Acute Cerebral Ischemic Lesions Research Articles

Clinical manifestation of acute cerebral infarcts in multiple arterial territories.

ObjectivesWe aimed to assess frequencies and radiological aspects of single‐ and multiterritory clinical manifestation among patients with acute cerebral infarcts in multiple arterial territories (MACI).Materials & methodsWe retrospectively reviewed admission records and diffusion‐weighted magnetic resonance imaging of patients with MACI admitted to our stroke unit between 2006 and 2017. MACI was defined as acute cerebral ischemic lesions in at least two out of three arterial cerebral territories, that is, the left anterior, right anterior and the bilateral posterior territory. Patients with single‐ and multiterritory clinical manifestation were then compared for topographical distribution of the ischemic lesions, the number of ischemic lesions, and The Oxfordshire Community Stroke Project classification.ResultsOut of 311 patients with MACI, 222 (71.4%) presented with single‐territory clinical manifestation. Involvement of the left hemisphere (OR = 0.37, 95% CI 0.16–0.82), less than five ischemic lesions (OR = 0.58, 95% CI 0.35–0.97), and partial anterior circulation infarct clinical stroke syndrome (OR = 0.57, 95% CI 0.34–0.97) were associated with single‐territory clinical manifestation. Involvement of all three territories (OR = 2.58, 95% = 1.48–4.50), more than 10 ischemic lesions (OR = 2.30, 95% CI 1.32–4.01) and total anterior circulation infarct clinical stroke syndrome (OR = 3.31, 95% CI 1.39–7.86) were associated with multiterritory clinical manifestation.ConclusionMost patients with MACI present with single‐territory clinical manifestation on admission. Diffusion‐weighted magnetic resonance imaging is therefore necessary for a definite diagnosis.

Acute progressive stroke with middle cerebral artery occlusion caused by idiopathic hypereosinophilic syndrome: a case report

BackgroundIdiopathic hypereosinophilic syndrome (IHES) is associated with various organ system dysfunctions. Neurologic abnormalities have been previously noted in this syndrome. Cerebral infarction secondary to occlusion of large cerebral artery is rarely reported. Here we described a patient with IHES presented progressive multiple cerebral infarctions caused by bilateral middle cerebral artery occlusion.Case presentationA 55-year-old Chinese woman presented to our hospital with acute onset of right limbs weakness and slurred speech. Laboratory tests showed a significant eosinophilia of 5.29 × 109/L (normal, < 0.5), 49.9% of leukocytes. Brain magnetic resonance imaging (MRI) revealed multiple acute cerebral ischemic lesions. Magnetic resonance angiography (MRA) demonstrated stenosis in horizontal segment of right middle cerebral artery. A pretibial skin biopsy revealed eosinophilic infiltration around the capillaries in deep dermis and adipose tissue. The patient was given oral dual anti platelet agents and intravenous methylprednisolone. However, one week later, the patient presented significant neurological deterioration with right-sided hemiparesis and totally motor aphasia. Brain MRI and computed tomography perfusion (CTP) demonstrated new acute cerebral ischemia in left hemisphere. Digital subtraction angiography (DSA) revealed left middle cerebral artery completely occluded. The patient received a high-dose of intravenous methylprednisolone 500 mg per day and the eosinophil count quickly fell to normal within 2 days. She was transferred to a rehabilitation center and her neurological symptoms improved with modified Ranking Scale from 4 to 2.ConclusionsIHES is one of the rare causes of acute ischemic stroke with large cerebral artery occlusion. An early high-dose of corticosteroids therapy should be considered in cases of IHES patients. Our case study is benefit to clinical diagnosis and treatment of cerebral infarction with IHES.

Short-Term Outcome and In-Hospital Complications After Acute Cerebral Infarcts in Multiple Arterial Territories.

