Acute Middle Cerebral Artery Infarction Research Articles

White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke

BackgroundKnowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. MethodsPatients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24–72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. ResultsThe study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). ConclusionsWhite matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.

Reversal of a Large Ischemic Lesion with Low Apparent Diffusion Coefficient Value by Rapid Spontaneous Recanalization

Cytotoxic edema at the site of a lesion following cerebral infarction is shown as a high signal on diffusion-weighted imaging, with a corresponding decreased apparent diffusion coefficient value on magnetic resonance imaging. These imaging findings have been used clinically as imaging markers of the infarction core, implying irreversible ischemic damage. However, reversal of diffusion lesions has been reported in patients with small lesions, relatively higher values of the apparent diffusion coefficient, or rapid endovascular reperfusion. Herein, we report a case of reversal of a large ischemic lesion on diffusion-weighted imaging with corresponding low apparent diffusion coefficient values in an acute middle cerebral artery infarction after immediate spontaneous recanalization. This case suggests that large ischemic lesions revealed by diffusion-weighted imaging may be reversed upon timely reperfusion, and could be considered as therapeutic targets.

Outcomes and risk factors of perforating and non-perforating middle cerebral artery infarctions after intravenous thrombolysis.

The clinical symptoms of perforating arteries differ, and responses to intravenous thrombolytic therapy are heterogeneous. Here, we investigated the effect of intravenous thrombolytic therapy and the related factors influencing acute perforating and non-perforating middle cerebral artery infarctions. We analyzed 320 patients with acute middle cerebral artery infarction who received alteplase thrombolysis within 4.5h of onset at two stroke centers from January 2016 to December 2019. Outcome measures included rates of a favorable functional outcome (modified Rankin Scale scores of 0-2), distribution of modified Rankin Scale scores, intracranial hemorrhage, and symptomatic cerebral hemorrhage at 14days, with comparisons between perforating artery and non-perforating artery cerebral infarction groups. In the perforating vessel disease group, 12 cases (17.4%) of intracranial hemorrhage occurred, with symptomatic cerebral hemorrhage in three cases (4.3%); there were no significant differences between the perforating and non-perforating vessel disease groups (all P > 0.05). In the perforating vessel disease group, the only significant prognostic factor was the National Institutes of Health Stroke Scale score before thrombolysis (Exp(B) = 1.365; 95% confidence interval [CI] 1.124-1.659; P = 0.002), and the only significant risk factor for hemorrhagic transformation was previous perforator disease (Exp(B) = 0.078; P = 0.038). Regardless of whether an acute infarction is perforating or non-perforating, intravenous thrombolytic therapy can yield a favorable outcome. Therefore, intravenous thrombolysis should be actively administered to treat perforating artery infarctions with a high risk of disability.

Arterial spin labeling signal ratio between the lesion and contralateral sides for evaluation of acute middle cerebral artery infarct.

The purpose of our study was to differentiate arterial transit artifact from post-recanalization luxury perfusion on arterial spin labeling (ASL) image, and obtain the relationship between ASL signal intensity and clinical outcomes in patients with acute ischemic stroke.Thirty-five subjects with an acute middle cerebral artery (MCA) infarct were enrolled (18 with recanalized and 17 with non-recanalized MCAs). ASL images were obtained using pseudo-continuous ASL technique with 1600 ms (millisecond) of post-label delay within 3 days from symptom onset. Signal intensities on color ASL images were classified as high, intermediate, and poor grade visually. The ratio of maximum ASL signal between the ischemic area and contralateral side was calculated and compared between patients with and without MCA recanalization. Among patients with non-recanalized MCA, ASL signal ratios were compared between patients with and without hyperintense vessel sign on fluid attenuated inversion recovery (FLAIR). Also, correlation between the ASL signal ratio and National Institutes of Health Stroke Scale (NIHSS) score was evaluated.High or intermediate grade on color ASL images were more frequently found in patients with recanalized MCA (P < .01). Patients with non-recanalized MCA had higher ASL signal ratio in overall ASL signal grade (P = .010) and intermediate grade (P = .011). Among patients with non-recanalized MCA, those with hyperintense vessel sign on FLAIR had higher ASL signal ratios (P = .049). ASL signal ratio was negatively correlated with both initial (P = .023) and final (P = .003) NIHSS scores.The ASL signal ratio could help to differentiate between the pial collaterals and post-recanalization luxury perfusion. A higher ASL ratio was related with the hyperintense vessel sign on FLAIR and lower NIHSS score.

