Advertisement

European Radiology

, Volume 27, Issue 10, pp 4145–4152 | Cite as

Importance of variants in cerebrovascular anatomy for potential retrograde embolization in cryptogenic stroke

  • Michael MarklEmail author
  • Edouard Semaan
  • LeRoy Stromberg
  • James Carr
  • Shyam Prabhakaran
  • Jeremy Collins
Magnetic Resonance

Abstract

Objectives

To test the hypothesis that variants in cerebrovascular anatomy will affect the number of patients demonstrating a plausible retrograde embolization mechanism from plaques in the descending aorta (DAo).

Methods

Thirty-five patients (aged 63 ± 17 years) with cryptogenic stroke underwent 4D flow MRI for the assessment of aortic 3D blood flow and MR angiography for the evaluation of circle of Willis, posterior circulation, and aortic arch architecture. In patients with proven DAo plaque, retrograde embolization was considered a potential mechanism if retrograde flow extended from the DAo to a supra-aortic vessel supplying the cerebral infarct territory.

Results

Retrograde embolization with matching cerebral infarct territory was detected in six (17%) patients. Circle of Willis and aortic arch variant anatomy was found in 60% of patients, leading to reclassification of retrograde embolization risk as present in three (9%) additional patients, for a total 26% of cryptogenic stroke patients.

Conclusion

4D flow MRI demonstrated 26% concordance with infarct location on imaging with retrograde diastolic flow into the feeding vessels of the affected cerebral area, identifying a potential etiology for cryptogenic stroke. Our findings further demonstrate the importance of cerebrovascular anatomy when determining concordance of retrograde flow pathways with vascular stroke territory from DAo plaques.

Key points

Retrograde embolization from descending aortic plaques constitutes a plausible etiology in cryptogenic stroke.

Common variants of cerebrovascular anatomy are important in determining retrograde embolization mechanism.

Variant cerebrovascular anatomy can link retrograde flow pathways with vascular stroke territory.

Keywords

4D flow MRI Stroke Plaque Retrograde flow Circle of Willis 

Notes

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Michael Markl.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Funding

This study has received funding through NIH NHLBI grant R21 HL132357.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Written informed consent was waived by the Institutional Review Board.

