Anterior Choroidal Artery Territory Infarction Research Articles

Elevated neutrophil-related immune-inflammatory biomarkers in acute anterior choroidal artery territory infarction with early progression

ObjectiveThe anterior choroidal artery territory (AChA) infarction has a high rate of progression and poor functional prognosis. The aim of the study is to search for fast and convenient biomarkers to forecast the early progression of acute AChA infarction. MethodsWe respectively collected 51 acute AChA infarction patients, and compared the laboratorial index between early progressive and non-progressive acute AChA infarction patients. The receiver-operating characteristics curve (ROC) analysis was used to determine the discriminant efficacy of indicators that had statistical significance. ResultsThe white blood cell, neutrophil, monocyte, white blood cell to high-density lipoprotein cholesterol ratio, neutrophil to high-density lipoprotein cholesterol ratio (NHR), monocyte to high-density lipoprotein cholesterol ratio, monocyte to lymphocyte ratio, neutrophil to lymphocyte ratio (NLR), and hypersensitive C-reaction protein in acute AChA infarction are significantly higher than healthy controls (P < 0.05). The NHR (P = 0.020) and NLR (P = 0.006) are remarkably higher in acute AChA infarction patients with early progression than non-progression. The area under the ROC curve of NHR, NLR, the combine of NHR and NLR are 0.689 (P = 0.011), 0.723 (P = 0.003), 0.751 (P < 0.001), respectively. But there are no significant differences in efficiency between NHR and NLR and their combined marker in predicting progression (P > 0.05). ConclusionNHR and NLR may be significant predictors of early progressive patients with acute AChA infarction, and the combination of NHR and NLR could be a preferable prognostic marker for AChA infarction with early progressive course in acute stage.

Anterior Choroidal Artery Territory Infarction due to Internal Carotid Artery Dissection Presumably Caused by Scuba Diving

We report a case of anterior choroidal artery territory infarction due to internal carotid artery dissection presumably caused by scuba diving. A 44-year-old man presented with left facial palsy and hemiparesis. He had a history of scuba diving for 18 months. His last dive was 7 days ago, and he skipped decompression practice at that dive. We assumed that repetitive traumas and microbubbles during scuba diving, which made endothelium vulnerable to damage may have caused a carotid dissection.

Hemodynamic ischemia of the anterior choroidal artery and reversal by carotid artery stenting 10 years after ipsilateral superficial temporal artery-middle cerebral artery bypass for symptomatic left middle cerebral artery stenosis.

The pathogenesis of anterior choroidal artery (AChA) territory infarction includes various mechanisms, but hemodynamic causes are rare and difficult to diagnose. 77- year-old man, who had moderate left ICA stenosis and he had treated with STA-MCA bypass surgery for severe symptomatic left MCA stenosis 10 years earlier, was admitted with right hemiparesis and confused state. On admission, magnetic resonance imaging and angiography demonstrated patent bypass, but severe stenosis of left ICA with no opacification of the left AChA and A1 portion of the left ACA. Diffusionweighted imaging demonstrated ischemic lesion in the left corona radiata. Together with clinical findings, hemodynamic ischemia of the AChA region was suspected and left carotid artery stenting resulted in prompt improvement of symptoms. Hemodynamic ischemia of the AChA territory is rare, however, should be considered as a potential target of treatment when the ipsilateral ICA, A1 and M1 show stenoocclusive lesions.

Delayed Anterior Choroidal Artery Territory Infarction after Carotid Ligation Surgery with an Extracranial to Intracranial High-flow Bypass for a Large Cavernous Carotid Aneurysm: A Case Report

A 65-year-old female presented with right oculomotor nerve palsy due to a large internal carotid artery (ICA) cavernous aneurysm. She underwent ligation of the right ICA with an external carotid artery to middle cerebral artery high-flow bypass (HFB).Although her postoperative course was uneventful, she developed a cerebral infarction at the right internal capsule 5 months after surgery.Cerebral angiography revealed a filling defect at the origin of the anterior choroidal artery. We suspected that the blood current from HFB and the posterior communicating artery formed a “currentrip” at the C1 segment of the right ICA. Soon after introduction of antithrombotic therapy, her symptoms completely resolved.Angiography 3 months after the stroke revealed no filling defect at that site.This is the first report demonstrating the occurrence of ischemic stroke in the chronic phase of carotid ligation surgery with HFB. Hence, careful observation is required for these patients, even after discharge.

