Cerebral infarcts - embolic shower

Case contributed by Bruno Di Muzio
Diagnosis certain


Confusion followed by decreased GCS.

Patient Data

Age: 65 years
Gender: Male

MRI Brain


There are multiple foci of restricted diffusion scattered bilaterally along the brain parenchyma, involving multiple vascular territories. Also, an hemorrhagic focus is noted in the right thalamus. The background brain demonstrates features of prominent white matter chronic small vessels changes. 

Case Discussion

This patient was shown to be hypertensive and on atrial fibrillation and, thus, these cardiovascular complications were considered as a plausible cause for the emboli showering leading to multiple brain infarcts and the hemorrhagic focus in the thalamus. The hemorrhagic focus could be explained either by the hypertensive episode alone or due to the hemorrhagic transformation of an embolic infarct

Generally, causes that could explain cardiac embolism to the brain are 1

  • blood stasis and thrombus formation in an enlarged left cardiac chamber: e.g. a ventricular aneurysm, atrial fibrillation, etc.
  • valvular surface releasing abnormal materials: e.g. mitral calcific degeneration, nonbacterial thrombotic endocarditis, infective endocarditis, etc.
  • paradoxical embolism (abnormal communication in between the venous to the arterial circulation): e.g. patent foramen ovale, pulmonary AVMs, etc.

Atrial fibrillation, which is the commonest sustained cardiac arrhythmia. is considered the major source for cardioembolic stroke 1

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