High-Resolution Intracranial Vessel Wall MRI Findings Among Different Middle Cerebral Artery Territory Infarction Types.

ObjectiveIntracranial atherosclerotic stroke occurs through various mechanisms, mainly by artery-to-artery embolism (AA) or branch occlusive disease (BOD). This study evaluated the spatial relationship between middle cerebral artery (MCA) plaques and perforating arteries among different MCA territory infarction types using vessel wall magnetic resonance imaging (VW-MRI).Materials and MethodsWe retrospectively enrolled patients with acute MCA infarction who underwent VW-MRI. Thirty-four patients were divided into three groups according to infarction pattern: 1) BOD, 2) both BOD and AA (BOD-AA), and 3) AA. To determine the factors related to BOD, the BOD and BOD-AA groups were combined into one group (with striatocapsular infarction [BOD+]) and compared with the AA group. To determine the factors related to AA, the BOD-AA and AA groups were combined into another group (with cortical infarction [AA+]) and compared with the BOD group. Plaque morphology and the spatial relationship between the perforating artery orifice and plaque were evaluated both quantitatively and qualitatively.ResultsThe plaque margin in the BOD+ group was closer to the perforating artery orifice than that in the AA group (p = 0.011), with less enhancing plaque (p = 0.030). In the BOD group, plaques were mainly located on the dorsal (41.2%) and superior (41.2%) sides where the perforating arteries mainly arose. No patient in the AA group had overlapping plaques with perforating arteries at the cross-section where the perforator arose. Perforating arteries associated with culprit plaques were most frequently located in the middle two-thirds of the M1 segment (41.4%). The AA+ group had more stenosis (%) than the BOD group (39.73 ± 24.52 vs. 14.42 ± 20.96; p = 0.003).ConclusionThe spatial relationship between the perforating artery orifice and plaque varied among different types of MCA territory infarctions. In patients with BOD, the plaque margin was closer and blocked the perforating artery orifice, and stenosis degree and enhancement were less than those in patients with AA.

Role of S100B Serum Concentration as a Surrogate Outcome Parameter After Mechanical Thrombectomy.

Background and ObjectivesTo establish serum concentration of protein S100B as an objective biomarker surrogate for astroglial tissue damage after mechanical thrombectomy in patients with acute ischemic stroke.MethodsThis prospective 2-center study recruited patients with acute middle cerebral artery infarctions caused by large vessel occlusion treated with mechanical thrombectomy. Blood samples were collected at day 2 after intervention and analyzed for S100B serum concentrations using ELISA techniques. Infarct size was determined on follow-up brain imaging and functional outcome according to modified Rankin Scale (mRS) was assessed at 90 days.ResultsA total of 171 patients were included (mean age ± SD: 70 ± 14 years, 42% female). S100B levels correlated with infarct size. Median S100B concentrations at day 2 after intervention were lower in patients with favorable outcome (mRS score 0–1) at 90 days compared to patients with unfavorable outcome (mRS score 2–6) (median 0.10 µg/L [interquartile range 0.07–0.14] vs 0.20 µg/L [0.11–0.48], p < 0.001). Younger age (odds ratio [OR] 1.120 [confidence interval (CI) 1.068–1.174]; p < 0.001), lower National Institutes of Health Stroke Scale score 24 hours after symptom onset (OR 1.232 [CI 1.106–1.372]; p < 0.001), and lower S100B serum concentrations (OR 1.364 [CI 1.105–1.683]; p = 0.004) were independently associated with a favorable outcome. S100B was able to eliminate the lateralization bias associated with the use of mRS for functional outcome assessment at 90 days after stroke.DiscussionS100B serum concentrations after mechanical thrombectomy indicate the extent of ischemic tissue damage. This can be assessed rapidly, independent of brain imaging and clinical outcome scales. Following prospective validation in further studies, this may provide an objective surrogate outcome measure both in clinical routine and interventional trials.Classification of EvidenceThis study provides Class I evidence that S100B 2 days following mechanical thrombectomy for acute ischemic stroke accurately distinguishes favorable from unfavorable functional outcome.

