Middle Cerebral Artery Area Research Articles

High-resolution MR vessel wall imaging and cardiovascular health for evaluating the occurrence of ischemic stroke

ObjectivesTo explore the value of high-resolution MR vessel wall imaging (HR-VWI) based plaque characteristics combined with cardiovascular health (CVH) metrics in the risk evaluation of ischemic stroke attributed to middle cerebral artery (MCA) atherosclerotic stenosis. MethodsRetrospective analysis of 209 participants with middle cerebral atherosclerosis, 146 patients with high signal in the MCA area on DWI were included in the symptomatic group, and 63 patients were included in the asymptomatic group. The degree of stenosis, enhancement ratio, plaque burden, remodeling index, and intraplaque hemorrhage were measured and compared between groups. Seven CVH metrics and other clinical data were obtained. The association between these factors and ischemic stroke was investigated by univariate and multivariate analysis. ResultsThe degree of stenosis [OR, 1.036 (95 % CI, 1.014–1.058); P = 0.001], plaque burden [OR, 0.958 (95 % CI, 0.928–0.989); P = 0.009], intraplaque hemorrhage [OR, 3.530 (95 % CI, 1.233–10.110); P = 0.019], physical activity [OR, 4.321 (95 % CI, 1.526–12.231); P = 0.006], and diet [OR, 8.986 (95 % CI, 2.747–29.401); P < 0.001] were the independent characteristics associated with the occurrence of ischemic stroke. ROC curve showed that the combination of plaque characteristics, diet, and physical activity achieved the highest AUC of 0.828 (95 % CI 0.770–0.877; P < 0.001), with sensitivity and specificity being 86.30 % and 66.67 %, respectively. ConclusionPlaque characteristics combined with CVH metrics may identify high-risk populations for ischemic stroke and offer novel insights into risk evaluation and stratification.

Abstract WP132: The Significance of Fluid-Attenuated Inversion Recovery Vascular Hyperintensity in Combination With Occlusion Site and Reperfusion Status by Mechanical Thrombectomy for Proximal and Distal Middle Cerebral Artery Occlusion

Introduction: In patients with acute ischemic stroke, FLAIR vascular hyperintensity (FVH) is a reliable indicator of large vessel occlusion and salvageable tissue requiring mechanical thrombectomy (MT). However, its significance in distal arterial occlusion has not been established. This study aimed to investigate the significance of FVH in DWI-negative areas, in combination with occlusion site and reperfusion status, by MT for regional tissue outcomes in proximal and distal middle cerebral artery (MCA) occlusion. Methods: The clinical records of patients admitted to a single institute between April 2017 and June 2022, who presented with MCA occlusion with initial NIHSS ≥ 5 and underwent MT within 24 h of onset were retrospectively analyzed. Proximal occlusion was defined as M1 segment occlusion, and distal occlusion as M2 or M3 segment based on initial MRA. Each cortical MCA area in Alberta Stroke Program Early CT Score (ASPECTS) ipsilateral to the occluded vessel was categorized into group A (DWI-, FVH-) or B (DWI-, FVH+) based on initial MRI. Regional collateral status on initial angiogram, expanded Thrombolysis in Cerebral Infarction (eTICI) grade on final angiogram, and regional unfavorable tissue outcome with the appearance of low or high density on CT 24 h after MT were recorded. Univariate and multivariate analyses using mixed-effects models for regional unfavorable tissue outcome were performed. Results: A total of 103 patients (56 with proximal and 47 with distal occlusion) were included. Categorizing cortical areas resulted in 256 areas in group A and 171 in group B. The rate of unfavorable tissue outcome in order of eTICI 0-2a, 2b50-67, and 2c-3 reperfusion status in group A were 14.3%, 11.3%, and 6.0%, respectively (p=0.06) while those in group B were 47.1%, 34.0%, and 12.9%, respectively (p&lt;0.01). In multivariate analysis, eTICI 0-2b67 vs. eTICI 2c-3 in group B of distal occlusion was an independent predictor for unfavorable regional tissue outcome (OR 7.8, 95% CI 1.1-55.6, p=0.04), along with ASPECTS M2 or M5 and poor angiographical collaterals. Conclusions: FVH in DWI-negative areas can reveal penumbra tissue secondary to both proximal and distal MCA occlusions. However, salvage requires fairly reliable reperfusion in distal occlusion.

