Anterior Cerebral Artery Occlusion Research Articles

Safety Evaluation and Flow Modification in the Anterior Cerebral Artery after Pipeline Embolization Device Deployment across the Internal Carotid Artery Terminus.

Method The clinical and imaging data of PEDs in the postmarket multicenter registry study (PLUS) in China were retrospectively analyzed, and patients were divided into two groups on the basis of the follow-up angiographic results: group 1 (no significant change in A1 blood flow) and group 2 (A1 occlusion or decreased blood flow). We collected patients' baseline data and evaluated the following imaging indicators: diameter and ratio of bilateral A1, M1, and internal carotid artery (ICA) vessels before stenting and the ratio of the PED size (sPED) to the ipsilateral ICA (I-ICA) diameter on the implantation side. Results A total of 1171 patients were included, of whom 48 met the inclusion criteria (17 in group 1 and 31 in group 2). In group 2, three patients experienced neurological deterioration at follow-up. From the univariate analysis of outcomes, single PED without coils, incomplete aneurysm occlusion (IAO), maximum aneurysm diameter, aneurysms involving the ICA bifurcation (ICAb), and large sPED/I-ICA diameter ratio were included in the multivariate analysis (P < 0.20). The multivariate regression analysis results showed that the ratio of sPED/I-ICA diameter was the factor influencing A1 vessel occlusion. The area under the ROC curve was 73.2%. When the sPED/I-ICA diameter ratio was 1.14, sensitivity was 70.6%, and specificity was 77.4%. Conclusion When an oversized PED is placed from M1 to the ICA, the higher porosity formed at the covered A1 orifice is conducive to maintaining stable A1 blood flow and reducing the risk of A1 vessel occlusion. This trial is registered with ClinicalTrials.gov identifier: NCT03831672.

Anterior Cerebral Artery Stroke: Role of Collateral Systems on Infarct Topography.

The circle of Willis (CoW) and leptomeningeal anastomoses play an important role in transforming infarct topography following middle cerebral artery occlusion. Their role in infarct topography following anterior cerebral artery occlusion is not well understood. The aim of this study was to evaluate the role of the CoW and leptomeningeal anastomoses in modifying regional variation in infarct topography following occlusion of the anterior cerebral artery and its branches. Perfusion and magnetic resonance imaging of patients with anterior cerebral artery stroke and evidence of vessel occlusion were segmented and manually registered to standard brain template for voxel-wise comparison. Next, a computer model of the cerebral arteries was formulated as network of nodes connected by cylindrical pipes. The experiments included occlusion of successive branches of the anterior cerebral artery while the configurations of the CoW were varied. Forty-seven patients with a median age of 77.5 years (interquartile range, 68.0–84.5 years) were studied. The regions with the highest probabilities of infarction were the superior frontal gyrus (probability =0.26) and anterior cingulate gyrus (probability =0.24). The regions around the posterior cingulate gyrus (probability =0.08), paracentral lobule (probability =0.05), precuneus and superior parietal lobule (probability =0.03) had a low probability of infarction. Following occlusions distal to the anterior communicating artery, the computer model demonstrated an increase in flow (>30%) in neighboring cortical arteries with leptomeningeal anastomoses. Traditionally the CoW has been regarded as the primary collateral system. However, our computer model shows that the CoW is only helpful in redirecting flow following proximal vessel occlusions (pre-anterior communicating artery). More important are leptomeningeal anastomoses, which play an essential role in distal vessel occlusions, influencing motor outcome by modifying the posterolateral extent of infarct topography.

