiding stroke management in patients with ITP as the primary stroke risk factor, there are multiple etiologies suggested including inflammation, antiphospholipid antibodies in some patients, or the effects of certain treatments such as glucocorticoids and Thrombopoietin receptor agonists (TPO‐RAs) Methods A single case report, literature review through PubMed Results A 65‐year‐old male with a history of unprovoked deep vein thrombosis (DVT) and pulmonary embolism (PE) while on Rivaroxaban presented with worsening headaches and cognitive dysfunction. A CT scan of the head revealed bilateral subacute frontal lobe infarcts with an embolic appearance. Initial laboratory tests showed thrombocytopenia (54,000), and a hypercoagulable workup, including tests for anticardiolipin antibodies, antiphospholipid antibodies, beta‐2 glycoprotein antibodies, factor V Leiden mutation, and Prothrombin gene mutation, returned negative. A bone marrow biopsy revealed immature megakaryocytes without morphological abnormalities. Transthoracic and transesophageal echocardiograms did not show any intracardiac or intrapulmonary shunts, and telemetry monitoring did not detect any arrhythmias. The patient was switched from Rivaroxaban to Warfarin, with an INR target of 2.0‐3.0, and was started on glucocorticoids and Rituximab. Follow‐up showed an improvement in platelet count. Eight months after discharge, the patient experienced a new right pontine infarct; at that time, his INR was 2.34, and a repeat stroke workup was inconclusive. The Warfarin dose was adjusted to achieve an INR target of 2.5‐3.5. Over a subsequent 4‐year follow‐up period, the patient did not experience any additional strokes. Conclusion Patients with immune thrombocytopenic purpura (ITP) face an increased risk of stroke, often of cryptogenic origin. While thrombocytopenia in ITP is not protective against thrombosis, it certainly increases the risk of bleeding in individuals on anticoagulant therapy, making management more complex. Further research is needed to develop guidelines for managing stroke in ITP patients particularly who lack conventional stroke risk factors Additionally, the potential role of anti‐inflammatory agents, such as glucocorticoids, in reducing stroke risk in this population warrants investigation.

Abstract 219: Cerebral Air Embolism After Coronary Artery Bypass Graft: A Case Report and Systematic Review of Current Literature

Introduction Cerebral air embolism (CAE) is a rare but serious complication of cardiac procedure, often leading to significant neurological deficits. The study presents a case of CAE after coronary artery bypass graft (CABG) and a systematic review to highlight the incidence, symptom presentation, and outcomes associated with CAE following cardiac surgeries and interventions. Case Presentation We present a case of a 71‐year‐old African‐American male with a past medical history of hypertension, hyperlipidemia, high‐degree AV block with a pacemaker, and cerebrovascular accident who presented with a non‐ST segment elevation myocardial infarction. Following a successful CABG, the patient had a normal postoperative neurological exam and was ambulating independently. During a physical therapy session one day after the operation, however, the patient suddenly lost consciousness requiring intubation. CT brain demonstrated diffuse bilateral hemispheric air emboli. CTA head and neck ruled out large vessel occlusion but was concerning for cortical vein embolism. Despite immediate interventions, including Trendelenburg and left lateral decubitus positioning and high‐flow oxygen therapy, the patient developed seizures and progressive neurological deterioration. On postoperative day two, the patient had absent cranial nerve reflexes and an MRI brain revealed anterior and posterior circulation, diffuse bilateral hemispheric ischemic infarcts including bilateral thalami, and brainstem. The patient's condition continued to deteriorate and was transitioned to hospice care. Method A systematic review was performed following PRISMA guidelines. The extracted data included diagnostic modalities, procedural factors, and neurological outcomes related to CEA. A descriptive analysis of such variables was performed. Result There were 20 articles with 43 patients of whom 27 were male (62.8%). The average age of the patient population was 57.3 (± 20). CAE was diagnosed primarily through clinical suspicion with iatrogenic air bubbles (27.9%) and air visualized on CT (20.9%). Other diagnostic criteria included clinical suspicion with iatrogenic air bubbles (4.7%) and clinical suspicion with air visualized intraprocedural (4.7%). The most common procedures associated with CAE were cardiac ablation (23.3%), CABG (20.9%), valve repair (14.0%), and a repair of cardiac structural anomaly (14.0%). Less common procedures included angiography (2.3%) and cardiac bypass surgery with biventricular assist device placement (2.3%). The presenting neurological symptoms included motor deficit (37.2%), decreased consciousness (20.9%), language deficit (11.6%), visual deficit (2.3%), and coma (2.3%). 12 patients died with a mortality rate of 27.9%. Conclusion This case and systematic review highlight the importance of early recognition and intervention in managing CAE, particularly in high‐risk cardiac surgical patients. Given the detrimental neurological outcomes, CAE must be identified as a potential cause of acute stroke following cardiovascular procedures. Timely diagnosis can aid in targeted neuroprotective strategies and tailored surgical interventions to mitigate cerebral injury and improve patient outcomes in this rare but devastating complication.