Open-cell stent and use of cone-beam CT enables a safe and effective coil embolization of true ophthalmic artery and anterior choroidal artery aneurysms with preservation of parent vessel: Clinical and angiographic results.

Background Treatment of true ophthalmic artery (OA) or anterior choroidal artery (AChA) aneurysms with preservation of the parent vessel may be challenging. Flow diverters have limitations when dealing with branch vessels arising from the aneurysm sac. Visual loss or AChA territory infarcts have been reported both for surgical and endovascular treatment. Methods We evaluated the safety and efficacy of an open-cell design, laser-cut, self-expanding Nitinol stent, and use of cone-beam computed tomography (CBCT) for stent-assisted coil embolization. Results A total of seven patients with unruptured OA or AChA aneurysms were enrolled in this prospective small case study and the data were analyzed retrospectively. A complete obliteration was achieved in all aneurysms immediately post-intervention or at six-month follow-up without any evidence for recanalization at up to three-year follow-up. All patients tolerated the procedure well and there was no change in baseline modified Rankin Scale. Conclusions Our study suggests that specific features of an open-cell stent allow a safe and effective treatment of OA or AChA aneurysms with a high technical success rate and excellent mid-term angiographic and clinical outcome. CBCT is a useful intraoperative imaging tool.

Anterior Choroidal Artery Territory Infarction: Lesions Confined to versus beyond the Internal Capsule

Background: Studies investigating the clinical features and stroke mechanisms of anterior choroidal artery (AchA) infarction have reported inconsistent results. This may be partly due to different degrees of inclusion of patients with isolated posterior limb of the internal capsule (PLIC) lesions, which may be supplied by lenticulostriate arteries rather than AchA. The purpose of this study was to investigate clinical features and stroke mechanisms of AchA infarction, with particular attention to the above problem. Methods: We evaluated patients with AchA infarction assessed with diffusion-weighted imaging and magnetic resonance angiography, who were admitted to the Asan Medical Center from July 2001 to April 2011. Probable AchA (pAchA) infarction was diagnosed when the lesions were confined to the lower part of the PLIC, while definite AchA (dAchA) infarction was diagnosed when the lateral geniculate body, the uncus, or the cerebral peduncle were concomitantly involved. We assessed imaging findings, stroke mechanisms, and clinical features, and investigated the differences between patients with dAchA infarction and those with pAchA infarction. Results: We identified 127 patients with AchA infarction: 34 with dAchA infarctions, 90 with pAchA infarctions, and 3 without PLIC lesions. The most important stroke mechanism was small artery disease (SAD), followed by large artery disease (LAD). In patients with LAD, distal internal carotid artery (ICA) disease was a relatively important cause of stroke. The dAchA group, as compared with the pAchA group, was more frequently related to cardioembolism (12 vs. 2%, p = 0.03), distal ICA steno-occlusion (35 vs. 2%, p = 0.001), severe neurologic deficits (higher National Institute of Health Stroke Scale scores and more severe limb weakness), and less often associated with SAD (56 vs. 78%, p = 0.02). Conclusion: In general, SAD was the most important stroke mechanism for AchA infarction followed by LAD. However, dAchA infarction and pAchA infarction differ in that the former was more often associated with cardioembolism, distal ICA steno-occlusion, a worse clinical status and less often associated with SAD than the latter. The different proportion of patients with pure PLIC lesions included in previous studies may have led to inconsistent and confusing results, which should be considered to gain a proper understanding of AchA infarction.

