Research Article| Volume 312, ISSUE 1-2, P127-130, January 15, 2012

Download started.


Evaluation of early dynamic changes of intracranial arterial occlusion is useful for stroke etiology diagnosis

  • A-Hyun Cho
    Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

    Department of Neurology, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Republic of Korea
    Search for articles by this author
  • Sun U. Kwon
    Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
    Search for articles by this author
  • Jong S. Kim
    Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
    Search for articles by this author
  • Dong-Wha Kang
    Corresponding author at: Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Republic of Korea. Tel.: +82 2 3010 3440; fax: +82 2 474 4691.
    Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
    Search for articles by this author
Published:August 29, 2011DOI:


      Background and purpose

      The etiologic diagnosis of intracranial arterial occlusion is sometimes challenging because of the dynamic nature of acute stroke. We investigated whether short-term follow-up vascular imaging adds additional information to the differential diagnosis between intracranial atherosclerotic and embolic occlusion.


      Acute ischemic stroke patients with symptomatic middle cerebral artery (MCA) occlusion on MR angiography (MRA) within 24 h of symptom onset were included. Follow-up MRA was performed 5–7 days after stroke onset. Stroke subtypes were independently determined at baseline and follow-up MRAs based on clinical, laboratory and imaging findings.


      In the 108 included patients, the most common etiologic subtype of initial stroke was intracranial large artery atherosclerosis (ICLAA) in 70 patients, followed by cardioembolism in 29 and other causes in 9. On follow-up MRA, 32 (29.6%) patients showed either significant or complete recanalization. Of these, 10 had been originally diagnosed with ICLAA, but were reclassified as a cryptogenic mechanism after follow-up MRA. Multiple logistic regression analysis showed that the presence of coexisting arterial atherosclerosis (odds ratio [OR], 6.91; 95% confidence interval [CI], 2.67–17.91; p<0.001); the absence of large territorial infarction (OR, 4.06; 95% CI, 1.39–11.85; p=0.010); and smoking (OR, 2.54; 95% CI, 1.028–6.29; p=0.043) were significantly associated with a final diagnosis of ICLAA.


