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Table of Contents    
COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 696-697

Importance of etiology-based workup and diagnosis in acute multiple infarcts in multiple cerebral circulations


1 Department of Neurology, Janakpuri Super Speciality Hospital, Janakpuri, New Delhi, India
2 Department of Pathology, Janakpuri Super Speciality Hospital, Janakpuri, New Delhi, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Man Mohan Mehndiratta
Department of Neurology, Janakpuri Super Speciality Hospital, Janakpuri, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263225

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How to cite this article:
Mehndiratta MM, Das A. Importance of etiology-based workup and diagnosis in acute multiple infarcts in multiple cerebral circulations. Neurol India 2019;67:696-7

How to cite this URL:
Mehndiratta MM, Das A. Importance of etiology-based workup and diagnosis in acute multiple infarcts in multiple cerebral circulations. Neurol India [serial online] 2019 [cited 2019 Dec 7];67:696-7. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/696/263225




Acute multiple infarcts in multiple cerebral circulations (AMIMCC) [anterior circulation: anterior cerebral artery, middle cerebral artery (MCA), and their major branches; posterior circulation: posterior cerebral artery and its major branches] are defined as noncontiguous infarcts involving more than one cerebral circulation (different territories). With the availability of advanced neuroimaging techniques, more and more of such types of cases are being diagnosed with ease. Etiology, pathomechanisms, clinical features, and prognosis of acute multiple infarcts (AMI) reflect wide variations in terms of geographical distribution (regions of the East versus West), location of infarcts, and age pattern of patients. Although, among various causes [Figure 1], cardioembolic etiology is predominantly encountered, other nonembolic causes are often overlooked, necessitating the cautious use of anticoagulation therapy for secondary prevention of such cases.[1]
Figure 1: Etiology of acute multiple infarcts in multiple cerebral circulations (hand drawn by Dr. Abhijit Das)

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The etiology may vary in multiple infarcts, according to the individual territory involved. Besides cardioembolism and atherosclerosis, multiple infarcts may be related to various angiopathies such as infectious arteritis, amyloid angiopathy, polyarteritis nodosa, Wegener's granulomatosis, hypersensitivity vasculitis, or familial vascular diseases such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; and, cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy. Infarcts of variable sizes involving multiple territories in AMIMCC are not uncommon; tantalizingly large infarcts are associated with a poor evaluation, suggesting that the infarct size rather than the number of infarcts correlates with a worse outcome. Embolism leading to AMI can be seen in three different settings: (i) embolism occluding the proximal part of major vessels, (ii) multiple emboli resulting in multiple infarcts, and (iii) a single large embolus breaking up and dispersing into multiple sites.[2]

AMI involving posterior circulation may have protean characteristic features.[2],[3] These are seldom preceded by transient ischemic attacks. In around two-thirds of cases, the stroke onset is not progressive, where no significant difference is found between various etiological groups such as cardioembolism, arterial embolism, small artery disease, and local thrombosis. No particular risk factor is correlated with a poor outcome, although acute multiple infarcts as compared to a single infarct in the posterior circulation are associated with a poorer prognosis.[2]

Studies addressing multiple brain infarcts and attempting to correlate them with underlying causes and mechanisms are on the rise. The actual data on AMI are still lacking, which may be due to the variable methodology adopted for the identification of such cases in various studies. The geographical distribution plays another role in disease causation. For example, MCA and internal carotid artery (ICA) diseases are the main causes of multiple infarcts in the anterior circulation territory in the Asians, whereas cardioembolism and ICA diseases are the main culprits of AMI in the Western countries. This discrepancy suggests that a high prevalence of intracranial arterial diseases is present in the Asians. Acute infarcts involving both cerebral hemispheres may be due to bilateral or unilateral large artery diseases or a small artery occlusion. In such cases, hyperviscosity may be an important contributory factor because elevated fibrinogen level or hematocrit is often found to be significantly associated with bilateral cerebral infarctions.[4],[5]

Increasing the use of advanced neuroimaging modalities such as diffusion weighted imaging (DWI) has proven to have a beneficial role in the diagnosis of AMIMCC. The DWI is very sensitive to acute cellular injury in cerebral ischemia, which helps in detecting small new infarcts as well as in differentiating a recent infarct from an old infarct.[5] AMIs are not uncommon nowadays and it is thought that several cases in the past might have been overlooked without proper systemic magnetic resonance imaging evaluation.[6] Considering the high yield nature of DWI to detect AMIMCC as compared with computed tomography brain, the practice of this advanced neuroimaging modality should be encouraged in all suspected cases of acute multiple infarcts.

