Calcified cerebral emboli: Incidence and implications

Abstract

INTRODUCTION: Calcified cerebral emboli are an increasingly recognized cause of ischaemic stroke, although recognition amongst general radiologists and clinicians can be limited. Recent literature suggests that calcified cerebral emboli are likely more common than originally thought. This study aims to define the prevalence of calcified cerebral emboli as the most likely aetiology within a cohort of confirmed cases of acute stroke, as well as compare and contrast these cases with cases of 'incidental' intracranial calcification. METHODS: Cases of confirmed stroke between May 2014 and May 2017 were reviewed by two readers to assess for the most likely aetiology. Cases of presumed calcified cerebral embolus were categorized in to 'possible' or 'definite'. The morphology, distribution and density were analysed by two independent readers, then subsequently discussed to reach a consensus. Cases were further studied in terms of likely proximal embolic source, therapeutic interventions and clinical outcomes. A further random selection of 220 non-contrast CT head examinations were reviewed over the same time period to assess for the presence of calcification which was favoured to be 'intravascular' using the same criteria. RESULTS: A total of 220 cases of confirmed stroke were reviewed. Thirteen of these cases were thought to be most likely secondary to calcified cerebral emboli (5.9%). Of the 13 cases, eight were considered 'definite' as previous premorbid imaging without calcification was available. Twelve patients had emboli within the anterior circulation and only one patient had an embolus in the posterior circulation. Moderate calcified atherosclerotic disease was noted within the aorta and carotid arteries of all patients. Of the 220 patients within the control group, three cases were thought to have intracranial calcification most likely to be intravascular without clinical sequelae or other supportive imaging findings of infarct. CONCLUSION: Previously thought to be a rare complication of intra-arterial instrumentation, calcified cerebral emboli have been shown to more commonly be associated with spontaneous cerebral infarction. Whilst literature in this area remains scant, recognition and differentiation of this entity has important clinical applications regarding immediate diagnosis of stroke on non-contrast imaging, modified treatment in the acute setting as well as in regards to recurrent event prognosis and secondary prevention.