Abstract TMP55: Arterial Spin Labeling Study Immediately After Thrombectomy: A Mechanism of Poor Prognosis Despite Recanalization

Introduction: In thrombectomy, the mechanism of poor prognosis despite complete recanalization is still unclear. Hyperperfusion may be a such poor prognostic mechanism. Residual microcirculatory dysfunction after restored large artery blood flow (no-reflow phenomenon) may also be a potential mechanism. MRI with arterial spin labeling (ASL) can easily assess cerebral perfusion. We here investigated the mechanism of poor prognosis despite recanalization by analyzing ASL images immediately after thrombus retrieval. Methods: This study included 41 consecutive cases (July 2019 to July 2023) with ICA or M1 embolic occlusions who underwent successful thrombectomy (mTICI3) and immediate post-operative ASL-MRI. Regional cerebral blood flow (CBF) on the ASL images were automatically quantified by means of 3DSRT software using 318 constant ROIs classified into 12 segments in each hemisphere. We evaluated the contralesional CBF ratio not only for the entire middle cerebral artery area and each of its segments, but also for each 3DSRT ROIs around the central sulcus (central arterial segment including 28 ROIs). These results of the post-operative ASL evaluation were compared between the favorable prognosis group (mRS 0-2 at 3 months) and the poor prognosis group (mRS 3-6). Results: There was no difference between the poor prognosis group (n=14) and the favorable prognosis group (n=27) in the comparison of the contralesional CBF ratio for the entire middle cerebral artery area or for each segment. However, the number of ROIs in the central segment decreased by 10% CBF or more and by 20% CBF or more compared to the contralesional side were significantly higher (both p&lt;0.01) in the poor prognosis group (19.1% against 11.8%, 3.1% against 0%, respectively). There was no difference in comparing the number of ROIs with increased CBF. Conclusions: This study showed that a high number of small-area (ROI) circulatory dysfunction (suggesting no-reflow phenomenon) was associated with a poor prognosis despite complete recanalization.

Intracerebral hemorrhage and ischaemic stroke due to Moyamoya disease in young patients: a case report

Link of Video Abstract: https://youtu.be/DWVi34rPNOg Background: Moyamoya disease (MMD) is a non-atherosclerotic cerebrovascular disorder characterized by progressive stenosis of the distal part of the internal carotid artery (ICA), thus forming an abnormal vascular network in the base of the brain. MMD is often found in women. The common symptoms of MMD are migraine, epilepsy, recurrent transient ischemic attack (TIA), ischemic stroke, and intracerebral hemorrhage. Stroke at young onset has challenges in looking for risk factors and etiology. A detailed examination is needed to prevent recurrent strokes. Case Presentation: Male 17-year-old complained of a throbbing headache on the right side for 5 months, with a numeric rating scale (NRS) 4. The headache duration was 24-72 hours, with a frequency of 1-2 times a month. Complaints are exacerbated by activity and improve when taking over medication. 2 months after the first onset, he felt severe headache with NRS 7, accompanied by weakness and tingling on the left side. All his laboratory results were within normal limits. Cerebral Digital Subtraction Angiography (DSA) results showed severe stenosis at the base of the right ICA bifurcation segment accompanied by slow flow at the right middle cerebral artery (MCA) and severe stenosis at the base of the left ICA accompanied by cross-filling to the contralateral anterior cerebral artery (ACA). Cortico-cortical collaterals were obtained from the posterior cerebral artery (PCA) branch covering the MCA area. The patient was diagnosed with MMD. Conclusion: MMD is a rare cerebrovascular disease that can be a risk factor for stroke at a young age. Diagnosis and evaluation of the collateral system need to be carried out through cerebral angiography so that the selection and consideration of appropriate management of recurrent stroke attacks can be carried out.

Intracranial Fibromuscular Dysplasia in a Male Child Presented by Middle Cerebral Artery Dissection and Stroke

Fibromuscular dysplasia (FMD) is a group of nonatherosclerotic, noninflammatory arterial diseases that most commonly involve the renal and carotid arteries it typically occurs in women aged between 30 and 50 years. FMD in children is rare and its most common site of involvement are renal arteries. Stroke in children is generally uncommon and due to FMD is even rarer, which is why it is often unrecognized. We present a case of a boy, with an inconspicuous previous anamnesis and orderly development, who woke up at the age of 9 with weakness of the left side of the body and speech disorders. MR showed an ischemic lesion in the irrigation area of the right middle cerebral artery (arteria cerebri media- ACM). In neurological status mild dysarthria with left central facial nerve lesion was noted as well as mild paresis of the left extremities. Neurosonological testing showed segmental extensions and narrowing of the right ACM with underlying dissection, which speaks in favour of fibromuscular dysplasia. Therapy with acetylsalicylic acid 50 mg was initiated, and with further follow-up of the patient, complete regression of symptoms and normal neurological status were recorded.

