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Liu W, Zhang J, Li J, Jia S, Wang Y, Geng J, Wang Y. First report of a p.Cys484Tyr Notch3 mutation in a CADASIL patient with acute bilateral multiple subcortical infarcts-case report and brief review. BMC Neurol 2024; 24:77. [PMID: 38408980 PMCID: PMC10895806 DOI: 10.1186/s12883-024-03573-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/16/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND CADASIL(Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)is an inherited small vessel disease caused by mutations in NOTCH3 gene. Although NOTCH3 has numerous hotspots of gene mutations, mutations in exons 9 are rare. The p.C484T gene mutation type associated with it has not been reported in any relevant cases yet. Furthermore, CADASIL patients rarely present with acute bilateral multiple subcortical infarcts. CASE PRESENTATION We report the case of a Chinese female patient with CADASIL who experienced "an acute bilateral subcortical infarction" because of"hemodynamic changes and hypercoagulability". In genetic testing, we discovered a new Cys484Tyr mutation in exon 9, which has also been found in the patient's two daughters. CONCLUSIONS It is important to note that this discovery not only expands the mutation spectrum of Notch3 mutations in CADASIL patients, but also examines the mechanism behind acute bilateral subcortical infarction in CADASIL patients via case reviews and literature reviews, in order to provide some clinical recommendations for early intervention, diagnosis, and treatment in similar cases in the future.
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Affiliation(s)
- Weili Liu
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jie Zhang
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jian Li
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Shuai Jia
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Yanqiang Wang
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jianhong Geng
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Yaozhen Wang
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China.
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Huang H, Xie W, Hu F, Lv H, Wu Y, Cai B. Acute bilateral multiple subcortical infarcts as manifestation in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Neurol Sci 2023; 44:4391-4399. [PMID: 37458844 DOI: 10.1007/s10072-023-06949-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 07/04/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is characterised by recurrent subcortical ischemic events, migraine with aura, dementia and mood disturbance. Strokes are typically lacunar infarcts; however, bilateral multiple subcortical lacunar infarcts have been described only sporadically. METHOD We described four CADASIL patients who presented with acute bilateral multiple subcortical infarcts as the first manifestation. We also briefly summarised the case reports detailing the bilateral multiple infarcts in CADASIL. RESULTS Patient 1 and patient 2 were family members, and they presented with cognitive impairment. Patient 3 and patient 4 presented with slurred speech and hemiparesis. Patients 1, 3 and 4 developed hemodynamic fluctuations before the occurrence of ischemic stroke. Laboratory tests revealed elevated fibrinogen levels in patients 3 and 4. The brain magnetic resonance imaging showed acute bilateral multiple subcortical infarcts on the periventricular white matter in all the patients. CONCLUSION CADASIL, with a poor brain hemodynamic reserve, is vulnerable to hemodynamic alterations (e.g. blood pressure fluctuation, dehydration, blood loss and anaemia) and intolerable to ischemia and hypoxia of the brain. Furthermore, blood hypercoagulation may contribute to acute multiple bilateral infarctions in CADASIL. Therefore, it is necessary to avert these predispositions in CADASIL patients in their daily life.
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Affiliation(s)
- Huiqing Huang
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Weijie Xie
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Fangwei Hu
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Huimin Lv
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yijia Wu
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Bin Cai
- Department of Neurology and Institute of Neurology, First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
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Incidental DWI Lesions in Patients with Recent Small Subcortical Infarctions. J Stroke Cerebrovasc Dis 2022; 31:106304. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/02/2022] [Indexed: 01/16/2023] Open
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4
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Clancy U, Garcia DJ, Stringer MS, Thrippleton MJ, Valdés-Hernández MC, Wiseman S, Hamilton OK, Chappell FM, Brown R, Blair GW, Hewins W, Sleight E, Ballerini L, Bastin ME, Maniega SM, MacGillivray T, Hetherington K, Hamid C, Arteaga C, Morgan AG, Manning C, Backhouse E, Hamilton I, Job D, Marshall I, Doubal FN, Wardlaw JM. Rationale and design of a longitudinal study of cerebral small vessel diseases, clinical and imaging outcomes in patients presenting with mild ischaemic stroke: Mild Stroke Study 3. Eur Stroke J 2020; 6:81-88. [PMID: 33817338 PMCID: PMC7995323 DOI: 10.1177/2396987320929617] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
Background Cerebral small vessel disease is a major cause of dementia and stroke, visible on brain magnetic resonance imaging. Recent data suggest that small vessel disease lesions may be dynamic, damage extends into normal-appearing brain and microvascular dysfunctions include abnormal blood–brain barrier leakage, vasoreactivity and pulsatility, but much remains unknown regarding underlying pathophysiology, symptoms, clinical features and risk factors of small vessel disease. Patients and Methods: The Mild Stroke Study 3 is a prospective observational cohort study to identify risk factors for and clinical implications of small vessel disease progression and regression among up to 300 adults with non-disabling stroke. We perform detailed serial clinical, cognitive, lifestyle, physiological, retinal and brain magnetic resonance imaging assessments over one year; we assess cerebrovascular reactivity, blood flow, pulsatility and blood–brain barrier leakage on magnetic resonance imaging at baseline; we follow up to four years by post and phone. The study is registered ISRCTN 12113543. Summary Factors which influence direction and rate of change of small vessel disease lesions are poorly understood. We investigate the role of small vessel dysfunction using advanced serial neuroimaging in a deeply phenotyped cohort to increase understanding of the natural history of small vessel disease, identify those at highest risk of early disease progression or regression and uncover novel targets for small vessel disease prevention and therapy.
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Affiliation(s)
- Una Clancy
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Michael S Stringer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Stewart Wiseman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Olivia Kl Hamilton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Rosalind Brown
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gordon W Blair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Will Hewins
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Emilie Sleight
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Lucia Ballerini
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mark E Bastin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Tom MacGillivray
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Charlene Hamid
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Carmen Arteaga
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alasdair G Morgan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cameron Manning
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ellen Backhouse
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Iona Hamilton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Dominic Job
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ian Marshall
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Nepal P, Batchala PP, Songmen S, Parashar K, Sapire J. An unresponsive COVID-19 patient. Emerg Radiol 2020; 27:755-759. [PMID: 32468357 PMCID: PMC8824721 DOI: 10.1007/s10140-020-01799-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/22/2020] [Indexed: 11/28/2022]
Abstract
Neurological manifestations and complications are increasingly reported in coronavirus disease-19 (COVID-19) patients. Although pulmonary manifestations are more common, patients with severe disease may present with neurological symptoms such as in our case. We describe a case report of a 50-year-old male without previous known comorbidity who was found unresponsive due to COVID-19-related neurological complications. During this pandemic, an emergency radiologist should be well acquainted with various neurological manifestations of COVID-19. In this article, we will discuss the pathogenesis, imaging findings, and differentials of this disease.
