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Chronic Cerebral Infarction


KEY FACTS

Imaging

  • Volume loss with gliosis along affected margins

  • Classic: Wedge-shaped area of encephalomalacia

  • Territorial infarction

    • Involves brain supplied by major cerebral artery

  • Watershed infarction

    • Involves brain between main vascular territories

  • Lacunar infarction(s)

    • Most common in basal ganglia/thalami, deep white matter

Top Differential Diagnoses

  • Porencephalic cyst

  • Arachnoid cyst

  • Postsurgical/posttraumatic encephalomalacia

  • Low-attenuating tumors

Pathology

  • Volume loss, gliosis are pathological hallmarks

Clinical Issues

  • Elderly patient with typical risk factors

  • Focal neurologic deficit

    • Varies depending on size, location of cerebral infarction

  • Stroke severity most consistent predictor of 30-day mortality after stroke

  • Lacunar stroke most common stroke subtype associated with vascular dementia

Diagnostic Checklist

  • Evaluate for associated acute infarcts in same or different vascular territory

  • Evaluate for underlying cause

    • CTA/MRA of extra-/intracranial vasculature

    • If negative, consider cardiac source

  • Evaluate for risk factors

Axial graphic shows chronic infarct involving the posterior left middle cerebral artery (MCA) territory. Infarct is lined with gliotic WM. Small lacunar infarctions and atrophy also depicted.

Axial gross pathology, sectioned through the midventricular level, shows a chronic left MCA infarct with encephalomalacia in the classic MCA vascular distribution
. Note the adjacent WM gliosis
and the mild compensatory enlargement of the left lateral ventricle
.

(Courtesy R. Hewlett, MD.)

Axial NECT scan 2 days after large territorial infarction in the left MCA territory shows wedge-shaped hypodensity
involving both cortex, WM, and basal ganglia. Moderate mass effect is present, with subfalcine herniation of the lateral ventricles.

Follow-up scan 2 months later shows findings of chronic infarct. The mass effect has resolved completely, and there is frank encephalomalacia in the left MCA territory
. The left lateral ventricle shows compensatory enlargement
.

TERMINOLOGY

Abbreviations

  • Cerebral infarction (CI)

Synonyms

  • Old ischemic stroke

  • Postinfarction encephalomalacia

Definitions

  • End result of prolonged cerebral ischemia

IMAGING

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