PMC8326076_01
PICA infarct with hemorrhagic transformation involving the posterior lobe of both cerebellar hemispheres seen on DWI (a), T2 (b) and the associated obstructive non-communicating hydrocephalus (c, d). After the EVD and the suboccipital craniectomy, the patient persisted with upward transtentorial herniation (e); notice the flattening of the quadrigeminal cistern, the "spinning top" appearance of the midbrain and the cerebral aqueduct occlusion. After the ETV, the upward transtentorial herniation was reversed (f) and the patient improved clinically.
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F1
Laboratory findings revealed thrombocytopenia and brain MRI showed a bilateral cerebellar ischemic stroke in PICA territory with hemorrhagic transformation, tonsillar herniation, and non-communicating obstructive hydrocephalus [Figures 1a-f].
Middle suboccipital craniectomy (a). Even though the MRI showed severe edema, the cerebellum was displaced dorsally away from the dural edge (a). During the endoscopic third ventriculostomy, we observed midbrain microhemorrhages and an active flow through the tuber cinereum fenestration (b and c).
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F2
After draining 10 cc of CSF, the patient developed bradycardia, hypertension, and bilateral mydriasis, he was transferred back to the OR, and we performed a middle suboccipital craniectomy; the cerebellum was 5 mm deep from the dura and it did not swell immediately through the dural defect [Figure 2a]. During the endoscopy, microhemorrhages were observed on the midbrain, the third ventricle was dorsally displaced and after the premamillary fenestration, an active pulsatile flow from the interpeduncular cistern was visualized [Figures 2b and c].