Patterns of Infarction in Hemodynamic Failure

Abstract

Background and Purpose: The mechanism of stroke in patients with atherosclerotic occlusive disease and hemodynamic failure may be primarily hemodynamic or a combination of hemodynamic and embolic factors. The purpose of this study was to investigate the clinical and imaging features of stroke in these patients. Methods: Eleven patients with complete atherosclerotic carotid artery occlusion and increased oxygen extraction fraction measured in the hemisphere distal to the occlusion developed an ischemic stroke during the observation phase of a prospective study of cerebral hemodynamics and stroke risk. The medical and study records related to the endpoint event for these 11 patients were reviewed. Records were reviewed for evidence of associated hypotension and for specific details of the neurological deficit. Infarct location was characterized, based on review of imaging and clinical features, as: (1) middle cerebral artery (MCA) core; (2) possible cortical border zone, or (3) internal border zone. Results: One patient had a retinal infarction; the remaining 10 had MCA territory strokes. Six of the 10 infarctions occurred in the MCA core territory. Two of these 6 were fatal hemispheric events. One of the 10 infarctions occurred in the cortical border zone region. Two of the remaining 3 infarctions were localized to the internal border zone. One was indeterminate. Conclusions: The clinical features and radiological patterns of stroke in many patients with hemodynamic impairment failure and carotid occlusion are most consistent with large artery thromboembolic stroke. These data suggest a synergistic effect between embolic and hemodynamic mechanisms for large artery thromboembolic stroke.

Change in Cerebral Perfusion after Carotid Angioplasty with Stenting Is Related to Cerebral Vasoreactivity: A Study Using Dynamic Susceptibility-Weighted Contrast-Enhanced MR Imaging and Functional MR Imaging with a Breath-Holding Paradigm

“…23,36 A recent study retrospectively analyzed the patterns of infarction in patients with carotid occlusion and hemodynamic failure, and the data suggested a synergistic effect between thromboembolic and hemodynamic mechanisms for the ischemic stroke. 37 Furthermore, impaired CVR may predict stroke or TIA risk in patients with either asymptomatic or symptomatic carotid stenosis. 21,22 However, whether CVR could be improved after carotid intervention and/or the incidence of stroke could decrease with CVR restored needs further investigation.…”

Misery Perfusion, Blood Pressure Control, and 5-Year Stroke Risk in Symptomatic Major Cerebral Artery Disease

“…Finally, recurrent thromboembolic stroke may occur more frequently in carotid occlusion patients with a higher BP than in those with a lower BP. Derdeyn et al 10 reported that most recurrent strokes were thromboembolic in patients with ICA occlusion and an increased OEF ratio. In our cohort, subcortical infarcts were a major type of recurrent ipsilateral strokes, in which the thromboembolic mechanism was less likely.…”

The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia

“…75 There may be a synergistic effect between embolic phenomenon from atherosclerotic plaque and impaired hemodynamics causing ischemic stroke in large artery atherosclerotic occlusions. 76,77 Compromised CVR is a key determinant of ischemic infarction, regardless of whether it is precipitated by embolic or hemodynamic factors. 75 Kuroda et al 2 describe a prospectively studied longitudinal cohort of 77 patients in which patients with decreased CBF and CVR resulting from internal carotid artery (ICA) or MCA occlusion had a higher risk of new ischemic stroke than those without.…”