Cerebral Artery Territory Ischemic Stroke Research Articles

Psychosocial Considerations in Management of Corticobasal Degeneration in Indian American Population

AbstractBackgroundCorticobasal degeneration (CBD) is a neurodegenerative tauopathy primarily affecting the cerebral cortex and basal ganglia, often featuring cognitive decline and parkinsonism. With no proven treatments for this rare condition, the goals of management are to improve patients' quality of life. We evaluate here the unique psychosocial factors that were considered for two women of Asian Indian descent with CBD.MethodPatient 1 was a 77‐year‐old woman who exhibited short‐term memory loss, and then suffered an acute left anterior cerebral artery territory ischemic stroke with right‐sided hemiparesis and neurogenic pain. MRI Brain confirmed the stroke’s location, but did not account for cognitive decline. Patient 2 was a 75‐year‐old woman who initially experienced dysphagia, and then developed right‐sided hemiparesis, right neck spasms, unstable gait, and short‐term memory loss. MRI Brain and Cervical Spine revealed only showed mild chronic microvascular changes and multilevel cervical spondylosis.ResultsPET‐FDG Brain studies were performed for both patients. Patient 1’s study revealed severe hypometabolism affecting bilateral basal ganglia, bilateral thalami, and left supplementary motor cortex, out of proportion to the known stroke and consistent with CBD. Patient 2’s study revealed mild hypometabolism at the left frontal and parietal lobes, sparing the precuneus and posterior cingulate, also consistent with CBD and helping to explain the right‐sided hemiparesis.ConclusionVarious psychosocial factors were considered during the evaluation and management for both patients. Both had limited English proficiency, so cognitive testing was performed with the aid of a medical interpreter to ensure accurate results. Symptomatic treatment was tailored for each patient: Patient 1 received carbidopa/levodopa for parkinsonian tremors, and Patient 2 received cyclobenzaprine for intermittent muscle spasms. Both patients had multigenerational households, and results and prognoses were discussed with multiple relatives so they could coordinate responsibilities. Both families initially resisted recommendations to have home health aides, expressing their cultural belief that families should take care of their relatives on their own. As we discussed this belief over time, and explained the expected progression of symptoms over time, both families came to be more accepting of introducing home health aides, seeing them as a supplement, and not a replacement, for the family’s role.

Diagnosis and Management of Cerebral Venous Sinus Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Diagnosis and Management of Cerebral Venous Sinus Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Middle cerebral artery stroke following massive hornet sting: a case report

Hornet stings are frequently encountered in practice in Nepal. Majority of patients sustain minor illness. However, complications like anaphylactic shock and the rare acute kidney injury, multiple organ dysfunction and acute myocardial infarction have been reported. Ischemic stroke following hornet stings has been reported infrequently in scientific publications. We report a case of fatal right Middle Cerebral artery territory ischemic stroke and acute kidney injury in a 40-year farmer.

The comparative efficacy of theta burst stimulation or functional electrical stimulation when combined with physical therapy after stroke: a randomized controlled trial

Objective: To study the long-term effectiveness of Theta Burst Stimulation (TBS) or Functional Electrical Stimulation (FES) combined with Physical therapy (PT) as compared to PT alone for improving arm functions in patients with acute stroke. Design: Single blind randomized controlled trial. Setting: Outpatient clinics and inpatient wards at tertiary care neurology center. Subjects: Adult patients with acute middle cerebral artery territory ischemic stroke. Interventions: 60 patients were randomized into three groups of 20 each: TBS+PT; FES+PT; and PT alone. TBS group received intermittent TBS of ipsilesional hemisphere and continuous TBS of contralesional hemisphere while FES group received FES of paretic limb, both for four weeks. All groups received supervised physical therapy for four weeks followed by home physiotherapy for one year. Outcome measures: Fugl Meyer Assessment upper limb score (FMA-UL) was primary outcome measure. Patients were evaluated at baseline and subsequently at one, three and six months and one year. Results: Compared to PT group, mean FMA-UL scores were higher in TBS and FES groups at all follow-ups (P < 0.001). From baseline to one year, mean (SD) FMA-UL scores increased from 14.9(2.1) to 55.55(2.46) in TBS group, 15.5(1.99) to 55.85(2.46) in FES group, and 14.3(2.2) to 43.3(4.22) in PT group indicating an increase of 273%, 260%, and 203% respectively. There was no difference between FES and TBS groups. Conclusion: A four-week intervention with TBS or FES combined with PT produces better long-term arm functions as compared to PT alone in patients with acute stroke.

Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now?

This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.

B-58 * Neuropsychological and Neurobehavioral Sequelae of Anti-NMDAR Encephalitis: Three Case Studies

Objective: Research on the neurocognitive profile of the autoimmune disorder anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is limited. The current case studies contribute to existing knowledge by investigating the neuropsychological sequelae of three patients, two of which are male, diagnosed with anti-NMDAR encephalitis during the acute rehabilitation phase. Method: Two patients with confirmed anti-NMDAR encephalitis were assessed using a battery of neuropsychological tests. Another patient, also confirmed anti-NMDAR encephalitis, was unable to be formally assessed due to persisting psychiatric dysregulation. Patient 1 was a 19-year-old, African-American female, with a previous medical history of seizures, diagnosed with anti-NMDAR encephalitis secondary to an ovarian teratoma. Treatment included steroids, laproscopic surgery, anti-virals, anti-psychotics, anti-epileptics, and intravenous immunoglobin. Patient 2 was a 30-year-old, Caucasian male, with no previous medical history, admitted with new-onset seizures, right middle cerebral artery territory ischemic stroke, and eventual anti-NMDAR encephalitis. Treatment included steroids, anti-virals, anti-depressants, and anti-epileptics. Patient 3 was a 41-year-old, African-American male with a previous medical history of hypertension, cholesterol, and hernias. Treatment included alkylating agents, mood stabilizers, and anti-epileptics. Results: Fluctuating neurobehavioral and psychiatric disturbances impacted acute rehabilitation treatment in these patients. Persisting diffuse cognitive dysfunction with prominent impairments in memory and executive functioning was demonstrated in the two patients who were formally assessed and observed in the third patient. Conclusion(s): Anti-NMDAR encephalitis produces persistent cognitive dysfunction in males and females and impacts their neurobehavioral presentation during acute rehabilitation. Neuropsychological assessment of patients with anti-NMDAR encephalitis significantly assists with developing targeted interventions for neurorehabilitative treatment.

Effect of Middle Cerebral Artery Territory Ischemic Stroke on QT Interval

Prolonged QT interval associates with increased risk for sudden cardiac death after acute ischemic stroke. However, pathophysiology of prolonged QT interval after stroke is poorly elucidated. In this study, we investigated whether QT interval dynamics is different in patients with right and left middle cerebral artery (MCA) territory stroke. Electrocardiogram (ECG) intervals were compared between baseline (retrieved retrospectively from medical records) and admission (acquired at the acute hospital admission) in 33 patients (65 ± 9.5 years) with right or left MCA territory ischemic stroke. Head computed tomography (CT), cardiac ultrasound, and cardiac CT scans were undertaken. Stroke was located in the right MCA territory in 21 (64%) and in the left MCA territory in 12 (36%) patients. Patients with right and left MCA stroke were similar with respect to time interval between baseline and admission ECG recordings, positive history of heart disease, and left ventricular dimensions. Increase in heart rate-corrected QT interval (QTc) from baseline to admission was demonstrated to occur more often in patients with right (16 of 21; 76%) than in patients with left (3 of 12; 25%; P < .01) MCA stroke. ΔQTc between baseline and admission was significantly longer in patients with right (23 ± 23 milliseconds) than in patients with left (-11 ± 19 milliseconds; P < .0001) MCA stroke. Percent ΔQTc between baseline and admission was longer in patients with right (5.5% ± 5.5%) than in patients with left (-2.6% ± 4.7%; P < .001) MCA stroke. Right MCA ischemic stroke results in prolongation of QT interval. Findings indicate cerebral asymmetry in brain-heart interaction during acute ischemic stroke.