Abstract WP91: Open-cell Stent Design for Coil Embolization of Side Branching Vessel Internal Carotid Artery Aneurysms: Clinical and Angiographic Results

Background and Purpose: Treatment of side branch internal carotid artery (ICA) cerebral aneurysms, i.e. ophthalmic and anterior choroidal artery aneurysms, pose unique treatment difficulties. Visual loss or anterior choroidal artery territory infarcts have been reported as clinical sequelae for both surgical and endovascular treatment approaches for these aneurysms. Here we evaluate the safety and efficacy of endovascular treatment by use of open cell design for stent assisted coil embolization of side branch ICA aneurysms. Materials and Methods: Between 2007 and 2012, 60 consecutive patients treated with open cell stent assisted coil embolization for a cerebral aneurysm were reviewed. Inclusion criteria were wide neck aneurysms incorporating an ICA branching vessel at the neck of the aneurysm. Aneurysm occlusion was assessed on cerebral angiograms by using the Raymond Score immediately after endovascular treatment and at 6 months follow-up. Clinical outcomes were assessed by the modified Rankin Scale (mRS) at baseline, discharge and 6 months follow-up. Results: Of the 60 consecutive patients treated with open cell stent assisted coil embolization, 6 patients were identified as having side branching ICA cerebral aneurysms. In each of these 6 cases, the side branching ICA vessel originated from the neck of the aneurysm. Flat panel CTA obtained post open cell stent deployment showed preferential outward herniation of open cell stent struts towards the neck of the aneurysm, thus protecting the side branching vessel. On immediate post treatment angiograms, a Raymond Score of 1 was assessed on each of these 6 aneurysms with patency of the side branching vessel. A mRS of 0 or 1 was assessed at baseline and at discharge on all 6 patients. A Raymond Score of 1 was also identified on 3 of the 6 aneurysms on the 6 months follow-up exam. 3 additional patients are still awaiting their 6 months follow-up. Of the 3 patients that have received 6 months follow-up, all 3 patients have a stable mRS of 0 or 1. Conclusions: Our short to mid-term results for open cell stent assisted coil embolization of side branch ICA aneurysms is safe and effective. The independent open cell stent strut’s outward radial force protects side branching vessels that originate from the neck of these aneurysms.

Dysgraphia due to anterior choroidal artery territory infarction: a case report

Dysgraphia due to anterior choroidal artery territory infarction: a case report

Microneurosurgical management of anterior choroidal artery aneurysms: a 16-year institutional experience of 102 patients

Objective: Surgical treatment of anterior choroidal artery aneurysms (AChAAs) continues to be challenging and technically demanding for vascular neurosurgeons. Ischemic stroke is the most common complication after surgical clipping of AChAAs. We retrospectively studied a series of 102 consecutive patients with AChAAs to evaluate the clinical outcomes and ischemic complications after surgical clipping.Methods: Between January 1995 and December 2010, 102 patients presenting at West China Hospital, with a total of 106 AChAAs that were treated with surgical clipping were included in this study. There were 40 men (39%) and 62 women (61%) with an average age of 52 years (range 34–78 years). There were 62 small, 40 medium, and 4 large aneurysms. Clinical outcomes, treatment-related complications, follow-up results, and the factors influencing the clinical outcomes were evaluated.Results: Eighty-three patients (81%) achieved a good outcome (Glasgow outcome scale score 4–5) at follow-up for a mean of 18·8 months (range 4–103 months). The surgical mortality rate was 7%, and the major surgical morbidity was 12%. Fifteen patients (15%) had clinical anterior choroidal artery (AChA) territory infarction confirmed by computerized tomography. In 36 patients, the AChAA was originated entirely or partially from the AChA itself, 10 (27·8%) of them had postoperative ischemic complication. None of the 95 followed patients had rebleeding or regrowth of residual aneurysm during this period.Conclusions: The surgery of AChAAs is not easy, surgical management of AChAAs carries with it a high risk of postoperative ischemic complications, especially for those aneurysms originating entirely or partially from the AChA itself.

Capsular infarcts: location, size and etiology of pure motor hemiparesis, sensorimotor stroke and ataxic hemiparesis.