Endovascular Thrombectomy for Large Vessel Occlusions in Covid-19 Patients

INTRODUCTIONCovid 19 infections has been shown to be associated with a range of thromboembolic disease that has implications for the neuro-endovascular management of large vessel occlusions.METHODSFive consecutive Covid-19 positive patients presented with large vessel occlusions to our institution. Covid-19 testing was performed using nasal swab. All thrombectomy cases was performed under general endotracheal anesthesia using a stent-aspiration combination as primary thrombectomy technique. The technical details of each case and the angiographic outcome are described. Routine labs including D-dimer, platelet count, coagulation panel (aPTT, INR), Interleukin 6 (IL-6), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were evaluated in all patients. Rotational thrombelastography (ROTEM) was performed on the patients' blood samples to assess real-time clot formation/dissolution properties.RESULTSFour patients had anterior circulation large vessel occlusions and one patient had both anterior and posterior circulation occlusions. Mean age was 52.8 years and 80% were males. TICI 3 revascularization was achieved in one patient, TICI 2B achieved in two patients andTICI 2A in two patients. In our cohort, patients were on average 52.8 years old and presented with a median NIHSS of 27. All our patients had very proximal occlusions. Three patients presented with intra-cranial ICA occlusions. Two patients presented with a tandem carotid bulb thrombus in conjunction with an intracranial vessel occlusion. One patient had an ICA terminus occlusion with a concomitant basilar occlusion. Second, the intravascular clots in all our patients were prone to fragment and migrate into both new vascular territories and into distal downstream vasculature. Distal emboli into a different territory (anterior cerebral artery occlusion) was seen in two two of our five patients (40%) and distal emboli into a downstream territory was seen in all five patients (100%). An average of 2.7 pstent-retriever passes was needed to achieve a final TICI revascularization of IIb or better.CONCLUSIONCovid-19 patients are predisposed to a hypercoagulable state. When presenting with large vessel occlusions, these patients present unique challenges that make successful revascularization difficult.

The Relationships between Anatomical Factors and Treatment Procedures for the Endovascular Treatment of Anterior Communicating Artery Aneurysms.

Endovascular treatment of anterior communicating artery aneurysms is difficult due to their complex anatomical structure. We retrospectively analyzed the relationships among the anatomical features, initial microcatheter positions, and initial occlusion outcomes. In all, 66 cases were treated at our hospital. We investigated the relationships among the anatomical features of the aneurysm and A1 segment of the anterior cerebral artery (ACA), treatment procedures, and initial occlusion outcomes. We divided the initial microcatheter positions into greater and lesser curvatures based on the curvature from A1 to the aneurysm, and evaluated the outcomes. In total, 54 out of 66 patients (82%) achieved complete obliteration (CO) or had residual neck (RN) aneurysms, and 12 had residual aneurysms (RAs: 18%). Neck diameters and superior position aneurysms were correlated with initial occlusion outcomes in the multivariate analysis. The relationship between initial occlusion outcomes and initial microcatheter positions in superior position aneurysms (37 patients) was then examined. Eleven out of 26 patients (42.3%) had residual aneurysms at the greater curvature microcatheter position, whereas no residual aneurysms were detected at the lesser curvature microcatheter position. The A1 angle was not correlated with the outcomes. Wide-necked aneurysms and superior position aneurysms were identified as factors leading to incomplete occlusion in the endovascular treatment of anterior communicating artery aneurysms. The microcatheter position at the greater curvature in superior position aneurysms was a factor for incomplete occlusion. This suggests that guiding the microcatheter to the lesser curvature position of A1 is important in the treatment of superior position aneurysms.

Isolated Sulcal Effacement and Response to Intravenous Thrombolysis in Acute Ischemic Stroke

Background and PurposeIsolated Sulcal Effacement (ISE) is focal cortical swelling without obscuration of cortical gray-white junction. The available information on its role in acute stroke patients treated with intravenous (IV) tissue plasminogen activator (tPA) is limited. MethodsISE along with ASPECT and rLMC collateral score were determined in pre-treatment CT/CT angiography of 195 consecutive acute stroke patients treated with IV tPA “only”. In addition, ISE-ASPECT score was created. Role of ISE on responsiveness to IV tPA, thrombolysis-associated hemorrhage and functional outcome were studied in 102 patients with CT-angiography-confirmed anterior system proximal vessel occlusion. ResultsISE was observed in 12 patients (6.2% of all and 11.4% of those with occlusion of the carotid terminus, M1, or proximal M2) corresponding to excellent specificity (100%) but fair sensitivity (12%) for diagnosis of anterior cerebral circulation proximal artery occlusion. ISE ASPECT score was significantly correlated with rLMC score (p=0.023). Presence of ISE was linked to younger age, female gender, lower NIHSS, along with higher ASPECT and rLMC scores. Albeit not persisted after adjustment for collateral status and NIHSS, dramatic response to IV tPA along with excellent (23% vs. 8%, p<0.05), good (21% vs. 6%, p<0.05) and acceptable (19% vs. 4%, p<0.05) functional outcome were significantly higher in patients with ISE. ConclusionsAs a plain CT marker of sufficient collateral status and increased cerebral blood volume, ISE indicates a better response to IV tPA. However, it should be noted that this relatively rare CT finding is highly specific for cerebral large vessel occlusions amenable neurothrombectomy.