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Affiliation(s)
- Pankaj Nepal
- St. Vincent’s Medical Center, Bridgeport, CT USA
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Das AS, Regenhardt RW, Feske SK, Gurol ME. Treatment Approaches to Lacunar Stroke. J Stroke Cerebrovasc Dis 2019; 28:2055-2078. [PMID: 31151838 PMCID: PMC7456600 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven K Feske
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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7
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Clinical Characteristics and Outcome of Patients with Lacunar Infarcts and Concurrent Embolic Ischemic Lesions. Clin Neuroradiol 2019; 30:511-516. [DOI: 10.1007/s00062-019-00800-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/13/2019] [Indexed: 11/26/2022]
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8
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Regenhardt RW, Das AS, Ohtomo R, Lo EH, Ayata C, Gurol ME. Pathophysiology of Lacunar Stroke: History's Mysteries and Modern Interpretations. J Stroke Cerebrovasc Dis 2019; 28:2079-2097. [PMID: 31151839 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/13/2019] [Accepted: 05/04/2019] [Indexed: 01/13/2023] Open
Abstract
Since the term "lacune" was adopted in the 1800s to describe infarctions from cerebral small vessels, their underlying pathophysiological basis remained obscure until the 1960s when Charles Miller Fisher performed several autopsy studies of stroke patients. He observed that the vessels displayed segmental arteriolar disorganization that was associated with vessel enlargement, hemorrhage, and fibrinoid deposition. He coined the term "lipohyalinosis" to describe the microvascular mechanism that engenders small subcortical infarcts in the absence of a compelling embolic source. Since Fisher's early descriptions of lipohyalinosis and lacunar stroke (LS), there have been many advancements in the understanding of this disease process. Herein, we review lipohyalinosis as it relates to modern concepts of cerebral small vessel disease (cSVD). We discuss clinical classifications of LS as well as radiographic definitions based on modern neuroimaging techniques. We provide a broad and comprehensive overview of LS pathophysiology both at the vessel and parenchymal levels. We also comment on the role of biomarkers, the possibility of systemic disease processes, and advancements in the genetics of cSVD. Lastly, we assess preclinical models that can aid in studying LS disease pathogenesis. Enhanced understanding of this highly prevalent disease will allow for the identification of novel therapeutic targets capable of mitigating disease sequelae.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryo Ohtomo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eng H Lo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cenk Ayata
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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9
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Obusez EC, Svensson L, Bullen J, Obuchowski N, Jones SE. Deep chronic microvascular white matter ischemic change as an independent predictor of acute brain infarction after thoracic aortic replacement. J Card Surg 2018; 33:552-560. [PMID: 30175455 DOI: 10.1111/jocs.13786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative brain injury is a cause of mortality and morbidity in patients who undergo thoracic aortic replacement. Chronic microvascular white matter ischemic change (WMIC) has been shown to be associated with acute brain infarction in the general population. WMIC has also been shown to be an independent predictor of non-focal neurocognitive changes, generalized seizures, and temporary neurologic dysfunction in patients who undergo thoracic aortic replacement. The aim of this study is to determine if WMIC is a risk factor for acute brain infarction in patients who undergo thoracic aortic replacement. METHODS A case-control study of patients who underwent thoracic aortic replacement between 2001 and 2014 were reviewed for neurological changes after surgery and acute brain infarction on postoperative diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI). Patients with neurological changes were matched with control patients who underwent thoracic aortic replacement and had postoperative neurological symptoms without acute brain infarctions. Acute infarction was re-assessed by reviewing DWI sequences on postoperative MRI. WMIC was assessed on FLAIR and T2WI sequences on both preoperative and postoperative MRI. Logistic regression was performed assessing the relationship of WMIC and acute ischemic infarction. RESULTS 5171 patients underwent thoracic aortic replacement; 179 had postoperative neurological changes, and of those 53 patients had acute brain infarction on postoperative DWI. Patients with deep WMIC were more likely to have acute DWI infarctions after thoracic aortic replacement (P = 0.023). CONCLUSION Our matched retrospective case-controlled study shows deep WMIC to be a predictor of acute brain infarction on DWI after thoracic aortic replacement.
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Affiliation(s)
- Emmanuel C Obusez
- Department of Neuroradiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars Svensson
- Department of Thoracic and Cardiovascular Surgery, Center for Aortic Surgery, Marfans Syndrome and Connective Tissue Disorder Clinic, Heart and Vascular Institute; Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Bullen
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Nancy Obuchowski
- Department of Neuroradiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stephen E Jones
- Department of Neuroradiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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Liqun Z, Park KH, Kim HJ, Lee SU, Choi JY, Kim JS. Acute Unilateral Audiovestibulopathy due to Embolic Labyrinthine Infarction. Front Neurol 2018; 9:311. [PMID: 29770122 PMCID: PMC5940739 DOI: 10.3389/fneur.2018.00311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Labyrinthine infarction is a cause of acute audiovestibulopathy, but can be diagnosed only in association with other infarctions involving the brainstem or cerebellar areas supplied by the anterior inferior cerebellar artery (AICA) since current imaging techniques cannot visualize an infarction confined to the labyrinth. This case series aimed to establish embolic labyrinthine infarction as a mechanism of isolated acute audiovestibulopathy. Methods We analyzed clinical features, imaging findings, and mechanisms of embolism in 10 patients (8 men, age range: 38–76) who had developed acute audiovestibulopathy in association with an obvious source of embolism and concurrent acute embolic infarctions in the non-anterior inferior cerebellar artery territories. The presence of audiovestibulopathy was defined when bedside or laboratory evaluation documented unilateral vestibular (head-impulse tests or caloric tests) or auditory loss (audiometry). Results Six patients showed combined audiovestibulopathy while three had isolated vestibulopathy. One patient presented isolated hearing loss. Audiovestibular findings were the only abnormalities observed in nine patients. In all patients, MRIs documented single or multiple infarctions in the cerebellum (n = 5) or cerebral hemispheres (n = 5). Especially three patients showed single or scattered foci of tiny acute infarctions only in the cerebral hemispheres. Cardiac sources of embolism were found in eight, and artery-to-artery embolism was presumed in two patients. Conclusion Selective embolism to the labyrinth may be considered in patients with acute unilateral audiovestibulopathy and concurrent acute infarctions in the non-AICA territories.
