Abstract
Introduction: Acute multiple cerebral infarcts in multiple arterial territories are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. Methods: We conducted a systematic review of the literature through PubMed, Scopus, Embase, Clinicaltrial.gov, ICTRP and Cochrane library. Studies containing multiple acute strokes in more than one arterial territory based on diffusion weighted imaging (DWI) findings were screened. Articles were excluded if they had limited inclusion criteria, performed limited subgroup analysis, or did not use DWI. Results: Out of 16551 stroke patients from 25 studies included in this study, 1967 (12%) patients had simultaneous acute cerebral infarcts in multiple arterial territories. 199 patients were excluded as their workup and diagnosis were not reported. Out of 1768 patients, 491 (28%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories (38%, 95%CI: 36-40%) followed by large artery atherosclerosis including aortic arch atheroma (23%, 95%CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 52 (3%, 95%CI: 2-4%) patients. Out of 143 patients who were reported to have simultaneous brain infarcts in bilateral hemispheres or anterior and posterior circulations, 78 (54%, 95%CI: 46-62%) were found to have cardiacembolism. Other etiologies for stroke in multiple arterial territories were intracranial atherosclerosis, vasculitis and other inflammatory diseases, infection, and iatrogenic causes. Conclusion: Simultaneous cerebral infarcts in multiple arterial territories occur among 12% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.
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