Microcatheter infusion of bolus-dose tirofiban for acute ischemic stroke due to distal intracranial artery occlusion

The utility of endovascular thrombectomy for acute occlusion of the distal intracranial artery (A2/A3/M2/M3/P2/P3) is unclear, and aspiration and stent thrombectomy are associated with risk of bleeding. We analyzed patients with acute occlusion of the distal intracranial artery to assess the safety and efficacy of microcatheter-based tirofiban infusion.We retrospectively reviewed data of the endovascular thrombectomy registry of our center between January 2018 and June 2019. Patients with distal intracranial artery occlusion who underwent endovascular thrombectomy with microcatheter-based infusion of tirofiban were recruited.Of 13 patients included, 1 presented with anterior cerebral artery occlusion, 2 with posterior cerebral artery occlusion, 2 with posterior inferior cerebellar artery occlusion, and 7 with middle cerebral artery M2 occlusion. The mean National Institute of Health Stroke scale score was 10.1 (3–19). Three patients (23.1%) underwent bridging treatment of intravenous thrombolysis with recombinant plasminogen activator and endovascular thrombectomy. The arithmetic mean onset-to-recanalization time was 696.3 minutes (140–1440) and average operating time was 47.1 minutes (30–80). After treatment, 10 patients (76.9%) underwent revascularization. No operative complications were observed in any case. All patients underwent angiography and were reviewed 7 to 14 days after surgery. Imaging revealed significant improvements in recanalization compared with the immediate postoperative period, with no reoccurrence of occlusion. The mean modified Rankin scale score at the 3-month follow-up was 0.54 (0–2).Microcatheter-based infusion of bolus-dose tirofiban can result in safe and effective recanalization of acute occlusion of the distal artery in the case of a relatively light thrombotic load.

The experience of simultaneous endovascular occlusion of arteriovenous malformation and saccular aneurism in a parturient woman

The clinical case of simultaneous endovascular bloodstream exclusion of arteriovenous malformation and saccular aneurysm in parturient woman is presented. Onyx liquid adhesive composition and monospiral aneurysm occlusion technique were used. Patient X., 31, was hospitalized to the clinic on the 10th day of the postpartum period. From the anamnesis: twice (at 20th and 27th weeks of pregnancy) patient suffered intraventricular hemorrhage due to the rupture of arteriovenous malformation in the posterior third of the corpus callosum, left lateral ventricle and left parietal lobe of the brain. After the first hemorrhage a conservative treatment tactic was determined, given the high risk of complications associated with the surgical intervention for the mother and fetus. After the second hemorrhage endovascular embolization of malformation was suggested, however, the patient and her husband refused surgery, preferring conservative therapy with subsequent surgical treatment after delivery. In addition to the malformation, according to the data of selective cerebral subtraction angiography multiple cerebral saccular aneurysms of the left Anterior Cerebral – Anterior Communicating Artery and 2 Anterior Cerebral Artery aneurysms (A2-A2, A3-A4-segments) on the right side were diagnosed. Endovascular subtotal embolization of arteriovenous malformation and occlusion of the right Anterior Cerebral Artery (A2-A3-segment) saccular aneurysm were performed during the operation. A control angiographic examination after 3 months showed a complete exclusion of these arteriovenous malformation and saccular aneurysm and disappearance of all aneurysms of the left Anterior Cerebral Artery – Anterior Communicating Artery and right Anterior Cerebral Artery (A3-A4-segment).

