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...