Decompensated chronic congenital hydrocephalus.

A 66 year-old woman with congenital macro cephaly and developmental delay presented with aphasia and right-sided weakness. Head CT revealed severe hydrocephalus of the lateral and third ventricles with a normal fourth ventricle due to a chronic congenital process (Fig. 1A). MRI confirmed subacute embolic infarcts of the left middle cerebral artery territory (Fig. 1B) and a heparin drip was initiated. The patient initially improved but then rapidly decompensated due to hemorrhagic transformation (Fig. 1C) and eventually expired despite protamine and ventricular shunting. Longstanding compensated congenital hydro cephalus (1, 2) can decompensate for various reasons including stroke.