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Zedde M, Grisendi I, Assenza F, Napoli M, Moratti C, Di Cecco G, Pavone C, Bonacini L, D'Aniello S, Valzania F, Pascarella R. Persistent intracranial steno-occlusion from calcified embolism: a treatment challenge. Neurol Sci 2024; 45:4037-4042. [PMID: 38709382 DOI: 10.1007/s10072-024-07575-9] [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: 02/26/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Calcified arterial cerebral embolism is a rare occurrence among large and medium vessel occlusions causing ischemic stroke and its diagnosis and treatment is a challenge. The sources of calcified embolism might be a calcific atheroma from the aortic arch and carotid artery, but also heart valve disease has been reported in the literature. Calcified embolism is frequently simultaneous on multiple vascular territories. The prognosis of patients is usually poor, including patients treated by using endovascular thrombectomy (EVT) and this diagnosis could be easily missed in the acute phase. In addition, the optimal secondary prevention has not been yet fully stated. METHODS We are presenting two cases of acute stroke due to calcified embolism in the middle cerebral artery (MCA) coming from a complicated carotid atheroma, non-stenosing in the first case (a 49 years old man) and stenosing in the second case (a 71 years old man) without clinical indications to intravenous thrombolysis and/or EVT, extensively investigated in the acute phase and followed-up for over 12 months with a favorable clinical course and the persisting steno-occlusion in the involved MCA. In both cases, antiplatelet treatment and targeting of vascular risk factors were done without recurrences in the follow-up period. DISCUSSION Cerebral calcified embolism has been reported in 5.9% of cases of acute ischemic stroke in a single center series and only in 1.2% of a large retrospective cohort of EVT-treated patients. In both series the prognosis was poor and only one third of EVT-treated patients had functional independence at 3-months follow-up. The natural history of these subtype of ischemic stroke is relatively poorly understood and both etiological diagnosis and treatment have not yet defined. It is possible that some cases might be underdiagnosed and underreported. CONCLUSIONS Calcified cerebral embolism is a rare cause of stroke, but it is largely underreported and both acute phase and secondary preventive treatment have to be defined.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy.
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Federica Assenza
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Giovanna Di Cecco
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Claudio Pavone
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Lara Bonacini
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Serena D'Aniello
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, Italy
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Menounos S, Matar W. Spontaneous calcified cerebral emboli: a comprehensive review and proposed diagnostic criteria. Front Neurol 2024; 15:1401820. [PMID: 39087019 PMCID: PMC11288925 DOI: 10.3389/fneur.2024.1401820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 07/08/2024] [Indexed: 08/02/2024] Open
Abstract
Spontaneous calcified cerebral emboli (SCCE) secondary to aortic valve calcification are a rare and underreported cause of acute ischaemic stroke. Only five cases of SCCE secondary to bicuspid aortic valve calcification have been reported in the literature. This review includes a unique case example of acute ischaemic stroke secondary to SCCE, as the first manifestation of a calcified bicuspid aortic valve. This is the first clinical case of calcified cerebral emboli (CCE) associated with borderzone infarction ('cortical ribbon sign'). Whilst previously assumed that most CCE are secondary to iatrogenic causes, recent literature suggests the majority of CCE are spontaneous and clinically silent. Despite CT imaging widely considered the 'gold standard' for diagnosis, CCE are frequently misdiagnosed and missed entirely. Misdiagnosis of CCE may have catastrophic consequences due to the high risk of recurrence and missed opportunity to prevent neurological disability and death. This review presents a revised CCE diagnostic criteria, using evidence that has emerged over the last decade to create both Compulsory (Major) and Supporting (Minor) criteria. Current CCE management is not evidence based and remains largely speculative. SCCE may be the first manifestation of cardiac or vascular disease and diagnosis should trigger aggressive treatment of emboligenic sources. Future epidemiological studies, analysing symptomatic and asymptomatic SCCE patients, would be beneficial in providing accurate quantification of disease burden. Other future research directions include exploring intracranial stenting for CCE revascularisation and cerebral intravascular lithotripsy.
