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Are multiple acute small subcortical infarctions caused by embolic mechanisms?

Division of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK

Correspondence to:
Correspondence to:
Professor J M Wardlaw
Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK; jmw{at}skull.dcn.ed.ac.uk

Objective: To seek evidence of potential embolic sources or other stroke mechanisms in patients who, on chance observation, had several apparently recent small subcortical infarcts on diffusion weighted magnetic resonance imaging (DWI).

Methods: Patients presenting with stroke and multiple hyperintense subcortical infarcts visible on DWI were identified prospectively. Detailed clinical and radiological assessments were done independently and blinded to each other.

Results: Of 10 patients with multiple hyperintense subcortical infarcts on DWI, a definite embolic source was identified in only one. Most patients were hypertensive and smoked. The DWI appearance suggested that the subcortical lesions had occurred within several weeks rather than at exactly the same time. Most patients also had significant white matter hyperintensities and four had microhaemorrhages.

Conclusions: Embolic sources were not identified in most patients but they did have systemic vascular risk factors and brain imaging features of "small vessel disease." A more generalised intrinsic process affecting many small cerebral vessels contemporaneously could explain multiple acute small subcortical infarcts. White matter hyperintensities, microhaemorrhages, and multiple small subcortical infarcts may share a common pathophysiological mechanism such as a diffuse cerebral microvascular abnormality which requires further exploration.

Abbreviations: DWI, diffusion weighted imaging; FLAIR, fluid attenuation inversion recovery; LACS, lacunar syndrome; OCSP, Oxford Community Stroke Project; PACS, partial anterior circulation stroke syndrome; POCS, posterior circulation syndrome

Keywords: stroke; cerebral infarction; lipohyalinosis; emboli

Relevant Article

Are multiple acute small subcortical infarctions caused by embolic mechanisms?

B Norrving
J. Neurol. Neurosurg. Psychiatry 2004 75: 1375. [Extract] [Full Text] [PDF]

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				T Seifert, C Enzinger, M K Storch, G Pichler, K Niederkorn, and F Fazekas Acute small subcortical infarctions on diffusion weighted MRI: clinical presentation and aetiology J. Neurol. Neurosurg. Psychiatry, November 1, 2005; 76(11): 1520 - 1524. [Abstract] [Full Text] [PDF]

				T. Wessels, C. Rottger, M. Jauss, M. Kaps, H. Traupe, and E. Stolz Identification of Embolic Stroke Patterns by Diffusion-Weighted MRI in Clinically Defined Lacunar Stroke Syndromes Stroke, April 1, 2005; 36(4): 757 - 761. [Abstract] [Full Text] [PDF]

				B Norrving Are multiple acute small subcortical infarctions caused by embolic mechanisms? J. Neurol. Neurosurg. Psychiatry, October 1, 2004; 75(10): 1375 - 1375. [Full Text] [PDF]