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Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 2004 May;75(5):727–732. doi: 10.1136/jnnp.2003.022574

Isolated middle cerebral artery disease: clinical and neuroradiological features depending on the pathogenesis

P Lee 1, S Oh 1, O Bang 1, I Joo 1, K Huh 1
PMCID: PMC1763587  PMID: 15090568

Abstract

Background: Isolated atherosclerotic middle cerebral artery (MCA) disease is often difficult to differentiate from cardioembolic disease if intracranial atherosclerosis coexists with cardiac disease.

Objectives: To evaluate whether clinical and neuroradiological features of isolated MCA disease differ according to the underlying aetiology.

Methods: Isolated MCA disease was defined as a unilateral angiographically occlusive lesion of the MCA on the symptomatic side without lesions of other intracranial or extracranial vessels. Patients with isolated MCA disease were divided into atherosclerotic and potentially cardioembolic, and the clinical, laboratory, and neuroradiological data analysed.

Results: Among the 850 consecutive patients with acute ischaemic stroke or transient ischaemic attack, 107 (12.6%) met the criteria for isolated MCA disease (76 with atherosclerotic disease and 31 with a potential source of cardiac embolism). Total anterior circulation infarcts were more common and baseline NIHSS score was higher in potentially embolic occlusions than in atherosclerotic disease (each p<0.001). While cortical infarcts and territorial infarcts were more common in the potential embolism group (p = 0.028 and p<0.001, respectively), subcortical border zone infarcts were more common in the atherosclerotic group (p<0.001). Multiple regression analysis showed that border zone infarcts and mild stroke were independently associated with atherosclerotic MCA disease, while territorial and cortical infarcts were associated with potential cardiac embolic disease.