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Affiliation(s)
- Spiro Menounos
- Department of Neurology, St George Hospital Kogarah, Sydney, NSW, Australia
- St George Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Walid Matar
- Department of Neurology, St George Hospital Kogarah, Sydney, NSW, Australia
- St George Clinical School, University of New South Wales, Sydney, NSW, Australia
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Rodrigues BA, Magriço M, Carmo E Pinto I, Vilela P, Marto JP. Calcified cerebral emboli: the salted pretzel sign. Pract Neurol 2024; 24:155-156. [PMID: 38050103 DOI: 10.1136/pn-2023-003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Bárbara Alves Rodrigues
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - Marta Magriço
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - Inês Carmo E Pinto
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - Pedro Vilela
- Neuroradiology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - João Pedro Marto
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
- iNOVA4Health, NOVA University Lisbon NOVA Medical School, Lisboa, Portugal
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Ikenouchi H, Saito T, Igasaki S, Kawabata Y, Yazawa Y. Successful Recanalization by Intravenous Thrombolysis in a Patient With Calcified Cerebral Emboli With Major Vessel Occlusion: A Case Report. Cureus 2024; 16:e52593. [PMID: 38370986 PMCID: PMC10870102 DOI: 10.7759/cureus.52593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
A 69-year-old man, with a history of left superficial temporal artery-middle cerebral artery bypass due to cerebral infarction by left internal carotid artery occlusion, was hospitalized with acute right hemispatial neglect and left hemiparesis. Diffusion-weighted imaging showed a high-intensity lesion in the right insular cortex. Although there seemed to be no arterial occlusion in magnetic resonance angiography (MRA), non-contrast computed tomography (CT) on admission showed calcification in the right Sylvian fissure. As hyperacute ischemic stroke within 4.5 hours after onset, we used an intravenous recombinant tissue plasminogen activator, and his symptoms improved. Follow-up MRA revealed recanalization of the right M2 branches with distal migration of calcification. Although calcification was identified on non-contrast CT in the initial assessment, the diagnosis of middle cerebral artery occlusion was missed. Therefore, arterial occlusion should be considered when calcification is observed in the brain sulcus. This case also illustrated that intravenous thrombolysis may be effective even in calcified cerebral emboli with major vessel occlusion.
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Affiliation(s)
| | - Takuya Saito
- Cerebrovascular Medicine, Kohnan Hospital, Sendai, JPN
| | - Shota Igasaki
- Cerebrovascular Medicine, Kohnan Hospital, Sendai, JPN
| | | | - Yukako Yazawa
- Cerebrovascular Medicine, Kohnan Hospital, Sendai, JPN
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Jing M, Yeo JYP, Holmin S, Andersson T, Arnberg F, Bhogal P, Yang C, Gopinathan A, Tu TM, Tan BYQ, Sia CH, Teoh HL, Paliwal PR, Chan BPL, Sharma V, Yeo LLL. Preprocedural Imaging : A Review of Different Radiological Factors Affecting the Outcome of Thrombectomy. Clin Neuroradiol 2021; 32:13-24. [PMID: 34709411 DOI: 10.1007/s00062-021-01095-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) has strong evidence for its effectiveness in treatment of acute ischemic stroke (AIS); however, up to half of the patients who undergo EVT still do not have good functional outcomes. Various prethrombectomy radiological factors have been shown to be associated with good clinical outcomes and may be the key to better functional outcomes, reduced complications, and reduced mortality. In this paper, we reviewed the current literature on these imaging parameters so they can be employed to better estimate the probability of procedural success, therefore allowing for more effective preprocedural planning of EVT strategies. We reviewed articles in the literature related to imaging factors which have been shown to be associated with EVT success. The factors which are reviewed in this paper included: anatomical factors such as 1) the type of aortic arch and its characteristics, 2) the characteristics of the thrombus such as length, clot burden, permeability, location, 3) the middle cerebral artery features including the tortuosity and underlying intracranial stenosis, 4) perfusion scans estimating the volume of infarct and the penumbra and 5) the effect of collaterals on the procedure. The prognostic effect of each factor on the successful outcome of EVT is described. The identification of preprocedural thrombectomy imaging factors can help to improve the chances of recanalization, functional outcomes, and mortality. It allows the interventionist to make time-sensitive decisions in the treatment of acute ischemic stroke.
