To determine the etiology spectrum and lesion distribution patterns of patients with acute multiple infarcts in multiple cerebral circulations (AMIMCC) and provide guidance for treatment and prevention.

The etiologies and mechanisms of AMIMCC were complicated deserving clinical attention.

Patients with acute ischemic stroke were consecutively included in this study between June 2012 and Apr 2022. AMIMCC was defined as noncontiguous focal lesions located at more than one cerebral circulation with acute neurological deficits. We retrospectively analyzed the clinical and imaging characteristics and etiology spectrums between patients with AMIMCC and non-AMIMCC. Infarct lesion patterns on DWI and its relevance with the etiology were further discussed. 

A total of 1213 patients were enrolled, of whom 145(12%) were diagnosed as AMIMCC. Compared with non-AMIMCC, AMIMCC patients manifested as younger age(P=.016), more often female(P=.001), less common for conventional vascular risk factors(P<.05). The constitution of TOAST classification was significantly different between patients with AMIMCC and non-AMIMCC(P=0.000), with higher proportion of stroke of other determined cause(67.6%vs12.4%).Regarding the detailed etiology of AMIMCC, autoimmune or hematologic diseases were the most common(27.6%), followed by peri-procedural infarcts(15.2%), cardioembolism(13.1%), malignant tumor(11.7%), large artery atherosclerosis (10.3%), sudden drop in blood pressure(8.3%). Hypercoagulability and systemic hypo-perfusion were the common underlying mechanisms of AMIMCC. Distinctive lesion distribution patterns were associated with stroke etiologies and mechanisms in AMIMCC patients. Sixty-five percent of the 20 patients diagnosed with SLE/APS and 52.9% of the 17 patients with malignant tumor tended to manifest as supratentorial infarcts. However, 68.4% of cardioembolism presented with both supratentorial and infratentorial infarct lesions. More than half of patients with SOC and SUC had intracranial or extracranial artery stenosis.

The etiologies and mechanism of AMIMCC were complicated compared to non-AMIMCC. The distribution characteristics of infarct lesions might have important implications for identification of etiology in AMIMCC patients, further guiding and optimizing clinical diagnosis strategy.