Computed tomographic patterns of proven embolic brain infarctions

Ringelstein, E. B.; Koschorke, S.; Holling, Andreas; Thron, A.; Lambertz, Heinz; Minale, C

doi:10.1002/ana.410260612

Cited by 122 publications

(59 citation statements)

References 30 publications

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“…11 Patients without such a lesion but with acute occlusion or intraluminal thrombus of the retinal or ophthalmic arteries or the distal part of brain supplying arteries as detected by digital subtraction angiography, CT-or MR-angiography, or Duplex sonography were also classified embolic stroke.…”

Section: Embolic Strokementioning

confidence: 99%

Retrograde Embolism From the Descending Aorta

Harloff

Strecker

Dudler

et al. 2009

Stroke

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Background and Purpose-The purpose of this study was to determine the role of plaques Ն4 mm and thrombi (complex plaques) in the descending aorta (DAo) as an embolic high-risk source for stroke. Methods-In 63 acute stroke patients scheduled for TEE, territory and embolic pattern of brain ischemia were prospectively assessed. Multidirectional 3D MRI velocity mapping of the aorta was performed to correlate the extent of retrograde diastolic blood flow with the distance of complex DAo plaques from the left subclavian artery (LSA). Embolic risk from the DAo was present for (1) retrograde flow connecting complex DAo plaques with the LSA, (2) embolic pattern of brain ischemia in a territory supplied by the left vertebral artery, and (3) stroke that could not be explained by other means. Results-33 of 63 patients had complex DAo plaques (distance to LSA 28.1Ϯ29.9 mm). Mean retrograde flow in these subjects was 26.2Ϯ12.3 mm. In 20 of 63 patients (31.7%) retrograde flow connected complex DAo plaques with the LSA. In 4 of these 20 patients (20%) with an embolic stroke in the territory of the brain stem, cerebellum or posterior cerebral artery, etiology could not be explained by other means. Conclusions-Substantial diastolic retrograde flow originating from complex plaques in the descending aorta was detected by multidirectional 3D MRI velocity mapping and constitutes a stroke mechanism that was previously not demonstrable. Key Words: atherosclerosis Ⅲ acute stroke Ⅲ embolic stroke Ⅲ MRI Ⅲ TEE C omplex plaques of the aortic arch with thickness Ն4 mm or containing mobile elements (most often thrombi) or both are considered high-risk sources of brain ischemia. 1 The incidence and thickness of such plaques is highest in the descending aorta (DAo). However, distal to the left subclavian artery they are usually not considered a potential source of stroke because retrograde embolization seems unlikely. [1][2][3] A previous transesophageal echocardiography (TEE) study analyzing the mobility of aortic thrombi in the DAo hypothesized that retrograde cerebral embolism would be theoretically possible especially in case of concomitant aortic valve insufficiency. 4 However, TEE is not able to demonstrate the direct correlation of plaque location and 3D blood flow patterns within the aorta. Accordingly, this stroke mechanism has not yet been systematically investigated.Multidirectional 3D velocity mapping allows the detailed visualization of physiological and pathological 3D blood flow characteristics 5,6 and the analysis of the continuation of flow from the distal aortic arch into the supra-aortic vessels. [7][8][9] Specifically, in combination with a novel MRI protocol for 3D aortic plaque detection, the direct interrelation of complex DAo plaques and individual retrograde flow channels was recently demonstrated in 2 patients with embolic stroke. 10 It was the aim of this study to apply this technique in a larger cohort of stroke patients and to investigate the potential role of complex DAo plaques as an embolic source in patients wit...

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Section: Embolic Strokementioning

confidence: 99%

Retrograde Embolism From the Descending Aorta

Harloff

Strecker

Dudler

et al. 2009

Stroke

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“…Early CT hypodensity was present in only 29% of patients, and angiography showed an intracranial and/or extracranial arterial occlusion in half of improving patients, with collateral blood supply in 80% and arterial patency (ie, normal angiograms or nonstenosing plaques in the internal carotid artery) in the remaining half of the patients. Since almost all of the latter presented a CT territorial infarct, generally considered to be caused by an embolic arterial occlusion, 17 we presumed that these patients also had had an arterial occlusion, with arterial reopening occurring before angiography. Therefore, the presence of effective collateral blood supply, with preservation of neuronal function, and very early recanalization, with rapid restoration of an adequate perfusion, were the proposed mechanisms underlying early improvement.…”

mentioning

confidence: 99%

“…The remaining 3 deteriorating patients with normal TCD at entry had early hypodensity at the first CT and an extended territorial infarct at the repeat CT. 17 This led us to hypothesize that these patients also had had an arterial occlusion, probably without adequate collateral blood supply, 10,16 that was no longer present by the time the first TCD was performed.…”

mentioning

confidence: 99%

Early Spontaneous Improvement and Deterioration of Ischemic Stroke Patients

Toni

Fiorelli

Zanette

et al. 1998

Stroke

119

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Background and Purpose-The purpose of our study was to investigate whether emergency transcranial Doppler (TCD) findings and their modifications over the first 48 hours are related to early neurological changes in acute ischemic stroke patients. Methods-Ninety-three patients underwent CT scan within 5 hours of a first-ever ischemic hemispheric stroke, and TCD serial examinations at 6, 24, and 48 hours after stroke onset. We classified TCD findings as follows: normal; middle cerebral artery (MCA) asymmetry (asymmetry index between affected and contralateral MCAs below -21%); and MCA no-flow (absence of flow signal from the affected MCA in the presence of ipsilateral anterior and posterior cerebral artery signals through the same acoustic window). We considered early deterioration and early improvement to be a decrease or an increase of 1 or more points, respectively, in the Canadian Neurological Scale score over the same period. Results-At 6-hour TCD examination, MCA asymmetry and MCA no-flow were present in 6 (22%) and 2 (7%), respectively, of 27 improving patients; in 20 (43%) and 10 (22%) of 46 stable patients, and in 9 (45%) and 8 (40%) of 20 deteriorating patients. TCD findings were normal in the remaining patients (Pϭ0.001). At serial TCD, we detected early (within 24 hours) recanalization (from no-flow to asymmetry or normal and from asymmetry to normal) in 2 (25%) improving patients, in 7 (23%) stable patients, and in 5 (29%) deteriorating patients and late (between 24 and 48 hours) recanalization in 4 (50%) improving patients, in 6 (20%) stable patients, and in none of the deteriorating patients (Pϭ0.03, 2 for trend, improving versus nonimproving irrespective of the timing of recanalization). One deteriorating patient (5%) developed a no-flow from an initial MCA asymmetry. Logistic regression selected normal TCD (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.06 to 0.46) as an independent predictor of early improvement and abnormal TCD (asymmetry plus no-flow) (OR, 5.02; 95% CI, 1.31 to 19.3) as an independent predictor of early deterioration. Conclusions-TCD examination within 6 hours after stroke can help to predict both early deterioration and early improvement. Serial TCD shows that propagation of arterial occlusion is rarely related to early deterioration, whereas the fact that it can detect early recanalization (within 24 hours) in deteriorating patients and both early and late recanalization (after 24 hours) in improving patients suggests the existence of individual time frames for tissue recovery.

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“…Hemodynamics has different relevance for an embolic occlusion of the medial cerebral artery than for a hemodynamic or lacunar infarction 68,69 . A hemodynamic stroke is caused by a worsening of hemodynamics and results in the formation of so-called watershed or borderzone infarctions.…”

Section: Transfusion Alternatives In Transfusion Medicinementioning

confidence: 99%