Anticoagulation Should Not Be Used in Most Patients With Stroke With Infective Endocarditis

One of the most worrisome consults to the stroke service is the patient with neurological symptoms in the setting of infective endocarditis (IE). Stroke is the main neurological complication of IE and in 50% to 75% is the presenting feature. The most effective strategy for the prevention of a first or recurrent stroke is the prompt institution of appropriate antibiotic therapy, which reduces the risk to 1% to 3% within the first week.1 Ischemic stroke is 3-fold more common than hemorrhagic stroke. Embolic patterns are seen on diffusion-weighted MR in 92% of patients with stroke or encephalopathy. Initiating anticoagulation may seem reasonable to prevent embolization of infected or bland platelet–fibrin valvular vegetations—perhaps enhanced in the presence of antiphospholipid antibodies—and it is the standard of care for most cardioembolic stroke; however, the stroke risk is similar in the presence or absence of anticoagulants at onset of IE. The most compelling reason to avoid anticoagulation in Staphylococcus aureus IE is the predominance of early …

Prediction of clinical outcome with baseline and 24-hour perfusion CT in acute middle cerebral artery territory ischemic stroke treated with intravenous recanalization therapy

We sought to determine whether Alberta Stroke Program Early CT Scores (ASPECTS) derived from baseline noncontrast CT (NCCT) and perfusion CT (CTP) imaging maps can predict clinical outcome after recanalization therapy in acute ischemic stroke of the middle cerebral artery (MCA) territory and whether changes in the ASPECTS from baseline to 24 h after recanalization therapy can help predict clinical outcome. We retrospectively studied consecutive patients with acute ischemic stroke of the MCA territory treated with intravenous tissue plasminogen activator (t-PA) or abciximab within 6 h of symptom onset. We performed NCCT and CTP before and 24 h after intravenous t-PA or abciximab treatment and determined the ASPECTS and the changes in the ASPECTS from baseline to 24 h. A favorable outcome was defined as a modified Rankin scale score of 0 or 1 at 3 months. During the 18-month study period 44 patients were studied. In multivariate logistic regression analysis, the cerebral blood volume (CBV) ASPECTS (OR 1.80, 95% CI 1.10 to 2.93) at baseline and the increase in cerebral blood flow (CBF) ASPECTS (OR 1.68, 95% CI 1.13 to 2.50) from baseline to 24 h were associated with a favorable outcome. The cutoff values for a favorable outcome using receiver operating characteristic curves were 8 and 1, respectively. When the CBV ASPECTS at baseline was 8 or more, its positive predictive value was only 58.1%. When the CBV ASPECTS at baseline was 8 or more and the increase in CBF ASPECTS from baseline to 24 h was 1 or more, the positive predictive value was 100% and the negative predictive value was 74.2%. The CBV ASPECTS derived from baseline CTP maps was found to be predictive of a favorable outcome, but its positive predictive value was suboptimal. The change in the CBF ASPECTS from baseline to 24 h after treatment was helpful in predicting outcome.

QEEG Prognostic Value in Acute Stroke

The objective of our study is to determine the predictive value of QEEG in patients suffering from an acute ischemic cerebral stroke. Twenty-eight patients were studied within the first 72 hours of clinical evolution of middle cerebral artery territory ischemic stroke. Thirty-seven QEEG recordings were obtained: 13 in the first 24 hours after cerebral stroke onset, 9 between 24-48 hours and 15 between 48-72 hours. Absolute Energies (AE) were the QEEG selected variables for statistical analysis: first, AE Z values were calculated using the Cuban QEEG norms, then the maximum and minimum AE Z values were selected within each frequency band and total power. The medians of the five neighboring Z values were also chosen. Regression models were estimated using the RANKIN scores as dependent variables and the selected QEEG variables as independent, then outcome predictions at hospital discharge and 3 months later were calculated. Percentages of concordance and errors between the estimated and real outcome scores were obtained. Alpha and theta AE were the best predictor for short-term outcome and delta AE for long-term outcome. We conclude that QEEG performed within the first 72 hours of ischemic stroke might be a powerful tool predicting short- and long-term outcome.

