Spectacular Shrinking Deficit Research Articles

EARLY SPONTANEOUS RECANALIZATION OF INTERNAL CAROTID ARTERY OCCLUSION

A 70-year-old male was admitted with a history of malignant disease diagnosed 3 years before. Two days after admission the patient became confused and presented with right-sided weakness and aphasia. Color-coded duplex ultrasonography of the cerebral vessels was immediately performed showing occlusion of the origin of the left internal carotid artery (Figure 1A). About 30 minutes later the patient showed spectacular shrinking deficit, and color-coded duplex ultrasonography of the cerebral vessels showed recanalization of the left carotid artery (Figure 1 B). CT showed no alterations in brain density. At follow-up after 7 and 30 days, color Doppler US showed persistent patency of the vessel lumen. The cause of this occlusion may have been cardiac embolism, plaque rupture with consequent thrombosis, vessel dissection with hematoma, embolism of paraneoplastic origin. Knowledge about dynamic vessel wall changes during the hyperacute phase of cerebrovascular diseases requires immediate neurovascular imaging and close follow-up. Detection of a cerebral vessel occlusion depends mainly on the time elapsed from clinical onset to the initial vascular evaluation. Several studies showed that early spontaneous recanalization infrequently occurs during the first few hours of acute stroke [1,2]. In the cerebral vessels examination color-coded duplex ultrasonography offers a clinical tool that can localize occlusion and detect recanalization in real time. It is non-invasive and low cost; furthermore it allows study of hemodynamics at the patient’s bedside and follow up investigations are easily possible [3].

Computed Tomography Perfusion Imaging in Spectacular Shrinking Deficit

Spectacular shrinking deficit (SSD) is characterized by abrupt onset of a major hemispheric stroke syndrome, followed by dramatic and rapid improvement. We retrospectively identified patients with SSD diagnosed at our institution between December 1, 2007, and June 30, 2009. We reviewed computed tomography perfusion (CTP) imaging to determine perfusion defect as a measure of initial ischemic penumbra, and magnetic resonance imaging diffusion-weighted imaging (DWI) to determine the final infarct core. Among the 472 consecutive ischemic stroke patients, 126 (27%) presented with major hemispheric ischemic stroke syndrome, defined as National Institutes of Health Stroke Scale score (NIHSS) ≥8 in the territory of the middle cerebral artery (MCA) or internal carotid artery (ICA). Out of these patients, we identified 8 SSD patients with available CTP data. In these 8 patients, the mean time to dramatic recovery was 3.4 hours (range, 0.75-7 hours), and the mean time from onset to CTP was 12.7 hours (range, 3-30 hours). All 8 patients had perfusion abnormalities in portions of the MCA territory (partial MCA territory in 5 patients and complete MCA territory in 3 patients). The mean time from onset to MRI DWI was 15.5 hours (range, 7.9-34 hours). Restricted diffusion was present in all patients in the corresponding MCA distribution. Vascular imaging revealed MCA occlusion in 2 patients. Cervical vascular imaging revealed carotid occlusion in 2 patients and high-grade carotid stenosis in 2 patients. The stroke mechanisms were cardioembolism in 2 patients, large artery in 4 patients, and unknown in 2 patients. Four patients had repeat CTP imaging available that demonstrated eventual resolution of the perfusion defect. SSD is associated with a "shrinking" clinical syndrome and a "shrinking" perfusion pattern on CTP that lags behind clinical recovery. CTP imaging corroborates that a larger territory is at risk in SSD and contributes to better understanding of SSD.

Transient basilar artery occlusion monitored by transcranial color Doppler presenting with a spectacular shrinking deficit: a case report

IntroductionWe describe the case of a 79-year-old Caucasian Italian woman with a transient basilar occlusion monitored by transcranial Doppler, with subsequent recanalization and clinical shrinking deficit. This is the first case of transient basilar occlusive disease diagnosed and monitored by transcranial Doppler. This case is important and needs to be reported because transient basilar occlusion may be easily diagnosed if transcranial Doppler is performed.Case presentationA 79-year-old woman affected by chronic atrial fibrillation and not treated with oral anticoagulants, cardioverted to sinus rhythm during a gastric endoscopy. She then showed a sudden-onset loss of consciousness, horizontal and vertical gaze palsy, tetraparesis and bilateral miosis and coma. Two hours later, the symptoms resolved quickly, leaving no residual neurologic deficits. Transcranial Doppler examination showed a dampened flow in the basilar artery in the emergency examination and a restored flow when the symptoms resolved.ConclusionThis is the first case of transient basilar occlusive disease diagnosed and monitored by transcranial Doppler. We believe that transcranial Doppler should be performed in all cases of unexplained acute loss of consciousness, in particular, if associated with signs of brainstem dysfunctions.

Cardioembolic infarction in the Sagrat Cor-Alianza Hospital of Barcelona Stroke Registry.

To describe the clinical features of cardioembolic infarcts. Cardioembolic infarct was diagnosed in 231 (15.4%) of 1500 consecutive stroke patients included in a prospective stroke registry over an 8-year period. Cardiac sources of emboli included isolated atrial dysrhythmia (57.1%), valvular heart disease (20.3%), and coronary artery disease (18.2%). Patients with cardioembolic stroke showed a significantly higher (P < 0.00001) frequency of sudden onset of neurological deficit (79.7%) and altered consciousness (31.2%) than patients with lacunar infarct (38% and 1.9%) and atherothrombotic infarction (46% and 24%). Eleven patients had a spectacular shrinking deficit and 6 a presumed cardioembolic lacunar infarct. Early recurrent embolisms occurred in 6.5% of patients mostly (60%) within 7 days of initial embolism. In-hospital mortality was 27.3% (0.8% in lacunar infarcts, 21.7% in atherothrombotic infarction, P < 0.00001). Cardioembolic infarction is a severe subtype of stroke with a high risk of early death. Clinical features at stroke onset may help clinicians to differentiate cerebral infarction subtypes and to establish prognosis more accurately.