The automatic evaluation of steno-occlusive changes in time-of-flight magnetic resonance angiography of moyamoya patients using a 3D coordinate attention residual network.

Moyamoya disease (MMD) is a rare cerebrovascular occlusive disease with progressive stenosis of the terminal portion of internal cerebral artery (ICA) and its main branches, which can cause complications, such as high risks of disability and increased mortality. Accurate and timely diagnosis may be difficult for physicians who are unfamiliar to MMD. Therefore, this study aims to achieve a preoperative deep-learning-based evaluation of MMD by detecting steno-occlusive changes in the middle cerebral artery or distal ICA areas. A fine-tuned deep learning model was developed using a three-dimensional (3D) coordinate attention residual network (3D CA-ResNet). This study enrolled 50 preoperative patients with MMD and 50 controls, and the corresponding time of flight magnetic resonance angiography (TOF-MRA) imaging data were acquired. The 3D CA-ResNet was trained based on sub-volumes and tested using patch-based and subject-based methods. The performance of the 3D CA-ResNet, as evaluated by the area under the curve (AUC) of receiving-operator characteristic, was compared with that of three other conventional 3D networks. With the resulting network, the patch-based test achieved an AUC value of 0.94 for the 3D CA-ResNet in 480 patches from 10 test patients and 10 test controls, which is significantly higher than the results of the others. The 3D CA-ResNet correctly classified the MMD patients and normal healthy controls, and the vascular lesion distribution in subjects with the disease was investigated by generating a stenosis probability map and 3D vascular structure segmentation. The results demonstrated the reliability of the proposed 3D CA-ResNet in detecting stenotic areas on TOF-MRA imaging, and it outperformed three other models in identifying vascular steno-occlusive changes in patients with MMD.

Summary a case of endovascular treatment of a patient with tandem occlusions of cerebral arteries caused by a mine-explosive injury

One case of successful endovascular treatment of a patient with a mine blast injury is presented, which due to the action of the blast wave led to traumatic dissection of the internal carotid artery and the right anterior cerebral artery, which in turn led to the development of a secondary ischemic stroke.The patient is a combatant, a 59-year-old man. During the artillery shelling of the position, he was thrown back by the explosive wave and briefly lost consciousness. Upon regaining consciousness, within two hours there was weakness and decreased sensation in the left limbs, which completely regressed, but cognitive impairment and communication problems were observed. Computed tomography of the brain performed in the hospital closest to the hostilities did not reveal any pathological changes. Two days later, the patient was taken to the Dnipropetrovsk Regional Hospital named after I.I. Mechnikov. Repeated computed tomography revealed a small infarct in the basin of Heubner's right artery. Cerebral angiography (CT angiography and subtraction selective cerebral angiography) revealed a short occlusion of the right internal carotid artery from its ostium to the upper border of its bulb, and lack of contrast of the A1-segment of the right anterior cerebral artery. Changes on the CT perfusion maps indicated critical oligemia in the entire basin area of the right middle cerebral artery. The patient at hospitalization is conscious, with preserved movements and sensitivity. However, the patient has significant cognitive decline (MoCA (Montreal Cognitive Assessment Scale) 17). After double antiplatelet preparation, endovascular recanalization and stenting of the occluded right internal carotid artery was performed via transfemoral access using combined proximal and distal antiembolic protection (Cello 9F balloon guide catheter and SpiderFX distal antiembolic protection device) and with implantation of a carotid stent Protégé. Blood flow in the right internal carotid artery has been restored, there are no carotid artery stenoses on the right, the basin of the middle cerebral artery on the right is completely contrasted. In two days, there is normalization on the CT perfusion maps and recovery of the patient's cognitive functions to the MoCA 24.

