1
|
Mosqueira AJ, Canneti B, Martínez Calvo A, Fernández Armendáriz P, Seijo-Martinez M, Pumar JM. Calcified cerebral embolism: a 9 case series and review of the literature. Neurologia 2022; 37:421-427. [PMID: 31331677 DOI: 10.1016/j.nrl.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 03/26/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months. CONCLUSIONS CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.
Collapse
Affiliation(s)
- A J Mosqueira
- Servicio de Radiodiagnóstico, Hospital Universitario Santiago de Compostela, Santiago de Compostela (La Coruña), España.
| | - B Canneti
- Servicio de Neurología, Complejo Hospitalario Universitario Pontevedra, Pontevedra, España
| | - A Martínez Calvo
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - P Fernández Armendáriz
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - M Seijo-Martinez
- Servicio de Neurología, Complejo Hospitalario Universitario Pontevedra, Pontevedra, España
| | - J M Pumar
- Servicio de Radiodiagnóstico, Hospital Universitario Santiago de Compostela, Santiago de Compostela (La Coruña), España
| |
Collapse
|
2
|
Mosqueira AJ, Canneti B, Martínez Calvo A, Fernández Armendáriz P, Seijo-Martinez M, Pumar JM. Calcified cerebral embolism: a 9-case series and review of the literature. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:421-427. [PMID: 34785159 DOI: 10.1016/j.nrleng.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 04/22/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Calcified cerebral embolus (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. We describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS We included patients with CCE from 3 different hospitals. We describe the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originating in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified Ranking Scale scores ≤ 2 at 3 months. CONCLUSIONS CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.
Collapse
Affiliation(s)
- A J Mosqueira
- Servicio de Radiodiagnóstico, Hospital Universitario Santiago de Compostela, Santiago de Compostela, La Coruña, Spain.
| | - B Canneti
- Servicio de Neurología, Complejo Hospitalario Universitario Pontevedra, Pontevedra, Spain
| | - A Martínez Calvo
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - P Fernández Armendáriz
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - M Seijo-Martinez
- Servicio de Neurología, Complejo Hospitalario Universitario Pontevedra, Pontevedra, Spain
| | - J M Pumar
- Servicio de Radiodiagnóstico, Hospital Universitario Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
| |
Collapse
|
3
|
Nagao Y, Nakajima M, Hirahara T, Wada K, Terasaki T, Nagamine M, Ando Y. Calcified Cerebral Embolism Due to a Calcified Amorphous Tumor. J Stroke Cerebrovasc Dis 2018; 27:e115-e116. [PMID: 29478938 DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/17/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022] Open
Abstract
A 59-year-old man developed brain embolism in the frontal and parietal cortex. Brain CT showed a high-density spot in the upper branch of the left middle cerebral artery, indicating calcified cerebral embolism. Calcified amorphous tumor attached to the mitral valve was identified as the cause of embolism. After surgical resection, anticoagulation was started and recurrent stroke did not occur.
Collapse
Affiliation(s)
- Yoichiro Nagao
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Japan; Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Tomoo Hirahara
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Kuniyasu Wada
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Tadashi Terasaki
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Michiko Nagamine
- Department of Pathology, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| |
Collapse
|
4
|
Walker BS, Shah LM, Osborn AG. Calcified cerebral emboli, a "do not miss" imaging diagnosis: 22 new cases and review of the literature. AJNR Am J Neuroradiol 2014; 35:1515-9. [PMID: 24651819 DOI: 10.3174/ajnr.a3892] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Calcified cerebral emboli are a rarely reported but devastating cause of stroke and may be the first manifestation of vascular or cardiac disease. Our aim was to evaluate the diagnosis, prevalence, imaging appearance, presumed embolic source, treatment, and outcome of patients with calcified cerebral emboli. MATERIALS AND METHODS Our radiology information system was searched for all CT scans by using keywords "calcified," "emboli," and their permutations. The radiology information system was also searched to identify all "stroke" CT reports to calculate the prevalence of calcified cerebral emboli. We also performed a MEDLINE search to identify all published case reports. RESULTS Twenty-two cases were identified from our database, and 48 were cases reported from the literature. The middle cerebral artery was the site of 83% of calcified emboli. Presumed sources were calcific aortic stenosis (36%), carotid atherosclerotic plaque (30%), and mitral annular calcification (11%). Spontaneous embolism occurred in 86%. Surgical treatment was performed in 34% of patients. Sixty-four percent of the patients with calcified aortic stenosis underwent aortic valve replacement. Among those with identifiable arterial disease, 53% underwent endarterectomy. Forty-one percent of patients experienced at least 1 recurrent stroke. The prevalence of calcified cerebral emboli identified on stroke CT scans at our institution was 2.7%. Seventy-three percent of cases were correctly identified. Twenty-seven percent were misdiagnosed on initial interpretation, while 9% were overlooked on preliminary interpretation. CONCLUSIONS Calcified cerebral emboli are more common than previously assumed, are frequently overlooked or misinterpreted, affect clinical course when diagnosed, and carry substantial risk for recurrent stroke.
