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A 65-year old man was admitted to the neurocritical care unit for possible hemorrhagic transformation of a recent left middle cerebral artery (MCA) stroke. His medical history was notable for atrial fibrillation, end-stage renal disease (ESRD) on hemodialysis, calciphylaxis, and hyperparathyroidism status post-parathyroidectomy. His laboratory test results at the time of the stroke were notable for hyperphosphatemia (7.2 mg/dL) and normal calcium levels (9.3 mg/dL). The patient started anticoagulation 2 weeks poststroke and underwent a routine head CT 1 day later (figure). The scan showed extensive high-density signal along the cortex of the recently infarcted left MCA territory. The signal measured at 80–100 Hounsfield units, higher than expected for acute blood. A dual-energy calcium overlap map revealed that the high-density material was consistent with acute mineralization, possibly potentiated by the patient's history of calciphylaxis and abnormal calcium phosphate metabolism in the setting of ESRD.1,2 This case illustrates accelerated mineralization and cortical laminar necrosis as a mimic of acute hemorrhagic transformation in a patient with advanced renal disease. Dual-energy CT, which uses 2 different energy levels to analyze material composition, differentiates between calcification and acute hemorrhage >90% sensitivity and specificity and is useful in this setting.3
Footnotes
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
- Received May 15, 2019.
- Accepted October 1, 2019.
- © 2019 American Academy of Neurology
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