Conclusions: Clinical and neuroradiological characteristics can differentiate isolated atherosclerotic MCA disease from MCA disease associated with potential sources of cardiac embolism, and may reflect the differences in underlying pathogenesis.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adams H. P., Jr, Bendixen B. H., Kappelle L. J., Biller J., Love B. B., Gordon D. L., Marsh E. E., 3rd Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993 Jan;24(1):35–41. doi: 10.1161/01.str.24.1.35. [DOI] [PubMed] [Google Scholar]
  2. Adams Harold P., Jr Emergent use of anticoagulation for treatment of patients with ischemic stroke. Stroke. 2002 Mar;33(3):856–861. doi: 10.1161/hs0302.104628. [DOI] [PubMed] [Google Scholar]
  3. Angeloni U., Bozzao L., Fantozzi L., Bastianello S., Kushner M., Fieschi C. Internal borderzone infarction following acute middle cerebral artery occlusion. Neurology. 1990 Aug;40(8):1196–1198. doi: 10.1212/wnl.40.8.1196. [DOI] [PubMed] [Google Scholar]
  4. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991 Jun 22;337(8756):1521–1526. doi: 10.1016/0140-6736(91)93206-o. [DOI] [PubMed] [Google Scholar]
  5. Bang Oh Young, Heo Ji Hoe, Kim Jung Yeon, Park Jae Hyun, Huh Kyoon. Middle cerebral artery stenosis is a major clinical determinant in striatocapsular small, deep infarction. Arch Neurol. 2002 Feb;59(2):259–263. doi: 10.1001/archneur.59.2.259. [DOI] [PubMed] [Google Scholar]
  6. Bogousslavsky J., Barnett H. J., Fox A. J., Hachinski V. C., Taylor W. Atherosclerotic disease of the middle cerebral artery. Stroke. 1986 Nov-Dec;17(6):1112–1120. doi: 10.1161/01.str.17.6.1112. [DOI] [PubMed] [Google Scholar]
  7. Bogousslavsky J., Regli F. Centrum ovale infarcts: subcortical infarction in the superficial territory of the middle cerebral artery. Neurology. 1992 Oct;42(10):1992–1998. doi: 10.1212/wnl.42.10.1992. [DOI] [PubMed] [Google Scholar]
  8. Bozzao L., Fantozzi L. M., Bastianello S., Bozzao A., Fieschi C. Early collateral blood supply and late parenchymal brain damage in patients with middle cerebral artery occlusion. Stroke. 1989 Jun;20(6):735–740. doi: 10.1161/01.str.20.6.735. [DOI] [PubMed] [Google Scholar]
  9. Cacciatore A., Russo L. S., Jr Lacunar infarction as an embolic complication of cardiac and arch angiography. Stroke. 1991 Dec;22(12):1603–1605. doi: 10.1161/01.str.22.12.1603. [DOI] [PubMed] [Google Scholar]
  10. Caplan L. R., Gorelick P. B., Hier D. B. Race, sex and occlusive cerebrovascular disease: a review. Stroke. 1986 Jul-Aug;17(4):648–655. doi: 10.1161/01.str.17.4.648. [DOI] [PubMed] [Google Scholar]
  11. Caplan L. R., Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998 Nov;55(11):1475–1482. doi: 10.1001/archneur.55.11.1475. [DOI] [PubMed] [Google Scholar]
  12. Del Sette M., Eliasziw M., Streifler J. Y., Hachinski V. C., Fox A. J., Barnett H. J. Internal borderzone infarction: a marker for severe stenosis in patients with symptomatic internal carotid artery disease. For the North American Symptomatic Carotid Endarterectomy (NASCET) Group. Stroke. 2000 Mar;31(3):631–636. doi: 10.1161/01.str.31.3.631. [DOI] [PubMed] [Google Scholar]
  13. Fiorelli M., Bastianello S., von Kummer R., del Zoppo G. J., Larrue V., Lesaffre E., Ringleb A. P., Lorenzano S., Manelfe C., Bozzao L. Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke. 1999 Nov;30(11):2280–2284. doi: 10.1161/01.str.30.11.2280. [DOI] [PubMed] [Google Scholar]
  14. Gandolfo C., Del Sette M., Finocchi C., Calautti C., Loeb C. Internal borderzone infarction in patients with ischemic stroke. Cerebrovasc Dis. 1998 Sep-Oct;8(5):255–258. doi: 10.1159/000015862. [DOI] [PubMed] [Google Scholar]
  15. Gorelick P. B., Caplan L. R., Hier D. B., Parker S. L., Patel D. Racial differences in the distribution of anterior circulation occlusive disease. Neurology. 1984 Jan;34(1):54–59. doi: 10.1212/wnl.34.1.54. [DOI] [PubMed] [Google Scholar]
  16. Kassem-Moussa Hassan, Graffagnino Carmelo. Nonocclusion and spontaneous recanalization rates in acute ischemic stroke: a review of cerebral angiography studies. Arch Neurol. 2002 Dec;59(12):1870–1873. doi: 10.1001/archneur.59.12.1870. [DOI] [PubMed] [Google Scholar]
  17. Kimura K., Minematsu K., Koga M., Arakawa R., Yasaka M., Yamagami H., Nagatsuka K., Naritomi H., Yamaguchi T. Microembolic signals and diffusion-weighted MR imaging abnormalities in acute ischemic stroke. AJNR Am J Neuroradiol. 2001 Jun-Jul;22(6):1037–1042. [PMC free article] [PubMed] [Google Scholar]
  18. Laloux P., Brucher J. M. Lacunar infarctions due to cholesterol emboli. Stroke. 1991 Nov;22(11):1440–1444. doi: 10.1161/01.str.22.11.1440. [DOI] [PubMed] [Google Scholar]
