Subcortical laminar necrosis of the basal ganglia following acute ischemic stroke: an atypical imaging presentation.

INTRODUCTION: Cortical laminar necrosis (CLN) is a well-described neuropathological entity typically involving the cerebral cortex and associated with hypoxia, metabolic derangements, and ischemia. Reports of CLN-like imaging patterns within subcortical structures are exceedingly rare. METHODS: Case report. CASE: An 89-year-old woman presented with acute aphasia and right-sided weakness due to a left middle cerebral artery (MCA) occlusion, successfully treated with mechanical thrombectomy. Her clinical course was complicated by metastatic lung adenocarcinoma, pulmonary embolism on anticoagulation, and respiratory failure. Follow-up computed tomography (CT) demonstrated hyperdensity within the left caudate and putamen, initially concerning for hemorrhagic transformation. Subsequent magnetic resonance imaging (MRI), performed approximately three weeks after stroke onset, revealed curvilinear T1 and fluid-attenuated inversion recovery (FLAIR) hyperintensity within the basal ganglia without corresponding susceptibility artifact, findings more consistent with laminar necrosis in an atypical subcortical location. CONCLUSION: While CLN is classically described in the cerebral cortex, this case demonstrates imaging features consistent with laminar necrosis in the basal ganglia. Recognition of this atypical presentation may help avoid misinterpretation as hemorrhagic transformation and expands the radiographic spectrum of laminar necrosis.