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Cerebral small artery disease with remote left and newer right deep hemispheric infarctions



went to Dartmouth yesterday for my appointment with neurologist after my aug 5th stroke. (they are very! busy people). we did a cat scan ~4 days after the stroke(mild, affected left hand - some parts of fingers numb, arm-- weaker than before and lost control when lifting a 10lb weight, and leg --think gait affected. my neurologist, showed me the scan taken and the infract which was on the right side and near the center of brain and was in a symmetric location to the stroke a year and a half ago(mild right side stroke). the first stroke was also a stroke deep in the brain.


as I have mentioned in a previous blog, in the days before my strokes and particularly on the day of the stroke, I with my walking/jogging, had got myself into a state of excessive exhaustion. on the day of the aug 5 stroke I did wonder after the walk if I had got myself into a little trouble. and sure enough I did. all strokes happened many hours later while asleep during the nite. and all were small arteries that clogged. the diagnosis is that my small arteries are damaged and their flowing diameter is restricted and can close. I note that there is no direct evidence for this conclusion. they are too small to be imaged.


the below are my thoughts : the fact remains that I had strokes and I assume that my small arteries are damaged. however there are lots and lots of small arteries in the brain and in all parts of the brain. however my strokes happen deep within the brain - near the center. there are two possibilities, 1 a small piece of plaque dislodges from somewhere and finds a deep small artery and plugs it. hence stroke. this doesn't really make sense since there are so many other small arteries that it could plug, why would it plug these deep ones. the second possibility is there is no piece of plaque but the artery simply closes since the blood pressure is too low to keep it open. but now my problem with this why don't the other small arteries in other regions of the brain also close. the only thing I can come up with is that being deep within the brain the pressure at the artery is less than the pressure at small arteries in other places in the brain. -- water flowing in a tube looses pressure as it traverses the length of the tube. and the location deep within the brain is on a different chain of tubes(arteries) than say small vessels near the surface of the brain and may experience a more significant pressure drop. this is the only scenario that does make some sense. coupled with the fact that it is generally thought that blood pressure falls when sleeping at nite.

my conclusion is that my state of excessive exhaustion produces a lower than usual night time blood pressure which is not sufficient to keep the deep small artery open. it then closes and a clot forms.

and now the catch 22. my blood pressure is a little high and am taking bp meds. however in lowering the blood pressure with the meds I may be putting myself into a more dangerous territory wrt the closure of these small vessels.


these are my thoughts on a January nite that also promises to be kind of cold. in a few hours I will go to bed and when waking up I will see what faculties may have been left behind in my dreams(lol). I must say that I am not left with a warm and fuzzy feeling concerning my visit to Dartmouth, not their fault and I do want to know what is what. and in about 2 min I want to focus on what I can do and ignore thoughts of what might be. and I am happy about what I can still do.


if you got to this point, thank you for reading these thoughts.




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David, I wonder if there is a connection, or if it is the same thing - white matter disease. Although no doctor mentioned it at all, when I got hubby's records, I read that 'white matter disease' was listed as one of the findings on his tests. Not one of the doctors will talk about it, they just change the subject like it doesn't matter. From what I read, the question is... did it happen because of the stroke.. or was it already happening separate from the stroke - no answers here.

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sandy I think that your white matter disease is seen in the mri by small little white dots in the white matter of the brain which is were the axons of all the neurons pass on their way to wherever they may be going. the location is I think near the center of the brain . the little dots in the mri are the left over results of small strokes and the arteries deep within the brain are I think also referred to small arteries. the disease happens and compromises the arteries by narrowing them with plaque and then the stroke happens when one of these gets clogged or collapses. and sandy from what I have learned a considerable fraction of mainly elderly people have this and it is mostly asymptomatic. I hope this helps a bit.






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My hubby's stroke was somewhat puzzling also. He had a fully occluded left carotid artery and partially clogged right artery. He is left side affected and this confused the doctors as he would normally be right side affected. The vascular surgeon did not want to do surgery on the right carotid until 6 weeks after his recovery. I decided to get a second opinion and the second surgeon said he did not believe the stroke was caused by the right carotid. He did not recommend surgery and so we do the dopplar scans every 6 months. I don't think the second surgeon knew for sure either what caused the stroke but said it could have been caused by "something in the brain". Larry did not have high cholesterol or high blood pressure either. It will be 4 years Feb. 5th since his stroke. I am glad we decided to avoid surgery.



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David, what I was wondering was, the small arteries you refer to that showed in your test, is it the same as white matter disease that they are seeing in your brain?

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hi jule I'm not familiar enough with carodid arteries to know that if the left one is "fully occluded" does that side of the brain get any blood. apparently it does since your husbands stroke affected the same side. you didn't say if larry had an mri which should have shown the location of the stroke. it certainly is not in keeping with our common accepted knowledge of the effects of cholesterol that larry should have so much plaque in these arteries. my own case was a little different as as larry I had low cholesterol levels and little or no plaque in carotid arteries but nevertheless had 3 strokes and all in or near the arteries in white matter area -- where the axons pass. I do hope that you continue to avoid this surgery. you do everything "right" but are still thrust into a life you didn't at all choose.


best wishes to you and larry


sandy: I am not sure what you are asking. they simply infer from the cat scan(no mri was taken of this stroke) and the position of the little darker region (near the center of the brain) that it was in the white matter AND that the artery that got clogged (resulting in the little dark region) was a small artery. I think their logic would be: if it was a large artery that got clogged I might not be typing this(lol). this is also an area that in lots of elderly people little white dots (white for how they appear in the mri scans) in this area with little/no symptoms. and they infer that these were small artery asymptomatic strokes. again they were strokes since the mri shows absent or dead volume which eventually gets filled with fluid. they can't really see the white matter disease(the damaged but still open small arteries) but again infer this from the location of the stroke. if this sandy is not very clear it is only that it is not so clear in my mind. the bottom line is you take an aspirin, a statin and and bp pill and hope!

best wishes to you and your husband sandy,





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