We investigated the types of syndrome, location, size and presumed causes of 72 patients with acute capsular lacunar infarction. Clinical syndromes were classified into pure motor hemiparesis (PM), sensorimotor stroke (SM) and ataxic hemiparesis (AH). Lesion sizes of AH were significantly smaller than those of PM (p < 0.01) or SM (p < 0.01). When the lesion volume was classified into two groups, > or = 1 ml and < 1 ml, the large volume group had more frequent cardioembolic sources than the small volume group (41% and 18% respectively, p < 0.05). In AH patients no cardioembolic sources could be detected. Significant carotid stenosis was found in only 4% of patients. Patients with anterior choroidal artery territory infarction had infrequent cardioembolic sources (7%). The results suggest that the lesion size varies with clinical syndrome and some etiological trends are seen in the volume and the location of lesions.

Inconspicuous visual field defect in anterior choroidal artery territory infarction

We describe a patient with a right anterior choroidal artery territory infarction and an inconspicuous left visual defect. The anterior choroidal artery is a unique artery of the cerebral circulation. The occlusion of this artery can result in dysfunction of motor, sensory, and visual systems with only rare involvement of higher cortical function. Among symptoms reported, visual abnormalities are the most variable and the least common. However, the visual field abnormality may be overlooked and the incidence underestimated since some patients may not be aware of the problem until uncovered by formal visual field testing.

Predictors for malignant middle cerebral artery infarctions

Early detection of malignant infarction of the middle cerebral artery (MI-MCA) is important because of possible treatment by hemicraniectomy. To investigate the anatomic and vascular predictors of MI-MCA. The authors evaluated 192 consecutive autopsies of patients with nonlacunar cerebral infarction affecting the MCA territory. MI-MCA was defined by an infarct with temporal or central brain herniation and brain swelling. The autopsy protocol included a systematic analysis of intracranial arteries (including the bony segments of carotid and vertebral arteries and the circle of Willis), extracranial arteries, the aortic arch, and the heart. A total of 45 patients with MI-MCA were identified. Their median (range) survival time was 6 (0 to 20) days as compared with 18 (0 to 2,040) days for non-MI-MCA patients. Compared with non-MI-MCA, MI-MCA cases more frequently involved the superficial and deep MCA territory and were more frequently associated with anterior cerebral and anterior choroidal artery territory infarcts. Hemorrhagic transformation, Duret hemorrhages, carotid occlusion, and ipsilateral abnormalities of the circle of Willis were also more frequent (p < 0.05). Multivariable analysis showed that younger age, female sex, absence of stroke history, higher heart weight, carotid artery occlusion, and abnormal circle of Willis ipsilaterally were all independently associated with MI-MCA (p < 0.03). Typical pathologic pattern for development of malignant infarction of the middle cerebral artery is a carotid occlusion with abnormal ipsilateral circle of Willis in a young patient who had a first-ever large hemispheric stroke including the superficial territory with possibly a slight predominance of female sex.