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Affiliation(s)
- Zhong Liqun
- Department of Neurology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Kee-Hong Park
- Department of Neurology, Gyeongsang National University Hospital, Jinju, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sun-Uk Lee
- Department of Neurology, Seoul National University College Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Seoul National University College Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Sener U, Ocek L, Ilgezdi I, Sahin H, Ozcelik M, Zorlu Y. Significance of Multiple Acute Ischemic Lesions on Initial Diffusion-weighted Imaging in Stroke Patients and Relation of Toast Classification. Ann Indian Acad Neurol 2018; 21:197-202. [PMID: 30258262 PMCID: PMC6137625 DOI: 10.4103/aian.aian_487_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background It is important to know whether or not the stroke risk factors and etiologies of patients with multiple acute infarcts are different to those of patients with a single acute infarct. Aim The frequency of multiple acute infarct was investigated in ischemic stroke patients and a comparison was made of the characteristics of stroke patients with and without multiple acute infarct. Patients and Methods We reviewed the clinical records of 988 ischemic stroke patients who were admitted within 1 week of the onset of stroke and diffusion-weighted imaging (DWI) was performed on first presentation. The clinical characteristics, laboratory, and imaging results were noted from the patient records. According to the DWI findings, the patients were separated into three groups as those with a single acute infarct in a single vascular territory (SI group), those with multiple acute infarcts in a single vascular territory (SMI group) and those with multiple acute infarcts in multiple vascular (MMI group) territories. The frequency of multiple acute infarcts was investigated, and a comparison was made of the characteristics of stroke patients with and without multiple acute infarcts. Results The SMI group included 119 (12%) patients and the MMI group 126 (12.8%). The most common mechanisms of multiple acute infarcts are large artery atherosclerosis and cardiac origin emboli. Moreover, the risk factors most determined were hypertension, diabetes mellitus, and hyperlipidemia in the MMI group. Conclusion No difference was determined between the groups in respect of stroke etiology and risk factors.
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Affiliation(s)
- Ufuk Sener
- Department of Neurology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Levent Ocek
- Department of Neurology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Irem Ilgezdi
- Department of Neurology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Hilal Sahin
- Department of Radiology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Murat Ozcelik
- Department of Neurology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Yasar Zorlu
- Department of Neurology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
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Shaharir SS, Osman SS, Md Rani SA, Sakthiswary R, Said MSM. Factors associated with increased white matter hyperintense lesion (WMHI) load in patients with systemic lupus erythematosus (SLE). Lupus 2017; 27:25-32. [PMID: 28467290 DOI: 10.1177/0961203317707062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction White matter hyperintense (WMHI) lesions are the most common finding in magnetic resonance imaging (MRI) of the brain in patients with systemic lupus erythematosus (SLE). Objective The objective of this article is to determine the clinical factors associated with an increase in WMHI lesion load among SLE patients. Method A total of 83 SLE patients with MRI of the brain from National University of Malaysia Medical Centre were included. The WMHI lesion load was determined using the Scheltens score and Fazekas scale, and their distribution was divided into the deep white matter (DWMHI) and periventricular (PVH) regions. The clinical correlates of WMHI lesions were initially determined using univariate analyses and subsequently multivariable regression analyses were performed to determine the independent factors of increased WMHI lesion load. Results MRI of the brain of 46 patients who had WMHI lesions were compared with 37 patients with normal MRI. We found significant association between the presence of WMHI lesions and age, presence of cerebral infarcts, positive antiphospholipid antibody (aPL), active disease, neuropsychiatric lupus (NPSLE) and disease damage. Age, SLEDAI scores, cerebral infarcts and disease damage were significantly associated with higher DWMHI and PVH Scheltens scores. Meanwhile, patients with active lupus nephritis (LN), lower serum albumin and more severe proteinuria were associated with larger Fazekas WMHI lesions. Multivariable regression analysis revealed that the independent factors associated with presence of WMHI lesions were positive aPL and SLEDAI scores ( p < 0.05). Higher WMHI Scheltens scores in both DWMHI and PVH were associated with presence of cerebral infarct but higher PVH lesion load was significantly associated with active SLE disease. Conclusion Presence of WMHI lesions in SLE was significantly associated with cerebral infarcts, aPL and high general SLE activity, suggesting both inflammation and ischaemia as the underlying pathology of these lesions.
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Affiliation(s)
- S S Shaharir
- 1 Department of Internal Medicine/Rheumatology, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - S S Osman
- 2 Department of Radiology, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - S A Md Rani
- 3 Department of Internal Medicine/Neurology, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - R Sakthiswary
- 1 Department of Internal Medicine/Rheumatology, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - M S M Said
- 1 Department of Internal Medicine/Rheumatology, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia
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Kövari E, Herrmann FR, Gold G, Hof PR, Charidimou A. Association of cortical microinfarcts and cerebral small vessel pathology in the ageing brain. Neuropathol Appl Neurobiol 2017; 43:505-513. [PMID: 27783888 DOI: 10.1111/nan.12366] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/19/2016] [Accepted: 10/26/2016] [Indexed: 11/29/2022]
Abstract
AIMS Cortical microinfarcts (CMI) are frequently observed in the ageing brain independent of cognitive decline, but their aetiology is not fully elucidated. To examine the potential role of different vessel pathologies, including cerebral amyloid angiopathy (CAA), arteriolosclerosis-hyalinosis and thromboembolism in the development of CMI, we examined 80 autopsy cases with more than one CMI on routine neuropathological examination. METHODS Pial and intracortical vessels around CMI were assessed for their integrity with haematoxylin-eosin staining and antibodies against amyloid-β protein and fibrinogen using a semiquantitative four-level rating scale (absent to severe) in the hippocampus, and the frontal, temporal and occipital cortex. Four histological categories of changes were defined: CAA, vessel pathology other than CAA, thromboembolism and absence of vessel pathology near CMI. RESULTS A differential distribution of microvascular pathology was observed depending on brain regions. In the occipital cortex, CAA was commonly associated with CMI. In contrast, in the hippocampus and the frontal cortex, cases without any vascular pathology in pial and intracortical vessels were significantly more frequent. CONCLUSIONS The aetiology of CMI differs depending on brain location. CAA may play a role principally in the occipital cortex. The large number of intact vessels around the CMI (mainly in the frontal cortex and hippocampus) raises the possibility that pathologies other than structural microangiopathy, including hypoperfusion/arterial hypotension or large vessel atherosclerosis, play a role in the development of microvascular lesions. These results are relevant in the context of aetiopathogenesis of vascular changes associated with conditions like vascular dementia.
