Cerebral infarction of the basal ganglia due to embolism from the heart.

Abstract

SUMMARY We studied 8 patients with cerebral infarction in the deep territory of the middle cerebral artery (MCA). All patients had a definite cardiac source of emboli and no known factors for thrombosis. Mixed sensory and motor deficit was found in all but one patient and CT scan showed larger lesions than usually reported in lacunar infarcts. Contrast enhancement was seen in all cases in which CT scan was performed in the second or third week. It is concluded that embolic infarcts in deep cerebral territory of MCA from a cardiac source are more frequent than previously reported. This diagnosis has to be consid ered when CT scan demonstrates a deep cerebral infarct.Stroke Patients and MethodsWe reviewed records of all patients with deep cere bral infarcts confirmed by CT seen during the period 1979-1981. Patients with hypertension (blood pres sure equal or more than 160/95 mm Hg in several determinations) diabetes, blood hematocrit greater than 45%, heavy cigarette smoking or vasculitis were excluded. This review yielded 8 patients without known risk factors for a thrombotic disease and with a definite heart disease with high probability of cerebral embolization. Six patients had rheumatic heart disease and mitral valve stenosis, five of them with atrial fi brillation. The disease was diagnosed by clinical histo ry and auscultation. In three cases it was confirmed at surgery. One patient had an aortic prosthetic valve (Starr-Edwards) and anticoagulation had been stopped one year before the stroke because of gastrointestinal bleeding. Another patient had a subacute bacterial en docarditis with blood cultures positive for Streptococ- cus salivarius and infected vegetations were confirmed at surgery. Results Clinical and CT findings are summarized in table 1.The clinical deficit had an abrupt onset, reaching its peak in a few minutes in half of the patients. In two patients, the deficit progressed during the next 3 hours; and in the remaining 2, a fluctuating course over sever al hours was seen before stabilization occurred. Neuro logical examination showed a complete (5 cases) or incomplete (3 cases) hemiplegia, accompanied by hypesthesia in 6 patients. A pure motor hemiplegia was only seen in one case. In three of them, a transitory anosognosia was clearly observed. In a further patient (case 8), the motor hemiplegia was accompanied by an expressive dysphasia. Her language disorder was char acterized by nonfluent conversational speech, naming and reading difficulties, dysgraphia and a normal audi tory comprehension. She was almost normal one year after the stroke. Recovery of the motor and sensory deficit was complete in two patients, moderate in four, and poor in two. EEG was performed on 7 patients. In all but one case, EEG showed a discrete focal slowing. The most common CT abnormality, seen in four cases, was a well-defined low density area placed in caudate, putamen and anterior limb of internal capsule ( fig. 1). In a further 3 cases, CT showed a posterior extension (fig. 2). The patient with aphasia had...

Clinical MRI Cutoff Points for Predicting Lacunar Stroke May Not Exist: Need for a Grading rather than a Dichotomizing System

“…Although controversy surrounds the question of whether large artery atherosclerosis or a cardioembolic source are coincidental [9,[24][25][26][27][28][29][30][31][32][33][34][35][36] or causative [11,[27][28][29] in patients with small deep infarcts, the documentation of mechanisms of stroke in patients with deep infarcts is important because different therapeutic approaches may be required, depending on their pathogenesis [17,22,30] .…”

Evolution and testing of the lacunar hypothesis.

“…Gorsselink et al 132 reported 12% of cases with small deep infarcts as having potential cardioembolic sources, similar to the 10% in the Harvard study, 2 though there were no such cases in Weisberg's study. 40 Santamaria et al 53 reported a series of patients with basal ganglia infarcts and a variety of cardiac conditions that frequently cause embolism. They noted that the clinical abnormalities were usually more extensive than the described lacunar syndromes, though three cases appear to have had sensorimotor strokes.…”

Carotid angiography in patients with lacunar infarction. A prospective study.

“…2 -514 - 17 Treatment of these extracranial lesions is controversial, especially since such potential sources of emboli might in fact be coincidental. 18 -20 It is unresolved whether carotid endarterectomy should be undertaken in patients who have had a transient ischemic attack or a minor stroke distal to an atherosclerotic lesion in the extracranial course of that artery, even if the location and size of the infarct are disregarded.…”