Background and Purpose- Patients with acute cerebral infarcts in multiple arterial territories (MACI) represent a substantial portion of the stroke population. There are no data on short-term outcome and in-hospital complications in patients with MACI. We compared patients with MACI with patients having acute cerebral infarct(s) in a single arterial territory. Methods- We analyzed 3343 patients with diffusion-weighted imaging-confirmed acute cerebral infarcts. MACI was defined as at least 2 acute cerebral ischemic lesions in at least 2 arterial cerebral territories. Patients with MACI were compared with patients with acute cerebral infarct(s) in a single arterial territory for relevant in-hospital complications and short-term outcome, namely National Institutes of Health Stroke Scale and modified Rankin Scale at day 7 after admission or at discharge when earlier. Results- A total of 311 patients (9.3%) met the definition of MACI. Both median National Institutes of Health Stroke Scale (2 [1-7] versus 1 [0-4]) and modified Rankin Scale (3 [1-4] versus 2 [1-3]) were higher in patients with MACI. MACI was independently associated with higher National Institutes of Health Stroke Scale and modified Rankin Scale. Deep venous thrombosis, myocardial infarction, and any complications were more frequent in patients with MACI. Conclusions- In-hospital complications were more frequent in patients with MACI, which may adversely affect short-term clinical and functional outcome. Closer follow-up of patients with MACI during hospitalization may prevent such events and negative progression.

Pitfall in the detection of acute lesions of transient ischemic attack with fluid-inversion prepared diffusion weighted imaging

Objective To explore the limits of fluid-inversion prepared diffusion weighted imaging (FLIPD) in detection of acute cerebral ischemic lesions. Methods From January 2012 to March 2014, forty-nine patients (33 males, 16 females, age (55.6±12.3) years) clinically diagnosed as transient ischemic attack (TIA) were included. Patients underwent brain MRI (conventional diffusion weighted imaging (DWI) and FLIPD) within 3 d after the onset of TIA. The detection ability of MRI with the two sequences was compared, and the relative signal intensity (rSI) and apparent diffusion coefficient (ADC) of acute ischemic lesions based on two sequences were compared. Kappa test and two-sample t test were used to analyze the data. Results A total of 87 acute ischemic lesions were detected in 21 patients by conventional DWI, and 54 were detected in 19 patients by FLIPD (Kappa=0.916, P<0.05). The rSI of ischemic lesions on FLIPD was significantly lower than that on conventional DWI (1.37±0.22 vs 1.57±0.26; t=6.647, P<0.001). The ADC value of ischemic lesions on FLIPD was slightly lower than that on conventional DWI: (0.54 ±0.10) ×10-3 mm2/s vs (0.57±0.13)×10-3 mm2/s (t=2.120, P<0.05). The missed lesions on FLIPD were located in the white matter (n=18), cerebellum and brainstem (n=8), and the cortex (n=7). Conclusions A slight diffuse abnormality may be missed on FLIPD, so this method is not suitable for the detection of acute ischemic lesions. FLIPD technology still needs improvement. Key words: Ischemic attack, transient; Diffusion magnetic resonance imaging; Fluid attenuated inversion recovery sequence

Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

BackgroundThe influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. MethodsAll patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm3 and correlated with 30-day rates of stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and receiver operating characteristic curves. ResultsA total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm3 (interquartile range [IQR], 7000 mm3). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm3 (IQR, 31,000 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .01) and 4500 mm3 (IQR, 17,450 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm3 (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P = .03). ConclusionsCIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

SS25. Impact of Acute Cerebral Ischemic Lesions and Their Volume on the Revascularization Outcome of Symptomatic Carotid Stenosis