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Affiliation(s)
- E Kövari
- Department of Mental Health and Psychiatry, University Hospitals and University of Geneva, Geneva, Switzerland
| | - F R Herrmann
- Department of Internal Medicine, Rehabilitation and Geriatrics, University Hospitals and University of Geneva, Thônex, Switzerland
| | - G Gold
- Department of Internal Medicine, Rehabilitation and Geriatrics, University Hospitals and University of Geneva, Thônex, Switzerland
| | - P R Hof
- Fishberg Department of Neuroscience, Friedman Brain Institute, and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Charidimou
- Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
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Novotny V, Thomassen L, Waje-Andreassen U, Naess H. Acute cerebral infarcts in multiple arterial territories associated with cardioembolism. Acta Neurol Scand 2017; 135:346-351. [PMID: 27109593 DOI: 10.1111/ane.12606] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism. MATERIALS AND METHODS We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories. RESULTS MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI. CONCLUSIONS Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.
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Affiliation(s)
- V. Novotny
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - L. Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | | | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
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15
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Taieb G, Renard D, Castelnovo G. Simultaneous subcortical infarcts as initial manifestation of CADASIL. Acta Neurol Belg 2015; 115:385-6. [PMID: 25163556 DOI: 10.1007/s13760-014-0351-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/04/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Guillaume Taieb
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, Place du Pr Debré, 30029, Nîmes Cedex 4, France,
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16
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Valdés Hernández MDC, Maconick LC, Muñoz Maniega S, Wang X, Wiseman S, Armitage PA, Doubal FN, Makin S, Sudlow CLM, Dennis MS, Deary IJ, Bastin M, Wardlaw JM. A comparison of location of acute symptomatic vs. 'silent' small vessel lesions. Int J Stroke 2015; 10:1044-50. [PMID: 26120782 PMCID: PMC4737263 DOI: 10.1111/ijs.12558] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/29/2015] [Indexed: 01/06/2023]
Abstract
Background Acute lacunar ischaemic stroke, white matter hyperintensities, and lacunes are all features of cerebral small vessel disease. It is unclear why some small vessel disease lesions present with acute stroke symptoms, whereas others typically do not. Aim To test if lesion location could be one reason why some small vessel disease lesions present with acute stroke, whereas others accumulate covertly. Methods We identified prospectively patients who presented with acute lacunar stroke symptoms with a recent small subcortical infarct confirmed on magnetic resonance diffusion imaging. We compared the distribution of the acute infarcts with that of white matter hyperintensity and lacunes using computational image mapping methods. Results In 188 patients, mean age 67 ± standard deviation 12 years, the lesions that presented with acute lacunar ischaemic stroke were located in or near the main motor and sensory tracts in (descending order): posterior limb of the internal capsule (probability density 0·2/mm3), centrum semiovale (probability density = 0·15/mm3), medial lentiform nucleus/lateral thalamus (probability density = 0·09/mm3), and pons (probability density = 0·02/mm3). Most lacunes were in the lentiform nucleus (probability density = 0·01–0·04/mm3) or external capsule (probability density = 0·05/mm3). Most white matter hyperintensities were in centrum semiovale (except for the area affected by the acute symptomatic infarcts), external capsules, basal ganglia, and brainstem, with little overlap with the acute symptomatic infarcts (analysis of variance, P < 0·01). Conclusions Lesions that present with acute lacunar ischaemic stroke symptoms may be more likely noticed by the patient through affecting the main motor and sensory tracts, whereas white matter hyperintensity and asymptomatic lacunes mainly affect other areas. Brain location could at least partly explain the symptomatic vs. covert development of small vessel disease.
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Affiliation(s)
| | - Lucy C Maconick
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Xin Wang
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Stewart Wiseman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul A Armitage
- Department of Cardiovascular Sciences, University of Sheffield, Sheffield, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cathie L M Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ian J Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK
| | - Mark Bastin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK
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17
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Wardlaw JM, Smith EE, Biessels GJ, Cordonnier C, Fazekas F, Frayne R, Lindley RI, O'Brien JT, Barkhof F, Benavente OR, Black SE, Brayne C, Breteler M, Chabriat H, DeCarli C, de Leeuw FE, Doubal F, Duering M, Fox NC, Greenberg S, Hachinski V, Kilimann I, Mok V, Oostenbrugge RV, Pantoni L, Speck O, Stephan BCM, Teipel S, Viswanathan A, Werring D, Chen C, Smith C, van Buchem M, Norrving B, Gorelick PB, Dichgans M. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol 2013; 12:822-38. [PMID: 23867200 PMCID: PMC3714437 DOI: 10.1016/s1474-4422(13)70124-8] [Citation(s) in RCA: 3484] [Impact Index Per Article: 316.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Cerebral small vessel disease (SVD) is a common accompaniment of ageing. Features seen on neuroimaging include recent small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, microbleeds, and brain atrophy. SVD can present as a stroke or cognitive decline, or can have few or no symptoms. SVD frequently coexists with neurodegenerative disease, and can exacerbate cognitive deficits, physical disabilities, and other symptoms of neurodegeneration. Terminology and definitions for imaging the features of SVD vary widely, which is also true for protocols for image acquisition and image analysis. This lack of consistency hampers progress in identifying the contribution of SVD to the pathophysiology and clinical features of common neurodegenerative diseases. We are an international working group from the Centres of Excellence in Neurodegeneration. We completed a structured process to develop definitions and imaging standards for markers and consequences of SVD. We aimed to achieve the following: first, to provide a common advisory about terms and definitions for features visible on MRI; second, to suggest minimum standards for image acquisition and analysis; third, to agree on standards for scientific reporting of changes related to SVD on neuroimaging; and fourth, to review emerging imaging methods for detection and quantification of preclinical manifestations of SVD. Our findings and recommendations apply to research studies, and can be used in the clinical setting to standardise image interpretation, acquisition, and reporting. This Position Paper summarises the main outcomes of this international effort to provide the STandards for ReportIng Vascular changes on nEuroimaging (STRIVE).