  19. Leung S. Y., Ng T. H., Yuen S. T., Lauder I. J., Ho F. C. Pattern of cerebral atherosclerosis in Hong Kong Chinese. Severity in intracranial and extracranial vessels. Stroke. 1993 Jun;24(6):779–786. doi: 10.1161/01.str.24.6.779. [DOI] [PubMed] [Google Scholar]
  20. Lyden P., Brott T., Tilley B., Welch K. M., Mascha E. J., Levine S., Haley E. C., Grotta J., Marler J. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke. 1994 Nov;25(11):2220–2226. doi: 10.1161/01.str.25.11.2220. [DOI] [PubMed] [Google Scholar]
  21. Molina C. A., Montaner J., Abilleira S., Ibarra B., Romero F., Arenillas J. F., Alvarez-Sabín J. Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke. Stroke. 2001 May;32(5):1079–1084. doi: 10.1161/01.str.32.5.1079. [DOI] [PubMed] [Google Scholar]
  22. Moriwaki H., Matsumoto M., Hashikawa K., Oku N., Ishida M., Seike Y., Watanabe Y., Hougaku H., Handa N., Nishimura T. Hemodynamic aspect of cerebral watershed infarction: assessment of perfusion reserve using iodine-123-iodoamphetamine SPECT. J Nucl Med. 1997 Oct;38(10):1556–1562. [PubMed] [Google Scholar]
  23. Moulin D. E., Lo R., Chiang J., Barnett H. J. Prognosis in middle cerebral artery occlusion. Stroke. 1985 Mar-Apr;16(2):282–284. doi: 10.1161/01.str.16.2.282. [DOI] [PubMed] [Google Scholar]
  24. Read S. J., Pettigrew L., Schimmel L., Levi C. R., Bladin C. F., Chambers B. R., Donnan G. A. White matter medullary infarcts: acute subcortical infarction in the centrum ovale. Cerebrovasc Dis. 1998 Sep-Oct;8(5):289–295. doi: 10.1159/000015868. [DOI] [PubMed] [Google Scholar]
  25. Ringelstein E. B., Biniek R., Weiller C., Ammeling B., Nolte P. N., Thron A. Type and extent of hemispheric brain infarctions and clinical outcome in early and delayed middle cerebral artery recanalization. Neurology. 1992 Feb;42(2):289–298. doi: 10.1212/wnl.42.2.289. [DOI] [PubMed] [Google Scholar]
  26. Ringelstein E. B., Koschorke S., Holling A., Thron A., Lambertz H., Minale C. Computed tomographic patterns of proven embolic brain infarctions. Ann Neurol. 1989 Dec;26(6):759–765. doi: 10.1002/ana.410260612. [DOI] [PubMed] [Google Scholar]
  27. Saito I., Segawa H., Shiokawa Y., Taniguchi M., Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome. Stroke. 1987 Sep-Oct;18(5):863–868. doi: 10.1161/01.str.18.5.863. [DOI] [PubMed] [Google Scholar]
  28. Samuels O. B., Joseph G. J., Lynn M. J., Smith H. A., Chimowitz M. I. A standardized method for measuring intracranial arterial stenosis. AJNR Am J Neuroradiol. 2000 Apr;21(4):643–646. [PMC free article] [PubMed] [Google Scholar]
  29. Tatu L., Moulin T., Bogousslavsky J., Duvernoy H. Arterial territories of the human brain: cerebral hemispheres. Neurology. 1998 Jun;50(6):1699–1708. doi: 10.1212/wnl.50.6.1699. [DOI] [PubMed] [Google Scholar]
  30. Timsit S. G., Sacco R. L., Mohr J. P., Foulkes M. A., Tatemichi T. K., Wolf P. A., Price T. R., Hier D. B. Brain infarction severity differs according to cardiac or arterial embolic source. Neurology. 1993 Apr;43(4):728–733. doi: 10.1212/wnl.43.4.728. [DOI] [PubMed] [Google Scholar]
  31. Tong D. C., Adami A., Moseley M. E., Marks M. P. Prediction of hemorrhagic transformation following acute stroke: role of diffusion- and perfusion-weighted magnetic resonance imaging. Arch Neurol. 2001 Apr;58(4):587–593. doi: 10.1001/archneur.58.4.587. [DOI] [PubMed] [Google Scholar]
  32. Wong K. S., Huang Y. N., Gao S., Lam W. W., Chan Y. L., Kay R. Intracranial stenosis in Chinese patients with acute stroke. Neurology. 1998 Mar;50(3):812–813. doi: 10.1212/wnl.50.3.812. [DOI] [PubMed] [Google Scholar]
  33. Wong Ka Sing, Gao Shan, Chan Yu Leung, Hansberg Tjark, Lam Wynnie W. M., Droste Dirk W., Kay Richard, Ringelstein E. Bernd. Mechanisms of acute cerebral infarctions in patients with middle cerebral artery stenosis: a diffusion-weighted imaging and microemboli monitoring study. Ann Neurol. 2002 Jul;52(1):74–81. doi: 10.1002/ana.10250. [DOI] [PubMed] [Google Scholar]
  34. Yamauchi H., Fukuyama H., Yamaguchi S., Miyoshi T., Kimura J., Konishi J. High-intensity area in the deep white matter indicating hemodynamic compromise in internal carotid artery occlusive disorders. Arch Neurol. 1991 Oct;48(10):1067–1071. doi: 10.1001/archneur.1991.00530220089024. [DOI] [PubMed] [Google Scholar]
  35. Yonemura Kiminobu, Kimura Kazumi, Minematsu Kazuo, Uchino Makoto, Yamaguchi Takenori. Small centrum ovale infarcts on diffusion-weighted magnetic resonance imaging. Stroke. 2002 Jun;33(6):1541–1544. doi: 10.1161/01.str.0000016961.01086.94. [DOI] [PubMed] [Google Scholar]
  36. van der Zwan A., Hillen B., Tulleken C. A., Dujovny M., Dragovic L. Variability of the territories of the major cerebral arteries. J Neurosurg. 1992 Dec;77(6):927–940. doi: 10.3171/jns.1992.77.6.0927. [DOI] [PubMed] [Google Scholar]

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