Lesions In Multiple Territories Research Articles

Safety Evaluation of Primary Carotid Stenting: Transcranial Doppler and MRI.

Cerebral emboli are generated by every step of standard carotid angioplasty and stenting. Primary carotid stenting (PCS) is a technique in which the use of balloon angioplasty (BA) is minimized to decrease the embolic load. The primary aim of this study is to establish the number of emboli generated by each step of primary stenting and determine the relationship to new diffusion (DWI) lesions on subsequent magnetic resonance imaging (MRI). Eighty-five patients with severe, symptomatic carotid stenosis were prospectively recruited and underwent carotid stenting. Intraoperative transcranial Doppler was performed in 77 patients. The number and size of microemboli for each of seven procedural steps were recorded. Correlation was made with the number and location of new DWI lesions. PCS was performed in 73 patients. BA was required in 12 patients. The mean number of microemboli was 114, and most microemboli were generated by stent deployment, followed by BA. Balloon techniques generated significantly more emboli than primary stenting (p = 0.017). There was a significant relationship between total microemboli and new DWI lesions (p = 0.009), and between new DWI lesions in multiple territories and the severity of pretreatment stenosis (p = 0.002). During PCS, more emboli are generated by stent deployment than during any other stage of the procedure. When BA is necessary, more malignant emboli are generated but total emboli are unchanged and there is no difference in new diffusion lesions on MRI. PCS is safe and is not inferior to historical controls for the generation of new DWI lesions.

Abstract TP100: Frequency, Spatial Distribution And Associations To Clinical Characteristics Of Multiple Lesions In A Large Multi-center Dataset Of Acute Ischemic Stroke Patients

Introduction: About ~10% of acute ischemic stroke (AIS) patients experience multiple acute lesions (MAL). However, the spatial distribution and clinical implications of such MAL are incompletely understood. Here, we scrutinized MAL in a large, radiologically deep-phenotyped cohort of AIS patients. Methods: We analyzed imaging and clinical data of 2.485 AIS patients [age: 63.3±14.8, 39%women] of the multi-site MRI-GENIE study. We computed occurrences of (i) MAL within one and, (ii) MAL in several vascular supply territories (with single or multiple lesions within single territories). We furthermore evaluated associations between the presence of MAL in multiple territories and stroke severity, white matter hyperintensity (WMH) and stroke lesion volumes, etiology, age and sex. Results: Half of all patients, i.e., 49.7%, presented with a single lesion. Another 37.3% experienced MAL in a single vascular territory, while 13% featured lesions in multiple vascular territories. For most vascular territories (anterior, middle and posterior cerebral artery, cerebellum) the ratio between single to multiple lesions in that territory equaled ~52%, only the brainstem region comprised fewer multiple compared to single lesions (19%). Combinations of anterior and posterior circulation lesions occurred in 5.6% of all patients, bilateral stroke in the anterior circulation in 3.4%. When comparing patients with lesions in only one compared to in more than one territory, there were no significant differences in WMH or lesion volume, stroke severity, age or sex ( p FDR-corrected >0.05). Patients with lesions in multiple territories had a significantly lower frequency of small vessel occlusions, but a significantly higher frequency of stroke of undetermined etiology. Differences in cardioembolic stroke frequency were only significant before correction for multiple comparisons ( p uncorrected =0.025). Frequencies of large vessel occlusions did not differ between the groups. Conclusions: Multiple lesions, especially those within one vascular territory, occurred frequently. Overall, there were no significant associations between MAL and stroke severity or cardioembolic stroke. Future studies are warranted to explore these findings in greater detail.

Utility of a scoring system for differentiating cancer-associated stroke from cryptogenic stroke in patients with cancer.

The commonest type of ischemic cerebral stroke in patients with cancer is cryptogenic stroke (CRS), the majority of which are considered cancer-associated strokes (CAS) caused by multiple microemboli associated with hypercoagulation, known as Trousseau syndrome. However, detection of microemboli and diagnosing CAS is difficult. We have therefore developed a scoring system for diagnosing CAS. We retrospectively examined data of patients with cancer and stroke between 2006 and 2017. We identified risk factors for CRS, assigned them one or two points, and calculated total scores (Trousseau score) for each patient. We used overall survival after stroke (OSs) to validate the utility of the system. In 181 consecutive strokes, CRS was the commonest type (43.6%) and had a short OSs (median 56days). We identified the following five risks for CRS: high D-dimer concentration (≥ 10.0μg/mL) and lesions in multiple territories (two points each); and active cancer, low platelet count (150,000/μL>) and female sex (one point each). Trousseau score ≥ 3 indicated CAS (50.3%), which had a median OSs of 50days. Only CAS (hazard ratio 3.44 [2.34-5.10], P < 0.0001) and poor performance status (3 or 4) (2.27 [1.50-3.39], P = 0.0002) were risk factors for OSs; CRS was not. OSs of patients with non-CAS/CRS was significantly longer than that of those with CAS/CRS (404.5days vs. 47days, P = 0.0114), whereas OSs of CAS/non-CRS was much shorter than that of non-CAS/non-CRS (53days vs. 547days, P < 0.0001). Trousseau scores simply and clearly identify CAS.

Clinical significance of acute and chronic ischaemic lesions in multiple cerebral vascular territories.