The influence of acute ischemic cerebral lesion (CIL) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the possible influence of CIL on symptomatic carotid revascularization outcome. All patients with symptomatic carotid artery stenosis who underwent to carotid endarterectomy (CEA) or stenting (CAS) between 2005 and 2014, were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography, quantified in mm3 and correlated with 30-day stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and ROC curve. A total of 489 symptomatic patients were treated by CEA (327-67%) or CAS (162-33%), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptoms onset. The stroke and stroke/death rate were not statistically different in CEA and CAS (3.3% vs 5.5%; P = .27; 3.8% vs 5.9%; P = .22). CILs were identified in 251 patients(53%) and were associated with similar stroke and stroke/death rate compared with no CIL patients (4.8% vs 3.5% [P = .46] and 5.6% v s3.5% [P = .26], respectively). However at the Pearson analysis, CIL volume significantly correlates with stroke (r = 0.15, P = .02) and stroke/death (r = 0.14, P = .04), and with stroke independently from the timing of revascularization (< 2 weeks: r = 0.16, P = .03; and >2 weeks: r = 0.21, P = .04). CIL volume correlates with stroke and stroke/death in CAS (r = .27, P = .005 and r = .24, P = .01) but not in CEA (r = 0.05, P = .55 and r = 0.03, P = .65). By the ROC curve analysis, a volume of 4000 mm3 is predictive of postoperative stroke with 75% sensitivity and 63% specificity. CIL volume >4000 mm3 was an independent risk factor for postoperative stroke (OR, 4.6; 95% CI, 1.1-19.1; P = .03). CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume >4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

Insufficient platelet inhibition and thromboembolic complications in patients with intracranial aneurysms after stent placement.

OBJECT Insufficient platelet inhibition has been associated with an increased incidence of thromboembolic complications in cardiology patients undergoing percutaneous coronary intervention. Data regarding the relationship between insufficient platelet inhibition and thromboembolic complications in patients undergoing neurovascular procedures remain controversial. The purpose of this study was to assess the relationship of insufficient platelet inhibition and thromboembolic complications in patients with intracranial aneurysm undergoing stent treatment. METHODS The authors prospectively recruited patients with intracranial aneurysms undergoing stent treatment and maintained the data in a database. MRI with diffusion-weighted sequences was performed within 24 hours of stent insertion to identify acute ischemic lesions. The authors used thromboelastography to assess the degree of platelet inhibition in response to clopidogrel and aspirin. Univariate and multivariate logistic regression analysis was used to identify potential risk factors of thromboembolic complications. RESULTS One hundred sixty-eight patients with 193 aneurysms were enrolled in this study. Ninety-one of 168 (54.2%) patients with acute cerebral ischemic lesions were identified by diffusion-weighted MRI. In 9 (5.4%) patients with ischemic lesions, transient ischemic attack or stroke was found at discharge, and these complications were found in 11 (6.5%) patients during the follow-up period. The incidence of periprocedural thromboembolic complications increased with resistance to antiplatelet agents, hypertension, hyperlipidemia, complete occlusion, and aneurysm of the anterior circulation. The multivariate regression analysis demonstrated that the anterior circulation and adenosine diphosphate (ADP) inhibition percentage were independent risk factors of perioperative thromboembolic complications. The maximum amplitude and ADP inhibition percentage were independent risk factors for thromboembolic complications during the follow-up period. CONCLUSIONS The ADP inhibition percentage is related to thromboembolic complications after stent placement for intracranial aneurysms. The increase of the ADP inhibition may decrease the risk of thromboembolic complications.

PT221 Nocturnal hypertension is associated with preclinical organ damage in untreated hypertension

