What are the causes and management of multiple cerebral infarcts?

Causes and Management of Multiple Cerebral Infarcts

Etiology of Multiple Cerebral Infarcts

Cardioembolism is the most common cause of multiple acute cerebral infarcts in different arterial territories, accounting for approximately 37% of cases, followed by large artery atherosclerosis at about 26%. 1

Common Causes:

• Cardioembolic sources (37.2% of cases):

  • Atrial fibrillation 2
  • Myocardial infarction with intracardiac thrombi 3
  • Valvular heart disease and prosthetic heart valves 3

• Large artery atherosclerosis (25.7% of cases):

  • Carotid artery stenosis (symptomatic or asymptomatic) 2
  • Aortic arch atheroma 1
  • Intracranial large vessel disease 4

• Hematologic disorders and hypercoagulable states (2.1% of cases):

  • Antiphospholipid antibody syndrome 3
  • Cancer-related hypercoagulability 4
  • Thrombotic thrombocytopenic purpura 3
  • Polycythemia vera and essential thrombocythemia 3
  • Disseminated intravascular coagulation 3

• Small vessel disease (1.8% of cases):

  • Hypertensive small vessel disease causing lacunar infarcts 1
  • Cerebral amyloid angiopathy 3

• Vasculitis and inflammatory disorders (0.2% of cases):

  • Primary CNS vasculitis 4
  • Systemic vasculitis 4

• Rare causes:

  • Moyamoya disease/syndrome 3
  • Cerebral arterial dissection 3
  • Sickle cell disease 3
  • Homocystinuria 3
  • Radiation-induced arteriopathy 3

• Undetermined etiology (approximately 27.6% of cases) 1

Risk Factors:

• Advanced age 2
• Female gender 2
• Hypertension 5
• Diabetes mellitus 5
• Smoking 3
• Hyperlipidemia 3
• Systemic inflammation (elevated C-reactive protein) 6

Diagnostic Approach

Initial Evaluation:

• Brain imaging:

  • MRI with diffusion-weighted imaging (DWI) is the gold standard for detecting acute multiple infarcts 1, 2
  • CT scan to rule out hemorrhage 3

• Vascular imaging:

  • Carotid Doppler ultrasound to identify carotid stenosis 3
  • CT angiography or MR angiography to evaluate intracranial and extracranial vessels 5

• Cardiac evaluation:

  • 12-lead ECG to detect atrial fibrillation 3
  • Echocardiography (transthoracic and/or transesophageal) to identify cardiac sources of embolism 3
  • Prolonged cardiac monitoring if paroxysmal atrial fibrillation is suspected 3

• Laboratory tests:

  • Complete blood count to assess for hematologic disorders 3
  • Coagulation profile 3
  • Inflammatory markers (ESR, CRP) 6
  • Homocysteine levels if homocystinuria is suspected 3
  • Antiphospholipid antibodies if appropriate 3

Management Strategies

Acute Management:

• Thrombolytic therapy:

  • Intravenous recombinant tissue plasminogen activator (rt-PA) within 3 hours of symptom onset 5

• Management of increased intracranial pressure:

  • Elevate head of bed to 20-30 degrees 7
  • Ensure proper airway management 7
  • Avoid hypoxia, hypercarbia, and hyperthermia 7
  • Restrict fluids mildly and avoid hypo-osmolar fluids 7
  • Maintain adequate cerebral perfusion pressure 7
  • Consider external ventricular drainage or decompressive craniectomy for refractory intracranial hypertension 7

Etiology-Specific Management:

• Cardioembolic stroke:

  • Anticoagulation therapy (warfarin or direct oral anticoagulants) for atrial fibrillation and other high-risk cardiac sources 5
  • Management of underlying cardiac condition 3

• Large artery atherosclerosis:

  • Antiplatelet therapy (aspirin, clopidogrel, or cilostazol) 5
  • Consider carotid endarterectomy for symptomatic carotid stenosis >70% 3
  • Aggressive risk factor modification 3

• Small vessel disease:

  • Blood pressure control 5
  • Antiplatelet therapy 5

• Hematologic disorders:

  • Treatment of underlying condition 3
  • Anticoagulation if appropriate 3

• Vasculitis:

  • Immunosuppressive therapy 4
  • Corticosteroids 4

• Sickle cell disease:

  • Regular blood transfusions to maintain hemoglobin S <30% 3
  • Hydroxyurea therapy 3

Secondary Prevention:

• Risk factor modification:

  • Blood pressure control 5
  • Diabetes management 5
  • Lipid-lowering therapy 5
  • Smoking cessation 3
  • Moderate alcohol consumption 3

• Antithrombotic therapy:

  • Antiplatelet agents for non-cardioembolic stroke 5
  • Anticoagulation for cardioembolic stroke 5

• Monitoring:

  • Regular follow-up imaging to assess progression or regression of disease 3
  • Monitoring of therapeutic interventions 3

Special Considerations

• Multiple cerebral infarcts may occur simultaneously or in a stepwise fashion, as suggested by mixed ADC signal patterns on MRI 6

• Only about 30% of patients with multiple infarcts present with symptoms suggesting multiple lesions before MRI, highlighting the importance of comprehensive imaging 4

• The presence of multiple infarcts in different vascular territories is associated with higher stroke severity (higher NIHSS scores) 2

• Systemic inflammation may play a role in the pathogenesis of multiple cerebral infarcts 6