Ca lâm sàng: Cơn cường giao cảm kịch phát sau đột quỵ nhồi máu não cấp

Background: Paroxysmal sympathetic hyperactivity (PSH) may occur after acute ischemic stroke. The clinical presentation of PSH results from increased sympathetic overdrive, including transient paroxysms of tachycardia, hypertension, hyperventilation, hyperthermia, dystonic posturing, and excessive sweating. The exact pathophysiology of PSH, however, remains unclear, and no definitive treatment is available. Case presentation: Herein, the authors report a case of PSH in a female patient who experienced an acute ischemic stroke, for which a good clinical outcome. An 88-year-old woman was admitted to 108 Military Central Hospital. She had a Glasgow Coma Scale (GCS) score of 9 (M4V2E3), right hemiplegia, NIHSS score of 29. At admission, computed tomography revealed a reduction in the density of the left hemisphere, the blood supply area of the left middle cerebral artery (ASPECT 2 points). 12 days after ischemic stroke, the patient was diagnosed with PSH based on PSH-AM score (19 points). Morphine, gabapentin, and baclofen were administered; the drug effect was sufficient. 17 days poststroke, the patient gradually recovered from the adrenergic symptoms of PSH, and head computed tomography performed 12 days after stroke revealed improvement. Ultimately, the patient recovered with GCS score of 12 (M5V3E4), NIHSS score of 16, and lived at home. Conclusion: The outcome of the present case demonstrates that PSH can be reversed if it is identified early and before it becomes irreversible, that is, post the development of hypoxic encephalopathy or hemorrhagic transformation in ischemic stroke. * Keywords: Paroxysmal sympathetic hyperactivity; Acute ischemic stroke.

Stroke in Maputo central hospital, Mozambique: a cross-sectional study 2014–18

Objective: Stroke is the second leading cause of death worldwide. The prevalence of hypertension (the major risk factor for stroke) in Mozambique increased from 33.1% in 2005 to 38.9% in 2014/2015, although awareness and control remained at very low levels (15% and 3%, respectively). The aim of this study is to characterize the demographic and clinical pattern of stroke in Maputo Central Hospital (MCH), Mozambique. Methods: A cross-sectional hospital-based study was carried out in MCH, collecting secondary data from hospitalized patients with stroke. Using systematic probabilistic sampling, clinical records were used to analyze data for the period 2014-18. Results: Of the 402 clinical records, 53.5% were female. The mean age was 60.68 years (13.98 SD). Around 96% was an acute stroke event, and 91% was first-ever episode. Thirty one percent did not receive a CT scan for confirmation. Of the 247 CT scanned patients, 50.2% were ischemic. The area of middle cerebral artery was affected in 83.4% patients. The most common co-morbidity was hypertension (87.1%). Near 96% of hemorrhagic stroke were associated with hypertension (Ischemic = 78.7%, p &lt; 0.001). The overall case-fatality was 22.9%. Confirmed hemorrhagic stroke patients were 6.47 years younger than ischemic (56.40 vs 62.87 years; p &lt; 0.001). Younger ages and female were associated with clinical improvement (aOR = 0.964; p = 0.002 and aOR = 1.890; p = 0.044, respectively). Hemorrhagic stroke were 56.8 percent points more likely associated with death (aOR = 0.432; p = 0.010). The likelihood of clinical improvement was 20.5 percent points better over the years (aOR = 1.205; p = 0.086) Conclusions: Stroke associated with hypertension is common in MCH, mostly likely due to an increase in hypertension prevalence and extremely low awareness and control. Favorable clinical outcome improved over the years. Efforts for CT scan to all stroke episodes should be emphasized by MCH managers.

Pseudo-continuous arterial spin labeling with short post-labeling delay time sensitively reflects the hemodynamics of symptomatic patients with permanent large vessel occlusion before and after revascularization.

This study evaluated the feasibility of arterial spin labeling (ASL) for diagnosing hemodynamic stroke due to permanent anterior circulation large vessel occlusion. Three-dimensional pseudo-continuous ASL data at two post-labeling delay (PLD) times (1.5 and 2.5s) in patients with unilateral permanent middle cerebral artery (MCA) segment 1 (M1) or internal cerebral artery (ICA) occlusion were acquired during routine magnetic resonance angiography. Sixty-one patients with symptomatic occlusion (M1, 24; ICA, 37) and 69 patients with asymptomatic occlusion (M1, 21; ICA, 48) were enrolled. Regions of interest were automatically placed in the MCA region using a template. The respective scans were compared with asymptomatic M1 or ICA occlusion scans. The ratio of signal intensity (occlusion side/non-occlusion side) in the perfusion area of MCA (asymmetry index [AI]) was compared between both groups. In both PLD groups, AI was significantly lower in symptomatic patients than in asymptomatic patients. The receiver operating characteristic curve showed moderate capacity for the prediction of symptomatic AI in both groups (area under the curve, 0.739 and 0.712, respectively). As a result of extracranial-intracranial bypass operation in 28 symptomatic (M1, eight; ICA, 20) patients, AI was significantly higher postoperatively in the PLD 1.5s group than in the PLD 2.5s group. In symptomatic patients with permanent large vessel occlusion, the signal intensity ratio of pseudo-continuous ASL with short PLD sensitively reflects the hemodynamics before and after revascularization; therefore, this technique may be an alternative method in situations where PET or SPECT cannot be performed.