Unusual lingual-mandibular continuous myoclonus

Lingual-mandibular myoclonus is a very unusual movement disorder. We report a very unusual case of continuous myoclonus invloving the tongue in a 34 years old patient. She is a case of cerebral palsy with undetermined etiology and she developed right anterior cerebral infarction. Consecutively she started to have rhythmic and persistent rythmic abnormal movements involving the tongue and the jaw in the same time. Her Imaging studies including brain CT scan, MRI and MRA showed occlusion of the right anterior cerebral artery with infarction in whole its territory.The abnormal movements subsided near completely on Depakine PO. The EEG monitoring failed to show epileptiform discharge. The pathophysiology of this exceptionally rare abnormal movements involving both the tonguye and the jaw is discussed. This is a very unusual presentation of abnormal movement responding to Depakine.

Automated Detection of Intracranial Large Vessel Occlusions on Computed Tomography Angiography: A Single Center Experience.

Background and Purpose- Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke. Methods- Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients' computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion. Results- CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60-80). Median processing time was 158 seconds (IQR, 150-167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion. Conclusions- The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.

Novel pathogenic TGFBR1 and SMAD3 variants identified after cerebrovascular events in adult patients with Loeys-dietz syndrome

IntroductionLoeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder due to heterozygous pathogenic variants in transforming growth factor beta (TGFβ) signaling-related genes. LDS types 1–6 are distinguished depending on the involved gene. LDS is characterized by multiple arterial aneurysms and dissections in addition to variable neurological and systemic manifestations.Patient 1: a 68-year-old man was admitted due to an aphasic transient ischemic attack (TIA). Brain CT-scan and CT angiography revealed a chronic and asymptomatic right vertebral artery dissection. Stroke diagnostic panel was unremarkable. His history showed mild stroke familiarity. At age of 49, he was treated for dissecting-aneurysm of the ascending aorta and started anticoagulation therapy. Seven years later, he underwent surgery for dissecting aneurysm involving aortic arch, descending-thoracic aorta, left subclavian artery, and both iliac arteries. Patient 2: a 47-year-old man presented a left hemiparesis due to right middle cerebral artery (MCA) and anterior cerebral artery (ACA) occlusion caused by right internal carotid artery (ICA) dissection after sport activity. Despite i.v. thrombolysis and mechanical thrombectomy, he developed malignant cerebral infarction and underwent decompressive hemicraniectomy. Digital subtraction angiography showed bilateral carotid and vertebral kinking, aneurysmatic dilatation on both common iliac arteries and proximal ectasia of the descending aorta. His father and his uncle died because of an ischemic stroke and a cerebral aneurysm rupture with a subarachnoid hemorrhage (SAH), respectively. Discussionin both cases, considering the family history and the multiple dissections and aneurysms, LDS molecular analysis was performed. In patient 1, the novel NM_005902.3 (SMAD3): c.840T > G; p.(Asn280Lys) likely pathogenic variant was identified, thus leading to a diagnosis of LDS type 3. In patient 2, the novel NM_004612.2 (TGFBR1): c.1225T > G; p.(Trp409Gly) likely pathogenic variant was found, allowing for a diagnosis of LDS type 1. ConclusionLDS is characterized by genetic and clinical variability. Our report suggests that this genetically-determined connective tissue disorder is probably underestimated, as it might firstly show up with cerebrovascular events, although mild systemic manifestations. These findings could lead to identify people at risk of severe vascular complications (i.e., through genetic consult on asymptomatic relatives), in order to perform adequate vascular assessments and follow-up to prevent complications such as stroke.