Introduction: Stroke related with catheterization was devastating complications after procedures. The rates of stroke range from 0.1-0.4% according to previous studies. Stroke was taken only as new neurological complications, therefore clinically unapparent cerebral embolisms were not taken into account. Diffusion weighted magnetic resonance imaging (DW-MRI) is very high sensitive tools for detecting acute cerebral ischemic lesions. Due to improvements of catheter design and approach, catheterization-related cerebral infarctions are expected to decrease, whereas this may be counterbalanced by increased risk profile of patients who undergo catheterization. Objectives: We aimed to examine the current prevalence and risk factors of symptomatic and asymptomatic catheterization-related cerebral infarctions by DW-MRI. Methods: We retrospectively analyzed 84 patients who underwent 1237 diagnostic and interventional catheterization procedures through the aortic arch conducted within 2010 and 2011 in our hospital and who obtained the MRI within 14 days a catheterization. Results: Ten patients who developed symptoms and 3 patients were finally diagnosed as stroke, which was defined as any neurological deficits lasting over 24 hours. The remaining 74 patients were asymptomatic and underwent MRI for various other reasons, including the assessment before coronary artery bypass graft (35%), valvular surgery (18%) or aortic repair (6.8%). The MRI revealed a fresh cerebral infarction in 22 of 74 asymptomatic patients (29.7%). Patients with cerebral infarction underwent longer procedures (mean SEM, 17.1 1.7 minutes vs. 22.7 2.4 minutes, p<0.05), used higher number of catheters and were more likely to be old (mean SEM, 74.1 1.67 vs. 70.4 1.1 years old), to have dyslipidemia, and to undergo in urgent settings and for interventional purposes. In DW-MRI findings, more patients with new infarction had multiple or bilateral lesions. More lesions were seen in the anterior and anterior plus posterior territories. Conclusion: Stroke after catheterization occurred 3 of 1237 (0.16%) patients, and this rate was almost equivalent to those seen in previous studies. However, the rate of small asymptomatic catheterization-related cerebral infarctions detected using diffusion-weighted MRI remains high in high-risk patients or candidates for cardiac surgery. Disclosure of Interest: None Declared

PT217 Catheterization-Related Cerebral Infarction Evaluated At Diffusion-Weighted Magnetic Resonance Imaging In High-Risk Patients

Introduction: Stroke related with catheterization was devastating complications after procedures. The rates of stroke range from 0.1-0.4% according to previous studies. Stroke was taken only as new neurological complications, therefore clinically unapparent cerebral embolisms were not taken into account. Diffusion weighted magnetic resonance imaging (DW-MRI) is very high sensitive tools for detecting acute cerebral ischemic lesions. Due to improvements of catheter design and approach, catheterization-related cerebral infarctions are expected to decrease, whereas this may be counterbalanced by increased risk profile of patients who undergo catheterization. Objectives: We aimed to examine the current prevalence and risk factors of symptomatic and asymptomatic catheterization-related cerebral infarctions by DW-MRI. Methods: We retrospectively analyzed 84 patients who underwent 1237 diagnostic and interventional catheterization procedures through the aortic arch conducted within 2010 and 2011 in our hospital and who obtained the MRI within 14 days a catheterization. Results: Ten patients who developed symptoms and 3 patients were finally diagnosed as stroke, which was defined as any neurological deficits lasting over 24 hours. The remaining 74 patients were asymptomatic and underwent MRI for various other reasons, including the assessment before coronary artery bypass graft (35%), valvular surgery (18%) or aortic repair (6.8%). The MRI revealed a fresh cerebral infarction in 22 of 74 asymptomatic patients (29.7%). Patients with cerebral infarction underwent longer procedures (mean SEM, 17.1 1.7 minutes vs. 22.7 2.4 minutes, p<0.05), used higher number of catheters and were more likely to be old (mean SEM, 74.1 1.67 vs. 70.4 1.1 years old), to have dyslipidemia, and to undergo in urgent settings and for interventional purposes. In DW-MRI findings, more patients with new infarction had multiple or bilateral lesions. More lesions were seen in the anterior and anterior plus posterior territories. Conclusion: Stroke after catheterization occurred 3 of 1237 (0.16%) patients, and this rate was almost equivalent to those seen in previous studies. However, the rate of small asymptomatic catheterization-related cerebral infarctions detected using diffusion-weighted MRI remains high in high-risk patients or candidates for cardiac surgery. Disclosure of Interest: None Declared

476 Presence of concomitant atrial septal aneurysm is associated with multiple acute cerebral ischemic lesions in cryptogenic stroke due to patent foramen ovale

476 Presence of concomitant atrial septal aneurysm is associated with multiple acute cerebral ischemic lesions in cryptogenic stroke due to patent foramen ovale