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Affiliation(s)
- Joanna M Wardlaw
- Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
- Correspondence to: Prof Joanna M Wardlaw, Division of Neuroimaging Sciences, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - Eric E Smith
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary and Seaman Family MR Research Centre, Calgary, AL, Canada
| | - Geert J Biessels
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, UMC Utrecht, Utrecht, Netherlands
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Richard Frayne
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary and Seaman Family MR Research Centre, Calgary, AL, Canada
| | - Richard I Lindley
- University of Sydney and George Institute for Global Health, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, Netherlands
| | - Oscar R Benavente
- Department of Medicine, Division of Neurology, Brain Research Centre, University of British Columbia, Vancouver, BC, Canada
| | | | - Carol Brayne
- Cambridge Institute of Public Health, School of Clinical Medicine, Cambridge, UK
| | | | - Hugues Chabriat
- Service de Neurologie, Hopital Lariboisiere, INSERM, Université Denis Diderot, Paris, France
| | - Charles DeCarli
- Department of Neurology, University of California at Davis, Sacramento, CA, USA
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Fergus Doubal
- Brain Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Marco Duering
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nick C Fox
- Department of Neurodegeneration, Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Steven Greenberg
- Massachusetts General Hospital, Stroke Research Center, Boston, MA, USA
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Ingo Kilimann
- German Center for Neurodegenerative Diseases (DZNE) Rostock and Greifswald, Rostock, Germany
| | - Vincent Mok
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Robert van Oostenbrugge
- Department of Neurology, School of Mental Health and Neuroscience, and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Leonardo Pantoni
- Azienda Universitario Ospedaliera Careggi, Department of Neuroscience, Pharmacology and Child's Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Oliver Speck
- Department of Biomedical Magnetic Resonance, Faculty for Natural Sciences, Institute for Experimental Physics, Otto-von-Guericke UniversityMagdeburg, Magdeburg, Germany
| | | | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE) Rostock and Greifswald, Rostock, Germany
| | - Anand Viswanathan
- Massachusetts General Hospital, Stroke Research Center, Boston, MA, USA
| | - David Werring
- Stroke Research Group, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - Christopher Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mark van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Bo Norrving
- Department of Clinical Sciences, Section of Neurology, Skåne University Hospital, Lund, Sweden
| | - Philip B Gorelick
- Saint Mary's Health Care, Hauenstein Neuroscience Center, Grand Rapids, MI, USA
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- Prof M Dichgans, Institute for Stroke and Dementia Research, Klinikum der Universität, Munich, Germany
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Mustanoja S, Putaala J, Haapaniemi E, Strbian D, Kaste M, Tatlisumak T. Multiple brain infarcts in young adults: clues for etiologic diagnosis and prognostic impact. Eur J Neurol 2012; 20:216-22. [DOI: 10.1111/j.1468-1331.2012.03872.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/17/2012] [Indexed: 11/30/2022]
Affiliation(s)
- S. Mustanoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - E. Haapaniemi
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
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19
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Lee JH, Kim YJ, Moon Y, Cho HJ, Kim HY. Acute simultaneous multiple lacunar infarcts: a severe disease entity in small artery disease. Eur Neurol 2012; 67:303-11. [PMID: 22517446 DOI: 10.1159/000336061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/18/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND We hypothesized that acute simultaneous multiple lacunar infarcts (sMLI) may have different clinico-radiological characteristics compared to acute single lacunar infarcts (SLI). METHODS We retrospectively reviewed stroke patients with sMLI or SLI in a consecutively collected stroke registry with a predefined long-term clinical follow-up. Clinical characteristics, including vascular risk factors, rheological profiles, premorbid functional status, and clinical outcome were evaluated. In addition, radiological characteristics, including white matter ischemic changes, previous lacunes, microbleeds, and concomitant intra- or extracranial arterial stenosis were evaluated. RESULTS Of the 548 acute ischemic stroke patients, sMLI was found in 23 (13.5%) and SLI in 148 (86.5%). There was no difference in vascular risk factors and rheological profiles between the two groups, except for advanced age and more frequent previous history of stroke in the sMLI group. The sMLI group also showed more previous lacunes (p < 0.001) and microbleeds (p < 0.001). A cardioembolic or atherothrombotic stroke mechanism was rare in both groups. Recurrent strokes were more frequent in the sMLI group. CONCLUSIONS The main pathophysiology of sMLI may be small artery disease. However, clinico-radiological characteristics suggest that sMLI may be a more severe entity of small artery disease compared to SLI.
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Affiliation(s)
- Joon Hwa Lee
- Department of Neurology, Konkuk University School of Medicine, Center for Geriatric Neuroscience Research, Institute of Biomedical Science and Technology, Research Institute of Biomedical Science, Seoul, Korea
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20
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Smith EE, Schneider JA, Wardlaw JM, Greenberg SM. Cerebral microinfarcts: the invisible lesions. Lancet Neurol 2012; 11:272-82. [PMID: 22341035 PMCID: PMC3359329 DOI: 10.1016/s1474-4422(11)70307-6] [Citation(s) in RCA: 326] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The association between small but still visible lacunar infarcts and cognitive decline has been established by population-based radiological and pathological studies. Microscopic examination of brain sections shows even smaller but substantially more numerous microinfarcts, the focus of this Review. These lesions often result from small vessel pathologies such as arteriolosclerosis or cerebral amyloid angiopathy. They typically go undetected in clinical-radiological correlation studies that rely on conventional structural MRI, although the largest acute microinfarcts can be detected by diffusion-weighted imaging. In view of their high numbers and widespread distribution, microinfarcts could directly disrupt important cognitive networks and thus account for some of the neurological dysfunction associated with lesions visible on conventional MRI such as lacunar infarcts and white matter hyperintensities. Standardised neuropathological assessment criteria and the development of non-invasive means of detection during life would be major steps towards understanding the causes and consequences of otherwise macroscopically invisible microinfarcts.
