Computed Tomography
Detection of a Cerebral
Calcific Embolus Following
Coronary Catheterization
Gerald R. Kirk, PhD
Department of Anatomy
Oklahoma State University
College of Osteopathic Medicine
1111 West 17th Street
Tulsa, OK 74107-1898

Jay K. Johnson, DO
Tulsa Neurology
Tulsa, OK

ABSTRACT
A 77-year-old man underwent coronary artery angiography quite well. However, several attempts were required to pass the
pigtail catheter across a calcified stenotic
aortic valve. On return to the floor, motor
aphasia and right hemiparesis developed
and improved steadily within a few days.
Computed tomography (CT) of the head
revealed a calcific density in the left middle

been performed prior to the present coronary
catheterization.
During angiography of the coronary vessels the aorta and aortic valve were found to
be stenotic and calcified. Several attempts
were required to pass the pigtail catheter
through the aortic valve. No other problems
were encountered and the procedure was
well tolerated by the patient. After he was
returned to his room, right-sided upper and
lower limb weakness and motor aphasia developed. CT of the head showed a calcific
plaque in the left middle cerebral artery
(MCA) adjacent to an infarct in the frontal lobe (Figs 1-3). The patient improved
steadily over the next 48 hours and was discharged. There were no emboli in the ophthalmic vessels at the time of discharge. A
search for emboli in other vessels was not
undertaken.
Discussion

Spontaneous embolization of calcific debris
from a stenotic aorta and/or calcified cardiac
valves to cerebral vessels is rare. Kapila and
Hart [1] reported a single case of stroke following retrograde heart catheterization in
which calcific emboli (CE) in the cerebral

arteries could be seen on CT scans. Holley
and coworkers [2] anatomically examined
165 patients with calcified aortic stenosis
(CAS) and reported 32 patients with spontaneous CE in the coronary vessels; 7 cases
involved renal vessels, 1 case involved the
central retina artery, and 1 case involved the
MCA. Vemhet and colleagues [3] reported
on 2 patients with CAS who presented with
symptoms of acute stroke. CT scans revealed CE in cerebral vessels without signs
of ischemia. In a study of 88 autopsied subjects with known CAS, Blondeau and colleagues [4] found 6 spontaneous CEs, 2 in
cerebral vessels, and 1 not specified. In another autopsy study of 81 patients with CAS,
CEs were found in one-third, occurring
spontaneously in only one-fifth. However,
most of these spontaneous CEs followed cardiac surgery, left-sided heart catheterization,
or bacterial endocarditis [5].
Yock [6] demonstrated 5 CEs in cerebral
arteries on CT scans following left-sided
heart catheterization. The CE originated
from carotid plaques, cardiac thrombi, and
calcific mitral valve thrombus. Walley and
colleagues [7] described a patient who died
from acute ischemia in a hypertrophied heart

cerebral artery. The authors believe the calcific plaque originated from the calcified
aorta and aortic valve. The patient was discharged within 48 hours with minimal neurological signs. Spontaneous calcified emboli to cranial vessels from calcific aortic
stenosis or other sources are rare. CT detection of a calcific plaque in a cranial vessel following coronary vessel catheterization is well documented in this patient.
Kirk GR, Johnson JK. Computed
tomography detection of a cerebral
calcific embolus following
coronary catheterization.
J Neuroimag 1994;4:241-242

Received Dec 9, 1993, and in revised form
Feb 7 and Mar 17, 1994. Accepted for
publication Mar 18, 1994.
Address correspondence to Dr Kirk.

Case History

A 77-year-old man had a history of coronary
artery disease and had had coronary artery
bypass grafting in 1988. His only medication
was aspirin. He did not smoke or drink alcohol and except for the coronary problems
appeared in good health. No previous computed tomography (CT) or brain scans had

Fig 1. Brain CT scan: The left middle cerebral artery (arrow) can clearly be seen and
appears to contain plaques.
Copyright© 1994 by the American Society of Neuroimaging

241

Fig 2. Brain CT scan: A calcific embolus (arrow) can be seen
within a branch of the left middle cerebral artery.

and coronary artery calcium emboli originating from a degenerative aortic valve prosthesis. The emboli were dislodged during a
catheterization procedure.
Ringelstein and colleagues [8] showed
that most patients with strokes due to internal carotid artery occlusion had detectable
MCA embolism on early angiograms.
The small size of the CEs might explain
their subclinical silence and the more common detection at autopsy and funduscopic
examination. Infarcts produced by CEs may
erroneously be reported to be due to other
hemodynamic events.
Strokes due to CEs from CAS are rare.
In very few patients, radiological detection
of CEs following stroke has been reported.
CE may be identified on CT scans as small
hyperdense dots along the route of cerebral
vessels, especially the middle, anterior, and
posterior cerebral arteries.
Mortality related to left-sided heart catheterization is rare (0.08-0.45% ). Emboli dislodged during catheterization may produce
stroke. Stroke patients with CAS should be
carefully examined radiologically for CEs
along the course of the major cerebral vessels following cardiac catheterization.

Fig 3.

Brain CT scan: An area of infarct (arrow) is present in the
left frontal lobe.

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