Lesiones cerebrales isquémicas tras procedimientos de revascularización carotídea: estudio comparativo con resonancia magnética por difusión

The risk of cerebral embolism following angioplasty-stent placement (AGP) is higher than that observed after a carotid endarterectomy (CE) using transcranial Doppler ultrasonography. Nevertheless, no studies have been conducted to compare the two revascularisation procedures with the latest neuroimaging techniques. To analyse the presence and repercussion of acute cerebral ischemia detected by diffusion-weighted magnetic resonance imaging (DMR) following carotid revascularisation procedures. Our prospective study included a sample of 20 consecutive patients with atherosclerotic stroke and symptomatic carotid stenosis > 70% according to NASCET criteria and treated by CE (n = 10) or AGP (n = 10). Patients were submitted to a DMR during the 48 hours prior to revascularisation and another within the 72 hours following the intervention in order to evaluate the existence of new acute cerebral ischemic lesions. Patients were explored by a neurologist before and after the intervention. DMR allowed new areas of cerebral ischemia to be detected in 10% of the CE and in 40% of the AGP patients. 50% of the post-AGP ischemic lesions were multiple and 10% of the lesions in each therapeutic group presented some clinical correlation in the form of transient neurological focal signs. No significant differences were observed with respect to the pattern of risk of complications between the two therapeutic groups and no factors associated to a higher risk of new ischemic lesions were detected by DMR in patients submitted to AGP. Carotid AGP is linked to a higher frequency of new ischemic lesions in the brain than in the case of CE. Nevertheless, these ischemic lesions detected by DMR are usually silent. Symptomatic complications were similar in the two procedures.

Early detection of periventricular leukomalacia by diffusion-weighted magnetic resonance imaging techniques

Periventricular leukomalacia (PVL), the principal form of brain injury in the premature infant, is characterized by overt focal necrotic lesions in periventricular white matter and less prominent, more diffuse cerebral white matter injury. The early detection of the latter, diffuse component of PVL is not consistently possible with conventional brain imaging techniques. We demonstrate the early detection of the diffuse component of PVL by diffusion-weighted magnetic resonance imaging (DWI). In a premature infant with no definite cerebral abnormality detectable by cranial ultrasonography or conventional magnetic resonance imaging, DWI showed a striking bilateral decrease in water diffusion in cerebral white matter. The DWI abnormality (ie, decreased apparent diffusion coefficient) was similar to that observed with acute cerebral ischemic lesions in adults. At 10 weeks of age, conventional magnetic resonance imaging and ultrasonography showed striking changes consistent with PVL, including the presence of small cysts. The observations indicate the importance of DWI in the early identification of the diffuse component of PVL and also perhaps the role of ischemia in the pathogenesis of the lesion. (J Pediatr 1999;134:631-4)

Acute experimental cerebral ischemia: MR enhancement using Gd-DTPA.

The effects of a paramagnetic contrast agent, gadolinium-DTPA (Gd-DTPA), on magnetic resonance (MR) imaging of acute cerebral ischemia was investigated in a feline model of middle cerebral artery occlusion. Imaging was performed both before and after administration of an intravenous dose of 0.2 mmol/kg of Gd-DTPA. The animals were then sacrificed for pathologic correlation. No changes in intensity or relaxation times were noted before or after Gd-DTPA administration in two animals with 2 hours of occlusion. Infarcts were noted before and after contrast enhancement in all six cats with ischemia of greater than 16-hours duration. Gd-DTPA caused significant increase in intensity of infarct but not in that of normal cerebral tissue. Rapid enhancement was visible in infarcts of 16-24 hours, but such enhancement was slower in infarcts of 72-168 hours, presumably owing to slowed inflow caused by increased vasogenic edema in the latter group. Contrast enhancement of acute cerebral ischemic lesions with Gd-DTPA offers no improvement in sensitivity of MR imaging, although the conspicuity of the lesion may be improved. Additionally, contrast media may provide potential temporal and pathophysiological data for better characterization of cerebral ischemia.