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Original article
Calcified cerebral embolism: a 9-case series and review of the literature
Embolia cerebral cálcica: presentación de una serie de 9 casos y revisión de la literatura
AJ. Mosqueiraa,
Corresponding author
drmosqueiramartinez@gmail.com

Corresponding author.
, B. Cannetib, A. Martínez Calvoc, P. Fernández Armendárizc, M. Seijo-Martinezb, J.M. Pumara
a Servicio de Radiodiagnóstico, Hospital Universitario Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
b Servicio de Neurología, Complejo Hospitalario Universitario Pontevedra, Pontevedra, Spain
c Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT scans of CCE in patients 7-9&#46; The first column shows CT scans performed prior to CCE&#44; the second column shows images of the CCE&#44; and the third column shows images of the corresponding stroke&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebral embolisms may originate from different sites and present a varied histopathological composition&#46; Three main types have been described&#58; arteriogenic &#40;with abundant red blood cells at the centre and platelets covering the fibrin layers at the periphery of the thrombus&#41;&#44; cardiogenic &#40;with clusters of platelets disseminated within fibrin-rich clots&#41;&#44; and calcified &#40;with large amounts of calcium phosphate&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Calcified cerebral embolism &#40;CCE&#41; is a poorly described but highly significant cause of stroke&#58; regardless of the sequelae of the cerebrovascular event&#44; it may be the first manifestation of a cardiac or arterial disease&#46; The peculiarity and advantage of CCE is that it may be identified in an initial assessment by non-contrast CT scan&#44; typically performed as the first diagnostic step in most patients with acute stroke&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this study&#44; we present 9 cases of CCE and describe the associated risk factors&#44; clinical and radiological presentation&#44; and treatment and medium-term prognosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We gathered data on a total of 9 cases of CCE from 3 hospitals&#46; We retrospectively collected demographic characteristics &#40;age&#44; sex&#44; and vascular risk factors&#41;&#44; NIHSS score at admission&#44; CCE characteristics at admission &#40;location&#44; thrombus density in Hounsfield units &#91;HU&#93;&#44; and progressive changes in follow-up CT scans&#41;&#44; the reperfusion treatment used&#44; and the medium-term prognosis as measured with the modified Rankin Scale &#40;mRS&#41; at 3 months&#46; We used the TOAST classification to define stroke aetiology&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We also describe complementary test findings potentially involved in the calcified origin of the embolism&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">Of our 9 patients&#44; 5 were women and 4 men&#44; with a mean age of 79&#46;1 years&#46; Baseline imaging assessment of all patients consisted of a CT scan&#44; which showed a unilateral CCE located at the middle cerebral artery &#40;MCA&#41; territory in all cases&#44; with the left MCA affected in 55&#46;5&#37; of cases &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Fig&#46; 1&#8211;3</a>&#41;&#46; The shape of the CCE was rounded or oval in all cases&#44; with a mean attenuation of 211&#46;4 HU&#46; One patient presented distal migration of the hyperdense area attributable to the CCE in a subsequent CT scan&#44; probably due to disintegration of the embolus&#46; The other 8 patients did not show progressive changes in the CCE in neuroimaging studies &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In all cases&#44; embolism was spontaneous&#44; ie&#44; not associated with medical procedures or trauma&#46; According to the TOAST classification&#44; stroke was cardioembolic in 4 cases &#40;44&#46;4&#37;&#41;&#44; atherosclerotic in 3 &#40;33&#46;3&#37;&#41;&#44; and of undetermined origin in 2 patients &#40;22&#46;2&#37;&#41;&#46; We identified the following heart diseases&#58; atrial fibrillation in 2 patients &#40;22&#46;2&#37;&#41;&#44; severe aortic stenosis and ischaemic heart disease in one patient &#40;11&#46;1&#37;&#41;&#44; and infectious endocarditis in one patient &#40;11&#46;1&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A possible calcified source was found in 6 patients &#40;66&#46;7&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; We detected a sclerotic&#44; calcified aortic valve in 2 patients &#40;22&#46;2&#37;&#41; and mitral annular calcification in one patient &#40;11&#46;1&#37;&#41;&#46; Three patients &#40;33&#46;3&#37;&#41; presented carotid stenosis as a possible cause of the CCE&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">For several reasons&#44; including high baseline mRS scores or progression times outside the therapeutic window&#44; revascularisation by mechanical thrombectomy was only performed in one patient &#40;11&#46;1&#37;&#41;&#44; and was unsuccessful&#46; No patient was eligible for intravenous fibrinolysis&#46; Prognosis was fatal in 3 cases &#40;33&#46;3&#37;&#41;&#44; and the majority of the remaining patients &#40;4&#59; 44&#46;4&#37;&#41; presented severe functional dependence &#40;mRS &#8805; 4&#41;&#59; only one patient &#40;11&#46;1&#37;&#41; achieved an mRS score &#8804; 2&#46; No recurrence was observed in the 3 months