Dynamic Cerebral Autoregulation in Acute Lacunar and Middle Cerebral Artery Territory Ischemic Stroke

We addressed whether dynamic cerebral autoregulation (dCA) is affected in middle cerebral artery (MCA) territory (MCAS) and lacunar ischemic stroke (LS). Blood pressure (MAP) and MCA velocity (V) were measured in 10 patients with large MCAS (National Institutes of Health Stroke score, 17+/-2; mean+/-SEM), in 10 with LS (score, 9+/-1), and in 10 reference subjects. dCA was evaluated in time (delay of the MCA Vmean counter-regulation during changes in MAP) and frequency domains (cross-spectral MCA Vmean-to-MAP phase lead). In reference subjects, latencies for MAP increments (5.3+/-0.5 seconds) and decrements (5.6+/-0.5 seconds) were comparable, and low frequency MCA Vmean-to-MAP phase lead was 56+/-5 and 59+/-5 degrees (left and right hemisphere). In MCAS, these latencies were 4.6+/-0.7 and 5.6+/-0.5 seconds in the nonischemic hemisphere and not detectable in the ischemic hemisphere. In the unaffected hemisphere, phase lead was 61+/-6 degrees versus 26+/-6 degrees on the ischemic side (P<0.05). In LS, no latency and smaller phase lead bilaterally (32+/-6 and 33+/-5 degrees) conformed to globally impaired dCA. In large MCAS infarcts, dynamic cerebral autoregulation was impaired in the affected hemisphere. In LS, dynamic cerebral autoregulation was impaired bilaterally, a finding consistent with the hypothesis of bilateral small vessel disease in patients with lacunar infarcts.

Magnetic Resonance Image Correlates of Hemiparesis After Neonatal and Childhood Middle Cerebral Artery Stroke

Motor impairment after neonatal and childhood-onset ischemic stroke (IS) is common, although the prevalence and type of hemiparesis differs between the 2 age groups. Lesion topography is an important predictor of hemiparesis after neonatal IS, but it is not known if the same topographic predictors of adverse motor outcome apply to childhood-onset IS. We used a consistent approach to define lesion topography and evaluate motor outcome in both age groups to (1) investigate whether early topographic predictors of hemiparesis after unilateral middle cerebral artery-territory stroke are the same in neonates and older children and (2) compare the prevalence of dystonia and loss of independent finger movements between the 2 age groups. Twenty-eight patients with neonatal-onset IS (Hammersmith Hospital, London, United Kingdom) were studied together with 43 patients with childhood-onset IS (Great Ormond Street Hospital, London, United Kingdom). All patients had exclusive unilateral middle cerebral artery-territory IS. Lesion topography was studied by using the first magnetic resonance image acquired after the onset of symptoms and was coded for involvement of cerebral cortex (CC), posterior limb of the internal capsule (PLIC), basal ganglia (BG), and white matter. The primary outcome was hemiparesis, and secondary outcomes were dystonia and loss of age-appropriate independent finger movements. Hemiparesis was more common after childhood-onset IS (56%) than neonatal-onset IS (24%). In neonatal-onset IS, concomitant involvement of BG, CC, and PLIC predicts the development of hemiparesis (odds ratio: 99; 95% confidence interval: 5.2-1883.8), and no child with 1 or 2 of these structures involved developed hemiparesis. In contrast, in childhood-onset IS, concomitant BG, CC, and PLIC lesions tended to be associated with hemiparesis (9 of 11), but this adverse outcome was seen also among patients with 1- or 2-site involvement. However, hemiparesis was less likely if the infarction involved BG only (odds ratio: 0.162; 95% confidence interval: 0.036-0.729). Dystonia was present in 15 of 24 in the childhood-onset group with hemiparesis but was not seen after neonatal-onset IS. In both age groups upper-limb impairment was more severe than lower-limb impairment, with frequent loss of independent hand function among hemiparetic patients. In neonatal and childhood-onset IS, early magnetic resonance imaging provides useful prognostic information about subsequent motor outcome. There are differences in the functional response of the neuromotor system to injury between the 2 age groups that cannot be attributed to methodological differences alone.

2-07-17 The value of three-phase spiral CT in acute middle cerebral artery territory ischemic stroke

2-07-17 The value of three-phase spiral CT in acute middle cerebral artery territory ischemic stroke