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Affiliation(s)
- Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie A. Schneider
- Departments of Pathology and Neurological Sciences, Rush Alzheimer’s Disease Centre, Rush University Medical Center, Chicago, IL, USA
| | - Joanna M. Wardlaw
- Centre for Cognitive Ageing and Cognitive Epidemiology (CCACE), University of Edinburgh, UK,Scottish Imaging Network, A Platform for Scientific Excellence (SINAPSE) Collaboration
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21
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Multiple subcortical acute ischemic lesions reflect small vessel disease rather than cardiogenic embolism. J Neurol 2012; 259:1951-7. [PMID: 22349872 DOI: 10.1007/s00415-012-6451-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 01/27/2012] [Accepted: 01/28/2012] [Indexed: 10/28/2022]
Abstract
Multiple acute ischemic lesions in different hemispheres or vascular territories are mainly considered to be of proximal embolic origin. However, despite careful diagnostic work-up, the etiological classification often stays undetermined. We propose that multiple acute ischemic lesions can sometimes be a phenomenon observed in small vessel disease (SVD). From a prospectively collected database of more than 7,000 stroke patients, 173 patients with acute bihemispheric infarction were identified. We analyzed those subjects with multiple small (< 15 mm Ø) subcortical acute ischemic lesions on diffusion-weighted MRI (DWI) and concomitant severe small vessel disease (Fazekas grades II-III) without a proximal embolic source as evaluated by cardiological investigations. Twenty patients (mean age 66 ± 12 years, 12 men) with a mean number of 2.95 ± 1.24 acute lesions on DWI (range of 2-7 lesions per patient) were identified (n = 5 Fazekas II°, n = 15 Fazekas III°). Most of the lesions were located in typical areas of lacunar infarction. The mean NIHSS score on admission was 2.95 ± 2.0 (range 0-8). Multiple acute ischemic lesions in different vascular territories might not always be of proximal cardiovascular embolic origin. Simultaneous small subcortical ischemic lesions may reflect remote ischemia due to small vessel disease reflecting simultaneous hemorheological dysfunction.
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Wardlaw JM. Differing risk factors and outcomes in ischemic stroke subtypes: focus on lacunar stroke. FUTURE NEUROLOGY 2011. [DOI: 10.2217/fnl.11.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Lacunar stroke has been a recognized stroke subtype for many years but its pathophysiology remains unknown, so prevention and treatment are suboptimal. Most lacunar strokes result from an intrinsic cerebral small vessel disease, probably part of a systemic disorder. Hypertension, diabetes and other vascular risk factors (but not atrial fibrillation and ipsilateral carotid stenosis) are equally common in lacunar as in large artery atherothromboembolic stroke, which, together with other factors, suggests that the patient’s response to vascular risk factors, not the vascular risk factors per se, determines whether they develop small vessel or large artery stroke. Inflammation and endothelial failure are probably involved in the pathogenesis of lacunar stroke, but their role needs to be clarified. The cerebral venules as well as arterioles are abnormal in this condition. The disorder may not be primarily ischemic; instead, arteriolar thrombosis may be a late-stage phenomenon secondary to chronic arteriolar wall damage resulting from leakage of plasma components across the BBB. Accurate diagnosis of lacunar stroke, avoiding risk factor-based classifications, is required to underpin future research.
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Affiliation(s)
- Joanna M Wardlaw
- Brain Research Imaging Centre, Edinburgh, SINAPSE Collaboration, c/o Division of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK
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23
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Clustering of multifocal cerebral infarctions in CADASIL: a case report. J Neurol 2010; 258:325-7. [DOI: 10.1007/s00415-010-5727-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 08/15/2010] [Accepted: 08/17/2010] [Indexed: 10/19/2022]
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24
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Affiliation(s)
- Geoffrey A Donnan
- National Stroke Research Institute, Heidelberg, Victoria, Australia.
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25
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Rapp JH, Hollenbeck K, Pan XM. An experimental model of lacunar infarction: embolization of microthrombi. J Vasc Surg 2008; 48:196-200. [PMID: 18486421 DOI: 10.1016/j.jvs.2008.01.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 01/10/2008] [Accepted: 01/12/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Microthrombi are undoubtedly the most common embolic material in the cerebral circulation, originating from even minor irregularities of the arterial wall, fibrillating atria, cardiac valves, and patent foramen ovale. Thrombus fragments are globular and likely to completely obstruct terminal vessels. In contrast, previous work with "atheroemboli" of needle-like cholesterol crystals rarely cause occlusions or infarctions instead creating small foci of inflammation. In this work, we asked if microthrombi would occlude terminal vessels and create lacunar type infarctions in the subcortical tissues of the rat brain where, as in human brain, collateral flow is limited relative to the cortex. METHODS Three treatment groups of adult male Sprague-Dawley rats were studied. All groups underwent general anesthesia with monitoring of temperature and blood pressure during cannulation of the right internal carotid artery. In the group embolized with thrombus fragments (n = 12), animals had injections of 300 fragments of thrombus size 60 to 100 microns, the cholesterol group (n = 6) had injections of 300 cholesterol crystals of similar size, and the control group (n = 4) had injections of saline. Brains were harvested at 4 days with perfusion fixation and were examined by immunohistochemical staining for breaks in the blood brain barrier (BBB) (albumin), microglial activation (CD11b), astrocyte activation (GFAP), and infarction (loss of NeuN staining). Size and location of the areas of injury and infarction were recorded. RESULTS Clot fragments caused discreet infarcts in 10/12 animals that were 0.1-1.7 mm in diameter and coincided with activation of microglia and astrocytes. In some areas, necrosis was already underway at this early time point. Consistent with our previous work, the infarcts caused by cholesterol crystals were smaller (P = .014). Foci of BBB disruption and microglial activation were distributed throughout the brain whereas areas of infarction were found almost exclusively in subcortical tissues (P = .029). CONCLUSIONS Injecting microthrombi reproducibly caused areas of necrosis resembling lacunar type infarctions. These were primarily located in the striatum and thalamus presumably because these areas lack the branching, collateral network seen in the cortex. In addition, these data give further evidence that the extent of brain injury from emboli depends upon composition and shape as well as size.
