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Wang L, Liu L, Zhao Y, Gao D, Yang Y, Chu M, Teng J. Analysis of Factors Associated with Hemorrhagic Transformation in Acute Cerebellar Infarction. J Stroke Cerebrovasc Dis 2022; 31:106538. [PMID: 35523054 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/18/2022] [Accepted: 04/24/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Hemorrhagic transformation (HT) is a frequent and severe complication of ischemic stroke. This study aimed to evaluate the factors associated with the occurrence of HT in patients with acute cerebellar infarction. MATERIALS AND METHODS A total of 190 patients, 141 male (74.2%) and 49 female (25.8%) with mean age 61.84 ± 12.16 years, who were admitted within 72 h of acute cerebellar infarction onset from January 2017 to March 2021 were retrospectively recruited. The multivariate logistic regression analysis was used to evaluate the independent influent factors for HT and receiver-operating characteristic (ROC) curve was applied to calculate the predictive value of those factors for HT in patients with acute cerebellar infarction. RESULTS 37 out of 190 recruited patients (19.47%) had HT within 14 days after acute cerebellar infarction onset. The incidence rates of HT occurring within 3 days, 3-7 days and 7-14 days were 13.5%, 40.5% and 45.9%, respectively. Results of the multivariable logistic regression analysis indicated that atrial fibrillation (AF) (OR 6.196, 95% CI 1.357-28.302, P = 0.019), infarct diameter (OR 5.813, 95% CI 2.932-11.526, P < 0.001), white matter hyperintensity (WMH) (OR 2.44, 95% CI 1.134-5.252, P = 0.023) were independent risk factors for HT in acute cerebellar infarction, while lymphocyte count (OR 0.319, 95% CI 0.142-0.716, P = 0.006) showed an independently protective effect. CONCLUSIONS Infarct diameter, AF and WMH are independent risk factors for HT in patients with acute cerebellar infarction, while the lymphocyte count is a protective factor.
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Affiliation(s)
- Lanjing Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China
| | - Lijun Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China
| | - Yanhong Zhao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China
| | - Di Gao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China
| | - Yanhong Yang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China
| | - Min Chu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jijun Teng
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, Shandong, China.
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Zhang SQ, Wang W, Ma XL, Xia YY, Liu AJ. Anticoagulation therapy is harmful to large-sized cerebellar infarction. CNS Neurosci Ther 2014; 20:867-73. [PMID: 24954500 DOI: 10.1111/cns.12299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 10/25/2022] Open
Abstract
AIM Anticoagulants are commonly used to treat ischemic stroke. Its impact on cerebellar infarction has not been fully understood. METHODS In the clinical study, we reviewed a consecutive series of patients with large-sized cerebellar infarction (diameter > 3 cm, n = 30) treated with or without anticoagulation. In animal study, cerebellar infarction operation was performed in 12 Cynomolgus monkeys. Then the animals were administrated with low molecular weight heparin (LMWH) or vehicle for 14 days. RESULTS Six patients died during the following treatment. All the subjects that died received anticoagulation therapy, while nobody in the survival group received such a therapy. Compared with sham-operated animals, all monkeys with cerebellar infarction have obvious neurological deficits. The number and size of the Purkinje cells in the cerebellar area were also reduced. Two animals in the LMWH group (33%) died, while all animals in the vehicle control group survived. Compared with the vehicle group, the neurological score in the LMWH group was significantly increased (P < 0.05). The water content in the cerebella was also significantly higher (P < 0.05). Edema, hemorrhage, and subarachnoid hemorrhage occurred in the cerebella as well as brainstem of all the LMWH treated animals. CONCLUSIONS These results indicated the harmful effects of anticoagulation therapy on large-sized cerebellar infarction.
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Affiliation(s)
- She-Qing Zhang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Sakamoto Y, Kimura K, Iguchi Y, Shibazaki K, Aoki J. Hemorrhagic transformation in acute cerebellar infarction. Cerebrovasc Dis 2011; 32:327-33. [PMID: 21921595 DOI: 10.1159/000329259] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 03/28/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a well-known consequence of acute ischemic stroke, but little is known about HT in cerebellar infarction. METHODS Patients with acute cerebellar infarction within 48 h of onset were retrospectively recruited. MRI, including diffusion-weighted imaging (DWI) and T(2)*-gradient echo imaging (T(2)*), was performed twice (upon admission and 2 weeks after stroke onset). Infarct diameter and volume were measured by manual tracing on initial DWI. HT was evaluated with follow-up T(2)*, and all patients were divided into two groups according to the presence of HT (HT group and non-HT group). The frequency of HT and the factors associated with HT were investigated. RESULTS Ninety-six patients (64 males, median age 74 years, IQR 65-81 years, and National Institute of Health Stroke Scale score 5, IQR 1-14) were enrolled. Forty-two patients (43%) showed HT on follow-up T(2)* (HT group). Infarct diameter and volume were larger in the HT group than in the non-HT group (3.2 vs. 1.6 cm, respectively, p < 0.001, for infarct diameter and 8.0 vs. 1.7 cm(3), respectively, p < 0.001 for infarct volume). Multivariate logistic regression analysis revealed that both infarct diameter >2.7 cm (OR 7.58, 95% CI 2.82-20.4, p < 0.001) and volume >4.5 cm(3) (OR 11.5, 95% CI 3.80-34.8, p < 0.001) were independent factors associated with HT. CONCLUSIONS Half of the patients with acute cerebellar infarcts had HT on follow-up T(2)*. Initial infarct diameter and volume on DWI were independent factors associated with HT.