Spectacular Shrinking Deficit: Insights from Multimodal Magnetic Resonance Imaging after Embolic Middle Cerebral Artery Occlusion in Sprague—Dawley Rats

Almost no data is available on the serial changes in the brain after spectacular shrinking deficit (SSD) that may help understand this relatively rare clinical phenomenon. Quantitative diffusion-(DWI), perfusion-(PWI), T(1)-(T1WI), T(2)-weighted (T2WI), and functional magnetic resonance imaging (fMRI) were performed before, during, and up to 7 days after embolic middle cerebral artery occlusion (eMCAO) in male Sprague-Dawley rats (n=9). Region of interest (ROI) analysis was used to evaluate structural and functional MR signal changes within three ROIs defined by the apparent diffusion coefficient (ADC), cerebral blood flow (CBF) signatures, and final tissue viability. DWI, PWI, and T2WI lesion volumes were calculated using previously established viability thresholds and final infarct volumes ascertained with 2,3,5-triphenyltetrazolium chloride (TTC) staining. Serial MRI demonstrated spontaneous reperfusion of initially hypoperfused MCA regions accompanied by substantial reduction of initial ADC and CBF lesions and gradual recovery of neurological outcome. Recovery rates of CBF/ADC abnormalities differed among ROIs. Functional magnetic resonance imaging showed persistent tissue dysfunction after the recovery of the CBF/ADC lesions. This study may facilitate our understanding of the pathophysiological mechanisms by which early, spontaneous reperfusion affects tissue fate and neurological function.

Magnetic Resonance Imaging and Clinical Patterns of Patients with ‘Spectacular Shrinking Deficit’ after Acute Middle Cerebral Artery Stroke

Background: Rapid resolution of neurological deficits after severe middle cerebral artery (MCA) stroke has been coined spectacular shrinking deficit (SSD). We studied clinical and MRI patterns in patients with SSD. Methods: Patients with acute MCA stroke <6 h were examined by stroke MRI (perfusion- and diffusion-weighted imaging (PWI, DWI), MR angiography (MRA)) at admission, day 1 and day 7. SSD was defined as a ≧8-point-reduction of neurological deficit in the National Institute of Health Stroke Scale (NIHSS) to a score of ≤4 within 24 h. PWI and DWI lesion volumes were measured on ADC (ADC < 80%) and time to peak maps (TTP > +4 s). Recanalization was assessed by MRA after 24 h. Final infarct volumes were defined on T2 weighted images at day seven. Outcome was assessed after 90 days using modified Rankin Scale (mRS) and Barthel Index (BI). Results: SSD was present in 14 of 104 patients. Initial DWI and PWI lesion volumes were smaller in SSD patients – ADC < 80%: 8.9 (4.3–20.5) vs. 30 (0–266.7) ml; TTP > +4 s: 91.6 (29.7–205.8) vs. 131.5 (0–311.5) ml. Early recanalization was associated with SSD resulted in smaller final infarct volumes (11.9 (2.4–25.9) vs. 47.7 (1.2–288.5)). All SSD patients were independent at day 90 (mRS 0 (0–2); BI 100). Conclusion: The clinical syndrome of SSD is reflected by a typical MRI pattern with small initial DWI and PWI lesion volumes, timely recanalization and small final infarct volumes.

Complete recovery after spontaneous thrombolysis of a middle cerebral artery embolism: An imaging report

A 53-year-old-man demonstrated an embolism of the left middle cerebral artery, a rapid spontaneous thrombolysis and a subsequent recovery of the cerebral perfusion. These events were documented using MR angiography, perfusion-weighted MR imaging and digital subtraction angiography. The patient recovered consciousness and his symptoms of right hemiparesis and aphasia disappeared completely, representing the so-called spectacular shrinking deficit. This case provides evidence that an early spontaneous thrombolysis may recover cerebral perfusion and alleviate the symptoms of the patient.

Abstracts of Literature

Abstracts of Literature

Recurrencia precoz de la regresión espectacular del déficit hemisférico neurológico como forma de presentación de un infarto cardioembólico

Spectacular shrinking deficit (SSD) is a little known neurovascular syndrome with a monophasic clinical course. It was observed in 4.8% (11 of 231 patients) with cardio-embolic cerebral infarcts in the records of patients with cerebrovascular disease at our hospital. We present the only patient in our records (0.04% of the cardio-embolic infarcts and 0.06% of the patients in the series, which consists of 1,500 consecutive patients with stroke studied over a period of 8 years) with recurrent SSD, which was the form of presentation of rheumatic mitral valve disease with atrial fibrillation. As far as we know, the recurrent clinical course of SSD has not previously been described. The clinical case presented shows that early recurrence is possible in SSD. The possibility of the presentation of a cerebral infarct of cardioembolic origin in the form of recurrent SSD should be borne in mind. Early recurrence of SSD should also be taken into account to avoid bias in selecting patients for clinical trials to be carried out during the acute phase of cerebrovascular disease.

P-1-110 - Incomplete infarcts in the unilateral caudoputamen and cerebral cortex in patients with spectacular shrinking deficit

P-1-110 - Incomplete infarcts in the unilateral caudoputamen and cerebral cortex in patients with spectacular shrinking deficit