THE EFFECT OF TASK ORIENTED FUNCTIONAL TRAINING PROGRAMME IN ELDERLY WITH HEMORRHAGIC STROKE- A CASE STUDY

BACKGROUND- A 70 year old unknown male patient was found unconscious on road and was brought to tertiary care hospital. On investigations and clinical correlation, patient was diagnosed as a case of left hemiparesis secondary to acute middle cerebral artery infarct. Patient regained consciousness on next day and was in state of complete dependence for bed mobility and daily living activities. He was managed conservatively and was referred to occupational therapy department for further management. METHOD- Patient was evaluated by using uniform terminology. Modied Barthel index, Modied Rankin Scale, Basic MOCA scale and Stroke Specic QOL scales were administered. Patient was given intervention for 5 weeks. Enabling activities with self-care functional activities were practised. Accident prevention, activity promotion, Compensatory strategies and environmental modications were done. Scales were administered post intervention and comparative data was obtained. RESULT- Change of pre-intervention and post- intervention score indicates improvements in performing activities of daily living, reduced disability, improved cognition and quality of living. There were signicant improvement in activities like eating, drinking milk, in bed mobility dressing and coming to sit. Minimum to moderate improvement was seen in activities like toileting, walking, stair climbing and use of wheelchair. Despite his age and lack of family support, signicant functional improvements were documented in this elderly stroke patient, and he was discharged to old age home. CONCLUSION- Supplementing enabling activities with task oriented functional training is feasible and effective in improving independence for activity of daily living in elderly stroke

Effect of decompressive hemicraniectomy in patients with acute middle cerebral artery infarction

Background/aim We aimed to determine in which cases this procedure may be more effective based on the data of patients who underwent decompressive hemicraniectomy (DHC).Material and methodsOverall, 47 patients who underwent DHC due to acute middle cerebral artery (MCA) infarction between January 2014 and january 2019 were retrospectively investigated. These patients were divided into two groups: those who died after DHC (Group A) and those who survived DHC (Group B). The groups were compared in terms of various parameters. We investigated whether the patient’s modified Rankin scale (mRS) status changed depending on age (> 60 and < 60 years).ResultsThe median age of all patients was 65 (37–80) years; groups A and B had median ages of 66.5 (37–80) and 61 (44–79) years (p = 0.111), respectively; 55.3% patients were male. The elapsed times until hospitalization after the onset of symptoms were 4.5 and 3 h in groups A and B, respectively (p = 0.014). The median GCS score at the time of admission was 7 (5–12) and 10 (8–14) in groups A and B, respectively (p = 0.0001). At the time of admission, 63.3% patients in group A had anisocoria, whereas no patient in group B had anisocoria (p = 0.0001). In postoperative period, 40% patients in group A and all patients in group B received AC/AA treatment. The survival of patients aged < 60 and > 60 years who underwent DHC for MCA infraction was 61.5% and 26.5%, respectively (p = 0,041). The median mRS of patients < 60 and > 60 years were 4 (1–6) and 6 (1–6), respectively (p = 0.018).Conclusion Age, DHC timing, and elapsed time until hospitalization or access to treatment directly affect the functional outcome and survival in MCA-infarcted patients who underwent DHC. In patients in whom the medical treatment fails, early DHC administration will increase survival without waiting for neurological worsening once herniation is detected radiologically.

Hemispheric Difference of Regional Brain Function Exists in Patients With Acute Stroke in Different Cerebral Hemispheres: A Resting-State fMRI Study.

