Background: Previous diffusion-weighted MRI (DWI) studies have indicated that 10–40% of patients have silent embolism during neurointerventional procedures. However, lesion patterns of the embolisms have not been adequately investigated. Methods: DWI was taken within 7 days before and 48 h after cerebral angioplasty and stent procedures. New lesions on the follow-up DWI were analyzed in the non-treated arterial territories. Based on the arterial territories, supratentorial lesions were classified into cortical lesions and subcortical lesions. Cortical lesions were subdivided into cortical border zone and cortical proper lesions. Subcortical lesions were divided into deep perforator and internal border zone lesions. Infratentorial lesions were divided into brainstem and cerebellar lesions. Results: 72 patients were included in this study. There were 223 new DWI lesions (1–23 lesions) in the non-treated arterial territories of 37 patients. There were 154 cortical lesions, 45 cerebellar lesions, 21 subcortical lesions and 3 brainstem lesions. Analysis of the distribution pattern of cortical lesions showed that 88 of 154 lesions were located at the cortical border zone. Of the subcortical lesions, 13 of 21 lesions were located at the internal border zone area, within the corona radiata and centrum ovale. Only 4 lesions were located at the deep perforator territory. Infratentorial lesions were mostly located at the cerebellar hemisphere (45/48). Most lesions were tiny infarcts (<5 mm diameter); 7 of 223 lesions were >10 mm in diameter. Conclusions: Interventional-angiography-related microembolisms mostly lodge in the cerebral cortical border zone area and cerebellar hemisphere. Microembolisms to the deep perforating artery territory are distinctly rare.

Keywords:
Embolism, Diffusion-weighted image, Neurointervention, Border zone infarct
1.
Bendszus M, Koltzenburg M, Burger R, Warmuth-Metz M, Hofmann E, Solymosi L: Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study. Lancet 1999;354:1594–1597.
2.
Bendszus M, Stoll G: Silent cerebral ischaemia: hidden fingerprints of invasive medical procedures. Lancet Neurol 2006;5:364–372.
3.
Jaeger HJ, Mathias KD, Hauth E, Drescher R, Gissler HM, Hennigs S, Christmann A: Cerebral ischemia detected with diffusion-weighted MR imaging after stent implantation in the carotid artery. AJNR Am J Neuroradiol 2002;23:200–207.
4.
Busing KA, Schulte-Sasse C, Fluchter S, Suselbeck T, Haase KK, Neff W, Hirsch JG, Borggrefe M, Duber C: Cerebral infarction: Incidence and risk factors after diagnostic and interventional cardiac catheterization – prospective evaluation at diffusion-weighted MR imaging. Radiology 2005;235:177–183.
5.
Brockmann C, Hoefer T, Diepers M, Neumaier-Probst E, Noelte I, Brockmann MA, Weiss C, Groden C, Scharf J: Abciximab does not prevent ischemic lesions related to cerebral angiography: a randomized placebo-controlled trial. Cerebrovasc Dis 2011;31:353–357.
6.
Sudlow CL, Warlow CP: Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. International stroke incidence collaboration. Stroke 1997;28:491–499.
7.
Wardlaw JM: What causes lacunar stroke? J Neurol Neurosurg Psychiatry 2005;76:617–619.
8.
Futrell N: Lacunar infarction: embolism is the key. Stroke 2004;35:1778–1779.
9.
Micheli S, Agnelli G, Palmerini F, Caso V, Venti M, Alberti A, Biagini S, Paciaroni M: Need for extensive diagnostic work-up for patients with lacunar stroke. J Neurol 2008;255:637–642.
10.
Derdeyn CP, Carpenter DA, Videen TO, Grubb RL, Jr., Powers WJ: Patterns of infarction in hemodynamic failure. Cerebrovasc Dis 2007;24:11–19.
11.
Tatu L, Moulin T, Bogousslavsky J, Duvernoy H: Arterial territories of the human brain: cerebral hemispheres. Neurology 1998;50:1699–1708.
12.
Floyd TF, Shah PN, Price CC, Harris F, Ratcliffe SJ, Acker MA, Bavaria JE, Rahmouni H, Kuersten B, Wiegers S, McGarvey ML, Woo JY, Pochettino AA, Melhem ER: Clinically silent cerebral ischemic events after cardiac surgery: their incidence, regional vascular occurrence, and procedural dependence. Ann Thorac Surg 2006;81:2160–2166.
13.
Momjian-Mayor I, Baron JC: The pathophysiology of watershed infarction in internal carotid artery disease: review of cerebral perfusion studies. Stroke 2005;36:567–577.
14.
Bogousslavsky J, Regli F: Unilateral watershed cerebral infarcts. Neurology 1986;36:373–377.
15.
Masuda J, Yutani C, Ogata J, Kuriyama Y, Yamaguchi T: Atheromatous embolism in the brain: a clinicopathologic analysis of 15 autopsy cases. Neurology 1994;44:1231–1237.
16.
Yong SW, Bang OY, Lee PH, Li WY: Internal and cortical border-zone infarction: clinical and diffusion-weighted imaging features. Stroke 2006;37:841–846.
17.
Caplan LR, Hennerici M: Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998;55:1475–1482.
18.
Pollanen MS, Deck JH: The mechanism of embolic watershed infarction: experimental studies. Can J Neurol Sci 1990;17:395–398.
19.
Amarenco P, Kase CS, Rosengart A, Pessin MS, Bousser MG, Caplan LR: Very small (border zone) cerebellar infarcts. distribution, causes, mechanisms and clinical features. Brain 1993;116:161–186.
20.
Canaple S, Bogousslavsky J: Multiple large and small cerebellar infarcts. J Neurol Neurosurg Psychiatry 1999;66:739–745.
21.
Park KY, Chung PW, Kim YB, Moon HS, Suh BC, Won YS: Association between small deep cerebellar ischemic lesion and small-vessel disease. Cerebrovasc Dis 2009;28:314–320.
22.
Macdonald RL, Kowalczuk A, Johns L: Emboli enter penetrating arteries of monkey brain in relation to their size. Stroke 1995;26:1247–1250; discussion 1250–1241.
23.
Hennerici M, Daffertshofer M, Jakobs L: Failure to identify cerebral infarct mechanisms from topography of vascular territory lesions. AJNR Am J Neuroradiol 1998;19:1067–1074.
24.
van der Zwan A, Hillen B: Review of the variability of the territories of the major cerebral arteries. Stroke 1991;22:1078–1084.
© 2011 S. Karger AG, Basel
2011
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.