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Affiliation(s)
- Yuki Sakamoto
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan.
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Vuillier F, Decavel P, Medeiros de Bustos E, Tatu L, Moulin T. [Cerebellar infarction]. Rev Neurol (Paris) 2011; 167:418-30. [PMID: 21529870 DOI: 10.1016/j.neurol.2011.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/26/2010] [Accepted: 01/17/2011] [Indexed: 11/30/2022]
Abstract
Cerebellar infarction can be difficult to diagnose because the clinical picture is often dominated by fairly non-specific symptoms, which are more indicative of a benign condition. When cerebellar infarction affects the brainstem, the semiology is richer, and pure cerebellar signs are rendered less important. A perfect knowledge of the organisation of the cerebellar artery territories is required, regardless of the infarct topography. This knowledge is essential for making an accurate diagnosis, understanding the mechanisms and organising a treatment plan. Clinical algorithms for the treatment of dizziness, headaches and vomiting would improve the selection of candidates for brain imaging. Thus, the early identification of patients with a high risk of subsequent deterioration would lead to a better prognosis in cases of cerebellar artery territory infarction.
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Affiliation(s)
- F Vuillier
- Service de neurologie 2, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Fleming, 25000 Besançon, France.
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Mohr J, Caplan LR. Vertebrobasilar Disease. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10026-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Flynn RWV, MacDonald TM, Murray GD, Doney ASF. Systematic review of observational research studying the long-term use of antithrombotic medicines following intracerebral hemorrhage. Cardiovasc Ther 2010; 28:177-84. [PMID: 20337638 DOI: 10.1111/j.1755-5922.2009.00118.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with intracerebral hemorrhage frequently have indications for antithrombotic therapy. This represents a therapeutic dilemma as intracerebral hemorrhage is considered a contraindication to antithrombotic medication. Previous systematic reviews have revealed no long-term randomised studies addressing this issue. Our objective was to review observational studies describing the long-term follow-up of patients receiving antithrombotic therapy following intracerebral hemorrhage. Searches were conducted in MEDLINE and EMBASE from 1984 to 2008 for any observational studies detailing use of antithrombotic treatments in patients with intracerebral hemorrhage. Included studies must have had follow-up extending beyond discharge. The primary endpoint was recurrent intracerebral hemorrhage. Secondary endpoints were ischemic events and serious vascular events. 1,301 articles were reviewed: two epidemiological studies and six case series met the inclusion criteria. These described a total of 46 subjects receiving antiplatelet agents (from one study) and 42 patients receiving oral anticoagulants (from one study and six case-series). For patients receiving subsequent aspirin there were seven recurrent intracerebral hemorrhages and four subsequent thrombo-occulsive events. Amongst patients restarting oral anticoagulation there were four recurrent intracerebral bleeds and nine subsequent thrombo-occulsive events. There is a marked paucity of evidence to guide clinicians when planning the long-term management of patients with intracerebral hemorrhage and cogent indications for antithrombotic therapy. Published guidance addressing this issue is not evidence based. In the continued absence of randomised studies addressing antithrombotic use following intracerebral hemorrhage, there is a clear requirement for further high quality observational data on the clinical impact of antithrombotic therapy in this important patient group.
