Anteromedial striatum and globus pallidus infarcts: Uncommon complications of cerebral herniation in the setting of acute subdural hemorrhage

Herniation of the temporal lobe through the tentorial notch often leads to compression of the ipsilateral posterior cerebral artery and stretching of the ipsilateral oculomotor nerve. Arterial compression classically results in infarcts of the inferior temporal and occipital lobes. Herniation of the cingulate gyrus beneath the falx cerebri often leads to compression of branches of the ipsilateral anterior cerebral artery, including the pericallosal artery, which classically results in infarcts of the cingulate gyrus and medial corpus callosum. A less common consequence of transtentorial herniation is compression of perforating branches from the internal carotid and anterior cerebral arteries supplying the inferomedial anterior basal ganglia. Compression of the anterior choroidal artery, a branch of the internal carotid, and the recurrent artery of Heubner, a branch of the anterior cerebral artery, can cause infarcts of the ipsilateral anteromedial striatum and globus pallidus, but these are rarely seen at autopsy. In this report, we present the case of a 51-year-old lady with a large left acute subdural hemorrhage (SDH). At autopsy, we observed left subfalcine and transtentorial herniations with a typical pattern of secondary infarcts due to compression of the posterior and anterior cerebral arteries. In addition, we observed cavitation of the left inferomedial anterior caudate and putamen and globus pallidus internus due to compression of perforating arteries, including the left anterior choroidal artery and the left recurrent artery of Heubner. This case illustrates perforating artery infarcts, an uncommon pattern of secondary ischemic injury, in the setting of SDH.