Acute ischaemic stroke is a debilitating disease and may lead to haemorrhagic transformation associated with few factors such as high National Institute of Health Stroke Scale (NIHSS), low Modified Rankin Score (MRS), cardio-embolic clot and others.1 We report herein a 61 years old man whom presented with left sided weakness and diagnosed with acute right middle cerebral artery (MCA) infarction. Thrombolytic therapy was not offered due to low Alberta Stroke Program Early CT (ASPECT) score and hence managed conservatively. However, within 24 hours, his Glasgow Coma Scale (GCS) reduced by 4 points and urgent Computed Tomography (CT) brain confirmed haemorrhagic transformation with midline shift. He underwent emergency surgical decompression and subsequently had prolonged hospital stay complicated by ventilated acquired pneumonia. He recovered after a course of antibiotic and discharged to a nursing home with MRS of 5.
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