Azygous Anterior Cerebral Artery Acute Occlusion Managed With Endovascular Mechanical Thrombectomy: 2-Dimensional Operative Video

Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3×30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4×40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

Abstract WP43: Successful Reperfusion in Patients With Concomitant Bi-territorial Anterior Circulation Strokes is Associated With Favorable Outcome and Decreased Symptomatic Hemorrhage and Mortality

Background and Purpose: Mechanical thrombectomy is now the gold standard treatment for patients presenting with acute ischemic stroke and proximal middle cerebral artery occlusion. The impact of mechanical thrombectomy in patients with concomitant anterior and middle cerebral arteries occlusions has not been evaluated. Methods: We analyzed data collected between January 2012 and june 2018 in a prospective clinical registry of consecutive acute ischemic stroke patients treated with mechanical thrombectomy. Every patient with concomitant anterior and middle cerebral arteries occlusions documented on initial imaging and angiographic first run were included. The primary study outcome was the percentage of patients who achieved a 90-day favorable outcome, defined as an mRS score of 0-2 or equal to the prestroke value. Results: Among 1242 strokes with anterior circulation occlusion treated by thrombectomy, 80 (6.4%) had biterritorial occlusions, defined as ischemic lesions in both anterior and middle cerebral artery territories and occlusions in both territories or carotid occlusion confirmed on first angiographic run. Among them, 67.5% had successful reperfusion of middle cerebral artery defined as mTICI 2B or 3. Patients with successful reperfusion had an increased rate of favorable outcome (28.6% versus 4.2%; P=0.043), decreased risk of symptomatic intracerebral hemorrhage (11.5% versus 45%; P=0.004) and decreased mortality (30.6% versus 66.7%; P=0.006), respectively. Conclusion: In patients with concomitant occlusions of anterior and middle cerebral arteries territories, successful reperfusion is associated with an increased rate of favorable outcome, a decreased risk of symptomatic intracerebral hemorrhage and a decreased mortality.

Clinical effect of mechanical thrombectomy for acute cerebral infarction caused by relatively small vessel occlusion

Objective To evaluate the safety and effectiveness of mechanical thrombectomy with Solitaire stent in intracerebral relatively small artery occlusions, such as the anterior cerebral artery, the posterior cerebral artery, the middle cerebral artery M2-M3. Methods The clinical data of thirteen cases of acute cerebral infarction caused by occlusion of relatively small vessels (anterior cerebral artery, posterior cerebral artery, middle cerebral artery M2-M3) caused by intravenous thrombolytic time window with relative small vascular occlusion in our hospital were reviewed and analyzed.The NIHSS score, occlusion of vascular recanalization, surgical complications, and clinical prognosis (3 months mRs) were analyzed before and after discharge, including 6 cases of M2-M3 occlusion in the middle cerebral artery, 3 cases of anterior cerebral artery occlusion and 4 cases of posterior cerebral artery occlusion. Results In 13 cases, the time window of thrombectomy was 3.5~7.0 h, the time from onset to reflow was (4.53±3.21) h, and 13 cases of blood vessels were completely repassed, of which 11 cases were grade 3 TICI, and 2 cases of 2b grade in TICI classification.2 cases of postoperative small lateral fissure and subarachnoid hemorrhage.The score of NIHSS was reduced from (19.53±1.62)points to (3.15±0.41)points at 2 weeks.The difference was statistically significant (t=1.763, P<0.01); the mRs scores of 90d were 0 points 7 cases(53.85%), 1 points 3 cases(23.08%), 2 points cases (23.08%), death 0 case. Conclusion The patients with acute cerebral infarction caused by relatively small vascular occlusion, such as the anterior cerebral artery, the posterior cerebral artery and the middle cerebral artery (M2-M3) are treated with stent embolectomy in the time window.The rate of vascular repassage is high and the complications are low, and the patient′s disability rate can be significantly reduced and the clinical prognosis is better. Key words: Small vessel Occlusion; Solitiare stent; Mechanical thrombectomy; Stroke