ObjectiveTo explore the different compensatory mechanisms of brain function between the patients with brain dysfunction after acute ischemic stroke (AIS) in the dominant hemisphere and the non-dominant hemisphere based on Resting-state Functional Magnetic Resonance Imaging (Rs-fMRI).MethodsIn this trial, 15 healthy subjects (HS) were used as blank controls. In total, 30 hemiplegic patients with middle cerebral artery acute infarction of different dominant hemispheres were divided into the dominant hemisphere group (DH) and the non-dominant hemisphere group (NDH), scanned by a 3.0 T MRI scanner, to obtain the amplitude of low-frequency fluctuations (ALFF) and regional homogeneity (ReHo) and compare the differences.ResultsCompared with the HS, increased ALFF values in the brain areas, such as the bilateral midbrain, were observed in DH. Meanwhile decreased ReHo values in the brain areas, such as the right postcentral gyrus (BA3), were also observed. Enhanced ALFF values in the brain areas, such as the left BA6, and enhanced ReHo values in the brain areas, such as the left precuneus, were observed in the NDH. The ALFF and ReHo values of the right BA9 and precentral gyrus were both increased. Compared with DH, the NDH group showed lower ALFF values in the left supplementary motor area and lower ReHo values in the right BA10.ConclusionAfter acute infarction in the middle cerebral artery of the dominant hemisphere, a compensation mechanism is triggered in brain areas of the ipsilateral cortex regulating motor-related pathways, while some brain areas related to cognition, sensation, and motor in the contralateral cortex are suppressed, and the connection with the peripheral brain regions is weakened. After acute infarction in the middle cerebral artery of the non-dominant hemisphere, compensatory activation appears in motor control-related brain areas of the dominant hemisphere. After acute middle cerebral artery infarction in the dominant hemisphere, compared with the non-dominant hemisphere, functional specificity in the bilateral supplementary motor area weakens. After acute middle cerebral artery infarction in different hemispheres, there are hemispheric differences in the compensatory mechanism of brain function.

Alberta Stroke Program Early CT Score (ASPECTS) in Real Time: A Prospective Study of its Interobserver Variation among Radiologists in a Training Hospital from a Low-Resource Setting

Background and Objectives. The Alberta Stroke Program Early CT Score (ASPECTS) is a standardized system used to quantify the extent of ischemic involvement in cases of acute middle cerebral artery (MCA) infarct. It aids in clinical decision-making to identify patients who are more likely to benefit from thrombolytic therapy. This study aimed to determine the interobserver variation of ASPECTS among training and expert radiologists in a real-time, low-resource setting. Patients and Methods. A prospective study was conducted on non-enhanced CT (NECT) images of 79 patients with acute stroke. Patients with hemorrhagic stroke, or ischemic stroke from territories other than the MCA, were excluded. The ASPECTS of each case was assessed by three groups of radiologists—residents, fellows, and an expert. The level of agreement among them was then analyzed. Results. ASPECT scores were dichotomized into &gt;7 and ≤7. With the expert’s reading as gold standard, residents had sensitivity of 0.94 [95% CI: 0.85, 0.99] and specificity of 0.68 [95% CI: 0.46, 0.85], while fellows had sensitivity of 0.96 [95% CI: 0.87, 1.00] and specificity of 0.76 [95% CI: 0.55, 0.91]. There was substantial agreement between residents and expert in overall ASPECTS rating (Κ = 0.66 [95% CI: 0.48, 0.85]; AC1 = 0.77 [95% CI: 0.62, 0.91]), and substantial to almost perfect agreement between fellows and expert (Κ = 0.76 [95% CI: 0.59, 0.92]; AC1 = 0.83 [95% CI: 0.71, 0.95]). Differences between the ASPECTS of the expert and trainees were within 2 points in most cases. Conclusion. ASPECTS is a reliable tool for both training and expert radiologists to quantify the extent of MCA infarcts. Assessment by trainees is comparable with that of the expert reader and is useful for immediate clinical decision making in low-resource settings.