A Special Case of Bilateral Pontine Infarct with the "Mushroom Appearance" Sign.

A Special Case of Bilateral Pontine Infarct with the "Mushroom Appearance" Sign.

Patient Improvement Following Acupuncture in the Treatment of Locked-In Syndrome Caused by Bilateral Pontine Infarction - A Case Report

Introduction: This report describes a case of locked-in syndrome (LIS) due to a bilateral pontine infarction.Case Presentation: A patient with LIS showed worsening despite treatment with thrombolytics, anticoagulants, and antiplatelet agents for acute pontine infarction. On the 8th day post-infarction, the patient was referred to the Internal Korean Medicine Department and received 83 days of acupuncture therapy. Treatments were conducted daily, excluding holidays and Sundays, for 15 minutes at various acupoints, including Baihui (GV20), Qubin (GB7), Jianyu (LI15), and Hegu (LI4). Muscle strength was assessed using manual muscle testing (MMT). Post-treatment, improvements were observed: right upper extremity strength increased from grades 0 and 1 to 2 and 4, while right lower extremity strength increased from 0 and 0 to 2 and 3; the results were similar for both left extremities.Conclusion: Acupuncture therapy led to a noticeable improvement in muscle strength in the LIS patient.

"Y appearance" infarction: caused by essential thrombocythemia.

Essential thrombocythemia (ET) is a myeloproliferative malignancy caused by the excessive proliferation of megakaryocytes in the bone marrow, resulting in the overproduction of peripheral platelets. ET can lead to thrombotic events, such as ischemic stroke (IS), though it is a rare cause of IS. Bilateral medial medullary infarction (BMMI), also known as "Y appearance" infarction due to its distinctive imaging morphology, is a rare clinical subtype of IS which typically has a poor prognosis and a high mortality rate. Herein, we report the case of a 43-year-old male with a history of ET. The patient's platelet count was poorly controlled, and he did not receive regular treatment. After developing symptoms such as dizziness, dysphagia, choking on water, slurred speech, blurred vision, and bilateral limb numbness. Head magnetic resonance imaging revealed a "Y appearance" infarction in the bilateral medial medulla. After admission, the patient was administered intravenous antiplatelet therapy with tirofiban. However, when he was switched to oral aspirin after three days, he experienced decreased muscle strength and worsening symptoms. Therefore, tirofiban was continued for 14 days. Upon discharge, the patient experienced residual limb numbness. His National Institutes of Health Stroke Scale score was 1, Modified Rankin Scale score was 0, and platelet count had decreased to the normal range. During the 9-month follow-up period after discharge, the patient still had only mild limb numbness. Our report presents a special case of "Y appearance" infarction due to ET. Owing to fluctuations in the patient's condition, he received long-term high-dose tirofiban, which ultimately led to a significant improvement in his symptoms.

Children and Adolescents With Sickle Cell Disease and Skull Infarction: A Systematic Review.