A Pilot Study of Radiomic Based on Routine CT Reflecting Difference of Cerebral Hemispheric Perfusion.

BackgroundTo explore the effectiveness of radiomics features based on routine CT to reflect the difference of cerebral hemispheric perfusion.MethodsWe retrospectively recruited 52 patients with severe stenosis or occlusion in the unilateral middle cerebral artery (MCA), and brain CT perfusion showed an MCA area with deficit perfusion. Radiomics features were extracted from the stenosis side and contralateral of the MCA area based on precontrast CT. Two different region of interest drawing methods were applied. Then the patients were randomly grouped into training and testing sets by the ratio of 8:2. In the training set, ANOVA and the Elastic Net Regression with fivefold cross-validation were conducted to filter and choose the optimized features. Moreover, different machine learning models were built. In the testing set, the area under the receiver operating characteristic (AUC) curve, calibration, and clinical utility were applied to evaluate the predictive performance of the models.ResultsThe logistic regression (LR) for the triangle-contour method and artificial neural network (ANN) for the semiautomatic-contour method were chosen as radiomics models for their good prediction efficacy in the training phase (AUC = 0.869, 0.873) and the validation phase (AUC = 0.793, 0.799). The radiomics algorithms of the triangle-contour and semiautomatic-contour method were implemented in the whole training set (AUC = 0.870, 0.867) and were evaluated in the testing set (AUC = 0.760, 0.802). According to the optimal cutoff value, these two methods can classify the vascular stenosis side class and normal side class.ConclusionRadiomic predictive feature based on precontrast CT image could reflect the difference of cerebral hemispheric perfusion to some extent.

EFFECT OF INDIVIDUALLY-TAILORED TDCS AND SYMBOLIC ART THERAPY FOR CHRONIC ASSOCIATIVE PROSOPAGNOSIA AFTER INFECTION BY SARS-COV-2, NEUROCOVID-19 AND ISCHEMIC STROKE

Background The rehabilitation of patients with chronic prosopagnosia that occurs following a stroke is a challenge for modern medicine. Dysfunction to the facial processing areas is permanent and standard rehabilitation brings only limited improvement. Therefore, therapists suggest reinforcing the compensatory strategies used by such patients such as voice, figure, and gait recognition to help with the identification of a particular person, which promotes their social functioning. New neurotechnologies, especially QEEG/ERPs, displays of functional brain impairment in prosopagnosia, may be helpful in developing an appropriate neurotherapy protocol and create the conditions for other forms of rehabilitation in such patients. The purpose of our study was twofold: 1) to evaluate QEEG/ ERPs shows of post-stroke functional impairment associated with prosopagnosia, 2) to construct a neurofeedback protocol based on these indices to sup- port the neuropsychological rehabilitation of the case study described herein. We present the case of a 23-year-old right-handed student of the Graphics Faculty of the Academy of Fine Arts, with chronic associative prosopagnosia after infection with SARS-CoV-2 followed by Covid-19 and a right hemisphere stroke. He was re- ferred in April 2021 for diagnosis and therapy at the Reintegration and Training Cen- ter of the Polish Neuropsychological Society (PTNeur). Six months earlier, in October 2020, the patient had been admitted to the Infectious Disease Hospital. COVID-19 was diagnosed based on coronavirus 2 (SARS-CoV-2) reverse transcrip- tion PCR (RT-PCR) on a nasopharyngeal swab. The neurological examination re- vealed muscle weakness on the left side of the body, slow and aprosodic speech, preserved comprehension, and acute left homonymous hemianopsia, as well as prosopagnosia and mirror symptom. The patient was sedated and mechanically ventilated for six days. The CT-scan showed foci in the posterior part of the superior temporal lobe and hyperintense changes in the blood supply area of the right middle cerebral artery. After 30 days of hospitalization, the patient was discharged from this hospital and referred to an outpatient rehabilitation center for five months. Ther- apy improved his general condition but did not remove the chronic prosopagnosia: a personal tragedy for the patient which prevented him from continuing his studies. He was diagnosed at the PTNeur Reintegration and Training Center within the next few weeks: (1). ophthalmologic examinations revealed no pathology; (2) neuropsy- chological testing confirmed the presence of chronic apperceptive prosopagnosia; (3) examination of event-related potentials (ERPs) revealed a large delay of the N170 wave, particularly on the right side, indicating a slowing of the rate of nerve impulses in early face processing and a cause of prosopagnosia. The patient was referred for rehabilitation: he participated in 20 sessions of individually tailored anodal transcranial direct current stimulation (tDCS) twice a week for ten weeks, and in parallel, for indi- vidualized Prosopagnosia Symbolic Art Therapy provided once a week for ten weeks. By the end of therapy, the patient was not only recognizing but also painting portraits of faces. He returned to college, finished and defended a master’s thesis in Artistic Drawing, in which facial presentation played an important role. Quantitative EEG (QEEG) and event-related potentials (ERPs) neuromarkers helped to understand the mechanism of prosopagnosia and to choose an individualized protocol, thus the appropriate application of tDCS in our patient, which accelerated the recovery of the ability to perform complex tasks and created the conditions for Symbolic Art Therapy. Modern medicine can successfully use such a management protocol in individuals with chronic prosopagnosia.