Ischemic Lesion Location Based on the ASPECT Score for Risk Assessment of Neurogenic Dysphagia

Dysphagia is common in patients with middle cerebral artery (MCA) infarctions and associated with malnutrition, pneumonia, and mortality. Besides bedside screening tools, brain imaging findings may help to timely identify patients with swallowing disorders. We investigated whether the Alberta stroke program early CT score (ASPECTS) allows for the correlation of distinct ischemic lesion patterns with dysphagia. We prospectively examined 113 consecutive patients with acute MCA infarctions. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 24 h after admission for validation of dysphagia. Brain imaging (CT or MRI) was rated for ischemic changes according to the ASPECT score. 62 patients (54.9%) had FEES-proven dysphagia. In left hemispheric strokes, the strongest associations between the ASPECTS sectors and dysphagia were found for the lentiform nucleus (odds ratio 0.113 [CI 0.028–0.433; p = 0.001), the insula (0.275 [0.102–0.742]; p = 0.011), and the frontal operculum (0.280 [CI 0.094–0.834]; p = 0.022). A combination of two or even all three of these sectors together increased relative dysphagia frequency up to 100%. For right hemispheric strokes, only non-significant associations were found which were strongest for the insula region. The distribution of early ischemic changes in the MCA territory according to ASPECTS may be used as risk indicator of neurogenic dysphagia in MCA infarction, particularly when the left hemisphere is affected. However, due to the exploratory nature of this research, external validation studies of these findings are warranted in future.

Proximal hyper-intense vessel sign on initial FLAIR MRI in hyper-acute middle cerebral artery ischemic stroke: a retrospective observational study.

A hyper-intense vessel sign on fluid attenuated inversion recovery magnetic resonance imaging (FHV) represents slow blood flow in the cerebral arteries. To investigate the relationship between the proximal FHV (pFHV) on initial magnetic resonance imaging (MRI) and the status of the culprit vessel (stenosis, obstruction) in hyper-acute strokes affecting the territory of the middle cerebral artery (MCA). The study participants consisted of 105 patients presenting to the emergency department (ED) with acute MCA infarction within 4.5 h of onset of symptoms. Patients underwent brain MRI within 45 min of arrival at the ED and angiography within 2 h of arrival. Culprit vessel status and presence of a pFHV on initial MRI were investigated retrospectively. The pFHV was observed in 71/105 (67.6%) patients who presented with a hyper-acute MCA infarction. All patients with hyper-acute MCA infarction caused by internal carotid artery (90.6% caused by M1 occlusion, 92.9% caused by M2 occlusion) showed a pFHV on initial MRI. After logistic regression analysis, the presence of a pFHV showed significant positive correlation with large vessel occlusion (adjusted odds ratio [OR] 34.533, 95% confidence interval [CI] 9.781-121.926; P < 0.001). A pFHV was not associated with severe large vessel stenosis. A pFHV is independently representative of the acute occlusion of intervention-eligible proximal arteries within the territory of the MCA. If a patient with a hyper-acute MCA infarction shows a pFHV, aggressive flow augmentation strategies and early activation of intervention team should be warranted for best patient outcome.

Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics.

Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863–0.972] and 0.913 [95% CI, 0.795–1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.

The predictive value of mean platelet volume, neutrophil lymphocyte ratio and platelet lymphocyte ratio in acute middle cerebral artery infarction patients

Objective: The aim of this study was to determine the predictive value of mean platelet volume (MPV), neutrophil-to-lymphocyte ratio(NLR) and platelet-to-lymphocyte ratio(PLR) in patients with acute middle cerebral artery (MCA)branch infarction. Method: This examination was performed on the files of 50 patients followed up at the Anesthesia and Reanimation ICU of Onsekiz Mart University Hospital between April 2017 and September 2019 for acute occlusion in the MCA branch, with no previous history of an ischemic stroke. These patients were assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Score (mRS). The ratios of the neutrophil and platelet countsto the lymphocyte count (NLR and PLR ratios) within the first hour of the stroke and MPV were compared to a control group. Results: The study included 50 patients with the acute ischemia of the MCA branch, of which 28 (56%) were female. The control group consisted of 50 healthy people, and 24 (48%) of these were female. The mean NIHSS score of the patients was 11.4 ± 2.6, and their mean mRS was 2.5 ± 1.5. Conclusions: In our study with patients who had acute middle cerebral artery infarction, we found that the NLR, PLR, and MPV levels within the first hour of stroke were higher in the patient group in comparison to the control group ona statistically significant level. However, multicenter studies with larger subject groups are needed for the use of hematological parameters as biomarkers in an ischemic stroke