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Affiliation(s)
- Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Y P Yeo
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Paul Bhogal
- Department of Neuroradiology, St.Bartholomew's and the Royal London Hospital, London, UK
| | - Cunli Yang
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching Hui Sia
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Prakash R Paliwal
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vijay Sharma
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore.
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Agarwal V, Choudhary N, Vyas S, Kumar A, Goyal M. "Calcified Clot March" after Intravenous Thrombolysis. Ann Indian Acad Neurol 2020; 23:568-570. [PMID: 33223687 PMCID: PMC7657272 DOI: 10.4103/aian.aian_532_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/08/2019] [Accepted: 01/18/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Vivek Agarwal
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | | | - Sameer Vyas
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - Ajay Kumar
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - Manoj Goyal
- Department of Neurology, PGIMER, Chandigarh, India
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Johnson S, McCarthy R, Fahy B, Mereuta OM, Fitzgerald S, Gaudirc J, Remadi JP, Shotar E, Sourour NA, Doyle K, Gilvarry M, McGarry P, McHugh PE, Clarençon F. Development of an in vitro model of calcified cerebral emboli in acute ischemic stroke for mechanical thrombectomy evaluation. J Neurointerv Surg 2020; 12:1002-1007. [PMID: 31900353 DOI: 10.1136/neurintsurg-2019-015595] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 01/22/2023]
Abstract
: BACKGROUND: Calcified cerebral emboli (CCEs) are a rare cause of acute ischemic stroke (AIS) and are frequently associated with poor outcomes. The presence of dense calcified material enables reliable identification of CCEs using non-contrast CT. However, recanalization rates with the available mechanical thrombectomy (MT) devices remain low. OBJECTIVE: To recreate a large vessel occlusion involving a CCE using an in vitro silicone model of the intracranial vessels and to demonstrate the feasability of this model to test different endovascular strategies to recanalize an occlusion of the M1 segment of the middle cerebral artery (MCA). : METHODS: An in vitro model was developed to evaluate different endovascular treatment approaches using contemporary devices in the M1 segment of the MCA. The in vitro model consisted of a CCE analog placed in a silicone neurovascular model. Development of an appropriate CCE analog was based on characterization of human calcified tissues that represent likely sources of CCEs. Feasibility of the model was demonstrated in a small number of MT devices using four common procedural techniques. : RESULTS: CCE analogs were developed with similar mechanical behavior to that of ex vivo calcified material. The in vitro model was evaluated with various MT techniques and devices to show feasibility of the model. In this limited evaluation, the most successful retrieval approach was performed with a stent retriever combined with local aspiration through a distal access catheter, and importantly, with flow arrest and dual aspiration using a balloon guide catheter. : CONCLUSION: Characterization of calcified tissues, which are likely sources of CCEs, has shown that CCEs are considerably stiffer than thrombus. This highlights the need for a different in vitro AIS model for CCEs than those used for thromboemboli. Consequentially, an in vitro AIS model representative of a CCE occlusion in the M1 segment of the MCA has been developed.
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Affiliation(s)
- Sarah Johnson
- Biomedical Engineering, National University of Ireland Galway, Galway, Ireland
| | - Ray McCarthy
- Cerenovus, Galway Neuro Technology Centre, Galway, Ireland
| | - Brian Fahy
- Cerenovus, Galway Neuro Technology Centre, Galway, Ireland
| | | | - Seán Fitzgerald
- Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | - Julien Gaudirc
- Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Jean-Paul Remadi
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitie-Salpetriere Hospital, Paris, France
| | | | - Karen Doyle
- Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | | | - Patrick McGarry
- Biomedical Engineering, National University of Ireland Galway, Galway, Ireland
| | - Peter E McHugh
- Biomedical Engineering, National University of Ireland Galway, Galway, Ireland
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitie-Salpetriere Hospital, Paris, France .,Sorbonne University, Paris, France
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Hickey TBM, Honig A, Ostry AJ, Chew JB, Caldwell J, Seidman MA, Masoudi H, Maguire JA. Iatrogenic embolization following cardiac intervention: postmortem analysis of 110 cases. Cardiovasc Pathol 2019; 40:12-18. [DOI: 10.1016/j.carpath.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 12/28/2018] [Accepted: 01/14/2019] [Indexed: 11/30/2022] Open