Analysis of cerebral perfusion of leptomeningeal branch and perforating branch of unilateral middle cerebral artery with severe stenosis or occlusion based on multi-delay arterial spin labeling

Objective: To compare the cerebral perfusion differences between the symptomatic patients and the asymptomatic patients with unilateral middle cerebral artery (MCA) severe stenosis or occlusion by using three post labeling delays (PLD) of the three-dimensional pseudo-continuous arterial spin labeling (pCASL) technique. Methods: The clinical characteristics and ASL data of the 27 patients with severe stenosis or occlusion of unilateral MCA (18 symptomatic, 9 asymptomatic) were prospectively enrolled from April 2018 to November 2019 in the Department of Radiology of China-Japan Friendship Hospital. There were 16 males and 11 females, age range from 29 to 85 (55±13) years. According to the symptoms, they were divided into symptomatic group (18 cases) and asymptomatic group (9 cases). The parameters of cerebral blood flow (CBF), mean cerebral blood flow (mCBF), arterial transit time (ATT) and arterial cerebral blood volume (aCBV) were obtained using the Cereflow software. One-way multivariate analysis of variance (one-way MANOVA) was used to compare the differences of cerebral perfusion parameters between symptomatic group and asymptomatic group, and between the affected side and the control side in the two groups. Two-way ANOVA was used to evaluate the effects of symptoms, hemisphere (affected and control side), PLD times (1.5, 2.0 and 2.5 s) and the interaction between the two factors. Results: The CBF of the affected leptomeningeal branch and perforating branch of MCA in symptomatic group was lower than that in asymptomatic group [(36.8±10.2) ml·100 g-1·min-1 versus (46.6±13.9) ml·100 g-1·min-1, F(1, 75)=13.279, P=0.000 49; (32.3±8.3) ml·100 g-1·min-1 versus (36.2±7.5) ml·100 g-1·min-1, F (1, 75)=4.065, P=0.047], and there was no interaction between the symptom and PLD [F(2, 75) =0.061, P=0.940]. In the symptomatic group, the CBF of the leptomeningeal branch and perforating branch of MCA in affected side was lower than that in control side [(36.8±10.2) ml·100 g-1·min-1 versus (43.7±10.0) ml·100 g-1·min-1, F(1, 102)=12.559, P=0.000 59; (32.3±8.3) ml·100 g-1·min-1 versus (36.4±8.0) ml·100 g-1·min-1, F(1, 102)=6.493, P=0.012]. In the symptomatic group, the CBF of leptomeningeal branch of MCA when PLD was 2.5 s was 7.34 ml·100 g-1·min-1, which were higher than that when PLD of 1.5 s (95%CI: 0.72-13.9, P=0.03). There was no interaction between PLD and hemisphere [F(2, 102) =0.307, P=0.736]. Conclusions: The collateral circulation in the blood supply area of MCA in asymptomatic patients with severe unilateral MCA stenosis or occlusion is more abundant than that in symptomatic patients. ASL can be an effective technique for evaluating the cerebral perfusion of collateral circulation in patients with severe stenosis or occlusion of MCA.

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages

Background and importanceIn cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages. Clinical presentationA 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital. ConclusionOpen surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.