Eating and Grooming Abilities Predict Outcomes in Patients with Early Middle Cerebral Infarction: A Retrospective Cohort Study.

Patients with cerebrovascular disorders are often forced to rest, with early prognosis made by bedside examination. However, overloading, for example, talking for a long time, may worsen the condition. We hypothesized that activities of daily living (ADL) from the Functional Independence Measure (FIM) that were actually performed regularly are useful to predict prognosis. The present study was aimed at determining the predictive items related to predicting prognosis from the status of early motor paralysis and ADL in patients with acute middle cerebral artery (MCA) infarction. We examined 367 patients with MCA infarction for Brunnstrom recovery stage (BRS) and FIM within 4 days of admission and modified the Rankin Scale before onset and just before discharge. Logistic regression analysis was used to compare two groups of patients based on their postdischarge destination (Home/another hospital or facility). The logistic regression analysis showed the following: BRS Hand: odds ratio (OR) 1.641 (95% CI 1.642 (1.336–2.017), p < 0.001); FIM Grooming: OR 1.279 (95% CI 1.220–1.807, p < 0.001); and FIM Eating: OR 1.280 (95% CI 1.102–1.488, p < 0.001). On the other hand, the ROC analysis showed the ROC area for Eating to be 0.830 (95% CI 0.787–0.874), for Grooming to be 0.81 (95% CI 0.765–0.865), and for BRS Hand to be 0.805 (95% CI 0.760–0.851). The BRS Hand and FIM Eating and Grooming domains were identified as predictive factors using the following cutoff points: BRS Hand stage V and FIM scores of 5 for Eating and 4 for Grooming. The cutoff points for the BRS Hand and FIM Eating revealed that, at a minimum, such patients can use the nonaffected hand. The presence of cognitive dysfunction or dysphagia affects these domains. Therefore, these results suggested that Eating and Grooming are appropriate as evaluation items.

Clinical prognosis analysis of collateral circulation and vascular recanalization in patients with acute ischemic stroke based on multiphase CTA

Objective To evaluate the relationship between the status of collateral circulation provided by multiphase CT angiography and the benefit and risk of vascular recanalization in patients with middle cerebral artery (MCA) occlusion. Methods This retrospective study included 49 patients diagnosed with acute MCA occlusion and treated with rt-PA in the First Affiliated Hospital of Nanjing Medical University from October 2017 to September 2018. According to the ASPECTS collateral circulation score, the patients were divided into two groups: good collateral group (n=31) and poor collateral group (n=18). The benefits and risks after thrombolysis in the two groups were compared, including 24-h NIHSS score, 30-day mortality, 90-day modified rankin scale (mRS) score, and the incidence of symptomatic cerebral hemorrhage. Statistical analysis was performed using t test, corrected χ2 test, or Fisher's exact test. Results The 24-h NIHSS score and 90-day mRS score in the good collateral group were significantly lower than those in the poor collateral group (4.6±5.6 vs 12.5±8.4, P=0.00; 1.7±1.7 vs 3.1±1.5, P 0.05), but the 30-day mortality of the poor collateral group was still greater than that of the good collateral group (11.1% vs 0%). Conclusion For patients with acute MCA infarction and receiving vascular recanalization therapy, patients with good collateral circulation can achieve good clinical outcomes, restore better recent neurological function, and obtain lower incidence of symptomatic cerebral hemorrhage and lower disability and mortality rate. Key words: Retrospective studies; Acute ischemic stroke; Intravenous thrombolysis; Multiphase CT angiography; Collateral circulation