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Affiliation(s)
- Robert W V Flynn
- Medicines Monitoring Unit (MEMO), Division of Medical Sciences, University of Dundee, Dundee, Scotland, UK
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Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008; 7:951-64. [DOI: 10.1016/s1474-4422(08)70216-3] [Citation(s) in RCA: 214] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Arthur ME, Castresana MR, Paschal JW, Patel VS. Acute Cerebellar Stroke After Inadvertent Cannulation and Pulmonary Artery Catheter Placement in the Right Vertebral Artery. Anesth Analg 2006; 103:1625-6. [PMID: 17122296 DOI: 10.1213/01.ane.0000246281.32826.e1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kumral E, Kisabay A, Ataç C. Lesion Patterns and Etiology of Ischemia in Superior Cerebellar Artery Territory Infarcts. Cerebrovasc Dis 2005; 19:283-90. [PMID: 15775708 DOI: 10.1159/000084496] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 11/01/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Infarcts in the territory of superior cerebellar artery (SCA) are uncommon. The clinical, and etiological mechanisms of different infarct patterns of SCA are not well known. Diffusion-weighted imaging (DWI) is superior to conventional magnetic resonance imaging for detecting acute small and multiple ischemic lesions. METHODS We studied 60 patients with lesions involving SCA territory proved by DWI, which have been selected from 3,800 patients with first ischemic stroke consecutively admitted to our stroke unit over a period of 5 years. RESULTS There are 7 distinctive SCA lesion patterns: (1) a lesion was found in the medial (m) branch territory of SCA (mSCA) in 14 patients; (2) a lesion in the lateral (l) branch territory of SCA (lSCA) was seen in 9 patients; (3) a coexisting lesion involving mSCA and lSCA was found in 9 patients; (4) a lesion in cortical borderzones between SCA and m/l branches of the posterior inferior cerebellar artery (PICA) was observed in 6 patients; (5) a lesion in deep borderzones between lSCA and mSCA, and lPICA and mPICA was present in 8 patients; (6) a lesion involving the medial rostral cerebellum between the right and left SCA was found in 4 patients; (7) multiple lesions involving SCA and other vertebrobasilar artery territories were present in 10 patients. The main cause was possible artery-to-artery embolism from atherosclerotic vertebrobasilar arteries to distal branches of SCA in 20 patients (33%). Fourteen patients had a source of cardioembolism (23%), and 6 patients (8%) had concomitant atherosclerotic vertebrobasilar artery disease and a source of cardioembolism. CONCLUSIONS An acute ischemic lesion in the SCA territory is mainly multiple. The lSCA territory was the most involved area. Small territorial infarcts were frequently associated with large territorial SCA infarcts. Borderzone SCA infarcts occurred in one third of the patients with transient benign symptoms. Mass effects are unusual despite the large amount of SCA involvement. Our results supported the fact that embolism is the predominant stroke mechanism in the SCA territory infarction.
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Affiliation(s)
- Emre Kumral
- Stroke Unit, Department of Neurology, Faculty of Medicine, Ege University, Izmir, Turkey.
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De Gaudio A, Consales G. Nontraumatic Brain Injury. Crit Care 2005. [DOI: 10.1016/b978-0-323-02262-0.50023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hongo K, Nitta J, Kobayashi S. Cerebellar Infarction and Hemorrhage. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
The practice of neurointensive care was initially developed to manage postoperative neurosurgical patients and expanded thereafter to the management of patients with primary head trauma, intracranial hemorrhage, vasospasm after subarachnoid hemorrhage, elevated intracranial pressure, and unstable pulmonary or cardiovascular medical conditions in neurologic patients. Can neurointensive care with its advanced medical and neurologic resources improve the outcome of the ischemic stroke patient? This review discusses selection of patients appropriate for admission to the neurologic intensive care unit (NICU) and current options for the intensive care management of severe ischemic stroke and its attendant complications. We propose that the NICU team is well suited to acute stroke management if they apply their advanced skills and technologic resources to manage the severe stroke patient from the time of presentation to the emergency ward. Study is needed to determine the effect that a critical care level of service has on functional outcome.
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Affiliation(s)
- Thanh Nguyen
- Stroke and Neurointensive Care Service, Massachusetts General Hospital, 55 Fruit Street, VBK 915, Boston, MA 02114, USA
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Abstract
Despite a traditional perception of reliance on computed tomography and lack of acceptance of magnetic resonance imaging (MRI) for detecting acute hemorrhage, MRI appears to be used increasingly in hemorrhagic stroke. This review addresses the MRI findings of acute hemorrhagic stroke obtained using relatively new imaging techniques. These new techniques have resulted in more acute stroke patients undergoing MRI examination. New information about the frequency and appearance of hemorrhage is emerging: for example, approximately 15-26% of cases of acute cerebral infarctions appear to be complicated by intracerebral hemorrhage. The MRI appearances of hemorrhagic transformation of ischemic infarction, as well as acute hypertensive intracerebral hemorrhage, are discussed based on clinical, biochemical, and technical aspects.