Study of the effectiveness of neuroprotective therapy in restoring motor function in patients during the acute period of ischemic stroke

The purpose of the work was to study the effect of neuroprotective therapy with Cellex on the features of recovery of movement disorders in patients in the acute period of ischemic stroke. A single-center randomized study was conducted to assess the efficacy and safety of the use of neuroprotective therapy with Cellex in patients in the acute period of ischemic stroke. The study included 60 patients with a stroke duration of no more than 3 days in the middle cerebral artery area and vertebrobasillar area with moderate and severe central hemiparesis. Patients of the study group received 1 ml of Cellex. subcutaneously 1 time per day for 10 days. All patients received drug therapy and rehabilitation measures within the framework of the standard of care for patients with ischemic stroke. Against the background of the therapy, by the end of the study on days 14-21, the study and control groups showed a significant improvement according to clinical scales: NIHSS, mRS, RMI. The patients of the study group showed a more pronounced recovery of motor function, relative to the comparison group, according to motor scales: «A-D» FMA (54 [53; 62] and 42 [34; 51], p=0.03), «E-F» FMA (29 [28; 33] and 25 [18; 27], p=0.03), ARAT (47 [48; 57], 32 [24; 48], p=0.046). Among the patients of the study group, by the end of the study, the severity of mild stroke was 67%, relative to the comparison group 11% (χ21df=6.48; p=0.01). The use of neuroprotective therapy in the form of Cellex had a positive effect on both the prognostic score and the long-term assessment according to the SSS scale, due to the regression of motor disorders of the upper and lower extremities. The study has demonstrated the effectiveness of the use of neuroprotective therapy in the treatment of movement disorders in patients in the acute period of ischemic stroke. Therapy with Cellex helped to reduce the severity of stroke, and had a positive effect on the prognosis of the disease.

Image Patch-Based Net Water Uptake and Radiomics Models Predict Malignant Cerebral Edema After Ischemic Stroke.

Malignant cerebral edema (MCE) after an ischemic stroke results in a poor outcome or death. Early prediction of MCE helps to identify subjects that could benefit from a surgical decompressive craniectomy. Net water uptake (NWU) in an ischemic lesion is a predictor of MCE; however, CT perfusion and lesion segmentation are required. This paper proposes a new Image Patch-based Net Water Uptake (IP-NWU) procedure that only uses non-enhanced admission CT and does not need lesion segmentation. IP-NWU is calculated by comparing the density of ischemic and contralateral normal patches selected from the middle cerebral artery (MCA) area using standard reference images. We also compared IP-NWU with the Segmented Region-based NWU (SR-NWU) procedure in which segmented ischemic regions from follow-up CT images are overlaid onto admission images. Furthermore, IP-NWU and its combination with imaging features are used to construct predictive models of MCE with a radiomics approach. In total, 116 patients with an MCA infarction (39 with MCE and 77 without MCE) were included in the study. IP-NWU was significantly higher for patients with MCE than those without MCE (p < 0.05). IP-NWU can predict MCE with an AUC of 0.86. There was no significant difference between IP-NWU and SR-NWU, nor between their predictive efficacy for MCE. The inter-reader and interoperation agreement of IP-NWU was exceptional according to the Intraclass Correlation Coefficient (ICC) analysis (inter-reader: ICC = 0.92; interoperation: ICC = 0.95). By combining IP-NWU with imaging features through a random forest classifier, the radiomics model achieved the highest AUC (0.96). In summary, IP-NWU and radiomics models that combine IP-NWU with imaging features can precisely predict MCE using only admission non-enhanced CT images scanned within 24 h from onset.

Combination of Single- and Paired-Pulse Somatosensory Evoked Potentials in Ischemic Monitoring: Preliminary Investigation in Carotid Endarterectomy.

IntroductionSevere ischemia induces cerebral excitability imbalance before completion of infarct. To investigate the clinical availability of this imbalance with ischemic monitoring, paired-pulse somatosensory evoked potentials (SEPs) were performed in conjunction with conventional SEPs during carotid endarterectomy.MethodsFor carotid endarterectomy patients with hemodynamic deficits of the middle cerebral artery area (n = 34), the excitability imbalances (Q) were measured by paired-pulse SEPs, wherein the second response (A2) was divided by the first (A1; Q = A2/A1). Regional cerebral saturation (rSO2) was also measured. Occlusion was performed twice using shunting.ResultsEach carotid occlusion induced a significant decrease in mean A1 and rSO2, and an increase in mean Q values (p < 0.001), which returned to the baseline level after occlusion. While neuronal imbalances were mostly transient, persistently increased Q values were observed in four cases (11.8%), all indicating postoperative abnormalities in diffusion-weighted magnetic resonance imaging (100%). Meanwhile, A1 detected the postoperative abnormality in only one case (25%). Preoperative Q values at the time of surgery were significantly higher in symptomatic patients having the upper limb deficits than those without (p < 0.01), indicating persistent or permanent imbalances.ConclusionPaired-pulse SEPs reliably identified transient, persistent or permanent neuronal imbalances, depending on the ischemic severity. These preliminary results indicated that paired-pulse SEPs, in combination with conventional SEPs (A1), may offer better ischemic monitoring.