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Bardon M, Hanson J, O'Brien B, Naeem A. Calcified cerebral emboli: Incidence and implications. J Med Imaging Radiat Oncol 2018; 62:499-503. [PMID: 29665308 DOI: 10.1111/1754-9485.12730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/01/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Calcified cerebral emboli are an increasingly recognized cause of ischaemic stroke, although recognition amongst general radiologists and clinicians can be limited. Recent literature suggests that calcified cerebral emboli are likely more common than originally thought. This study aims to define the prevalence of calcified cerebral emboli as the most likely aetiology within a cohort of confirmed cases of acute stroke, as well as compare and contrast these cases with cases of 'incidental' intracranial calcification. METHODS Cases of confirmed stroke between May 2014 and May 2017 were reviewed by two readers to assess for the most likely aetiology. Cases of presumed calcified cerebral embolus were categorized in to 'possible' or 'definite'. The morphology, distribution and density were analysed by two independent readers, then subsequently discussed to reach a consensus. Cases were further studied in terms of likely proximal embolic source, therapeutic interventions and clinical outcomes. A further random selection of 220 non-contrast CT head examinations were reviewed over the same time period to assess for the presence of calcification which was favoured to be 'intravascular' using the same criteria. RESULTS A total of 220 cases of confirmed stroke were reviewed. Thirteen of these cases were thought to be most likely secondary to calcified cerebral emboli (5.9%). Of the 13 cases, eight were considered 'definite' as previous premorbid imaging without calcification was available. Twelve patients had emboli within the anterior circulation and only one patient had an embolus in the posterior circulation. Moderate calcified atherosclerotic disease was noted within the aorta and carotid arteries of all patients. Of the 220 patients within the control group, three cases were thought to have intracranial calcification most likely to be intravascular without clinical sequelae or other supportive imaging findings of infarct. CONCLUSION Previously thought to be a rare complication of intra-arterial instrumentation, calcified cerebral emboli have been shown to more commonly be associated with spontaneous cerebral infarction. Whilst literature in this area remains scant, recognition and differentiation of this entity has important clinical applications regarding immediate diagnosis of stroke on non-contrast imaging, modified treatment in the acute setting as well as in regards to recurrent event prognosis and secondary prevention.
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Affiliation(s)
- Miguel Bardon
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Julian Hanson
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Bill O'Brien
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Adil Naeem
- Gosford Hospital, Gosford, New South Wales, Australia
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Calcified cerebral emboli: numerous particles on computed tomography. Acta Neurol Belg 2017; 117:915-918. [PMID: 28390008 DOI: 10.1007/s13760-017-0779-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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Raghib MF, Mutzenbach JS, Rösler C, Otto F, Coy MM, Müller-Thies-Broussalis E, Pikija S. Acute treatment of stroke due to spontaneous calcified cerebral emboli causing large vessel occlusion. J Clin Neurosci 2017; 47:56-61. [PMID: 29102234 DOI: 10.1016/j.jocn.2017.10.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/11/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Calcified cerebral emboli (CCE) are rarely responsible for large vessel occlusion (LVO) in acute anterior stroke, and therefore therapeutic experience is scarce. We sought to expand current knowledge upon therapeutic options with three new cases and a review of current literature. METHODS Systematic search of patients with acute anterior stroke due to LVO in one comprehensive stroke center throughout a 4 year period. Literature search for reported cases of CCE. RESULTS In total, 21 cases (19 found in literature and 3 from our institution) are reported with a median age of 72 years (interquartile range [IQR] 63-80). Eleven patients were treated acutely, 4 of them with endovascular thrombectomy (EVT). Middle cerebral artery (MCA) M1 was the most affected segment and large artery atherosclerosis (LAA) and cardioembolism (CE) was causative in 41% of cases. EVT was significantly superior to intravenous recombinant tissue plasminogen activator (rtPA) at p = .048 (Fisher's exact test, chi square 6.7). CONCLUSIONS Given the small sample reported in literature and no reported randomised studies, definitive recommendations could not be reached. However, considering thrombus composition, thrombolysis is most probably not sufficient and priority should be given to EVT.
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Affiliation(s)
| | - Johannes Sebastian Mutzenbach
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Cornelia Rösler
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ferdinand Otto
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Mark Mc Coy
- Department of Neuroradiology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Slaven Pikija
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria.