Identité et appartenance corporelle: fantômes et membres surnuméraires

The phantom limb phenomenon constitutes a spectacular example of alteration in body scheme. It is common after amputation and commonly described following any interruption of the nervous tracks, such as the peripheral nerves, brachial plexus and spinal cord. Even if classical, phantom limbs are scarcely reported after central damage (supernumerary phantom limb). We studied a previously unreported form of supernumerary limb, which specifically developed with motor intent in a patient with severe sensorimotor hemiparesis following anterior choroidal artery territory infarction. A cognitive model of motor control was used to interpret this persisting kinaesthesicproprioceptive phantom illusion of a third arm. According to this model, action initiation awareness depends upon a representation of the predicted consequences of action execution rather than on its actual consequences (because sensory feedback from the moving limb itself is delayed relative to the actual movement). This 'premovement brain signal of action', called 'efference copy', relies on the integrity of controllers which provide the motor commands necessary to achieve a desired movement and the predictors which estimate the sensory consequences of the ensuing action. As a consequence, a patient with a paralysed limb may feel that his limb is moving, provided that the motor output system is functional together with a failure to register the discrepancy between predicted and actual limb states. We suggest that in our patient, motor commands could still be issued leading to prediction of movement. Because of the absence of contradictory sensory feedback, the concordance between intended and predicted movement could lead to the illusion of movement and supernumerary limb. Finally, the interruption of thalamic afferences probably prevented any insight into the mismatch between expected and effective movement, allowing the persistence and stability of the kinaesthetic illusion. In a second step, haemodynamic correlates of supernumerary phantom limb were studied with an fMRI motor paradigm showing an increased activity in the basal ganglia-thalamus-cortex pathway during virtual movement of the supernumerary hand. We suggest that this fMRI activation reflected an abnormal closed-loop functioning of the thalamocortical system due to interruption of sensory inputs, while integrity of predictors allowed the generation of the internal phantom representation of limb position. Our findings demonstrate that supernumerary phantom limb may develop and persist after a deep brain lesion sparing cortex and provide new contributions to the critical role of the motor system in the genesis of body scheme distortions. Our study indeed shows how a preserved sense of agency provided by intact pre-motor processes translating intention into action can lead to the feeling of a non-executed movement in a paralysed limb.

Ischemic complications of surgery for anterior choroidal artery aneurysms.

Anterior choroidal artery (AChA) aneurysms account for 4% of all intracranial aneurysms. The surgical approach is similar to that for other supraclinoid carotid artery lesions, but surgery may involve a higher risk of debilitating ischemic complications because of the critical territory supplied by the AChA. Between 1968 and 1999, 51 AChA aneurysms in 50 patients were treated using craniotomy and clipping at the Mayo Clinic. There were 22 men (44%) and 28 women (56%) whose average age was 53 years (range 27-79 years). Twenty-four AChA aneurysms (47%) had hemorrhaged; nine patients (18%) had subarachnoid hemorrhage from another aneurysm. Three AChA aneurysms (6%) were associated with symptoms other than rupture. Forty-one patients (82%) achieved a Glasgow Outcome Scale (GOS) score of 4 or 5 at long-term follow up. The surgical mortality rate was 4%, and major surgical morbidity (GOS < or = 3) was 10%. Eight patients (16%) had clinically and computerized tomography-demonstrated AChA territory infarcts. Five of these strokes manifested in a delayed fashion 6 to 36 hours after the operation, and progressed from mild to complete deficit over hours. In 41 patients the aneurysm arose from the internal carotid artery adjacent to the AChA, and in nine patients the aneurysm arose directly from the origin of the AChA itself; four of these nine patients had postoperative infarction. Surgical treatment of AChA aneurysms involves a significant risk of debilitating ischemic complications. Most postoperative strokes occur in a delayed fashion, offering a potential therapeutic window. Patients with aneurysms arising from the AChA itself have an extremely high risk for postoperative stroke.

Anterior choroidal artery territory infarcts. Study of presumed mechanisms.

A previous study suggested that occlusive diseases of small penetrating arteries account for most anterior choroidal artery (AChA) territory infarcts, but half of the patients did not have an echocardiogram. Cases of AChA territory infarcts associated with internal carotid artery stenosis or atrial fibrillation suggest that this hypothesis may be wrong. The aim of this study was to determine the mechanism of 16 nonselected consecutive AChA territory infarcts. The study population consisted of 8 men and 8 women aged 17 to 89 years. They underwent a computed tomographic scan at the acute stage, Doppler ultrasonography and B-mode echotomography of the cervical arteries, bidimensional transthoracic echocardiography, and cerebral magnetic resonance imaging, replaced by a second computed tomographic scan in 3 patients. Ten patients underwent cerebral angiography. We defined the presumed cause of stroke according to the criteria used in the trial of Org 10172 in acute stroke treatment. The presumed cause of stroke was definite cardio-embolism in 4 patients (atrial fibrillation in 2, paradoxical embolism in 1, and left ventricular akinesia in 1); definite large-vessel atherosclerosis in 2; dissection of the internal carotid artery in 2; and definite small-vessel occlusion in 1. Seven patients had a negative diagnostic workup. Six patients had no risk factors for small-vessel occlusion. The AChA was not visible on angiography in 4 patients. One patient had two arterial cutoffs, suggestive of emboli in other cerebral arteries. This study suggests that AChA territory infarcts are rarely related to small-vessel occlusion and therefore require a complete diagnostic workup.