Methodology

• retrospective

• cross-sectional study

• performed at one institution

References

  1. 1.
    Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO (1999) Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 30:2513–2516CrossRefPubMedGoogle Scholar
  2. 2.
    Guercini F, Acciarresi M, Agnelli G, Paciaroni M (2008) Cryptogenic stroke: time to determine aetiology. J Thromb Haemost 6:549–554CrossRefPubMedGoogle Scholar
  3. 3.
    Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU (2001) Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 32:2735–2740CrossRefPubMedGoogle Scholar
  4. 4.
    Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO (2000) Ischemic stroke subtypes : a population-based study of functional outcome, survival, and recurrence. Stroke 31:1062–1068CrossRefPubMedGoogle Scholar
  5. 5.
    Mohr JP, Thompson JL, Lazar RM, Levin B, Sacco RL, Furie KL et al (2001) A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 345:1444–1451CrossRefPubMedGoogle Scholar
  6. 6.
    Bang OY, Lee PH, Joo SY, Lee JS, Joo IS, Huh K (2003) Frequency and mechanisms of stroke recurrence after cryptogenic stroke. Ann Neurol 54:227–234CrossRefPubMedGoogle Scholar
  7. 7.
    Kronzon I, Tunick PA (2006) Aortic atherosclerotic disease and stroke. Circulation 114:63–75CrossRefPubMedGoogle Scholar
  8. 8.
    Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, Besson G et al (1994) Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 331:1474–1479CrossRefPubMedGoogle Scholar
  9. 9.
    Reimold SC, Maier SE, Aggarwal K, Fleischmann KE, Piwnica-Worms D, Kikinis R et al (1996) Aortic flow velocity patterns in chronic aortic regurgitation: implications for Doppler echocardiography. J Am Soc Echocardiogr 9:675–683CrossRefPubMedGoogle Scholar
  10. 10.
    Bogren HG, Mohiaddin RH, Kilner PJ, Jimenez-Borreguero LJ, Yang GZ, Firmin DN (1997) Blood flow patterns in the thoracic aorta studied with three-directional MR velocity mapping: the effects of age and coronary artery disease. J Magn Reson Imaging 7:784–793CrossRefPubMedGoogle Scholar
  11. 11.
    Bogren HG, Buonocore MH, Valente RJ (2004) Four-dimensional magnetic resonance velocity mapping of blood flow patterns in the aorta in patients with atherosclerotic coronary artery disease compared to age-matched normal subjects. J Magn Reson Imaging 19:417–427CrossRefPubMedGoogle Scholar
  12. 12.
    Harloff A, Strecker C, Frydrychowicz AP, Dudler P, Hetzel A, Geibel A et al (2007) Plaques in the descending aorta: a new risk factor for stroke? Visualization of potential embolization pathways by 4D MRI. J Magn Reson Imaging 26:1651–1655CrossRefPubMedGoogle Scholar
  13. 13.
    Ebbers T (2011) Flow imaging: cardiac applications of 3D cine phase-contrast MRI. Curr Cardiovasc Imaging Rep 4:127–133CrossRefGoogle Scholar
  14. 14.
    Markl M, Kilner PJ, Ebbers T (2011) Comprehensive 4D velocity mapping of the heart and great vessels by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 13:7CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Frydrychowicz A, Francois CJ, Turski PA (2011) Four-dimensional phase contrast magnetic resonance angiography: potential clinical applications. Eur J RadiolGoogle Scholar
  16. 16.
    Markl M, Frydrychowicz A, Kozerke S, Hope M, Wieben O (2012) 4D flow MRI. J Magn Reson Imaging 36:1015–1036CrossRefPubMedGoogle Scholar
  17. 17.
    Hope MD, Sedlic T, Dyverfeldt P (2013) Cardiothoracic magnetic resonance flow imaging. J Thorac Imaging 28:217–230CrossRefPubMedGoogle Scholar
  18. 18.
    Stankovic Z, Allen BD, Garcia J, Jarvis KB, Markl M (2014) 4D flow imaging with MRI. Cardiovasc Diagn Ther 4:173–192PubMedPubMedCentralGoogle Scholar
  19. 19.
    Harloff A, Strecker C, Dudler P, Nussbaumer A, Frydrychowicz A, Olschewski M et al (2009) Retrograde embolism from the descending aorta: visualization by multidirectional 3D velocity mapping in cryptogenic stroke. Stroke 40:1505–1508CrossRefPubMedGoogle Scholar
  20. 20.
    Harloff A, Simon J, Brendecke S, Assefa D, Helbing T, Frydrychowicz A et al (2010) Complex plaques in the proximal descending aorta: an underestimated embolic source of stroke. Stroke 41:1145–1150CrossRefPubMedGoogle Scholar
  21. 21.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al (1993) 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 24:35–41CrossRefPubMedGoogle Scholar
  22. 22.
    Markl M, Harloff A, Bley TA, Zaitsev M, Jung B, Weigang E et al (2007) Time-resolved 3D MR velocity mapping at 3T: improved navigator-gated assessment of vascular anatomy and blood flow. J Magn Reson Imaging 25:824–831CrossRefPubMedGoogle Scholar
  23. 23.
    Bock J, Kreher B, Hennig J, Markl M. Optimized pre-processing of time-resolved 2D and 3D phase contrast MRI data. Proceedings of the 15th Annual Meeting of ISMRM, Berlin, Germany. 2007:3138.Google Scholar
  24. 24.
    Hashimoto J, Ito S (2013) Aortic stiffness determines diastolic blood flow reversal in the descending thoracic aorta: potential implication for retrograde embolic stroke in hypertension. Hypertension 62:542–549CrossRefPubMedGoogle Scholar
  25. 25.
    Wehrum T, Kams M, Strecker C, Dragonu I, Gunther F, Geibel A et al (2014) Prevalence of potential retrograde embolization pathways in the proximal descending aorta in stroke patients and controls. Cerebrovasc Dis 38:410–417CrossRefPubMedGoogle Scholar
  26. 26.
    Bell R, Severson MA 3rd, Armonda RA (2009) Neurovascular anatomy: a practical guide. Neurosurg Clin N Am 20:265–278CrossRefPubMedGoogle Scholar
  27. 27.
    Dimmick SJ, Faulder KC (2009) Normal variants of the cerebral circulation at multidetector CT angiography. Radiogr: Rev Publ Radiol Soc North Am Inc 29:1027–1043CrossRefGoogle Scholar
  28. 28.
    Iqbal S (2013) A comprehensive study of the anatomical variations of the circle of willis in adult human brains. J Clin Diagn Res: JCDR 7:2423–2427PubMedPubMedCentralGoogle Scholar
  29. 29.
    Janic M, Lunder M, Sabovic M (2014) Arterial stiffness and cardiovascular therapy. Biomed Res Int 2014:621437CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© European Society of Radiology 2017

Authors and Affiliations

  • Michael Markl
    • 1
    • 2
    Email author
  • Edouard Semaan
    • 1
  • LeRoy Stromberg
    • 3
    • 4
  • James Carr
    • 1
  • Shyam Prabhakaran
    • 3
  • Jeremy Collins
    • 1
  1. 1.Department of Radiology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Department of Biomedical Engineering, McCormick School of EngineeringNorthwestern UniversityChicagoUSA
  3. 3.Department of Neurology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  4. 4.Department of RadiologyEdward HospitalNapervilleUSA

Personalised recommendations