Anterior Cerebral Artery Territory Infarction Research Articles

Delayed intraoperative rupture of clipped aneurysm during the awaking from anaesthesia

Introduction. Intraoperative rupture (IOR) of an aneurysm is a frightful complication that causes significant morbidity and mortality worldwide. IOR can be attributed to various parameters, including hypertension, increased intracranial pressure (ICP), fragility of the vessels, and inadequate anaesthesia. IOR due to insufficient anaesthesia is scarcely reported in the literature. Here, we describe a re-ruptured anterior communicating artery (ACoA) after incomplete clipping of the neck during craniotomy closure due to unintended early wake-up from anaesthesia with a discussion about the management. Case description. A 38-year-old male suddenly developed a severe headache, a brief loss of consciousness, and vomiting. Computed tomography (CT) scan showed a subarachnoid haemorrhage in the basal cistern. CT angiography showed a bilobed right ACoA aneurysm with a wide neck and Murphy's teat. The patient was considered for surgery. Clipping of the aneurysm neck was done through two curved clips. During craniotomy closure, the patient started coughing and gagging then a huge IOR was encountered. These events can be mainly attributed to unintended inadequate anaesthesia, particularly muscle relaxants. The bleeding ceased after two suction catheters were inserted, temporary clips were applied, and the readjustment of permanent clips. After surgery, the patient showed a left-sided weakness. His postoperative CT scan showed a right distal anterior cerebral artery (ACA) territory infarction. The weakness improved in the follow-up period. Conclusion. Delayed IOR due to early awaking from anaesthesia should be considered a potential source of complications and bad outcomes in aneurysm surgery.

Iron Deficiency Anemia and Ischemic Stroke in Premenopausal Women (P14-5.022)

<h3>Objective:</h3> We describe three young women with iron deficiency anemia who developed ischemic strokes in the absence of typical risk factors. <h3>Background:</h3> Ischemic stroke is the third leading cause of death in women. Women have unique risk factors for ischemic stroke. Iron deficiency anemia disproportionately affects premenopausal women and has previously been identified to be associated with ischemic stroke. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 39-year old woman with hypertension and menorrhagia presented with left leg weakness and dizziness. Labs revealed a hemoglobin of 5.9g/dL, a unremarkable hypercoagulable work up, transesophageal echo, urine toxicology, rheumatological evaluation, and MRA brain vessel wall imaging. An ultrasound of her uterus revealed a pelvic fibroid measuring 6.5cm and MRI brain revealed a small right anterior cerebral artery territory infarction. A 46-year-old woman with chronic iron deficiency anemia with a hemoglobin of 6.8g/dL who presented with left mild sided weakness and was found to have a right MCA M3 occlusion by CT angiography of the head. She received intravenous tenecteplase and underwent decompressive craniectomy for a right temporal infarct associated with cerebral edema seen on MRI brain. Investigations revealed a normal hemoglobin electrophoresis, urine toxicology, hypercoagulable evaluation, rheumatological evaluation and transesophageal echo. A 43 year old woman presented with diplopia secondary to a vertical gaze palsy. MRI brain revealed an infarct in the left thalamus, cerebral peduncle, and midbrain. Cerebral angiography, transesophageal echocardiogram, urine toxicology, rheumatological evaluation, and hypercoagulable work up were unremarkable. Hemoglobin was 7.2g/dL on presentation and an EGD revealed an antral and duodenal ulcer. All three patients received packed RBC transfusions, iron replacement therapy and discontinuation of aspirin until hemoglobin stabilized. <h3>Conclusions:</h3> Iron deficiency anemia may be an important yet under-recognized risk factor for acute ischemic stroke and should be treated aggressively in premenopausal women. Further studies are warranted. <b>Disclosure:</b> Dr. Imam has nothing to disclose. Dr. Salahuddin has nothing to disclose.

A RARE CAUSE OF PARAPLEGIA: DISTRIBUTIVE SHOCK CAUSING BORDER ZONE STROKES

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Simultaneous bilateral cerebrovascular infarction is relatively uncommon and is an entity seen rarely in watershed cerebral infarctions which occur at the border between cerebral vascular territories in the setting of severe hypotension. CASE PRESENTATION: 84-year-old male with history of CAD, cerebellar stroke, peripheral arterial disease was admitted to the ICU with distributive shock and intubated for toxic metabolic encephalopathy. Initial CT head on admission was unremarkable. On day 2 of hospitalization his neuro assessment was notable for bilateral lower extremity paresis with preservation of sensation, proprioception and temperature but had sluggish reflexes and loss of motor strength. Repeat CT head did not show a bleed and subsequently, MRI brain with MRA head and neck revealed bilateral acute anterior cerebral artery strokes. Given the location and duration of symptoms he was not a TPA candidate and was treated with medical management with aspirin and statin. Echocardiogram and carotid ultrasounds were done that were unremarkable for embolic cause of stroke. DISCUSSION: The anterior cerebral artery is a major vessel supplying blood to the interhemispheric region. ACA territory infarction accounts for only 0.3% to 4.4% of cerebral infarctions. Bilateral ACA infarction is even rarer. Twenty-seven cases of ACA territory infarction were reported among 1490 cases of cerebral infarction in the Lausanne Stroke Registry; among them, only two cases had bilateral ACA territory infarction. Bilateral ACA infarction can occur due to vasospasm in the setting of subarachnoid hemorrhage caused by a rupture of aneurysms of the anterior communicating arteries or distal ACAs, thrombosis or embolism in case of anomaly of circle of Willis or bilateral anaplastic ACAs. In our patient the area of infarction was in a watershed zone bilaterally, unfortunately affected by hypotension which is rare in the absence of any of the above-mentioned anomalies as predisposing factors. The true incidence of bilateral ACA infarction is unknown, with few cases reported in the literature. CONCLUSIONS: This case report highlights the possibility of developing simultaneous bilateral cerebral infarctions in the setting of profound systemic hypotension and shock, especially if the patient has baseline chronic small vessel changes. REFERENCE #1: Orlandi G, Moretti P, Fioretti C, Puglioli M, Collavoli P, Murri L. Bilateral medial frontal infarction in a case of azygous anterior cerebral artery stenosis. Ital J Neurol Sci. 1998;19:106–108. doi: 10.1007/BF02427567. [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Gacs G, Fox AF, Barnett HJ, Vinuela F. Occurrence and mechanisms of occlusion of the anterior cerebral artery. Stroke. 1983;14:952–959. [PubMed] [Google Scholar] REFERENCE #3: Bogousslavsky J, Regli F. Anterior cerebral artery territory infarction in the Lausanne Stroke Registry. Clinical and etiologic patterns. Arch Neurol. 1990;47:144–150. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Christine Blaski, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

Bilateral anterior cerebral artery thrombosis - a mimicker of basilar artery thrombosis: a case report

We present a rare case of bilateral anterior cerebral artery (ACA) territory infarction with akinetic mutism, quadriparesis and frontal lobe release signs along with limbic dysfunction mimicking a basilar artery thrombosis. The etiology was thrombosis of the anterior communicating artery with propagation or embolism of the thrombus to both A2 segments of the anterior cerebral artery and restricted or absent blood flow in the branches arising from the A2 and A3 segments causing extensive infarction. We also aim to review the anatomy of the ACA to understand localization of lesions.

Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study

BackgroundIsolated anterior cerebral artery territory (ACA) infarction is a rare phenomenon, and is known to have distinctive clinical features. Little is known regarding the clinical prognosis of isolated ACA territory infarction with associated factors, and its impact on dwelling and job status. We investigated the short- and long-term outcomes of anterior cerebral artery (ACA) territory infarction, and the associated factors involved in the development of the distinctive symptoms.MethodsThis retrospective study in a prospective cohort of acute ischaemic stroke patients included consecutively enrolled patients with isolated ACA territory infarction. We investigated the functional status using the modified Rankin scale (mRS) score at discharge, three months’ post-discharge, and one-year post-discharge. We also investigated the occlusion site of the ACA (proximal vs. distal); presence of distinctive symptoms of ACA territory infarction including behaviour changes, indifference, aphasia, and urinary incontinence; and the effect of these symptoms on dwelling and job status one year after discharge.ResultsBetween April 2014 and March 2019, 47 patients with isolated ACA territory infarction were included. Twenty-nine patients (61.7 %) had good outcomes (mRS ≤ 2) at discharge; however, the mRS score increased at three months (40; 85.1 %, p < 0.001) and one year (41; 87.2 %) post-discharge. Occlusion of the ACA proximal segment was independently associated with the development of distinctive symptoms (adjusted odds ratio, 17.68; 95 % confidence interval: 2.55–122.56, p < 0.05). Twenty-one (48.8 %) patients with good outcomes at one year experienced a change in dwelling status and job loss; 20 (95.2 %) of them had distinctive ACA territory symptoms with proximal ACA occlusion.ConclusionsShort- and long-term outcomes of isolated ACA territory infarction were favourable. However, proximal segment occlusion was associated with the development of distinctive symptoms, possibly related to future dwelling and job status.

MASSIVE STROKE IN A CRITICALLY ILL COVID-19 POSITIVE PATIENT DESPITE DUAL ANTI-PLATELET THERAPY AND VTE PROPHYLAXIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Current evidence suggests that COVID-19 infection leads to increased incidence of thrombotic events in critically ill patients [1]. Studies regarding the benefits of anticoagulation in COVID-19 patients have yielded mixed results[2,3]. The literature is unclear as to an effective strategy for VTE prevention in COVID-19 patients. In this case we will present a COVID-19 positive critically ill patient who suffered a large ischemic cerebrovascular accident despite receiving daily VTE prophylaxis and dual anti-platelet therapy. CASE PRESENTATION: Our patient is a 66-year-old female with a past medical history of uterine cancer receiving chemotherapy at the time of admission. Patient presented with hypoxemic respiratory failure secondary to COVID-19 pneumonia. Initial head CT scan demonstrated no definite acute intracranial findings. Patient was intubated without complications and admitted to the ICU. She was continued on her home doses of Plavix 75mg daily and Aspirin 81mg daily and started on subcutaneous Enoxaparin 40mg once daily for VTE prophylaxis. On hospital day #15 patient’s sedation was discontinued in preparation for spontaneous breathing trial, yet she did not return to baseline mental status. On hospital day #18 head CT scan was performed which revealed interval development of large late subacute/chronic left anterior and middle cerebral artery territory infarction (Image 1). At this time our patient is still receiving treatment for complications of COVID-19 pneumonia and has had no change in her mental status. DISCUSSION: In this case report our patient with COVID-19 pneumonia suffered an ischemic stroke despite dual anti-platelet therapy and VTE prophylaxis. Thrombotic complications are common in critically ill COVID-19 patients with an incidence reported to be as high as 31% [1]. One study found decreased mortality in critically ill COVID-19 patients receiving therapeutic anticoagulation [2]. However, another found a significant incidence of thrombotic events despite anticoagulation [3]. The role of dual anti-platelet therapy in conjunction with standard VTE prophylaxis has not been studied. Currently no cases of a COVID-19 patient suffering a thrombotic event while on dual anti-platelet therapy and VTE prophylaxis have been reported. A limitation of this case is that our patient was actively being treated for cancer, a known pro-thrombotic state, which may have contributed to her thrombotic event. CONCLUSIONS: This case report demonstrates that despite dual anti-platelet therapy and VTE prophylaxis our COVID-19 patient suffered a thrombotic event. These findings suggest that COVID-19 VTE prevention requires enhanced anticoagulation strategies compared to usual VTE prevention regimens. Further studies examining the role of dual anti-platelet therapy as well as various doses of anticoagulation are needed to elucidate effective strategies for VTE prevention in COVID-19 patients. Reference #1: Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19 [published online ahead of print, 2020 Apr 10]. Thromb Res. 2020;S0049-3848(20)30120-1. doi:10.1016/j.thromres.2020.04.013 Reference #2: Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5):1094-1099. doi:10.1111/jth.14817 Reference #3: Llitjos JF, Leclerc M, Chochois C, et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [published online ahead of print, 2020 Apr 22]. J Thromb Haemost. 2020;10.1111/jth.14869. doi:10.1111/jth.14869 DISCLOSURES: No relevant relationships by Mark Guirguis, source=Web Response No relevant relationships by Michael Nicholson, source=Web Response No relevant relationships by Yuriy Takhalov, source=Web Response

Poor Outcomes Related to Anterior Extension of Large Hemispheric Infarction: Topographic Analysis of GAMES-RP Trial MRI Scans

BackgroundWe aimed to assess the correlation of lesion location and clinical outcome in patients with large hemispheric infarction (LHI). MethodsWe analyzed admission MRI data from the GAMES-RP trial, which enrolled patients with anterior circulation infarct volumes of 82-300 cm3 within 10 hours of onset. Infarct lesions were segmented and co-registered onto MNI-152 brain space. Voxel-wise general linear models were applied to assess location-outcome correlations after correction for infarct volume as a co-variate. ResultsWe included 83 patients with known 3-month modified Rankin scale (mRS). In voxel-wise analysis, there was significant correlation between admission infarct lesions involving the anterior cerebral artery (ACA) territory and its middle cerebral artery (MCA) border zone with both higher 3-month mRS and post-stroke day 3 and 7 National Institutes of Health Stroke Scale (NIHSS) total score and arm/leg subscores. Higher NIHSS total scores from admission through poststroke day 2 correlated with left MCA infarcts. In multivariate analysis, ACA territory infarct volume (P = .001) and admission NIHSS (P = .005) were independent predictors of 3-month mRS. Moreover, in a subgroup of 36 patients with infarct lesions involving right MCA-ACA border zone, intravenous (IV) glibenclamide (BIIB093; glyburide) treatment was the only independent predictor of 3-month mRS in multivariate regression analysis (P = .016). ConclusionsAnterior extension of LHI with involvement of ACA territory and ACA-MCA border zone is an independent predictor of poor functional outcome, likely due to impairment of arm/leg motor function. If confirmed in larger cohorts, infarct topology may potentially help triage LHI patients who may benefit from IV glibenclamide. Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01794182.

Imaging of Brain Infarctions: Beyond the Usual Territories.

In this review, our intension is to present imaging features of several categories of uncommon cases of brain infarctions including infarctions associated with neurovascular variants, infarctions along small arterial territories, and brainstem stroke syndromes. Infarctions associated with neurovascular variants include azygos anterior cerebral artery territory infarction and artery of Percheron infarction. In the second group, we discuss anterior choroidal artery infarction and artery of Heubner infarction. The third group highlights brainstem stroke syndromes, including Claude and Benedikt syndromes due to midbrain infarction; Foville, Marie Foix, and locked-in syndromes due to pontine infarction; and Dejerine (medial medullary), bilateral medial medullary, and Wallenberg (lateral medullary) syndromes.

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.

Stroke Status Developed After Herpes Viridae Infection: A Report of Two Cases

: High mortality herpes simplex virus encephalitis (HSVE) presents with fever, headache, changes in personality, focal neurologic findings, and epileptic attacks. It causes common destruction in brain parenchyma with necrotic, inflammatory and hemorrhagic lesions, and neuron losses. Central nervous system vasculitis during HSV infection can develop strokes especially related to both hemorrhagic and ischemic reasons. Ramsay-Hunt syndrome (RHS) is characterized by the re-activation of the latent varicella zoster virus (VZV) in the geniculate ganglion of the facial nerve; it presents with peripheral facial nerve paralysis. Neurogenic pulmonary edema is the situation of respiratory failure occurring hours after the serious neurogenic incident without other reasons causing lung edema, which is developed by increase in sympathetic activity, and progressed by increase in alveolar and interstitial fluid. In the current study, a patient with developed neurologic pulmonary edema with ischemic stroke status as a result of cerebral hematoma and middle cerebral artery (MCA) ischemia following HSVE was followed up and a patient that developed anterior cerebral artery (ACA) and MCA territory infarction after RHS was mentioned.

Asymptomatic Massive Cerebral Abscess Following Malignant Cerebral Infarct—Aggressive Surgery—Ray of Hope

AbstractThe aim of this article was to present a rare and potentially life-threatening complication of malignant cerebral infarct turning into a massive cerebral abscess. Cerebral abscess complicating cerebral infarction is rare. Only 13 cases have been reported. Unexplained fever is the presenting symptom. The case presented here is unique, as the patient was totally asymptomatic and the abscess was detected incidentally during surgery. A 42-year-old man with malignant left anterior cerebral artery and middle cerebral artery territory infarct underwent decompressive craniotomy 5 weeks before presenting to the authors’ institution. The patient had features of sunken skin flap syndrome. Therefore, cranioplasty was planned. During surgery, false dura was inadvertently opened due to adherence with pia and pus started coming out. On exploration, approximately 150 mL of pus was evacuated. The whole infarcted brain was seen to be converted into a cavity full of pus. Adequate drainage and debridement were done. Cranioplasty was deferred. The patient was treated with broad-spectrum antibiotics postoperatively, and he recovered well. Cerebrovascular accident (CVA) is one among the common causes for mortality and morbidity worldwide. The infarcted or ischemic brain acts like a fertile ground for the pathogens to grow. Disruption of blood–brain barrier and lack of normal blood flow by the vascular event facilitate microbial seeding and formation of cerebral abscess. Abscess formation following stroke is rare. It could prove to be fatal if misdiagnosed or not properly treated. Uncontrolled fever in a stroke patient should raise the suspicion of this rare complication. A routine contrast computed tomography of the brain prior to cranioplasty may pick up this complication in asymptomatic patients. Conservative treatment alone proves fatal in almost all cases.

Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection

Background and purposeStanford type A aortic dissection (AAD) sometimes causes acute ischemic stroke (AIS) or transient ischemic attack (TIA). There is little understanding of cerebrovascular imaging of AIS or TIA in patients with AAD. MethodsConsecutive AIS/TIA patients with AAD who were admitted within 4.5 h of onset were reviewed. We compared findings of MRI/MRA between these and consecutive AIS/TIA patients without AAD within 4.5 h of onset. ResultsSeventeen AAD and 249 non-AAD patients were identified. Compared to non-AAD patients, AAD patients had infarcts more frequently in the right anterior cerebral artery (ACA) territory (18% vs. 2%, P = 0.007) and the right middle cerebral artery (MCA) territory (71% vs. 29%, P < 0.001). There was no difference between the groups regarding whether it was perforator or cortical infarct, single or multiple infarcts, unilateral or bilateral infarcts, or ischemic change extension. On the MRA imaging, the AAD patients more frequently had poor visualization of the right internal carotid artery (ICA) (47% vs. 6%, P < 0.001). After adjustment for sex, age and confounding factors, the right ACA territory infarct [odds ratio (OR), 12.2; 95% confidence interval (CI), 1.4–119.4], the MCA territory infarct (OR, 4.9; 95% CI, 1.0–25.0) and poor visualization of the right ICA (OR, 18.1; 95% CI, 4.0–101.9) were independently associated with AAD. ConclusionIn emergency AIS/TIA patients, right anterior circulation infarct and poor visualization of the right ICA on cerebrovascular imaging are potential imaging markers of AAD.

Cerebral Infarction in a Child after Moderate Brain Trauma: A Case Report

AbstractIntracranial hematomas and contusions are common entity after traumatic brain injury in children and young population. However, cerebral infarction after traumatic head injury is a rare entity with frequency ranging from 1.9 to 10.4%. We herein report a case of cerebral infarction in right anterior cerebral artery (ACA) and parts of middle cerebral artery (MCA) territory after moderate head injury in a 14-year-old boy, in whom computed tomographic (CT) scan of the brain was performed 3.5 hours after injury, which showed specks of pneumocephalus in sellar suprasellar region, and 12 hours after injury showed right ACA territory infarct and evolving infarct in right MCA territory. Bony injury included right orbital roof and right sphenoid wing linear undisplaced fractures. Possible mechanism for development of infarction is right internal carotid artery (ICA) dissection by fractured bone fragments and/or thrombosis. The patient developed hemiplegia on second day after trauma. Intracranial pressure (ICP) monitoring was done, which was suggestive of raised ICP. The patient underwent right fronto-temporo-parieto craniotomy and decompression (tissue sent for histopathologic analysis) and augmentative duraplasty with bone flap replacement on fifth day after trauma. Histopathology was suggestive of cerebral infarct with hemorrhage. The patient was improved at follow-up, 10 months after trauma after rehabilitation, and physiotherapy to modified Rankin scale (mRS) score 3. Hence delayed CT scan plays a vital role in detecting developing posttraumatic infarcts, and rigorous rehabilitation care is necessary for clinical improvement.

Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage.

Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25-50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.