The anterior choroidal artery does not supply the corona radiata and lateral ventricular wall.

We sought first to characterize the clinical syndromes of patients found to have angiographic, computed tomographic, or magnetic resonance imaging scan indexes of anterior choroidal artery territory infarction and then to determine the frequency of involvement of the periventricular corona radiata in such patients. Sixteen patients were selected based on angiographically, or surgically, documented occlusion of the anterior choroidal artery or based on infarcts whose minimal lesions included the anterior choroidal territory as defined by Kolisko and Beevor. We mapped the lesions using the templates of the Matsui and Hirano atlas and entered them into a computer using a program allowing overlapping diagrams of the cases. The anatomic distributions were fairly uniform, all involving the lower portion of the posterior limb of the internal capsule, the medial pallidum (75% of cases), cerebral peduncle in 44%, thalamus in 37%, and the medial temporal lobe in 38%. None extended outside these areas to include the upper corona radiata. The clinical picture corresponded to the well-established neurological syndrome featuring motor deficits with varying degrees of visual field and sensory impairments. Only two showed hypesthetic ataxic hemiparesis. Our findings indicate that the syndrome of anterior choroidal artery infarction is fairly uniform; ataxic hemiparesis occurs infrequently; and lesions in the lateral ventricular wall and the corona radiata are not part of the territory supplied by the anterior choroidal artery.

Carotid artery findings associated with infarcts in different carotid vascular territories

Brain infarctions in different vascular territories may be caused by different principal mechanisms. To assess the importance of extracranial carotid artery stenosis as a cause of brain infarctions, we compared carotid findings with infarcts in different vascular territories within the carotid circulation in 141 patients. Infarct location was documented with computed tomography, magnetic resonance imaging, or ophthalmoscopy. All patients had a carotid artery study (arteriography in 83 and duplex ultrasound in the remaining 58). Carotid stenosis ipsilateral to infarct was found in 37/69 (54%) patients with superficial infarcts, 7/17 (41%) patients with lenticulostriate territory infarcts, 14/24 (58%) patients with retinal infarcts, but in only 4/31 (13%) patients with anterior choroidal artery territory infarcts (p = 0.001). Among patients with superficial infarcts, hypertension was less common (p = 0.05), and the side with greater carotid stenosis correlated with the side of infarction (p < 0.001). Extracranial carotid stenosis appears to be an important cause of infarctions in the carotid territory, especially in the superficial territories, but not in the anterior choroidal artery territory.

Anterior choroidal artery territory infarction: a small vessel disease.

To investigate the cause(s) of infarction in the anterior choroidal artery territory, we studied 31 patients (18 men, 13 women) aged 19-82 (mean 58) years, with infarction in this territory documented by computed tomography. All patients were evaluated within 30 days after infarction and had carotid artery studies (arteriography in 17, duplex ultrasound in 14). Fifteen patients had echocardiography. Risk factors for atherosclerosis were chronic hypertension in 20 patients, smoking in 17, diabetes in 10, age greater than 69 years in eight, and elevated serum cholesterol concentration in three. The percentage of patients with extracranial carotid artery stenosis (four of 31, 13%) and the severity of stenosis (mild in two, moderate in two) were similar to that reported in neurologically asymptomatic individuals. The percentage of patients with intracranial carotid artery stenosis (one of 17, 6%) or potential cardiac sources of emboli (two of 31, 6%) was also low. Our findings suggest that infarctions in the anterior choroidal artery territory usually result from small-vessel disease. Associated carotid artery stenosis and potential sources of cardiac emboli are rare and may be coincidental.