      In the absence of follow-up vascular imaging, a substantial proportion of patients with intracranial middle cerebral arterial occlusion may be misdiagnosed as ICLAA. Evaluation of early dynamic changes in intracranial middle cerebral arterial occlusion may provide useful information for the differential diagnosis of intrinsic atherosclerosis and embolic occlusion.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Nagao T.
        • Sadoshima S.
        • Ibayashi S.
        • Takeya Y.
        • Fujishima M.
        Increase in extracranial atherosclerotic carotid lesions in patients with brain ischemia in Japan. An angiographic study.
        Stroke. 1994; 25: 766-770
        • Feldmann E.
        • Daneault N.
        • Kwan E.
        • Ho K.J.
        • Pessin M.S.
        • Langenberg P.
        • et al.
        Chinese-white differences in the distribution of occlusive cerebrovascular disease.
        Neurology. 1990; 40: 1541-1545
        • Brust Jr., R.W.
        Patterns of cerebrovascular disease in Japanese and other population groups in Hawaii. An angiographical study.
        Stroke. 1975; 6: 539-542
        • Arenillas J.F.
        • Molina C.A.
        • Montaner J.
        • Abilleira S.
        • Gonzalez-Sanchez M.A.
        • Alvarez-Sabin J.
        Progression and clinical recurrence of symptomatic middle cerebral artery stenosis: A long-term follow-up transcranial Doppler ultrasound study.
        Stroke. 2001; 32: 2898-2904
        • Akins P.T.
        • Pilgram T.K.
        • Cross 3rd, D.T.
        • Moran C.J.
        Natural history of stenosis from intracranial atherosclerosis by serial angiography.
        Stroke. 1998; 29: 433-438
        • Chimowitz M.I.
        • Lynn M.J.
        • Howlett-Smith H.
        • Stern B.J.
        • Hertzberg V.S.
        • Frankel M.R.
        • et al.
        Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis.
        N Engl J Med. 2005; 352: 1305-1316
        • Lee D.K.
        • Kim J.S.
        • Kwon S.U.
        • Yoo S.H.
        • Kang D.W.
        Lesion patterns and stroke mechanism in atherosclerotic middle cerebral artery disease: Early diffusion-weighted imaging study.
        Stroke. 2005; 36: 2583-2588
        • Molina C.A.
        • Montaner J.
        • Arenillas J.F.
        • Ribo M.
        • Rubiera M.
        • Alvarez-Sabin J.
        Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes.
        Stroke. 2004; 35: 486-490
        • Kwon S.U.
        • Cho Y.J.
        • Koo J.S.
        • Bae H.J.
        • Lee Y.S.
        • Hong K.S.
        • et al.
        Cilostazol prevents the progression of the symptomatic intracranial arterial stenosis: The multicenter double-blind placebo-controlled trial of cilostazol in symptomatic intracranial arterial stenosis.
        Stroke. 2005; 36: 782-786
        • Ay H.
        • Furie K.L.
        • Singhal A.
        • Smith W.S.
        • Sorensen A.G.
        • Koroshetz W.J.
        An evidence-based causative classification system for acute ischemic stroke.
        Ann Neurol. 2005; 58: 688-697
        • Furlan A.
        • Higashida R.
        • Wechsler L.
        • Gent M.
        • Rowley H.
        • Kase C.
        • et al.
        Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: A randomized controlled trial. Prolyse in acute cerebral thromboembolism.
        JAMA. 1999; 282: 2003-2011
        • Rother J.
        • Schellinger P.D.
        • Gass A.
        • Siebler M.
        • Villringer A.
        • Fiebach J.B.
        • et al.
        Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke <6 hours.
        Stroke. 2002; 33: 2438-2445
        • 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; 42: 289-298
        • Zanette E.M.
        • Roberti C.
        • Mancini G.
        • Pozzilli C.
        • Bragoni M.
        • Toni D.
        Spontaneous middle cerebral artery reperfusion in ischemic stroke. A follow-up study with transcranial doppler.
        Stroke. 1995; 26: 430-433
        • Kaps M.
        • Damian M.S.
        • Teschendorf U.
        • Dorndorf W.
        Transcranial doppler ultrasound findings in middle cerebral artery occlusion.
        Stroke. 1990; 21: 532-537
        • Molina C.A.
        • Montaner J.
        • Abilleira S.
        • Arenillas J.F.
        • Ribo M.
        • Huertas R.
        • et al.
        Time course of tissue plasminogen activator-induced recanalization in acute cardioembolic stroke: A case–control study.
        Stroke. 2001; 32: 2821-2827
        • Lammie G.A.
        • Sandercock P.A.
        • Dennis M.S.
        Recently occluded intracranial and extracranial carotid arteries. Relevance of the unstable atherosclerotic plaque.
        Stroke. 1999; 30: 1319-1325
        • Rha J.H.
        • Saver J.L.
        The impact of recanalization on ischemic stroke outcome: A meta-analysis.
        Stroke. 2007; 38: 967-973
        • Molina C.A.
        • Montaner J.
        • Abilleira S.
        • Ibarra B.
        • Romero F.
        • Arenillas J.F.
        • et al.
        Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke.
        Stroke. 2001; 32: 1079-1084
        • Hirai T.
        • Korogi Y.
        • Ono K.
        • Nagano M.
        • Maruoka K.
        • Uemura S.
        • et al.
        Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: Combined MR angiography and CT angiography compared with digital subtraction angiography.
        AJNR Am J Neuroradiol. 2002; 23: 93-101
        • Sansoy V.
        • Abbott R.D.
        • Jayaweera A.R.
        • Kaul S.
        Low yield of transthoracic echocardiography for cardiac source of embolism.
        Am J Cardiol. 1995; 75: 166-169
        • Knopman D.S.
        • Anderson D.C.
        • Asinger R.W.
        • Greenland P.
        • Mikell F.
        • Good D.C.
        Indications for echocardiography in patients with ischemic stroke.
        Neurology. 1982; 32: 1005-1011
        • Bergeron G.A.
        • Shah P.M.
        Echocardiography unwarranted in patients with cerebral ischemic events.
        N Engl J Med. 1981; 304: 489