Skull infarction is an uncommonly reported complication of sickle cell disease. We aimed to characterize the clinical and imaging features of skull infarction in pediatric patients with sickle cell disease. We searched the PubMed database for case reports on skull bone infarction in pediatric patients with sickle cell disease. Out of 67 records retrieved, 15 met inclusion criteria, and a 16th case reported by the senior author was included. We extracted and analyzed clinical and imaging data. The most common symptom at onset was headache (88%). Bilateral skull infarction (50%) and parietal bone involvement (82%) were frequent imaging findings. Epidural hematoma developed in 65% of the cases, 30% of patients required drainage, and exchange infusion was reported in 18%. No fatal outcomes were reported. Skull infarction is a potentially severe complication of sickle cell disease presenting unique clinical challenges. Acute headaches should raise suspicion for this condition and may require additional investigation.

Tinnitus and reduced word recognition with a bilateral inferior colliculus infarction after cerebellar arteriovenous malformation embolization.

The Article Abstract is not available.

Bovine Arch and Laterality of Cardioembolic Stroke

Aims and Objectives: We aimed to find the correlation between cardioembolic and non-cardioembolic stroke incidence with bovine arch anatomical variation. Materials and Methods: Retrospectively, we identified about 1,500 brain MRI/MRA and neck MRA studies, from which 605 patients were found to have had an acute stroke, with a mean age of 62. Images were reviewed to identify anatomical variations of the aortic arch, particularly bovine configuration, and characterization of anterior and posterior circulation stroke. Results: Some 60% of patients had had a left-sided stroke. About 17% of patients had had an anterior embolic ischemic stroke, and another 7% had had a posterior embolic stroke. Within the non-embolic stroke, 56% were in the anterior circulation, while 27% were posterior non-embolic ischemic strokes. Some 30% of the patients were found to have bovine arch; from patients with ischemic stroke and bovine arch, about 17% were in the anterior circulation and 5% in the posterior. Conclusion: The bovine aortic arch is a risk factor for young-onset anterior circulation stroke. Bilateral and left-sided infarcts were more common.

Association between Bilateral Vertebral Artery Blood Flow Changes and Posterior Circulation Infarction in Patients with Severe Intracranial Stenosis

Plain Language SummaryThis study investigates the relationship between vertebral artery (VA) blood flow and posterior circulation infarctions (PCI), which are strokes in the back of the brain. VAs play a crucial role in supplying blood to this area. Using color duplex ultrasonography, we measured blood flow in 234 patients with severe VA narrowing (≥70%). These patients were divided into two groups: those who had experienced PCI and those who had not. We analyzed the correlation between blood flow in the VAs and various brain imaging data to understand the occurrence of PCI under different conditions. The findings showed that lower blood flow through the VAs was significantly associated with a higher risk of PCI, particularly in cases involving large artery atherosclerosis (a type of artery disease). However, this association was not observed in cases of branch artery occlusive disease. A detailed analysis revealed that for every 10 mL/min increase in blood flow, the risk of PCI decreased by 11%. This relationship also varied according to the patients’ blood glucose levels: patients with lower blood glucose levels showed a stronger link between increased blood flow and reduced PCI risk compared to those with moderate or high blood glucose levels. In conclusion, measuring the blood flow in the VAs can help identify patients at high risk of strokes in the back part of the brain. However, it is important to consider this measurement in combination with blood glucose levels to improve the identification of high-risk patients.

Decompressive Craniectomy for Bilateral Anterior Cerebral Artery Infarction: Case Report and Brief Literature Review

Decompressive craniectomy for “malignant” bilateral anterior cerebral artery infarction (BACAI) has not been reported in the literature. Here we present such a case in relation to its presentation, surgical management, outcome and anatomical basis.Bifronto-temporal decompressive craniectomy was performed on a patient diagnosed with acute infarction in bilateral anterior cerebral artery (ACA) territories and rapidly deteriorating having clinical and radiological signs of tonsillar herniation. Patient sustained several motor disabilities at sixth week following surgery, however, post-operative CT showed reversing of the “conning” with spaced basal cisterns which was compatible with clinical improvement.