Mechanical Thrombectomy for Acute Anterior Cerebral Artery Occlusion

We sought to examine the presentation, treatment, and outcomes of anterior cerebral artery (ACA) occlusions in patients undergoing mechanical thrombectomy (MT). Two-hundred ninety-eight consecutive patients with large-vessel occlusion treated with MT were analyzed to identify all patients with acute ACA occlusion who underwent MT. The primary end point was defined as achieving a thrombolysis in cerebral infarction score ≥2b. The secondary end point included the 90-day modified Rankin Scale (mRS) score and symptomatic intracranial hemorrhage. Nine patients with a median National Institutes of Health Stroke Scale score of 24 presented with acute ACA occlusion. The median time from onset to recanalization was 229 minutes. The ACA occlusion was a primary embolic occlusion in 5 patients, secondary to an interventional maneuver in 4 patients. Recanalization (thrombolysis in cerebral infarction ≥2b) was achieved in 9 of 9 patients (100%) without procedural complications. All patients had a 90-day mRS score ≥3, and 2 patients had an mRS score of 6. Two patients developed hemorrhagic infarction, and 1 patient had subarachnoid hemorrhage. Although MT can be considered in patients with ACA occlusions, our data suggest that future clinical trials are needed to determine the efficacy of MT for ACA occlusions. Unfavorable outcomes in our study were considered to occur because of a larger infarct volume due to internal carotid artery, middle cerebral artery, and anterior cerebral artery territory infarction. The time from onset to recanalization was longer because MT was performed for occlusions of multiple arteries.

Beyond Large Vessel Occlusion Strokes

Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes. Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. The data that support the findings of this study are available from the corresponding author on reasonable request. Retrospective review of a prospectively collected endovascular database (2010-2015, n=949) for all patients with distal intracranial occlusions treated endovascularly. Distal occlusions were defined as any segment of the anterior cerebral artery (ACA), posterior cerebral artery, or occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. Distal occlusions were treated in 69 patients. The mean age was 66.7±15.8 and 57% were male. Patients (29 [42%]) received intravenous tPA (tissue-type plasminogen activator). The median preprocedure National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-23). The distal occlusion was the primary treatment location in 45 patients, in 23 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal large vessel occlusion strokes, and 1 patient had both primary and rescue treatment. The locations of the primary cases were MCA-M3 (n=21), ACA alone (n=8), ACA with a concomitant MCA-M1 or MCA-M2 (n=10), ACA with a concomitant MCA-M3 (n=3), and posterior cerebral artery (n=3). The locations of the rescue cases were MCA-M3 (n=11), ACA (n=7), posterior cerebral artery (n=4), and both MCA-M3 and ACA (n=1). There was a single patient with primary ACA and MCA-M2 occlusions treated, who then had a rescue MCA-M3 thrombectomy addressed after initial reperfusion. The most common treatment modalities used were stent-retrievers (n=37, 54%), intra-arterial tPA (n=36, 52%), and thromboaspiration (n=31, 45%). Near complete or complete reperfusion of the distal territory (modified Treatment In Cerebral Ischemia [mTICI] 2b-3) was achieved in 57 cases (83%). Three parenchymal hematomas (4%) occurred in the territory of the treated distal occlusion with 2 of these patients also receiving intravenous tPA. At 90 days, 21 patients (30%) had a modified Rankin Scale score of 0 to 2 and 14 (20%) had died. Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. These results need to be corroborated by larger prospective controlled studies.

Mechanical thrombectomy for acute large vessel occlusion stroke with mild symptoms

Objective To evaluate the safety and efficacy of mechanical thrombectomy for acute large vessel occlusion stroke (LVO) with mild symptoms. Methods A retrospective analysis was conducted on 16 patients with LVO and National Institutes of Health Stroke Scale (NIHSS) score <6, who were admitted to Department of Neurosurgery, Xuanwu Hospital, Capital Medical University from April 2014 to November 2017. Among them, 5 cases had occlusion in middle cerebral artery (MCA) and included 2 cases in M1 and 3 cases in M2. In addition, there were 1 case with anterior cerebral artery (ACA) occlusion and 8 cases with vertebral-basilar artery occlusion. Besides thrombectomy, 6 cases with severe stenosis of large artery underwent acute angioplasty. Results Successful reperfusion[thrombolysis in cerebral infarction (TICI) score of 2b-3] was achieved in all 16 patients. One case developed symptomatic hemorrhage after recanalization. There were no procedure-related complications. At 90 days, 13 patients obtained good outcome: the modified Rankin scale (mRS) of 0 was reported in 8 patients, 1 in 2, 2 in 3 and 6 (death) in 1 case. Conclusion Endovascular mechanical thrombectomy appears to be safe and effective in patients presenting with mild stroke symptoms and acute large vessel occlusion. Key words: Stroke; Arterial occlusive diseases; Mild; Mechanical thrombectomy