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Affiliation(s)
- A Zaheer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
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Koh MG, Phan TG, Atkinson JL, Wijdicks EF. Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect. Stroke 2000; 31:2062-7. [PMID: 10978030 DOI: 10.1161/01.str.31.9.2062] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The decision to proceed with surgery in cerebellar infarct with mass effect (CIMASS) in deteriorating patients is based on clinical features. The potential role of neuroimaging in predicting deterioration has not been systematically studied. In this study we determine the role of neuroimaging in predicting deterioration in CIMASS. METHODS -We retrospectively reviewed the clinical and neuroimaging features in 90 patients with cerebellar infarcts. We selected for detailed analysis CIMASS in 35 patients. RESULTS Eighteen patients remained stable and 17 deteriorated. Of these 17 patients, 8 were treated conservatively and 9 had surgery. Radiological features indicative of progression were more common in deteriorating patients compared with stable patients: fourth ventricular shift (82.3% versus 50%, P:=0.075, OR=4. 67), hydrocephalus (76.5% versus 11.1%, P:=0.0001, OR=26), brain stem deformity (47% versus 5.6%, P:=0.0065, OR=15.1), and basal cistern compression (35.3% versus 0%, P:=0.0076, OR=20.91). Differences in upward displacement of the aqueduct and pontomesencephalic junction from Twining's line, tonsillar descent on sagittal MRI, and infarct volumes between stable and deteriorating patients were not statistically significant. CONCLUSIONS Hydrocephalus, brain stem deformity, and basal cistern compression may herald deterioration in CIMASS. Admission to a neurological-neurosurgical intensive care unit and consideration of preemptive surgery are warranted in these patients. Vertical displacement of tonsils or aqueduct, demonstrated by MR imaging, did not predict deterioration.
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Affiliation(s)
- M G Koh
- Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Abstract
The use of heparin, heparin analogues, and oral anticoagulation in the treatment of brain ischemia remains controversial. We review the mechanism of action of the heparins and warfarin as well as the data regarding their efficacy and complications in patients with ischemic stroke and venous sinus thrombosis. None of these drugs have proven effective for all forms of cerebral ischemia. Further studies examining the efficacy of anticoagulants in different stroke subgroups will be necessary in order to clarify optimal clinical practice.
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Affiliation(s)
- C J Chaves
- Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA.
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Roquer J, Lorenzo JL, Pou A. The anterior inferior cerebellar artery infarcts: a clinical-magnetic resonance imaging study. Acta Neurol Scand 1998; 97:225-30. [PMID: 9576636 DOI: 10.1111/j.1600-0404.1998.tb00642.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute infarcts of the anterior inferior cerebellar artery (AICA) are unusual. We report 15 cases of AICA infarcts and their correlation with the topography of the lesion by brain MRI. During 2 years we prospectively identified 7 cases of AICA infarcts among 770 acute strokes (0.9% of the acute strokes seen in our department). We studied these cases and also another 8 that we found retrospectively. Most patients (8/15) had a unilateral affectation of both middle cerebellar peduncle (MCP) and inferior lateral pontine area (ILP), in these cases the main symptoms were vertigo, ataxia, peripheral facial palsy and hypoacusia. Two other patients had isolated MCP infarcts and were characterized by peripheral vertigo and ataxia, without hypoacusia or facial palsy. Another 2 patients had isolated ILP territory infarct characterized by vertigo, left peripheral facial palsy without hypoacusia and mild or no ataxia. One patient had a Gasperini syndrome. Finally 3 patients had bilateral AICA infarcts due to basilar thrombosis. The etiology was atherosclerosis in 9 patients, lacunar due to hypertension in 1, cardiac embolism in 1, migraine in 1 and unknown in 3. Among the 15 patients only 2 died, both with AICA plus infarcts. In the remaining patients a follow-up during a mean of 31 months (3 months to 12 years) showed no recurrences.
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Affiliation(s)
- J Roquer
- Servei de Neurologia, Hospital Universitari del Mar, Barcelona, Spain
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Terao S, Sobue G, Izumi M, Miura N, Takeda A, Mitsuma T. Infarction of superior cerebellar artery presenting as cerebellar symptoms. Stroke 1996; 27:1679-81. [PMID: 8784148 DOI: 10.1161/01.str.27.9.1679] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND MRI of the brain has facilitated the diagnosis of cerebellar infarction in the territory of the superior cerebellar artery (SCA). We analyzed the data on patients with SCA infarction who presented with only cerebellar symptoms in an attempt to define its underlying pathophysiology. SUMMARY OF REPORT Ten patients with SCA infarction who presented with cerebellar symptoms were studied by brain MRI, angiography, and underlying pathology. Brain MRI demonstrated an infarct in the SCA territory in the anterior rostral cerebellum of all patients. None had abnormalities in the brain stem. In four patients, a hemorrhagic infarct was present in the same region. Cerebral angiography revealed no obvious SCA occlusion or atherosclerotic vascular disease in any patient. Eight of the 10 patients had heart disease, such as atrial fibrillation or old myocardial infarction. The presumed diagnosis was occlusion of the SCA in its periphery due to cardiogenic embolism. CONCLUSIONS When a patient presents with only cerebellar symptoms and has cerebellar infarction demonstrated by brain MRI, the SCA branch is probably occluded by cardiogenic embolism.
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Affiliation(s)
- S Terao
- Fourth Department of Internal Medicine, Aichi Medical University, Japan
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