PMC9210153_01
Axial CT brain. Localised extra-axial hyperdensity in the left temporal region (red arrowhead) and left temporal lobe parenchymal hyperdensity (red star) representing subpial haemorrhage with intraparenchymal extension. The cortical hypodensity (white arrow) represents ischaemia. Blood products also identified in the ventricular system (red curved arrow) with hydrocephalus and transependymal oedema (white curved arrow).
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The underlying cortex was hypodense, likely reflecting ischaemic changes (Figure 1).
Axial MRI sequences. T2-weighted (a), diffusion-weighted imaging (DWI) (b), gradient recalled echo (GRE) (c) and T1 weighted (d) reveal left temporal T2 hypointense subpial haemorrhage with blooming on GRE. Left temporal lobe intraparenchymal extension (star), intraventricular extension and hydrocephalus noted (curved arrow). The T2-weighted and DWI sequences demonstrate the classic 'yin-yang sign' of subpial hypointensity and underlying cortical hyperintensity (circled in red).
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T2-weighted (T2W) and diffusion-weighted imaging (DWI), resembling the 'yin-yang sign' (Figure 2a and b). The intraparenchymal and intraventricular extension demonstrated significant blooming on the gradient recalled echo (GRE) sequence (Figure 2c). There was also mass effect with mild midline shift to the right.
Follow-up axial MRI brain at 6 months of age. T2-weighted (a), diffusion-weighted imaging (DWI) (b), gradient recalled echo (GRE) (c) and T1 weighted (d) demonstrate resolution of the subpial haemorrhage with cystic encepahalomalacia and haemosiderin staining (arrowhead). Associated underlying temporal lobe volume loss (curved arrow). Gyriform T1 hyperintensity and blooming on GRE suggested left temporal cortical laminar necrosis with haemosiderin deposition (arrow).
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MR imaging revealed extra-axial cystic changes in the left temporal region with no new haemorrhage (Figure 3a and c). T1 hyperintensity with blooming on GRE, suggesting cortical laminar necrosis (Figure 3c and d). Therapy with oral phenobarbitone was continued, as repeat EEG showed occasional seizure-like spikes of activity.