Stroke-like Migraine Attacks after Radiation Therapy (SMART) Syndrome Followed by Cerebral Infarction

A 36-year-old man with a history of irradiation for acute lymphoblastic leukemia developed headache with cortical dysfunction lasting for 4 weeks. The clinical features were consistent with stroke-like migraine attacks after radiation therapy (SMART) syndrome. Six months later, he developed cerebral infarction due to occlusions of the left anterior and middle cerebral arteries. This is the first case report describing SMART syndrome followed by severe cerebral infarction. Although an association between the two episodes was not assumed, this case indicates that protective therapies against infarction might need to be considered for patients with SMART syndrome.

Causes, clinical and imaging characteristics of moyamoya disease in children

Introduction: Moyamoya disease is a progressive, chronic occlusive vascular disease of the circle of Willis arteries leading to the development of collateral circulation to compensate the occlusion. Purpose: This study aims to investigate the potential causes and clinical and imaging characteristics of Moyamoya Disease (MMD) in children. Methods: A retrospective analysis was performed on the clinical data of 14 MMD children, in which the potential causes were analysed, and the clinical and imaging characteristics were observed. Results: The average patient age was 6.15 y (range 21 months-13 y), and the female/male ratio was 1.3:1.0. There were 332 cases of ischemia and 196 hemorrhages. Eight cases had inducing factors including five cases of upper respiratory tract infection. Twelve cases exhibited limb weakness or hemiplegia. Among these patients, eight cases developed these manifestations as initial symptoms. Furthermore, seven cases presented language barriers, two cases had twitch, and two cases had headaches with unclear vision. All 14 patients underwent cranial Magnetic Resonance Imaging (MRI) and the results revealed that twelve cases had cerebral infarction, and two cases had cerebral hemorrhage. Five of 14 patients experienced stenosis or occlusion at the siphon part of the bilateral internal carotid arteries, seven patients had bilateral anterior cerebral artery stenosis or occlusion, 8 were bilateral middle cerebral artery stenosis or occlusion, and 2 were bilateral posterior cerebral artery stenosis or occlusion. All patients smoke-like vessels in the basal ganglia region. Conclusion: High-risk age of child MMD ranged between 4-10 y old, which mostly manifested as transient cerebral ischemic insults; and inducing factors were mostly upper respiratory tract infections.

Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts

IntroductionIt remains unclear whether patients presenting with large vessel occlusion strokes and mild symptoms benefit from thrombectomy.ObjectiveTo compare outcomes of endovascular therapy versus medical management in patients with large vessel...

Test repositioning for functional assessment of neurological outcome after experimental stroke in mice.

Stroke is a cerebrovascular pathology for which the only approved treatment is fibrinolysis. Several studies have focused on the development of new drugs but none has led to effective therapies to date, due, among others, to the difficulty to evaluate clinical deficits in experimental animal models. The present study aims to explore the applicability of known behavioral tests not commonly used in ischemia for the neurological assessment of mice after experimental stroke in different brain areas. A total of 225 CD1 male mice were randomly assigned to permanent middle cerebral artery occlusion by ligature (pMCAO) or permanent anterior cerebral artery occlusion by photothrombosis (pACAO) models. Modified neuroseverity score, footprint test, forced swim test and elevated plus maze were performed. Under these experimental conditions, modified neuroseverity score showed neurological impairment early after experimental stroke in both models. By contrast, the footprint test and the elevated plus maze detected short-term neurological deterioration in the pMCAO model but not in the pACAO model. Furthermore, the forced swim test identified depression-like behavior in mice after ischemia only when the left hemisphere was affected. In conclusion, we propose the repositioning of known neurobehavioral tests, but not commonly used in the stroke field, for the fast detection of neurological impairments early after ischemia, and even specific to discriminate the territory affected by arterial occlusion as well as the hemisphere where brain damage occurs. All these findings may prove useful to improve the experimental design of neuroprotective drugs in order to bridge the gap between experimental studies and clinical trials.