following the ischaemic event&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Neuroimaging is increasingly relevant in the aetiological diagnosis of stroke&#46; MRI&#44; specifically&#44; is able to distinguish fibrin-rich thrombi from those with abundant red blood cells&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; this differentiation may be complex and have limited benefit in normal clinical practice&#46; However&#44; calcified emboli may be simply and reliably diagnosed by CT&#44; a readily available technique frequently used in the management of stroke patients&#46; Together with the hyperdensity of the occluded vessel&#44; the loss of grey-white differentiation&#44; and sulcal effacement&#44; CCE may be an early CT finding in patients with acute ischaemic stroke&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">While CCE is infrequently reported in the literature&#44; recent studies have described considerable prevalence &#40;2&#46;7&#37;&#41; among stroke patients undergoing CT studies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The risk of stroke recurrence in these patients is high&#44; at approximately 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#59; however&#44; this early recurrence was not observed in any patient in our series&#46; Despite the epidemiological relevance and the prognostic and therapeutic implications of CCE&#44; the condition is underdiagnosed&#46; Up to 27&#37; of patients may be misdiagnosed&#44; and up to 9&#37; of CCEs may go undetected in the preliminary analysis of a CT scan&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Distinguishing CCE from intrinsic vascular calcification may represent a diagnostic challenge&#46; One of the parameters to be assessed for this purpose is the location of the calcification&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Thus&#44; within intracranial arteries&#44; calcifications are more frequently located in the carotid siphon and are associated with atherosclerosis&#44; but rarely involve the MCA or anterior cerebral artery&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The presence of a calcified lesion in the MCA&#44; accompanied by infarction in the territory distal to the lesion&#44; strongly suggests CCE as the most probable cause of stroke&#46; More than 75&#37; of patients had also undergone CT scans prior to the ischaemic event&#44; revealing no calcification&#44; which&#44; together with lesion location&#44; supports the embolic origin of the calcification&#46; CCEs are generally small in size &#40;2-3&#160;mm diameter&#41;&#44; with significantly higher density &#40;162 HU&#41; than that of intraluminal thrombi &#40;typically 50-70 HU&#41;&#46; Lastly&#44; rounded or oval shapes&#44; rather than linear or tube shapes typical of vessel wall calcifications&#44; also support the diagnosis of CCE&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although CCE may be explained by displacement of the embolus after a heart or carotid vascular intervention&#44; catheterisation or surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#8211;9</span></a> cervical manipulation&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or cardiopulmonary resuscitation&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> embolism is spontaneous in the great majority of cases&#44; as in our series&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In line with other published studies&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the embolic source could be identified in most of our patients&#46; In our series&#44; embolisms were classified as atherothrombotic in 4 patients &#40;44&#46;4&#37;&#41;&#44; cardioembolic in 3 patients &#40;33&#46;3&#37;&#41;&#44; and of undetermined origin in 2 patients &#40;22&#46;2&#37;&#41;&#44; according to the TOAST classification&#46; Furthermore&#44; 6 patients &#40;66&#46;6&#37;&#41; presented carotid &#40;33&#46;3&#37;&#41; or cardiac &#40;33&#46;3&#37;&#41; calcifications with potential involvement in the CCE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bilateral CCEs suggest a left annular&#47;valvular source or origin in the aortic arch&#44; whereas recurrent ipsilateral events suggest calcified carotid stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In our series&#44; 22&#46;2&#37; of patients presented degenerative aortic valve disease with sclerosis and calcification&#59; this contrasts with the results of other series that suggest aortic heart disease as the most frequent cause&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> with up to one-third of patients requiring subsequent surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In one of our patients&#44; we detected severe aortic insufficiency secondary to endocarditis&#44; together with degenerative signs in the mitral valve&#46; Although CCE is usually related to a long-term complication of endocarditis&#44; hearts with an underlying calcified valve disease may be more vulnerable to infection&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However&#44; it is frequently difficult to establish a definitive causal relationship with the calcified source&#44; given the high frequency of some of these findings in the elderly population&#46; In fact&#44; the association between CCE and some heart diseases&#44; such as annular calcification&#44; is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> In other cases&#44; as occurred in one-third