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Manual Aspiration Thrombectomy in Patients with Acute Stroke-Related Calcified Cerebral Emboli. J Stroke Cerebrovasc Dis 2017; 26:2050-2054. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/10/2016] [Accepted: 07/02/2016] [Indexed: 01/19/2023] Open
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13
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Utility of Carotid Ultrasonography in Management of an Atypical High Vascular-Risk Patient with Recurrent Calcified Cerebral Embolic Stroke. J Stroke Cerebrovasc Dis 2017; 26:e156-e159. [PMID: 28549916 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 01/04/2017] [Accepted: 04/29/2017] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To describe a case of recurrent calcified cerebral emboli (CCE)-related acute ischemic stroke (AIS) and the diagnostic utility of plaque morphology characterization on carotid ultrasound. BACKGROUND CCE are a rare cause of AIS. CCE-related AIS has been previously reported only in high vascular-risk patients such as those with severe carotid stenosis, widespread atheromatous disease, or cardiac valvular disease. CCE-related AIS from a carotid origin has not been reported in patients without carotid stenosis. CASE A 69-year-old man with no known medical history presented with hemiparesis and aphasia was found to have a curvilinear calcification in the left sylvian fissure on brain imaging, consistent with CCE. Two months later, he developed a second episode of CCE-related AIS. Standard workup, as well as advanced imaging with digital subtraction angiography, revealed no carotid stenosis or valvular disease. Carotid ultrasound demonstrated normal flow velocities but a left carotid heterogeneous plaque with multiple ulcerative craters and lucencies, suggestive of an active thromboembolic source. CONCLUSION To our knowledge, this is the first case reporting CCE-AIS from carotid origin in a patient with no carotid stenosis. Carotid ultrasound serves a diagnostic role in these patients.
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Uneda A, Kanda T, Suzuki K, Hirashita K, Yunoki M, Yoshino K. Acute Cerebral Artery Occlusion by a Calcified Embolus with False Patency Sign on Computed Tomographic Angiography. J Stroke Cerebrovasc Dis 2017; 26:e5-e7. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/18/2016] [Accepted: 09/22/2016] [Indexed: 11/24/2022] Open
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Abstract
The heart and the carotid arteries are the most common sites of origin of embolic disease to the brain. Clots arising from these locations are the most common types of brain emboli. Less common cerebral emboli include air, fat, calcium, infected vegetations, and tumor cells as well as emboli originating in the venous system. Although infarcts can be the final result of any type of embolism, described herein are the ancillary and sometimes unique imaging features of less common types of cerebral emboli that may allow for a specific diagnosis to be made or at least suspected in many patients.
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Affiliation(s)
- Nader Zakhari
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Mauricio Castillo
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, Room 3326 Old Infirmary Building, Manning Drive, Chapel Hill, NC 27599-7510, USA
| | - Carlos Torres
- Neuroradiology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
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Deng Q, Zhang Y, Ding H, Dong Q, Fu J. Calcific emboli originating from the brachiocephalic trunk causing acute cerebral infarction and worm-like calcification in the right middle cerebral artery. J Clin Neurosci 2015; 22:889-90. [DOI: 10.1016/j.jocn.2014.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/11/2014] [Accepted: 11/26/2014] [Indexed: 11/25/2022]
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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.
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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
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Mayor Gómez S, Muñoz Arroniz R, Olier Arenas J, Gállego Cullere J. Infarto cerebral por embolismo cálcico y tratamiento trombolítico ineficaz. Neurologia 2014; 29:123-5. [DOI: 10.1016/j.nrl.2012.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 06/02/2012] [Accepted: 06/27/2012] [Indexed: 10/27/2022] Open
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Cerebral infarct due to calcium embolism and ineffective thrombolytic treatment. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2013.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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20
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Seike N, Matsumoto K, Hirota Y, Kobessho H. [Effective thrombolytic therapy for calcified cerebral embolism originating from a calcified plaque in the internal carotid artery]. Rinsho Shinkeigaku 2014; 54:916-919. [PMID: 25420568 DOI: 10.5692/clinicalneurol.54.916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 72-year-old man was transported to our emergency department after rear-ending another vehicle. He presented with acute left hemispatial neglect, left hemianopsia, and mild left hemiparesis. Computed tomography (CT) on admission showed a calcified embolus in the right middle cerebral artery. After intravenous thrombolytic therapy, the patient showed drastic improvement of neurological deficits. Follow-up CT showed disappearance of embolus, but distal migration of emboli to the downstream of the right middle cerebral artery was seen, sparing the massive territory of the right middle cerebral artery. Carotid duplex sonography and 3-dimensional CT angiography showed a calcified plaque with ulceration at the origin of the right internal carotid artery, representing the presumptive origin of the emboli. We report a rare case of effective intravenous thrombolysis for calcified cerebral embolism from the carotid artery. Further consideration of the mechanism, efficacy, and indication of intravenous thrombolysis for calcified cerebral emboli is needed.