Collapse
Affiliation(s)
- B S Walker
- From the Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah.
| | - L M Shah
- From the Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - A G Osborn
- From the Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
5
|
Chaudhry FS, Vela-Duarte D, Biller J. Stroke due to calcific embolism after cardiac procedures. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:416. [PMID: 23828539 DOI: 10.1590/0004-282x20130051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/11/2013] [Indexed: 11/21/2022]
|
6
|
Chandran V, Pai A, Rao S. Calcified embolism: a rare cause of cerebral infarction. BMJ Case Rep 2013; 2013:bcr-2013-009509. [PMID: 23632190 DOI: 10.1136/bcr-2013-009509] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Calcified cerebral emboli (CCE) are a rare cause of stroke and these emboli can be identified on a CT scan of the brain performed for the initial evaluation of stroke. In this report we present a patient who developed a CCE following cardiac catheterisation that lodged in the left middle cerebral artery with resultant right hemiparesis and aphasia. The calcified embolus was seen on CT but could not be identified on MRI. Predisposing factors for CCE include angiography and valve or vessel wall calcification. The natural history and response to standard therapy in patients with CCE as compared with stroke of other aetiologies have not been studied until now. Increased awareness and ability to identify calcified emboli will help us to have an improved understanding of strokes resulting from CCE.
Collapse
Affiliation(s)
- Vijay Chandran
- Department of Neurology, Kasturba Medical College, Manipal, Karnataka, India.
| | | | | |
Collapse
|
7
|
Bande D, Abbara S, Kalva SP. Acute renal infarction secondary to calcific embolus from mitral annular calcification. Cardiovasc Intervent Radiol 2010; 34:647-9. [PMID: 20661568 DOI: 10.1007/s00270-010-9944-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 06/17/2010] [Indexed: 10/19/2022]
Abstract
We report a case of a 62-year-old man who presented with right groin pain who subsequently was found to have a renal infarct secondary to calcific embolus from mitral annular calcification on CT and angiography. We briefly review the literature and discuss the importance of this entity in clinical practice.
Collapse
Affiliation(s)
- Dinesh Bande
- Department of Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | | | | |
Collapse
|
8
|
Okazaki S, Sakaguchi M, Sugiyama Y, Ooe H, Kitagawa K, Sakoda S. [Ineffective thrombolytic therapy for calcified cerebral emboli originated from calcified internal carotid artery stenosis]. Rinsho Shinkeigaku 2009; 49:281-4. [PMID: 19594108 DOI: 10.5692/clinicalneurol.49.281] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 71-year-old man who presented with acute right hemiparesis and aphasia The admission CT and CT angiogram showed multiple small calcified emboli in branches of the left middle cerebral artery. The patient had shown no sign of improvement after intravenous thrombolytic therapy. Follow-up CT indicated acute multiple infarctions in the left middle cerebral artery area coincident with the calcified emboli. Carotid duplex sonography and cervical CT angiogram showed calcified plaque with ulceration at the origin of left internal carotid artery, which is the origin of those emboli Since calcified cerebral emboli (CCE) are rare, it should be further investigated if intravenous thrombolysis is effective in CCE.
