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Multiple Embolic Cerebral Infarctions


KEY FACTS

Terminology

  • Infarcts in multiple arterial distributions from embolic source, often cardiac origin

Imaging

  • Best imaging clue: DWI restriction in multiple vascular distributions

  • NECT: Multiple regions of low attenuation, loss of gray-white differentiation

  • T2/FLAIR: Multiple supratentorial and infratentorial regions of hyperintensity, often in vascular distribution

    • May be of different ages

  • Embolic infarcts tend to involve terminal cortical branches, producing wedge-shaped infarcts

  • Cardiac echocardiography may show valve vegetations, intracardiac filling defect, or atrial or ventricular septal defect

  • Best imaging tool: MR with DWI, FLAIR, T1WI C+

Top Differential Diagnoses

  • Hypotensive cerebral infarction

  • Multiple sclerosis

  • Parenchymal metastases

  • Vasculitis

Clinical Issues

  • Multiple focal neurologic complaints not conforming to singular vascular distribution

  • Peripheral signs of emboli, such as splinter hemorrhages or paradoxical emboli

  • Cardiac source most common etiology of multiple embolic infarcts

    • May be septic or benign

  • Carotid artery disease may cause multiple embolic infarct, if associated with variant posterior cerebral artery origin

  • Cardiac and vascular evaluation → treat underlying disease

Axial DTI trace image shows multiple regions of diffusion hyperintensity
related to acute middle cerebral artery (MCA) distribution ischemia in bilateral hemispheres in a patient with embolic disease from a cardiac source.

Axial FLAIR MR shows bilateral chronic MCA distribution ischemia
related to untreated atrial fibrillation. Note the areas of encephalomalacia
with surrounding gliosis
, typical of chronic ischemia.

Axial DTI trace shows acute ischemia in the left hemisphere in multiple vascular distributions. Note the involvement of the recurrent artery of Heubner from the ACA distribution (head of caudate)
, as well as the MCA
and PCA
territories, in this patient with severe internal carotid artery atherosclerotic disease and a fetal origin PCA.

Axial T1 C+ FS MR shows multiple foci of enhancement
in bilateral hemispheres related to septic emboli in a patient with cardiac valve vegetations.

TERMINOLOGY

Definitions

  • Infarcts in multiple arterial distributions from embolic source, often cardiac origin

IMAGING

Imaging Anatomy

  • Embolic infarcts tend to involve terminal cortical branches, producing wedge-shaped infarcts

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