of our patients&#44; the cause of calcification cannot be identified&#46; Such factors as age and comorbidities may limit the diagnostic screening assessments performed&#59; as a result&#44; some conditions with relevance to CCE may go undetected&#44; with calcified atheromatosis of the aortic arch being one example&#46; Therefore&#44; screening for cardiac and carotid diseases becomes especially relevant in patients with CCE&#44; with a view to indicating surgery for secondary prevention of cerebrovascular disease&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There is little evidence on acute-phase reperfusion therapy in patients with CCE&#46; Regarding intravenous thrombolytic treatment&#44; both negative<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> and positive results are reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Theoretically&#44; we should not expect thrombolytic treatment to be efficacious&#44; due to the calcified nature of the embolus&#46; However&#44; mechanical thrombectomy&#44; which is able to remove the CCE&#44; is a promising alternative&#46; Nevertheless&#44; this technique has shown limited effectiveness to date&#44; partly due to the hardness of the calcified plaque preventing adequate adaptation to stent mesh&#44; and also to the higher number of reported complications associated with this procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> Only one of our patients was treated with mechanical thrombectomy by aspiration&#44; which was unsuccessful&#46; The technological development of more sophisticated stent retrievers or thromboaspiration devices may lead to better results in the future&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">CCE is a reasonably frequent condition&#44; although it may go undetected during diagnosis&#46; Recognising the condition is essential&#44; as it may help to determine the aetiology of the ischaemic stroke and&#44; therefore&#44; its treatment and prognosis&#46; New endovascular treatment alternatives for CCE should be explored&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres1740759"
          "titulo" => "Abstract"
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          "titulo" => "Keywords"
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          "identificador" => "xres1740760"
          "titulo" => "Resumen"
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              "titulo" => "Objetivo"
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              "titulo" => "Resultados"
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          "titulo" => "Introduction"
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        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-07-27"
    "fechaAceptado" => "2019-04-22"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1535286"
          "palabras" => array:3 [
            0 => "Stroke"
            1 => "Embolism"
            2 => "Neuroimaging"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Ictus"
            1 => "Embolismo"
            2 => "Neuroimagen"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Calcified cerebral embolus &#40;CCE&#41;&#44; a rarely reported and underdiagnosed cause of stroke&#44; may be the first manifestation of a vascular or cardiac disease&#46; We describe the characteristics of CCE in a series of 9 cases and review the literature on the subject&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">We included patients with CCE from 3 different hospitals&#46; We describe the diagnostic approach&#44; neuroimaging findings&#44; origin of the embolism&#44; treatment&#44; and prognosis of these patients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke&#46; In all cases&#44; the middle cerebral artery was affected&#59; all patients underwent CT&#46; A possible calcific source was found in 6 patients &#40;66&#46;6&#37;&#41;&#44; originating in the carotid arteries in 3 &#40;33&#46;3&#37;&#41; and in the heart in the other 3 patients &#40;33&#46;3&#37;&#41;&#46; Only one patient was treated in the acute phase &#40;trombectomy&#41; and only 11&#37; of patients had modified Ranking Scale scores &#8804; 2 at 3 months&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CCE is more frequent than previously thought and&#44; although the condition continues to be underdiagnosed&#44; it is of considerable prognostic relevance in the aetiological study of stroke&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los embolismos cerebrales c&#225;lcicos &#40;ECC&#41; representan una causa de ictus poco descrita e infradiagnosticada&#44; que puede ser la primera manifestaci&#243;n de una enfermedad vascular o card&#237;aca&#46; El objetivo del presente trabajo es describir las caracter&#237;sticas de los ECC en una serie de casos y revisar la literatura&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Tres centros hospitalarios aportaron casos al trabajo&#46; Se evaluaron los m&#233;todos diagn&#243;sticos&#44; las caracter&#237;sticas de neuroimagen&#44; la fuente emb&#243;lica&#44; el tratamiento y el pron&#243;stico de los pacientes con ECC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se recogieron un total de 9 casos con ECC espont&#225;neo como causa de ictus isqu&#233;mico agudo&#46; Todos afectaron a la arteria cerebral media y se estudiaron mediante TC&#46; Se encontr&#243; una posible fuente c&#225;lcica en 6 pacientes &#40;66&#44;6&#37;&#41;&#58; carot&#237;dea