European Radiology

, Volume 29, Issue 3, pp 1338–1347 | Cite as

Clinical significance of acute and chronic ischaemic lesions in multiple cerebral vascular territories

  • Hebun ErdurEmail author
  • Lennart S. Milles
  • Jan F. Scheitz
  • Kersten Villringer
  • Karl Georg Haeusler
  • Matthias Endres
  • Heinrich J. Audebert
  • Jochen B. Fiebach
  • Christian H. Nolte



To investigate the association between acute and chronic ischaemic lesions in a multiple territory lesion pattern (MTLP) detected by 3-Tesla MRI and stroke aetiology, specifically atrial fibrillation-associated stroke.


We analysed data from the 1000+ study – a prospective, observational 3-Tesla MRI cohort study of consecutively included acute stroke patients. Acute and chronic lesions were detected by DWI and fluid-attenuated inversion recovery, respectively. Observers blinded to clinical data allocated lesions to the right anterior, left anterior or posterior circulation. Lesion pattern was categorised as MTLPa/c when more than one territory was affected by either acute or chronic lesions or as MTLPa when more than one territory was affected by acute lesions alone.


Of the 1,000 included patients, an MTLPa/c was found in 43% and MTLPa in 24%. Advanced age (aOR=1.21 per 10 years, 95% CI 1.06–1.39), atrial fibrillation (aOR=1.44, 95% CI 1.06–1.94), aortic arch atherosclerosis (aOR=2.52, 95% CI 1.10–5.77), malignant disease (aOR=1.99, 95% CI 1.25–3.16) and lower estimated glomerular filtration rate (eGFR) (aOR=0.90 per 10 ml, 95% CI 0.84–0.97) were associated with MTLPa/c. Only malignant disease (aOR=2.03, 95% CI 1.27–3.23) and lower eGFR (aOR=0.91 per 10 ml, 95% CI 0.85–0.97) were associated with MTLPa.


An MRI-detected multiple territory lesion pattern of acute and chronic ischaemic lesions is frequent and more often present in older patients and patients with atrial fibrillation, aortic arch atherosclerosis, malignant disease and lower eGFR. Considering not only acute but also chronic ischaemic lesions may facilitate identifying atrial fibrillation-associated or aorto-embolic stroke.

Key Points

• Brain imaging with MRI may help to determine the aetiology of stroke.

• Of 1,000 stroke patients undergoing 3-Tesla MRI, 43% had acute and chronic ischaemic lesions in multiple cerebral vascular territories.

• Atrial fibrillation, aortic arch atherosclerosis and malignant disease were associated with a multiple territory lesion pattern.


Stroke Magnetic resonance imaging Atrial fibrillation Aorta, thoracic Neoplasms 



Atrial fibrillation




Estimated glomerular filtration rate


Multiple territory lesion pattern


Multiple territory lesion pattern defined by acute lesions only


Multiple territory lesion pattern defined by either acute or chronic lesions


National Institutes of Health Stroke Scale


Recombinant tissue-plasminogen activator


Trial of Org 10172 in Acute Stroke Treatment



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Hebun Erdur.

Conflict of Interest

The authors of this manuscript declare relationships with the following companies:

Dr. Hebun Erdur, Dr. Lennart S Milles, and PD Dr. Jan F Scheitz report no disclosures. Dr. Kersten Villringer reports receiving consulting fees by Parexel and is supported by the Federal Ministry of Education and Research via the grant Centre for Stroke Research Berlin (01EO0801 and 01EO01301). PD Dr. Karl-Georg Häusler has received grant support by Bayer and speaker/consultancy honoraria from Boehringer Ingelheim, Bayer Healthcare, Sanofi, Daiichi-Sankyo, Pfizer, Bristol-Myers-Squibb and Medtronic. Prof. Dr. Matthias Endres receives funding from the Deutsche Forschungsgemeinschaft (Excellence cluster NeuroCure; SFB TR43, KFO 247, KFO 213), Bundesministerium für Bildung und Forschung (Centre for Stroke Research Berlin), European Union (European Stroke Network, Wake-Up, Counterstroke), and Volkswagen Foundation (Lichtenberg Program) and reports advisory board and lecture fees paid to the Charité from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Ever, Glaxo Smith Kline, Novartis, Pfizer, and Sanofi. Prof. Dr. Heinrich J Audebert has received grant support (by Pfizer) and speaker/consultancy honoraria from Boehringer Ingelheim, Bayer Healthcare, Sanofi, Daiichi-Sankyo, Pfizer, Bristol-Myers-Squibb, ReNeuron and EVER Neuropharma. Prof. Dr. Jochen B Fiebach has received consulting, lecture, and advisory board fees from BioClinica, Cerevast, Artemida, Brainomix, and Lundbeck as well as a grant from the German Federal Ministry of Education and Research (01EO0801 and 01EO01301). As PI he receives funding from the European Union Seventh Framework Program [FP7/2007–2013] under grant agreement no. 278276 (WAKE-UP). Prof. Dr. Christian H Nolte has received funding for travel or speaker honoraria or consultancies from Bayer, Boehringer Ingelheim, Gore, Sanofi and BMS/Pfizer.

Statistics and biometry

Dr. Hebun Erdur and Prof. Dr. Christian H Nolte have significant statistical expertise. No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study in accordance with laws and regulations in the Federal State of Berlin.

Ethical approval

Institutional Review Board approval was obtained for the prospective 1000+ study (Institutional Review Board number EA4/026/08). An ethics committee approval was not required for the current substudy, in accordance with laws and regulations in the Federal State of Berlin.


• Retrospective

• Observational

• Performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Hebun Erdur
    • 1
    • 2
    Email author
  • Lennart S. Milles
    • 1
  • Jan F. Scheitz
    • 1
    • 2
    • 3
    • 4
  • Kersten Villringer
    • 1
    • 3
  • Karl Georg Haeusler
    • 1
    • 3
    • 5
  • Matthias Endres
    • 1
    • 2
    • 3
    • 4
    • 6
  • Heinrich J. Audebert
    • 1
    • 3
  • Jochen B. Fiebach
    • 1
    • 3
  • Christian H. Nolte
    • 1
    • 2
    • 3
    • 4
    • 6
  1. 1.Department of NeurologyCharité – Universitätsmedizin BerlinBerlinGermany
  2. 2.Berlin Institute of Health (BIH)BerlinGermany
  3. 3.Center for Stroke Research BerlinCharité – Universitätsmedizin BerlinBerlinGermany
  4. 4.DZHK (German Center for Cardiovascular Research)Partner Site BerlinBerlinGermany
  5. 5.Department of NeurologyUniversitätsklinikum WürzburgWürzburgGermany
  6. 6.DZNE (German Center for Neurodegenerative Diseases)Partner Site BerlinBerlinGermany

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