Some interesting facts obtained from various studies performed in AMIMCC till date are as follows:

  • There is heterogeneity of clinical, etiological, and topographical features of acute multiple infarcts [2]
  • Topographic patterns of AMIMCC may correlate with different vascular pathologies and stroke mechanisms [5]
  • Vascular anatomic variations may have a role in the pathogenesis of AMI involving both anterior and posterior circulation as well as bilateral cerebral infarcts [5]
  • Increased blood viscosity and malignancy-associated hypercoagulable states are frequently found to be associated with bilateral cerebral infarcts [5]
  • Undetermined causes account for a major percentage of acute multiple infarcts, hence a comprehensive universal workup protocol needs to be established for better characterization of such groups in the near future [1]
  • The scenario of acute multiple infarcts complicating diagnostic coronary angiography is another area of rising concern in the present era. Although a prompt diagnosis and an immediate intra-arterial thrombolytic therapy are beneficial in some cases, future large studies primarily targeting these types of patients are required to establish a standardized management protocol [7]
  • Vascular risk factors such as atherosclerosis and atrial fibrillations are much less frequent in young adults than in elderly patients.[8] Thus, the etiology of multiple brain infarcts differs in elderly patients as compared with younger patients.[9]


An early recognition of AMIMCC may have implications for the emergency therapy options. More studies need to be performed to evaluate the concomitant vascular diseases or multiple simultaneous etiologies of acute multiple infarcts. As limited data are available in the published literature on acute multiple infarcts in young patients, further studies involving such groups need to be carried out in the future to categorize the differential characteristics of age-wise variations in etiopathogenesis.



 
  References Top

1.
Novotny V, Khanevski AN, Thomassen L, Waje-Andreassen U, Naess H. Time patterns in multiple acute cerebral infarcts. Int J Stroke 2017;12:969-75.  Back to cited text no. 1
    
2.
Bernasconi A, Bogousslavsky J, Bassetti C, Regli F. Multiple acute infarcts in the posterior circulation. J Neurol Neurosurg Psychiatry 1996;60:289-96.  Back to cited text no. 2
    
3.
Mehndiratta M, Pandey S, Nayak R, Alam A. Posterior circulation ischemic stroke-clinical characteristics, risk factors, and subtypes in a north Indian population: A prospective study. Neurohospitalist 2012;2:46-50.  Back to cited text no. 3
    
4.
Mehndiratta MM, Agarwal P, Sen K, Sharma B. Stroke in young adults: A study from a university hospital in north India. Med Sci Monit 2004;10:CR535-41.  Back to cited text no. 4
    
5.
Roh JK, Kang DW, Lee SH, Yoon BW, Chang KH. Significance of acute multiple brain infarction on diffusion-weighted imaging. Stroke 2000;31:688-94.  Back to cited text no. 5
    
6.
Depuydt S, Sarov M, Vandendries C, Guedj T, Cauquil C, Assayag P, et al. Significance of acute multiple infarcts in multiple cerebral circulations on initial diffusion weighted imaging in stroke patients. J Neurol Sci 2014;337:151-5.  Back to cited text no. 6
    
7.
Serry R, Tsimikas S, Imbesi SG, Mahmud E. Treatment of ischemic stroke complicating cardiac catheterization with systemic thrombolytic therapy. Catheter Cardiacvasc Interv 2005;66:364-8.  Back to cited text no. 7
    
8.
Putaala J, Haapaniemi E, Kaste M, Tatlisumak T. How does number of risk factors affect prognosis in young patients with ischaemic stroke? Stroke 2012;43:356-61.  Back to cited text no. 8
    
9.
Mustanoja S, Putaala J, Haapaniemi E, Strbian D, Kaste M, Tatlisumak T. Multiple brain infarcts in young adults: Clues for etiologic diagnosis and prognostic impact. Eur J Neurol 2013;20:216-22.  Back to cited text no. 9
    


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