To investigate the association between acute and chronic ischaemic lesions in a multiple territory lesion pattern (MTLP) detected by 3-Tesla MRI and stroke aetiology, specifically atrial fibrillation-associated stroke. We analysed data from the 1000+ study - a prospective, observational 3-Tesla MRI cohort study of consecutively included acute stroke patients. Acute and chronic lesions were detected by DWI and fluid-attenuated inversion recovery, respectively. Observers blinded to clinical data allocated lesions to the right anterior, left anterior or posterior circulation. Lesion pattern was categorised as MTLPa/c when more than one territory was affected by either acute or chronic lesions or as MTLPa when more than one territory was affected by acute lesions alone. Of the 1,000 included patients, an MTLPa/c was found in 43% and MTLPa in 24%. Advanced age (aOR=1.21 per 10 years, 95% CI 1.06-1.39), atrial fibrillation (aOR=1.44, 95% CI 1.06-1.94), aortic arch atherosclerosis (aOR=2.52, 95% CI 1.10-5.77), malignant disease (aOR=1.99, 95% CI 1.25-3.16) and lower estimated glomerular filtration rate (eGFR) (aOR=0.90 per 10 ml, 95% CI 0.84-0.97) were associated with MTLPa/c. Only malignant disease (aOR=2.03, 95% CI 1.27-3.23) and lower eGFR (aOR=0.91 per 10 ml, 95% CI 0.85-0.97) were associated with MTLPa. An MRI-detected multiple territory lesion pattern of acute and chronic ischaemic lesions is frequent and more often present in older patients and patients with atrial fibrillation, aortic arch atherosclerosis, malignant disease and lower eGFR. Considering not only acute but also chronic ischaemic lesions may facilitate identifying atrial fibrillation-associated or aorto-embolic stroke. • Brain imaging with MRI may help to determine the aetiology of stroke. • Of 1,000 stroke patients undergoing 3-Tesla MRI, 43% had acute and chronic ischaemic lesions in multiple cerebral vascular territories. • Atrial fibrillation, aortic arch atherosclerosis and malignant disease were associated with a multiple territory lesion pattern.

Abstract WP224: Etiology of Lesions with Restricted Diffusion in the Corpus Callosum

Background: Infarction of the corpus callosum (CC) is a rare event that has been poorly described in the literature. Multiple non-vascular lesions may also cause restricted diffusion in the CC on MRI, leading to diagnostic uncertainty. We sought to identify the etiology of lesions with diffusion restriction in the CC, hypothesizing they were often due to a non-vascular etiology and, in cases of infarct, that the mechanism of stroke would often be atypical. Methods: CC lesions with diffusion restriction on MRI were identified in the radiology database at our institution over a 10 year period using the search terms “callosum,” “diffusion,” and “restricted/restriction”. Known trauma, brain tumor, and/or post-surgical cases were excluded. Radiographic and clinical features were independently reviewed by two investigators to determine the etiology of the lesion and the underlying mechanism. Vascular and non-vascular cases were compared. Results: One hundred and twenty one cases were reviewed. Of these, 67% were stroke and 33% were non-vascular. Lesions were present in the genu in 26%, body in 30%, and splenium in 63% of cases; 17% had lesions in multiple territories and 5% in all territories. Additional lesions with restricted diffusion were found outside of the CC in 80% of cases. Atypical mechanisms of stroke such as vasculitis or hypercoaguable state were most common (37% of stroke cases), followed by cardioembolic (28%), cryptogenic (22%), large vessel (7%), and multiple causes (5%). The most common non-vascular etiology was demyelination (35%). Patients with a non-vascular lesion were younger, (46 years vs 56 years, p=0.0036), more often had lesions in multiple CC segments, 25% vs 12% (p=0.078), less often had additional lesions outside the CC (68% vs 86%, p=0.014) and were less likely to have vascular risk factors including hypertension (24% vs 76%, p=0.02), diabetes (19% vs 81%, p=0.06), and atrial fibrillation (7% vs 93%, p=0.03). Conclusions: Diffusion restriction in the CC is due to a non-vascular cause in one third of cases. In cases of stroke, atypical etiologies are common. Clinical and imaging characteristics can help distinguish stroke from non-vascular lesions in the CC.

Stroke as the first manifestation of concealed cancer

Background and purpose Trousseau's syndrome (TS) is defined as a malignancy–related thromboembolism occurring in patients with an underlying or undiagnosed malignancy. Stroke seldom occurs as the first manifestation of a cancer. We investigated the clinical and radiological features of patients with TS. Methods We reviewed the clinical, pathologic, and radiological records of consecutive stroke patients, whose cancers were diagnosed at stroke presentation. Cancer-related stroke was defined if no definite cause was confirmed and malignancy was detected within 6 months of first stroke onset without cancer-related treatment. All patients underwent brain diffusion-weighted MRI (DWI), MR angiography, and echocardiography. The sizes, numbers, and locations of all hyperintense lesions in the DWI were noted. Results Ten patients were finally analyzed. Histologically, cancers were often proven to adenocarcinomas (50%, 5/10) of advanced stage. Six of 10 patients tested (60%) had elevated D-dimer. Seven of the 10 patients (70%) showed bihemispheric anterior and posterior involvement. DWI features showed numerous small and medium or large lesions in multiple territories in 9 patients (90%). Conclusions The authors emphasize that when presented with multiple bihemispheric infarctions on DWI and an unknown etiology, the neurologist must consider the existence of a concealed cancer.