Myelin and Axonal Damage in Normal-Appearing White Matter in Patients with Moyamoya Disease.

Although chronic ischemia is known to induce myelin and axonal damage in animal models, knowledge regarding patients with Moyamoya disease is limited. We aimed to investigate the presence of myelin and axonal damage in Moyamoya disease and their relationship with cognitive performance. Eighteen patients with Moyamoya disease (16-55 years of age) and 18 age- and sex-matched healthy controls were evaluated with myelin-sensitive MR imaging based on magnetization transfer saturation imaging and 2-shell diffusion MR imaging. The myelin volume fraction, which reflects the amount of myelin sheath; the g-ratio, which represents the ratio of the inner (axon) to the outer (axon plus myelin) diameter of the fiber; and the axon volume fraction, which reflects axonal components, were calculated and compared between the patients and controls. In the patients with Moyamoya disease, the relationship between these parameters and cognitive task-measuring performance speed was also evaluated. Compared with the healthy controls, the patients with Moyamoya disease showed a significant decrease in the myelin and axon volume fractions (P < .05) in many WM regions, while the increases in the g-ratio values were not statistically significant. Correlations with cognitive performance were most frequently observed with the axon volume fraction (r = 0.52-0.54; P < .03 in the right middle and posterior cerebral artery areas) and were the strongest with the g-ratio values in the right posterior cerebral artery region (r = 0.64; P = .004). Myelin-sensitive MR imaging and diffusion MR imaging revealed that myelin and axonal damage exist in patients with Moyamoya disease. The relationship with cognitive performance might be stronger with axonal damage than with myelin damage.

Fatal cerebral and cardiac infarction due to embolism of a mobile thrombus from aorta sinotubular junction atheroma in a 40-year-old female

Strokes in young adults present a challenging problem in terms of care and social impact. Most of cases in this cohort are classified as strokes of uncertain etiology. Application of multimodality diagnostic approach could help in the estimation of risk factors and underlying mechanisms. Simultaneous acute cardio-cerebral infarction is a rare manifestation, especially in young individuals. Large artery atherosclerosis should be excluded as a potential cause. Transesophageal echocardiography plays an important role in the diagnostic algorithm. The current article presents a clinical case of a fatal acute cardio-cerebral infarction in a 40-year old female without previous cardiovascular diseases and negative family history. Transesophageal echocardiography identified a large mobile thrombus at the sinotubular junction of ascending aorta. Transthoracic echocardiography revealed regional akinesia of the inferior wall, despite normal electrocardiogram. The autopsy findings confirmed co-occurrence of thromboembolic stroke in the right middle cerebral artery area and left ventricular inferior myocardial infarction due to thrombosis of the right coronary artery. This case documents an exceedingly rare phenomenon in this cohort of a cardio-cerebral thromboembolism due to single atherosclerotic plaque destabilization.

Use of Middle Cerebral Artery Visualization with Coronal Computed Tomography to Access Target Artery in Mechanical Thrombectomy

Background: When introducing a microguidewire into an occluded vessel during mechanical thrombectomy (MT), visual information on the vessel course distal to the occluded site could help to avoid perforation. We examined whether visualization of the middle cerebral artery (MCA) by coronal images of nonenhanced computed tomography (coronal CT) provides useful preoperative information on the vessel course in the setting of MT. Methods and Results: We retrospectively studied 29 patients with ischemic stroke of the internal carotid artery and MCA occlusion who were admitted to our hospital within 4.5 hours from stroke onset and underwent MT. Coronal CT images were preoperatively created by a dedicated workstation and adjusted to visualize the M1 segment of the MCA (M1) and nearby areas. We referred to these images while performing MT. The shape and course of M1 on preoperative coronal CT images were compared with that in intraoperative angiography after recanalization. The median time from the start of imaging to arterial puncture was 40 minutes (interquartile range: 32.5-55.0 minutes). Successful recanalization of the thrombolysis in cerebral infarction 2b-3 was achieved in 89.7% of patients. The degree of matching was assessed as moderate to excellent, and was useful as preoperative information in 27 (93.1%) patients. Conclusions: Preoperative information on the vessel course by coronal CT well matched that in the intraoperative angiography. Only a little extra time and a small additional procedure are necessary for this technique. The addition of coronal CT images could contribute to a safe and successful MT.