Hospital: H.U. Virgen del Rocío /Servicio Andaluz de Salud.
Aut@r o Autores: J. Jurado Serrano, M. Espinosa De Los Monteros Fernández, F. Galvan Banqueri, P. Gómez-Millán Ruíz, T. Rocha Iñigo, J.M. Duro Garrido.
A 82 years-old woman with a history of diabetes, hypertension and dyslipidemia presented with difficulty speaking after waking up. National Institutes of Health Stroke Scale score on admission of 8. She was independent in her activities of daily living. Laboratory tests and EKG were normal. A noncontrast CT scan of the brain revealed a hyperdense (250 HU) attenuation in the M3 segment of the left middle cerebral artery (parietal branch) and a hipodense M6 region with blurring of gray-white matter interface. A CT angiography confirmed the location of the hyperdensity, which was almost isodense to the iodinated contrast. A CT perfusion showed a prolonged mean transit time (MMT) with normal cerebral blood volume (CBV) in the M6 region. An echocardiogram done during admission demonstrated a calcific aortic stenosis.
A diagnosis of acute ischemic stroke secondary to a calcified cerebral embolus was done. Although the CT perfusion suggested ischemic penumbra of the affected area, the noncontrast CT was consistent with infarction. Unfortunately, criteria for eligibility for thrombolysis treatment with recombinant tissue plasminogen activator or thrombectomy were not met. Calcified cerebral emboli are an uncommon cause of ischemic stroke, occurring in less than 3% of patients. They are often small (2-3 mm), round or oval, hyperdense (80-430 HU) and can be overlooked as hemorrhage, vascular calcification, cavernomas or neurocysticercosis. They can be isodense to the iodinated contrast and overlooked in CT angiography. Most commonly, they originate from calcific aortic stenosis, calcified carotid and mitral annular calcifications. It is important to recognize them because of the poor response to IV thrombolytic therapy and because they constitute a contraindication of clot retrieval / angioplasty, due to the risk of vessel rupture. Calcified cerebral emboli have a high risk of recurrence and mortality. That is why surgical correction of underlying cardiac or vascular disease is recommended.
Calcified cerebral embolus is a uncommon cause of stroke, but it is important to recognize them because of the high risk of recurrence and mortality.
- Walker BS, Shah LM, Osborn AG. Calcified cerebral emboli, a "do not miss" imaging diagnosis: 22 new cases and review of the literature. AJNR Am J Neuroradiol. 2014, 35(8): 1515-9. - Sharma R et al. Calcified cerebral embolus [Internet]. 2017 [cited 26 M