Collapse
|
9
|
Christian BA, Kirzeder DJ, Boyd J, Laing J, Gash JR. Showered Calcific Emboli to the Brain, the ‘Salted Pretzel’ Sign, Originating From the Ipsilateral Internal Carotid Artery Causing Acute Cerebral Infarction. Stroke 2009; 40:e319-21. [DOI: 10.1161/strokeaha.108.538009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Jim Boyd
- From the University of Tennessee Medical Center, Knoxville, Tenn
| | - Jeffery Laing
- From the University of Tennessee Medical Center, Knoxville, Tenn
| | - Judson R. Gash
- From the University of Tennessee Medical Center, Knoxville, Tenn
| |
Collapse
|
10
|
Bugnicourt JM, Bonnaire B, Lepage L, Garcia PY, Lefranc M, Godefroy O. Infarctus cérébral par embolie calcaire spontanée révélant un rétrécissement aortique calcifié. ACTA ACUST UNITED AC 2008; 33:106-9. [DOI: 10.1016/j.jmv.2008.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 02/21/2008] [Indexed: 11/27/2022]
|
11
|
Halloran JI, Bekavac I. Unsuccessful Tissue Plasminogen Activator Treatment of Acute Stroke Caused by a Calcific Embolus. J Neuroimaging 2004. [DOI: 10.1111/j.1552-6569.2004.tb00270.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
12
|
Debruxelles S, Sibon I, Rouanet F, Orgogozo JM. Infarctus cérébral par embolie calcaire : complication spontanée révélatrice d’un rétrécissement aortique calcifié. Rev Neurol (Paris) 2004; 160:582-4. [PMID: 15269680 DOI: 10.1016/s0035-3787(04)70992-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Calcified aortic stenosis (CAS) is an unusual cause of cerebral infarct. The presence of cerebral intra-vascular or intra-parenchymatous calcifications, symptomatic or not, is suggestive of the diagnosis of CAS. We report two patients who experienced stroke induced by spontaneous calcic emboli from a calcified aortic valve and underline the importance of brain CT scan.
Collapse
Affiliation(s)
- S Debruxelles
- Fédération de Neurosciences Cliniques, CHU, Bordeaux
| | | | | | | |
Collapse
|
13
|
Thompson DB, Burton B, Watters M, Belden C, Emery RL, Beall DP. Calcific cerebral arterial embolization in the setting of bacterial endocarditis superimposed on prior rheumatic aortic valvular disease. Clin Imaging 2003; 27:304-6. [PMID: 12932679 DOI: 10.1016/s0899-7071(02)00564-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Stroke from a calcific cerebral artery embolus demonstrated by noncontrast computed tomography (CT) is rare. Although the ability of CT to demonstrate early acute cerebral emboli is limited, in the uncommon event of a calcific cerebral embolus, CT can easily visualize the embolized material. We present an unusual case of calcific cerebral arterial embolization to the proximal middle cerebral artery and illustrate the usefulness of CT in diagnosing this rare entity in conjunction with important predisposing clinical factors.
Collapse
Affiliation(s)
- Darin B Thompson
- Department of Radiology, Brooke Army Medical Center, 3851 Rodger Brooke Drive, Fort Sam, Houston, TX 78234, USA.
| | | | | | | | | | | |
Collapse
|
14
|
|
15
|
Kissela BM, Kothari RU, Tomsick TA, Woo D, Broderick J. Embolization of calcific thrombi after tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2001; 10:135-8. [PMID: 17903815 DOI: 10.1053/jscd.2001.25467] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2000] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Embolic stroke has been reported after thrombolysis in cardiac patients but has not yet been documented after thrombolytic therapy for acute ischemic stroke. DESCRIPTION OF CASES Patient 1 had a calcific embolus in the right M1 region on head computed tomography (CT) scan when treated with tissue plasminogen activator (tPA). Repeat imaging within hours showed distal migration of calcific fragments into the M2 region. Patient 2 had a calcific embolus in the right M1 region, as well as distal calcific emboli in multiple vascular distributions on initial head CT scan. She was treated with intravenous tPA but became unresponsive within 2 hours. Repeat imaging showed new calcium-density signal in the basilar artery. CONCLUSIONS We present 2 cases of radiographically evident, calcific embolization after tPA therapy for acute ischemic stroke. Emboli with a calcific component may lyse with tPA, but such patients should be carefully monitored for distal or recurrent embolization.
Collapse
Affiliation(s)
- B M Kissela
- Department of Neurology, University of Cincinnati, OH 45267-0525, USA
| | | | | | | | | |
Collapse
|