en 3 &#40;33&#44;3&#37;&#41; y cardiaca en otros 3 &#40;33&#44;3&#37;&#41; pacientes&#46; Solo 1 paciente se trat&#243; en la fase aguda mediante trombectom&#237;a y solo un 11&#37; tuvieron un mRS &#8804;2 a los 3 meses&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los ECC son m&#225;s frecuentes de lo que se cre&#237;a en el pasado y aunque siguen siendo frecuentemente infradiagnosticados&#44; tienen una gran relevancia pron&#243;stica a la hora de dirigir el estudio etiol&#243;gico del ictus&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mosqueira AJ&#44; Canneti B&#44; Mart&#237;nez Calvo A&#44; Fern&#225;ndez Armend&#225;riz P&#44; Seijo-Martinez M&#44; Pumar JM&#46; Embolia cerebral c&#225;lcica&#58; presentaci&#243;n de una serie de 9 casos y revisi&#243;n de la literatura&#46; Neurolog&#237;a&#46; 2022&#59;37&#58;421&#8211;427&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT scans of CCE in patients 1-3&#46; The first column shows CT scans performed prior to CCE&#44; the second column shows images of the CCE&#44; and the third column shows the image of the corresponding stroke &#40;except for the first patient&#44; for whom the follow-up study after the CCE was not available&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT scans of CCE in patients 4-6&#46; The first column shows CT scans performed prior to the CCE&#44; the second column shows images of the CCE&#44; and the third column shows images of the stroke in the corresponding territory&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT scans of CCE in patients 7-9&#46; The first column shows CT scans performed prior to CCE&#44; the second column shows images of the CCE&#44; and the third column shows images of the corresponding stroke&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; AHT&#58; arterial hypertension&#59; AMI&#58; acute myocardial infarction&#59; DL&#58; dyslipidaemia&#59; DM&#58; diabetes mellitus&#46;</p>"
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                  \t\t\t\t">4 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Mean age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">AHT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;77&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;44&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;5-17&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Sclerotic and calcified aortic valve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mitral annular calcification&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Unknown&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Histologic features of acute thrombi retrieved from stroke patients during mechanical reperfusion therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;H&#46; Ahn"
                            1 => "R&#46; Hong"
                            2 => "I&#46;S&#46; Choo"
                            3 => "J&#46;H&#46; Heo"
                            4 => "H&#46;S&#46; Nam"
                            5 => "H&#46;G&#46; Kang"
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                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Stroke"
                        "fecha" => "2016"
                        "volumen" => "11"
                        "paginaInicial" => "1036"
                        "paginaFinal" => "1044"
                      ]
                    ]
                  ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Classification of subtype of acute ischemic stroke&#46; Definitions for use in a multicenter clinical trial&#46; TOAST&#46; Trial of Org 10172 in acute stroke treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;P&#46; Adams Jr"
                            1 => "B&#46;H&#46; Bendixen"
                            2 => "L&#46;J&#46; Kappelle"
                            3 => "J&#46; Biller"
                            4 => "B&#46;B&#46; Love"
                            5 => "D&#46;L&#46; Gordon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Stroke J Cereb Circ"
                        "fecha" => "1993"
                        "volumen" => "24"
                        "paginaInicial" => "35"
                        "paginaFinal" => "41"
                      ]
                    ]
                  ]
                ]
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              "etiqueta" => "3"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Should clot composition affect choice of endovascular therapy&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46;P&#46; Mehta"
                            1 => "R&#46;G&#46; Nogueira"
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                      "doi" => "10.1212/WNL.0b013e3182695859"
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Article information
ISSN: 21735808
Original language: English
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2023 November 43 60 103
2023 October 33 34 67
2023 September 16 5 21
2023 August 31 8 39
2023 July 45 6 51
2023 June 34 1 35
2023 May 94 2 96
2023 April 63 5 68
2023 March 42 10 52
2023 February 54 4 58
2023 January 38 6 44
2022 December 51 10 61
2022 November 78 7 85
2022 October 43 10 53
2022 September 47 13 60
2022 August 48 21 69
2022 July 34 13 47
2022 June 27 10 37
2022 May 27 7 34
2022 April 21 14 35
2022 March 32 10 42
2022 February 25 8 33
2022 January 23 17 40
2021 December 27 12 39
2021 November 14 6 20
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos