Anterior Cerebral Research Articles

EnDovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for MedIum distal VeSsel Occlusion sTroke (DISTAL): An international, multicentre, randomized-controlled, two-arm, assessor-blinded trial.

Whether endovascular therapy (EVT) in addition to best medical treatment (BMT) in people with acute ischemic stroke (AIS) due to a medium distal vessel occlusion (MDVO) is beneficial remains unclear. To determine if people experiencing an AIS due to an isolated MDVO (defined as the co- or non-dominant M2 segment, the M3 or M4 segment of the middle cerebral artery, the A1, A2, or A3 segment of the anterior cerebral artery or the P1, P2 or P3 segment of the posterior cerebral artery) will have superior outcome if treated with EVT in addition to BMT compared to BMT alone. To randomize 526 participants 1:1 to EVT plus BMT or BMT alone. A multicentre, international, prospective, randomized, open-label, blinded-endpoint (PROBE) superiority trial. The primary efficacy endpoint is the distribution of disability levels on the modified Rankin Scale at 90 days. Secondary clinical efficacy outcomes include normalized change in National Institutes of Health Stroke Scale score from baseline to day 1, cognitive outcome at 90 days, and health-related quality of life at 90 days. Safety outcomes include all serious adverse events, symptomatic intracranial hemorrhage within 24 h, and all-cause mortality up to 90 days. Secondary imaging outcomes include successful reperfusion at end of EVT procedure and recanalization of target artery at 24 h. DISTAL will inform physicians whether EVT in addition to BMT in people with AIS due to a MDVO is more efficacious than BMT alone.

Anatomical Markers Associated With the Presence of Intracranial Aneurysms in Individuals Screened for Aneurysms

BACKGROUND Hemodynamic stress is linked to the development of intracranial aneurysms (IAs) and may be influenced by anatomic variation of intracranial arteries. We assessed diameters and bifurcation angles of intracranial arteries forming the circle of Willis in a cohort of individuals screened for the presence of IAs. METHODS Individuals with and without IAs identified at screening with magnetic resonance angiography were compared. Diameters and bifurcation angles of the following arteries were measured using semiautomatic methods: A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery, P1 segments of the posterior cerebral artery, posterior communicating artery (Pcom), internal carotid artery, vertebral artery, and basilar artery. We employed univariate general linear models to assess group differences. This included subgroup comparisons between individuals with IAs at specific locations and matched controls, and comparisons on group level between individuals with and without IAs, corrected for age and sex. RESULTS In 94 of the 1049 individuals (9.0%) included, IAs were detected. Individuals with middle cerebral artery IAs had wider ipsilateral M2–M2 bifurcation angles compared with controls (121±25° versus 97±19°; P <0.01). Individuals with anterior communicating artery IAs showed smaller angles for the A1–A2 bifurcation (106±16° versus 120±17°; P  = 0.02), while those with Pcom IAs had wider Pcom–C7 bifurcation angles (147±14° versus 127±17°; P  = 0.02) and smaller diameters below the ipsilateral internal carotid artery top (2.86±0.36 mm versus 3.10±0.33 mm; P  = 0.03) compared with controls. CONCLUSION We found associations between wider M2–M2 bifurcation angles or narrower A1–A2 bifurcation angles and IA presence, consistent with prior literature. Moreover, we uncovered previously unexplored associations, including wider Pcom–C7 bifurcation angles and smaller internal carotid artery diameters in individuals with Pcom IAs. Future research should explore the potential of these markers in predicting IAs in at‐risk populations during follow‐up screenings.

Arterial transit artifacts and carotid plaque-RADS may predict symptoms in patients with carotid stenosis.

To analyze the correlation of carotid stenosis severity, the Plaque Reporting and Data System (RADS) score, arterial transit artifacts (ATAs), and cerebral blood flow (CBF) with clinical cerebral ischemic symptoms in patients with carotid artery stenosis (CAS). Sixty-one patients with unilateral internal carotid artery stenosis or occlusion (≥50% stenosis) diagnosed by ultrasound, Computed Tomography(CT) angiography, or Magnetic Resonance(MR) angiography in Yichang City Central People's Hospital from January 2022 to February 2024 were retrospectively enrolled and divided into two groups according to the presence or absence of symptoms. Both groups underwent MR plaque imaging and arterial spin labeling (ASL)-based 3.0 T MRI to compare the differences in stenosis degree, Plaque-RADS score, ATA grade, and CBF between the two groups. Binary regression analysis was used to identify the parameters with statistically significant differences between the two groups and to evaluate their diagnostic efficacy using the area under the workup curve of the subjects. The Plaque-RADS score, ATA grade, and CBF differences in the anterior cerebral artery(ACA)blood supply region were correlated with symptoms, and the areas under the ROC curves for the CBF differences in the ACA blood supply region, Plaque-RADS score, ATA grade and a joint model that combines all three to predict symptoms in CAS patients were 0.672, 0.796, 0.788 and 0.919, respectively. CBF, Plaque-RADS and ATAs were identified as independent risk factors for symptoms in patients with CAS and have a certain predictive value for symptoms, and the combined predictive value is greater, potentially providing a more effective imaging modality for clinical treatment and evaluation.

Distribution of Silent Cerebral Infarcts in Adults With Sickle Cell Disease.

Previously we demonstrated that 90% of infarcts in children with sickle cell anemia occur in the border zone regions of cerebral blood flow (CBF). We tested the hypothesis that adults with sickle cell disease (SCD) have silent cerebral infarcts (SCIs) in the border zone regions, with a secondary hypothesis that older age and traditional stroke risk factors would be associated with infarct occurrence in regions outside the border zones. Adults with SCD 18-50 years of age were enrolled in a cross-sectional study at 2 centers and completed a 3T brain MRI. Participants with a history of overt stroke were excluded. Infarct masks were manually delineated on T2-fluid-attenuated inversion-recovery MRI and registered to the Montreal Neurological Institute 152 brain atlas to generate an infarct heatmap. Border zone regions between anterior, middle, and posterior cerebral arteries (ACA, MCA, and PCA) were quantified using the Digital 3D Brain MRI Arterial Territories Atlas, and logistic regression was applied to identify relationships between infarct distribution, demographics, and stroke risk factors. Of 113 participants with SCD (median age 26.1 years, interquartile range [IQR] 21.6-31.4 years, 51% male), 56 (49.6%) had SCIs. Participants had a median of 5.5 infarcts (IQR 3.2-13.8). Analysis of infarct distribution showed that 350 of 644 infarcts (54.3%) were in 4 border zones of CBF and 294 (45.6%) were in non-border zone territories. More than 90% of infarcts were in 3 regions: the non-border zone ACA and MCA territories and the ACA-MCA border zone. Logistic regression showed that older participants have an increased chance of infarcts in the MCA territory (odds ratio [OR] 1.08; 95% CI 1.03-1.13; p = 0.001) and a decreased chance of infarcts in the ACA-MCA border zone (OR 0.94; 95% CI 0.90-0.97; p < 0.001). The presence of at least 1 stroke risk factor did not predict SCI location in any model. When compared with children with SCD, in adults with SCD, older age is associated with expanded zones of tissue infarction that stretch beyond the traditional border zones of CBF, with more than 45% of infarcts in non-border zone regions.

Validation of a Simplified Model for Subarachnoid Hemorrhage in Mice.

Subarachnoid hemorrhage (SAH) represents a severe injury to the brain and is associated with a high mortality (40%). Several experimental SAH models are described in the literature requiring specialized equipment and a high degree of surgical expertise. Our goal was to validate a simplified, cost-effective model to permit future studies of SAH. SAH was induced by injection of homologous blood into the cisterna magna. Perfusion-fixation then perfusion of gelatinous India ink was performed. Brains and brainstems were collected and imaged for analysis of cerebral vasospasm. Triphenyl tetrazolium chloride (TTC) staining was used to analyze brain tissue cell death 24 hours following stroke. A composite neuroscore was utilized to assess SAH-related neurologic deficits. Anterior cerebral artery and basilary artery diameters were significantly reduced at 24 hours post SAH induction. Middle cerebral artery diameter was also reduced; however, the results were not significant. TTC staining showed no infarcted tissue. Neuroscores were significantly lower in the SAH mice, indicating the presence of functional deficits. This simplified model of SAH elicits pathological changes consistent with those described for more complex models in the literature. Therefore, it can be used in future preclinical studies examining the pathophysiology of SAH and novel treatment options.

The Safety and Efficacy of Leo Stents with Coiling or Alone for Anterior Cerebral Artery Aneurysms

Introduction: Treatment of anterior cerebral artery (ACA) aneurysms is still not well established. The Leo stent with blood flow direction is a retrievable stent for intracranial aneurysms, whereas it needs to be studied clearly in patients with ACA aneurysms. Methods: Consecutive patients with ACA aneurysms were retrospectively enrolled in three neurosurgical centers between January 2016 and October 2021. The data on demographics, aneurysm characteristics, symptom resolution, and postoperative course were collected and analyzed. The aneurysm occlusion status was appraised by Raymond-Ray Occlusion Class (RROC). Results: A total of 57 patients with ACA aneurysms were included in our study. Immediate postprocedural angiograms showed that 20 aneurysms (35.1%) were in complete occlusion (RROC 1), 26 aneurysms (45.6%) were in near-complete occlusion (RROC 2), 11 aneurysms (19.3%) were in incomplete occlusion (RROC 3). The angiographic follow-up found that the rate of complete occlusion increased to 57.9%, and near-completion and incomplete occlusion dropped to 29.8% and 12.3%, respectively. The angiographic result of the last follow-up improved significantly (Z=- 2.805, P=0.005). Univariate analysis indicated that distal location of aneurysms (Z=4.538, P=0.033) and ruptured aneurysms (χ2=.6120, P=0.032) were potential risk factors for intra-parent artery narrowing. Furthermore, multivariate logistic regression analysis found that A3 aneurysms (95% CI 1.427~32.744, P=0.016) are the key risk factor for intra-parent artery narrowing. Conclusions: The Leo stent is safe and effective for aneurysms located in ACA circulations. The overall occlusion degree improved during follow-up. A distal, small artery was the risk factor for intra-parent artery narrowing.

Prognostic value of resistive index (measured in anterior cerebral artery) in term neonates with hypoxic ischemic encephalopathy

Background: Perinatal asphyxia refers to a condition during the first and second stage of labor and soon after birth in which impaired gas exchange leads to acidosis, hypoxemia, and hypercarbia. The Doppler technique is a non-invasive method that can be used at the bed side without disturbing patients, for risk of subsequent neurodevelopment impairment in HIE. It has been proven that impaired cerebral circulation plays the main role in the pathogenesis of hypoxic ischemic brain injury in neonates. Methods: Doppler sonography conducted in all enrolled subjects. Cerebral blood flow parameters-peak systolic velocity, end diastolic velocity and resistive index were measured in anterior cerebral artery bilaterally on parasagittal planes obtaining the images through the anterior fontanelle with in first 72 hours. Results: In our study we found that death during hospital stay in neonates with normal RI and abnormal RI is 13% and 28.6% respectively (p&lt;0.01). Abnormal neurological outcome of 70.6% at 6 months and 64.7% at 12 months in patients with abnormal RI and 23.3% at 6 months and 18.6% at 12 months in patients with normal RI (p&lt;0.01). Conclusions: There is a significant correlation between neurodevelopmental disabilities and cerebral blood flow parameters in neonates with hypoxic ischemic encephalopathy. Detection of increased or decreased in cerebral blood flow velocities in neonates with in first 72 hours postpartum has a significant prognostic value related to death and long-term neurodevelopmental outcome.

Recurrent Artery of Heubner Guiding the Clip Application for Internal Carotid Artery Bifurcation Aneurysm: 2-Dimensional Operative Video.

Aneurysms of the bifurcation of the internal carotid artery (ICA) represent approximately 5% of intracranial aneurysms and tend to occur in younger patients.1-3 They typically have a superior orientation, in close relationship with the medial (branches of the anterior cerebral artery, segment A1) and lateral (branches of the middle cerebral artery, segment M1) lenticulostriate arteries (LSA), including recurrent artery of Heubner (RAH). RAH commonly originates in the junction of A1 and A2, courses medially to laterally between LSA and anterior cerebral artery, ICA bifurcation, and middle cerebral artery before entering the lateral portion of the anterior perforated substance.4-7 Damage to these arteries are catastrophic. This complex vascular anatomy makes treatment challenging, either endovascular or microsurgical.8-13 We present a video case of microsurgical clipping for the left ICA bifurcation aneurysm. This study was approved by the ethics committee of our institution. The patient, a 46-year-old man, was diagnosed with an unruptured ICA bifurcation aneurysm during workup for intermittent headache. Morphological characteristics of the aneurysm supported intervention over conservative treatment. Digital subtraction angiography showed a prominent proximal RAH crossing between the aneurysm neck and LSA, providing anatomical protection for clip application. Microsurgical clipping was chosen, and the procedure went uneventfully. The patient consented to the procedure and to the publication of his/her image. We discussed and demonstrated throughout the video how we used this anatomic variation and trajectory of the RAH to prevent clipping of LSA unwittingly and achieve complete occlusion of the aneurysm neck.

E035 Tocilizumab and the reversible cerebral vasoconstriction syndrome

Abstract Background/Aims Reversible cerebral vasoconstriction syndrome (RCVS) describes a group of conditions characterised by thunderclap headache and radiographic evidence of multifocal cerebral artery vasoconstriction. While typically following a benign course to resolution within a period of days to weeks, a small proportion of patients experience complications such as stroke, seizure or cerebral oedema. While a wide range of aetiological factors have been implicated in the clinical literature, there is, to our knowledge, only one prior publication reporting an association between tocilizumab and RCVS. Methods Here, we describe the case of a patient who developed RCVS following treatment with tocilizumab for rheumatoid arthritis. Results A 41 year old lady presented to her local emergency department after waking from sleep with sudden onset thunderclap headache with associated photophobia and vomiting. There was no prior history of headache. Her past medical history included rheumatoid arthritis and depression. At time of admission, her prescribed medications included folic acid, sertraline, methotrexate and tocilizumab. For the past 5 years, her rheumatoid arthritis had been controlled with a combination of methotrexate and etanercept, but, with her disease flaring, the etanercept was switched for tocilizumab six weeks prior to admission. Initial evaluation with CT head, CT venogram and lumbar puncture did not reveal any underlying abnormalities. A subsequent CT angiogram of the head and neck revealed multiple smooth stenoses bilaterally within the anterior cerebral arteries (ACA), middle cerebral arteries (MCA) and posterior cerebral arteries (PCA). A diagnosis of RCVS was made and tocilizumab was discontinued. Conclusion In patients taking tocilizumab, particular consideration should be given to the possibility of RCVS when performing a diagnostic evaluation of thunderclap headache. Tocilizumab may be an aetiological factor in this condition and its discontinuation may prevent the development of more serious complications. Disclosure B. Corney: None. C. Rhys-Dillon: None.

Predictive value of the hemispheric magnetic resonance angiography score on the development of indirect pial synangiosis after combined revascularization surgery for adult moyamoya disease.

It is difficult to precisely predict indirect bypass development in the context of combined bypass procedures in moyamoya disease (MMD). We aimed to investigate the predictive value of magnetic resonance angiography (MRA) signal intensity in the peripheral portion of the major cerebral arteries for indirect bypass development in adult patients with MMD. We studied 93 hemispheres from 62 adult patients who underwent combined direct and indirect revascularization between 2005 and 2019 and genetic analysis for RNF213 p.R4810K. The signal intensity of the peripheral portion of the major intracranial arteries during preoperative MRA was graded as a hemispheric MRA score (0-3 in the middle cerebral artery and 0-2 in the anterior cerebral and posterior cerebral arteries, with a high score representing low visibility) according to each vessel's visibility. Postoperative bypass development was qualitatively evaluated using MRA, and we evaluated the correlation between preoperative factors, including the hemispheric MRA score and bypass development, using univariate and multivariate analyses. A good indirect bypass was observed in 70% of the hemispheres. Hemispheric MRA scores were significantly higher in hemispheres with good indirect bypass development than in those with poor indirect bypass development (median: 3 vs. 1; p < 0.0001). Multiple logistic regression analysis revealed hemispheric MRA score as an independent predictor of good indirect bypass development (odds ratio, 2.1; 95% confidence interval, 1.3-3.6; p < 0.01). The low hemispheric MRA score (< 2) and wild-type RNF213 predicted poor indirect bypass development with a specificity of 0.92. Hemispheric MRA score was a predictive factor for indirect bypass development in adult patients who underwent a combined bypass procedure for MMD. Predicting poor indirect bypass development may lead to future tailored bypass surgeries for MMD.

A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (&gt; 24 hours): A 7-Year Retrospective Study of 302 Patients

Abstract Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (&gt; 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Rare combo: moyamoya and lupus in men.

Moyamoya syndrome (MMS) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis at the apices of the intracranial internal carotid arteries, including the proximal anterior cerebral arteries and middle cerebral arteries. Cerebral angiography images are used for detection through measurement. Systemic lupus erythematosus (SLE) is an autoimmune disease that can cause multisystemic involvement. The coexistence of SLE and MMS has been rarely reported in the literature. A 46-year-old male patient with malar rash, Raynaud phenomenon presented to the hospital with a complaint of weakness in the left lower extremity, which began 3days before the date of the visit. In the diffusion magnetic resonance imaging, multiple diffusion restrictions were observed in the right frontal region. The patient underwent MR angiography, revealing stenosis in the terminal and supraclinoid segments of the right internal carotid artery, which made us consider moyamoya disease. This patient, with a malar rash and Raynaud's, a positive antibody profile, was diagnosed as a male with SLE accompanied by MMS.

Vessel wall imaging in the diagnosis of antiphospholipid syndrome presenting as Moyamoya syndrome-A case report.

Objectives: We describe a case of anti-phospholipid syndrome (APLS) vasculopathy presenting with Moyamoya syndrome (MMS) and show the associated intracranial vessel wall MRI (VWI) findings. Methods: A 37-year-old-woman presented with acute onset dizziness and left-sided weakness. Neurologic exam revealed a left facial droop and left hemiparesis. She underwent a comprehensive laboratory work-up for stroke. Neuroimaging included a CT head, CT angiogram, VWI, and digital subtraction angiography. Results: Work-up revealed a triple-positive APLS antibody profile. CT of the head showed an acute right basal ganglia infarction and right frontal subarachnoid hemorrhage. CT angiogram revealed severe stenosis of the right internal carotid artery terminus in a Moyamoya pattern. Intracranial VWI showed long-segment concentric vessel wall thickening and homogeneous vessel wall enhancement and T2-hyperintense wall edema of the stenotic right ICA terminus, M1 middle cerebral artery, and A1 anterior cerebral artery. She was treated with long-term anticoagulation with warfarin and a right superficial temporal artery to middle cerebral artery bypass. Discussion: We present intracranial VWI features of vessel wall pathology in a patient with primary APLS presenting with MMS.

Woven endo bridge device for recurrent intracranial aneurysms: A systematic review and meta-analysis.

Recurrent intracranial aneurysms present a significant clinical challenge, demanding innovative and effective treatment approaches. The Woven EndoBridge (WEB) device has emerged as a promising endovascular solution for managing these intricate cases. This study aims to assess the safety and efficacy of the WEB device in treating recurrent intracranial aneurysms. We conducted a comprehensive search across multiple databases, including PubMed, Scopus, Embase, and Web of Science, from inception to June 5, 2023. Eligible studies focused on evaluating WEB device performance and included a minimum of five patients with recurrent intracranial aneurysms. The complete and adequate occlusion rates, neck remnant rates, and periprocedural complication rates were pooled using SATA V.17. Our analysis included five studies collectively enrolling 73 participants. Participant ages ranged from 52.9 to 65 years, with 64.4% being female. Aneurysms were wide-necked and predominantly located in the middle cerebral artery, basilar artery, and anterior cerebral artery. Previous treatments encompassed coiling, clipping, and the use of WEB devices. Our study found an overall adequate occlusion rate of 0.80 (95% CI 0.71-0.89), a complete occlusion rate of 0.39 (95% CI 0.28-0.50), and a neck remnant rate of 0.38 (95% CI 0.27-0.48). Periprocedural complications were reported at a rate of 0%, although heterogeneity was observed in this data. Notably, evidence of publication bias was identified in the reporting of periprocedural complication rates. Our findings suggest that the WEB device is associated with favorable outcomes for treating recurrent wide-neck intracranial aneurysms.

High-resolution magnetic resonance vessel wall imaging provides new insights into Moyamoya disease.

Moyamoya disease (MMD) is a rare condition that affects the blood vessels of the central nervous system. This cerebrovascular disease is characterized by progressive narrowing and blockage of the internal carotid, middle cerebral, and anterior cerebral arteries, which results in the formation of a compensatory fragile vascular network. Currently, digital subtraction angiography (DSA) is considered the gold standard in diagnosing MMD. However, this diagnostic technique is invasive and may not be suitable for all patients. Hence, non-invasive imaging methods such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are often used. However, these methods may have less reliable diagnostic results. Therefore, High-Resolution Magnetic Resonance Vessel Wall Imaging (HR-VWI) has emerged as the most accurate method for observing and analyzing arterial wall structure. It enhances the resolution of arterial walls and enables quantitative and qualitative analysis of plaque, facilitating the identification of atherosclerotic lesions, vascular entrapment, myofibrillar dysplasia, moyamoya vasculopathy, and other related conditions. Consequently, HR-VWI provides a new and more reliable evaluation criterion for diagnosing vascular lesions in patients with Moyamoya disease.

The interpositional bypass with a parietal branch of superficial temporal artery graft for symptomatic atherosclerotic anterior cerebral artery stenosis or occlusion.

For nonmoyamoya patients with anterior cerebral artery (ACA) stenosis or occlusion, whether direct revascularization of the ACA territory can prevent stroke is still unclear. The objective of this study was to investigate the efficacy and safety of a parietal branch of superficial temporal artery-interposed superficial temporal artery-to-ACA bypass (PISAB) for preventing stroke in patients with symptomatic atherosclerotic ACA stenosis or occlusion (SAASO). We retrospectively analyzed the data from patients with SAASO who had undergone PISAB in our center between April 2016 and November 2021. The rates of patency, satisfaction (revascularization grades A and B) of bypass, perioperative complications, recurrence of ischemic stroke, changes in bypass flow, and improvements in cerebral blood perfusion were analyzed. A total of 19 SAASO patients were involved in this study. Sixteen out of 19 (84.2%) patients were free from any cerebral ischemic events after surgery. Only 3 patients (15.8%) had recurrent stroke postoperatively. Two (10.5%) surgery-related complications occurred, including hyperperfusion syndrome and minor stroke. No skin ischemic complications occurred. The average follow-up period was 50.6 ± 18.3 months. The flow rate of the bypass was significantly increased half a year after surgery (56.2 ± 8.0 mL/min vs. 44.3 ± 5.3 mL/min, p < 0.001). The ratio of ipsilateral/contralateral mean transit time in the superior frontal gyrus was decreased significantly after bypass (1.08 ± 0.07 vs. 1.23 ± 0.05, p < 0.001) and continued to decrease 6 months after surgery (1.05 ± 0.04 vs. 1.08 ± 0.07, p = 0.002). The patency rate of PISAB was 94.7% (18/19) 2 years after surgery. The satisfaction rate of bypass was 89.5% (17/19). The results of this study indicate that PISAB, as a safe superficial bypass, can effectively reduce the risk of stroke in SAASO patients. More precise conclusions will require randomized control studies.

Case report: Three characteristics of tyrosine kinase inhibitor-associated cerebrovascular stenosis. High threshold for infarction, atypical infarct area, and vascular recoverability under the use of ponatinib

While tyrosine kinase inhibitors (TKI)-associated cerebral vascular stenosis (CVS) exhibit distinct mechanisms compared to conventional stroke in basic research, the clinical strategy remains nearly the same other than TKI-switching. We present the case of a 22-year-old female with chronic myeloid leukemia without stroke risk factors, who developed ponatinib-associated CVS. Three potential characteristics of TKI-associated CVS were identified: a heightened threshold for infarction, an atypical infarct area, and vascular recoverability. Specifically, brain computed tomography remained normal despite 20 h of severe hemiplegia. The ischemic distribution was confined in gray matter and the anterior cerebral artery territory on magnetic resonance imaging, despite severe stenosis of the internal carotid artery. Ischemic changes resolved within 10 days and arterial stenosis improved after ponatinib withdrawal. These unique features, distinct from typical stroke, could lead to misdiagnosis as non-organic neurological disorders or other conditions in ponatinib-treated patients.

Clinico-radiological factors associated with aphasia outcome in post stroke patients: A prospective follow up study from eastern part of India

BackgroundAphasia is a language disorder acquired secondary to brain damage. This study aims to evaluate clinical and radiological profile of patients with post stroke aphasia and factors affecting its recovery. MethodsWe conducted a prospective study of patients with first left Middle or Anterior Cerebral Artery infarct or Intracerebral Hemorrhage (ICH) with aphasia admitted within 14 days of stroke onset. Aphasia Quotient (AQ) was assessed at 2 weeks (AQ1) and 3 months (AQ2) using Western Aphasia Battery-Hindi version. Magnetic Resonance Imaging of brain with Diffusion Tensor Imaging (DTI) of bilateral Arcuate Fasciculus (AF) and Corticospinal Tract was done at admission, and stroke volume, Laterality Indices of Fractional Anisotropy (LI-FA), Mean Diffusivity (LI-MD), Radial Diffusivity (LI-RD), Axial Diffusivity (LI-AD) and Apparent Diffusion Coefficient (LI-ADC) were obtained. Results36 patients [8 ICH and 28 Acute Ischemic Stroke (AIS)] were included. AQ1 and AQ2 were significantly higher in subcortical stroke than cortical. AQ2 and increase in AQ scores (including its subscores) were significantly higher in ICH than AIS. National Institutes of Health Stroke Scale score at admission and volume of stroke had significant negative correlation with AQ1 and AQ2. Laterality Index of Fractional Anisotropy of Arcuate Fasciculus [LI-FA (AF)] had significant positive correlation with AQ2 and naming score at 3 months. Laterality Index of Mean Diffusivity of Arcuate Fasciculus [LI-MD (AF)] had significant negative correlation with AQ1, AQ2 and all subcomponents of AQ2. Significant positive correlation was seen between improvements in Modified Rankin Scale score and AQ. ConclusionThe study shows that DTI can be used to predict severity of aphasia at follow up and recovery in language and motor functions occur in parallel

Transcranial Doppler imaging of the middle and anterior cerebral arteries in pediatric patients with sickle cell anemia in Osun State, Nigeria

Transcranial Doppler imaging of the middle and anterior cerebral arteries in pediatric patients with sickle cell anemia in Osun State, Nigeria

405 The Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Moyamoya Disease Using Quantitative Magnetic Resonance Angiography

INTRODUCTION: Moyamoya disease (MMD) is a chronic steno-occlusive disease primarily of the anterior circulation leading to significant pial collateralization. Changes in the distribution of intracranial blood flow after revascularization surgery are not well understood. METHODS: We conducted a retrospective chart review of 46 patients with unilateral MMD who underwent cerebral revascularization from 2011-2019. Patients who underwent pre- and post- QMRA NOVA were included in the study. Flow was measured at the M1 segment of the middle cerebral artery (MCA), P2 segment of the posterior cerebral artery (PCA), and A2 segment of the anterior cerebral artery (ACA). Pial collaterals were defined as the sum of (A2+P2) flow. Total hemispheric flow was calculated as (M1+PCA+A2) pre-operatively and (M1+PCA+A2+Bypass) post-operatively, with the incorporation of the bypass graft. RESULTS: A total of 46 patients with unilateral MMD underwent revascularization with pre and post QMRA. Total intracranial flow at baseline prior to revascularization was lower in the side of disease (214.9 ml/min vs. 269.1 ml/min). Total intracranial flow at baseline after revascularization remained lower on the ipsilateral side of disease with an increased flow in the contralateral healthy side (211.7 ml/min vs 286.1 ml/min). Pre-bypass there was a higher flow through pial collaterals on the ipsilateral diseased side (183 ml/min) than the contralateral healthy side (135 ml/min). Post-bypass this difference in pial flow between ipsilateral and contralateral sides decreased from 48 ml/min to 22 ml/min (p = 0.02). Collateral ratio decreased significantly (0.46 preoperatively vs. 0.18 postoperatively) (P &lt; 0.01). CONCLUSIONS: The results of this study quantitatively confirm that direct cerebral revascularization decreases collateral stress in patients with moyamoya disease.