Pathological Yawning in Patients with Acute Middle Cerebral Artery Infarction: Prognostic Significance and Association with the Infarct Location

Background:Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke.Aims:To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location.Study Design:Cross-sectional study.Methods:We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ≥3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short- and long-term outcomes of the patients were evaluated.Results:Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p<0.05). Pathological yawning was related to higher National Institutes of Health Stroke Scale scores. Patients with severe stroke (National Institutes of Health Stroke Scale score ≥10) presented with more pathological yawning than those with mild to moderate strokes (p<0.05). The clinical outcomes and mortality rates showed no significant relationship with the occurrence of pathological yawning.Conclusion:Pathological yawning in middle cerebral artery stroke was associated with stroke severity, presence of cortical involvement, and insular and opercular infarcts. However, no association was found with long-term outcome and mortality.

Early and Sustained Increases in Leukotriene B4 Levels Are Associated with Poor Clinical Outcome in Ischemic Stroke Patients

Leukotriene B4 (LTB4) has been implicated in ischemic stroke pathology. We examined the prognostic significance of LTB4 levels in patients with acute middle cerebral artery (MCA) infarction and their mechanisms in rat stroke models. In ischemic stroke patients with middle cerebral artery infarction, plasma LTB4 levels were found to increase rapidly, roughly doubling within 24 h when compared to initial post-stroke levels. Further analyses indicate that poor functional recovery is associated with early and more sustained increase in LTB4 rather than the peak levels. Results from studies using a rat embolic stroke model showed increased 5-lipoxygenase (5-LOX) expression in the ipsilateral infarcted cortex compared with sham control or respective contralateral regions at 24 h post-stroke with a concomitant increase in LTB4 levels. In addition, neutrophil influx was also observed in the infarcted cortex. Double immunostaining indicated that neutrophils express 5-LOX and leukotriene A4 hydrolase (LTA4H), highlighting the pivotal contributions of neutrophils as a source of LTB4. Importantly, rise in plasma LTB4 levels corresponded with an increase in LTB4 amount in the infarcted cortex, thereby supporting the use of plasma as a surrogate for brain LTB4 levels. Pre-stroke LTB4 loading increased brain infarct volume in tMCAO rats. Conversely, administration of the 5-LOX-activating protein (FLAP) inhibitor BAY-X1005 or B-leukotriene receptor (BLTR) antagonist LY255283 decreased the infarct volume by a similar extent. To conclude, targeted interruption of the LTB4 pathway might be a viable treatment strategy for acute ischemic stroke.

Letter: Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements.

Letter: Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements.

The Effect of Intravenous Magnesium Sulfate in Improvement of Acute Ischemic Stroke Induced Disability: A Randomized Double Blinded Clinical Trial

Background: Stroke is the third main cause of death and chronic disabilities in adults, which requires finding neuroprotective drugs to reduce its mortality and morbidity. Objectives: To determine the efficacy of magnesium sulfate as an adjunctive neuroprotective agent in patients with stroke. Materials &amp; Methods: This randomized double-blind clinical trial recruited 120 patients with acute ischemic stroke in the middle cerebral artery territory presenting to Ahvaz Golestan Hospital from 2015 to 2016. The patients were randomly assigned into two groups. The first group received 4 grams bolus intravenous magnesium sulfate and then 16 grams/24 hours for 5 consecutive days. The second group received normal saline as placebo. Functional disability was assessed on admission and at the end of the first and third months after stroke by modified National Institutes of Health Stroke Scale (mNIHSS) and modified Rankin Scale Score (mRSS). Qualitative variables were compared using chi-square test in SPSS V. 16. Results: The results showed that difference of the mean mNIHSS, before (P=0.596) and one (P=0.512) and three (P=0.664) months after the treatment was not statistically significant between magnesium and placebo groups. Also it was true for mRSS before (P=0.669) and three month (P= 0.878) after the treatment. Conclusion: IV magnesium sulfate probably did not have significant positive effects on the outcome of patients with acute middle cerebral artery infarction. Studies on larger populations are recommended to show its possible effects.