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Takhtani D, Dundamadappa S, Almast J. Role of noncontrast head CT in the assessment of vascular abnormalities in the emergency room. Emerg Radiol 2013; 20:529-41. [PMID: 23739799 DOI: 10.1007/s10140-013-1136-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/27/2013] [Indexed: 11/28/2022]
Abstract
Noncontrast CT of the head is a widely used noninvasive investigation for a variety of acute and chronic neurological conditions. Since CT head without contrast is usually the first and often the only investigation in the emergency room for many neurological symptoms, it is imperative to detect subtle vascular changes, which in many patients can be life-saving. The vascular abnormalities may present with increased density and/or size of the vessels, filling defects, and be associated with parenchymal and bony changes. In this article, we present examples of several vascular pathologies which can be identified on the noncontrast CT of the head, and learn imaging and interpretation techniques to help recognize what often are nebulous changes. While some of the findings are diagnostic by themselves and others subtle, any suspicious abnormality should be followed with dedicated vascular imaging such as CT/MR angiogram, venogram, or catheter angiogram for confirmation and better characterization.
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Affiliation(s)
- Deepak Takhtani
- University of Massachusetts Medical School, UMass Memorial Hospital, Worcester, MA, 01655, USA,
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Petzold A, Islam N, Hu HH, Plant GT. Embolic and Nonembolic Transient Monocular Visual Field Loss: A Clinicopathologic Review. Surv Ophthalmol 2013; 58:42-62. [DOI: 10.1016/j.survophthal.2012.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 02/01/2012] [Accepted: 02/07/2012] [Indexed: 12/01/2022]
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Uchida Y, Uchida Y, Sakurai T, Kanai M, Shirai S, Nakagawa O. Cardioscopic detection of left ventricular thrombi. -With special reference to a comparison with left ventriculography and echocardiography-. Circ J 2011; 75:1920-6. [PMID: 21697606 DOI: 10.1253/circj.cj-11-0248] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Thrombosis occurs in the left ventricle and causes ischemic cerebral attacks. However, differences in the incidence of left ventricular thrombi (LVT) among various categories of heart diseases are not known. METHODS AND RESULTS From April 2000 to 31 March 2008, 258 patients (104 females and 154 males; age 63 ± 6 years) with a heart disease underwent cardioscopy of the left ventricle. LVT were detected by cardioscopy in 78 of 258 patients; 12.5% of 57 patients with stable angina, 0% of 9 with unstable angina, 45.2% of 42 with acute myocardial infarction, 23.2% of 43 with old myocardial infarction, 61.9% of 21 with idiopathic acute myocarditis, 44.3% of 68 with idiopathic chronic myocarditis, 33.3% of 6 with rheumatic valvular disease, 25.7% of 31 with idiopathic dilated cardiomyopathy and in 8.0% of 12 with idiopathic hypertrophic cardiomyopathy. Nine of 78 thrombi were globular and 69 were mural. The detection rate of LVT by cardioscopy, left venticulography, non-contrast and contrast echocardiography was 30.2%, 2.7%, 1.9% and 7.0%, respectively. CONCLUSIONS LVT were frequently detected by cardioscopy in patients with heart diseases. Although invasive, cardioscopy was more sensitive in detecting LVT than left ventriculography, and non-contrast and contrast echocardiography.
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Affiliation(s)
- Yasuto Uchida
- Department of Cardiology, Toho University Medical Center Ohmori Hospital, Japan.
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