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Affiliation(s)
- Joseph H Rapp
- Vascular Surgery Service, The San Francisco Department of Veterans Affairs Medical Center, San Francisco, CA 94117, USA.
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26
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Cho AH, Kim JS, Jeon SB, Kwon SU, Lee DH, Kang DW. Mechanism of multiple infarcts in multiple cerebral circulations on diffusion-weighted imaging. J Neurol 2007; 254:924-30. [PMID: 17401747 DOI: 10.1007/s00415-006-0397-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 12/05/2005] [Accepted: 01/09/2006] [Indexed: 10/23/2022]
Abstract
Acute multiple infarcts in multiple cerebral circulations (AMIMC) are thought to suggest the presence of cardioembolic sources or systemic hypercoagulopathy. However, the mechanism and the simultaneous occurrence of AMIMC are not well known. We reviewed 685 consecutive acute ischemic stroke patients who underwent diffusion-weighted imaging (DWI) within 48 hours of onset. AMIMC was defined as multiple acute DWI lesions distributed in more than one cerebral circulation (i.e., 2 anterior and 1 posterior circulations). Signal intensities on apparent diffusion coefficient (ADC) maps corresponding to acute DWI lesions were classified as 'low', 'iso-' or 'high' signals. Blood markers obtained within 24 hours after admission were compared between patients with and without AMIMC. Sixty-seven (9.8%) patients had AMIMC. Frequency of cardioembolism in AMIMC patients was only 29.9% (20/67), which was not different from non-AMIMC patients (21.7%, p = 0.16). Large-artery atherosclerosis (LAA) or small-vessel occlusion (SVO) in multiple circulations or combined LAA and SVO were identified in 34.3% (23/ 67) of AMIMC patients, although pure LAA and pure SVO were less frequent than in non-AMIMC patients. ADC signals were purely 'low' in 38 (56.7%) and 'mixed' (low with iso- or high) in 29 (43.3%). Cardioembolism tended to be associated with 'low' ADC signals (75.0%) compared with other stroke mechanisms (48.9%; p = 0.062). C-reactive protein was higher in AMIMC than in non- AMIMC patients (p = 0.009). Stroke mechanisms responsible for AMIMC are heterogeneous. ADC findings suggest that AMIMC commonly occur stepwise and may be useful in determining stroke mechanism. Systemic inflammation may be associated with the pathogenesis of AMIMC.
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Affiliation(s)
- A-Hyun Cho
- Department of Neurology, Asan Medical Center University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea
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Abstract
PURPOSE OF REVIEW While chronic risk factors for stroke are reasonably well understood, the acute precipitants, or triggers, of stroke, remain relatively understudied. RECENT FINDINGS Several converging lines of evidence indicate that transient perturbations in systemic metabolism may provoke the onset of cardiovascular events, including stroke. Epidemiologic data, including studies utilizing novel designs that consider intraindividual differences across different time periods, have been used to clarify triggers for myocardial ischemia, and these methods are beginning to be employed in stroke research. Acute infections, particularly upper respiratory infections, and other inflammatory stimuli have emerged as important triggers of acute ischemic stroke. The mechanisms involved include immunologically mediated activation of platelets and endothelial dysfunction. There also appears to be a period of time, or 'stroke-prone state', characterized by diffuse activation of the vasculature during which patients may be at increased risk of initial and recurrent ischemic events. SUMMARY Confirmation of these findings in further studies may help elucidate the mechanisms behind this short-term increase in stroke risk. Improved methods of assessment of this period of heightened susceptibility could lead to more temporally focused preventive interventions.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Columbia University, New York-Presbyterian Hospital, New York, New York, USA.
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Pavlovic AM, Pekmezovic T, Zidverc-Trajkovic J, Pavlovic DM, Jovanovic Z, Mijajlovic M, Petrovic M, Kostic VS, Sternic N. Is there a difference in risk factors for single and multiple symptomatic lesions in small vessel disease? Clin Neurol Neurosurg 2006; 108:358-62. [PMID: 15869840 DOI: 10.1016/j.clineuro.2005.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 03/10/2005] [Accepted: 03/21/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES/PURPOSES Small vessel disease (SVD) is associated with traditional vascular risk factors (RF). The aim of our study was to determine whether different SVD types, single lacunar infarction (LI) and multiple LI (MLI) with or without white matter lesions (WML), have different RF profiles. PATIENTS AND METHODS Forty RF parameters were analysed in 201 consecutive patients with magnetic resonance imaging finding of SVD. RESULTS History of arterial hypertension, higher systolic and mean blood pressure (BP) but also hypotension, and higher plasma homocysteine levels were more frequent in MLI compared to single LI patients (p<0.05). Patients with one LI were younger, more frequently had clinically evident stroke and family history of cardiovascular disease (CVD) (p<0.05). Significant difference between groups was found only in these RF, indicating that similar pathological processes led to both types of SVD. CONCLUSION Positive correlation with age and family history of CVD necessitates further analyses of other factors, predominantly genetic, as the key to the answer why patients develop different lesions in SVD.
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Affiliation(s)
- Aleksandra M Pavlovic
- Institute of Neurology, Clinical Center of Serbia, Dr. Subotica 6, 11000 Belgrade, Serbia.
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Rabinstein AA, Chirinos JA, Fernandez FR, Zambrano JP. Is TEE useful in patients with small subcortical strokes? Eur J Neurol 2006; 13:522-7. [PMID: 16722979 DOI: 10.1111/j.1468-1331.2006.01283.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the role of transesophageal echocardiography (TEE) in the investigation of stroke mechanism is well established, the value of this test in patients with lacunar presentation is unclear. Review of 214 patients with acute cerebral ischemia referred for TEE to exclude cardioaortic sources of embolism after non-diagnostic basic work-up including carotid ultrasound and transthoracic echocardiography. TEE was considered positive when it showed large or complex aortic arch plaques, left atrial thrombus, mitral or aortic valve vegetations, or patent foramen ovale with atrial septal aneurysm. Multivariate regression analysis was performed to assess the value of lacunar syndrome and radiological small subcortical infarctions in predicting TEE result. Predictive values and likelihood ratios for these variables were calculated. Fifty-two patients (24%) had positive TEE. The most common embolic source was large or complex aortic plaques in 19% of patients. Neither clinical presentation with lacunar syndrome nor the presence of small subcortical infarction on CT scan predicted a negative TEE result on univariate or multivariate analysis. However, the combination of lacunar syndrome with radiological small subcortical infarction was uniformly associated with negative TEE (P=0.01; negative predictive value 100%). The combination of lacunar syndrome with small subcortical radiological infarct predicts the absence of cardioaortic sources of embolism on TEE in patients with acute cerebral ischemia.