Multifocal Myoclonus after Stroke and Rehabilitation - A Case Report

Movement disorders are a rare recognized complication of stroke. Different types of hyperkinetic and hypokinetic movement disorders have been reported and can be seen after ischemic and haemorrhagic strokes. Failure to address these involuntary movements poses a challenge for post-stroke intensive multidisciplinary rehabilitation. We describe a patient presenting with multifocal myoclonus after an Anterior Cerebral Artery (ACA) territory infarct whose symptoms were brought under control with clonazepam. Additionally, we discussed on our experience and the challenges faced in the diagnostic process, management, and rehabilitation of this patient.

Case Report of Both Anterior Cerebral Artery Territory Infarction

It was aimed to report a case of both anterior cerebral artery territory infarction patient improved by korean medical treatment. The patient was diagnosed by brain magnetic resonance imaging(MRI) and magnetic resonance angiography(MRA). The symptoms were quadriplegia, urinary frequency, urinary incontinence and abulia. I applied herbal medicine, acupuncture, moxibustion, pharmacopuncture, cupping and physical exercise therapy. As a result of them, the symptoms of the patient were improved considerably. Status of the patient was evaluated by manaul muscle test(MMT), modified barthel index(MBI) and functional independence measure(FIM) and medical interview. MBI score was changed from 35 to 95 and FIM score was changed from 66 to 115. Therefore this report suggests that korean medical treatment could be effective to the anterior cerebral artery territory infarction.

Prediction of lower limb motor outcomes based on transcranial magnetic stimulation findings in patients with an infarct of the anterior cerebral artery

The aim was to investigate the relationship between transcranial magnetic stimulation (TMS) at the early stage of stroke and 6-month motor outcome for patients with anterior cerebral artery territory infarct. Patients were classified into TMS(+) and TMS(−) groups. At the 6-month evaluation, lower limb motor function for the TMS(+) group was significantly better than those for the TMS(−) group. Thus, early TMS evaluation is useful for predicting recovery of lower limb motor function in patients experiencing this type of stroke.

Akinetic Mutism Following Bilateral Anterior Cerebral Artery Territory Infarction Due to Aneurysm: A Case Report

Bilateral anterior cerebral artery (ACA) territory infarction is rare localization in stroke which should always prompt a search for an anterior communicating artery (ACoA) aneurysm. The common neurological manifestations are contralateral weakness predominate in the lower extremity, behaviour disturbance, motor inertia, muteness, incontinence, grasp reflex, diffuse rigidity, akinetic mutism. We describe a 38-year-old woman presented with a left sided hemiparesia and decrease of speech for last days. She was a smoker and morbide obese. She had no any diagnosed disease. Her neurological examination had weakness of left extremities affected leg more than the arm and akinetic mutism like as no spontaneously speech and move and grasp reflex. CT showed bilateral ACA infarction which included cingulate gyrus, the right side more than left and subarachnoid hemorrhage in the interhemispheric fissure. MRI angiography showed the appearance of AcoA aneurysm. We report a patient with bilateral infarction in the ACA which a rare localization and clinicians must be alert to exist AcoA aneurysm which may bleed, different symptoms and signs like as akinetic mutism, primitive reflexes.

Cerebral infarction caused by pituitary apoplexy: case report and review of literature

Pituitary apoplexy followed by cerebral infarction is rare. In this report, we present a 42-year-old man who had been diagnosed of pituitary adenoma presented with a sudden onset of unconsciousness, left hemiplegia and right ptosis. Investigations revealed the development of pituitary apoplexy. The extension of tumor mass compressed the supraclinoid portion of the right internal carotid artery, resulting in the cerebral infarction in the right anterior and middle cerebral artery territory. Left anterior cerebral artery territory infarction was also found, which could be caused by vasospasm provoked by pituitary apoplexy. The patient underwent decompression surgery via transsphenoidal approach after four weeks' conservative treatment, and pathological examination revealed hemorrhage and necrosis of the pituitary adenoma. His symptoms improved within five months' follow-up. Since pituitary apoplexy producing cerebral infarction is rare, clinicians should be alert to that possibility, and delayed transsphenoidal surgery following conservative management with steroids is the appropriate management of such an occurrence.

Bilateral Anterior Cerebral Artery Territory Infarction Due to Subarachnoid Hemorrhage: Two Case Reports

Bilateral Anterior Cerebral Artery Territory Infarction Due to Subarachnoid Hemorrhage: Two Case Reports