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Affiliation(s)
- A A Rabinstein
- Department of Neurology, Cerebrovascular Division, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL 33101, USA.
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Scharf J, Brockmann MA, Daffertshofer M, Diepers M, Neumaier-Probst E, Weiss C, Paschke T, Groden C. Improvement of Sensitivity and Interrater Reliability to Detect Acute Stroke by Dynamic Perfusion Computed Tomography and Computed Tomography Angiography. J Comput Assist Tomogr 2006; 30:105-10. [PMID: 16365583 DOI: 10.1097/01.rct.0000187417.15321.ca] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the benefits of additional computed tomography perfusion (CTP) and computed tomography angiography (CTA) on the detection of early stroke, vessel occlusion, estimated infarct size, and interrater reliability. METHODS Sixty-seven consecutive patients underwent nonenhanced computed tomography (CT) imaging, CTA, and CTP. The final diagnosis of stroke was made from follow-up neuroimaging. A first diagnosis was made on-site by the physician on duty. Three experienced neuroradiologists blinded to follow-up findings analyzed the data set off-line, evaluated CT for signs of acute stroke, and subsequently evaluated CTP and CTA for infarction-related perfusion deficits and vessel abnormalities. RESULTS Computed tomography perfusion and CTA increased the time from CT start to diagnosis from 2 minutes to 10 minutes. Sensitivity to detect acute stroke increased significantly in all investigators from 0.46-0.58 to 0.79-0.90 compared with CT (<0.005). The interrater weighted kappa value increased from 0.35 to 0.64. Estimation of infarct size was not improved. CONCLUSION Computed tomography perfusion and CTA provide an effective add-on to standard CT in acute stroke imaging by significantly increasing the sensitivity and reliability of infarct detection.
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Affiliation(s)
- Johann Scharf
- Department of Neuroradiology, University Hospital Mannheim, Mannheim, Germany.
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Seifert T, Enzinger C, Storch MK, Pichler G, Niederkorn K, Fazekas F. Acute small subcortical infarctions on diffusion weighted MRI: clinical presentation and aetiology. J Neurol Neurosurg Psychiatry 2005; 76:1520-4. [PMID: 16227543 PMCID: PMC1739418 DOI: 10.1136/jnnp.2005.063594] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the clinical presentation and aetiology of small subcortical infarctions as found on diffusion weighted magnetic resonance imaging (DWI). DWI is both sensitive and specific in the early detection of acute ischaemic brain lesions irrespective of pre-existing vascular damage. METHODS Ninety three patients were identified showing subcortical or brainstem DWI lesions <1.5 cm in diameter within a maximum of 7 days from the onset of stroke symptoms. The patients' clinical status on admission was reviewed according to the Oxfordshire Community Stroke Project (OCSP). The results of procedures searching for cerebrovascular risk factors, large artery disease, and potential sources of cardiac embolism were included to determine stroke aetiology. Magnetic resonance imaging scans were also reviewed for concomitant changes that could support the aetiologic classification. RESULTS Only 41 (44.1%) patients presented clinically with a lacunar syndrome according to OCSP criteria. The nine (9.7%) patients who showed two or more DWI lesions in different vascular territories were also significantly more likely to have potential sources of cardiac embolism (5/9, 55.6% v 20/84, 23.8%). Hypertension was significantly more prevalent in the group of patients who showed a microangiopathy related imaging pattern, but this pattern did not exclude the presence of large artery disease or a possible cardioembolic source of stroke. CONCLUSION Identification of small subcortical infarctions as the cause of stroke appears quite uncertain based on clinical characteristics only. DWI adds significant aetiologic information but does not obviate the search for other potentially causative mechanisms.
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Affiliation(s)
- T Seifert
- Department of Neurology, Graz Medical University, A-8036 Graz, Austria.
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Wessels T, Röttger C, Jauss M, Kaps M, Traupe H, Stolz E. Identification of Embolic Stroke Patterns by Diffusion-Weighted MRI in Clinically Defined Lacunar Stroke Syndromes. Stroke 2005; 36:757-61. [PMID: 15746460 DOI: 10.1161/01.str.0000158908.48022.d7] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A number of clinical syndromes describing the presentation of deep brain infarcts are called lacunar syndromes resulting from small vessel occlusion (SVO). To verify the reliability of the clinical diagnosis "lacunar syndrome," the value was investigated with diffusion-weighted MRI (DWI). METHODS AND RESULTS A total of 73 patients (mean age 66 years; range 35 to 83 years) with sudden onset of a classical lacunar syndrome were enrolled. On the basis of the DWI findings, patients were divided into 3 groups: group 1, single subcortical lesion (<15-mm lesion; 43 patients; 59%); group 2, large (> or =15 mm) or scattered lesions in 1 vascular territory (16 patients; 22%); and group 3, multiple lesions in multiple vascular territories (14 patients; 19%). A stroke mechanism other than SVO could be identified in 17 (23%) patients. Cardiac work-up revealed a cardiac embolic source in 8 patients (11%). Duplex sonography revealed symptomatic stenosis in 9 patients (12%). Based on the work-up information, 29 patients (40%) were found to have a potential cause of stroke other than SVO. A significant correlation with >1 single lesion on DWI-MRI and a clinical proven embolic source was observed (P=0.002). In 9 patients with MRI suspicious for a pathomechanism other than SVO, no embolic source was found. CONCLUSIONS The use of DWI-MRI improves the accuracy of the subtype diagnosis of stroke. Inaccuracy has to be expected in approximately one third if lacunar diagnosis is based on clinical and computed tomography findings. Most of these "false-positive" cases are attributable to large artery or cardiogenic embolic stroke.
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Affiliation(s)
- Tiemo Wessels
- Department of Neurology, Justus-Liebig-University of Giessen, Germany.
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