Cerebral Territory Research Articles

Paradoxically Decreased Mean Transit Time in Patients Presenting With Acute Stroke.

Computed tomography perfusion (CTP) has become a mainstay in acute stroke management. The aim of this study was to investigate the occurrence of an unreported phenomenon of a paradoxically decreased mean transit time (MTT) in the cerebral area of ischemia. In this retrospective study, patients with an acute anterior circulation ischemic stroke were selected. Computed tomography perfusion diffusion maps of all patients were reviewed by 2 blinded and experienced neuroradiologists. A total of 31 patients were included in the study. Eighteen subjects (58%) had a paradoxical MTT perfusion map, whereas only 13 (42%) had an expected CTP profile. No significant associations between the paradoxical MTT perfusion and the size of the infarct, the side of the occlusion, or the age of the patients were observed. However, a trend in collateral circulation status and paradoxical MTT was noted. A paradoxical MTT response is a frequent finding in CTP analysis of patients with acute stroke. Its presence is not associated to the location or size of the affected cerebral territory and could be related to the presence of collateral circulation.

Effect of Core Temperature and Embolic Load During Cardiac Surgery on Motion Perception

Cognitive decline post-cardiac surgery is of clinical concern. To better understand it a sensitive and specific measure of post-surgery brain impairment is required. The cerebral territory most likely to be adversely affected by surgery is the posterior "watershed" territory. We have designed a psychophysical task involving reading letters defined by motion aimed at measuring the integrity of a cortical area (MT) located in this territory. Patients undergoing coronary artery bypass grafting (CABG) and a healthy control group were given the psychophysical test twice, pre- and post-surgery for the patient group. There was no overall difference in performance between the surgery group and the control group at either pre- or post-surgery testing. However, multivariate analysis of surgical variables such as body temperature and embolic load to the brain as measured by Transcranial Doppler showed that patients with warmer core temperatures and higher embolic loads performed significantly worse on the motion defined letter reading tasks than those with more favourable surgical variables. These results demonstrate that high embolic load and warm core body temperatures lead to poor motion perception post-cardiac surgery, implying damage to the posterior watershed cortex.

Brain perfusion evaluated by perfusion-weighted magnetic resonance imaging before and after stenting internal carotid artery stenosis in asymptomatic and symptomatic patients

PurposeTo evaluate the brain perfusion with MRI perfusion weighted imaging (PWI) before and after ICA stenting in asymptomatic and symptomatic patients. Materials and methodsPWI was performed 3–21 days before and 3 days after ICA stenting in 31 asymptomatic patients with ICA >70% stenosis – Group I, and in 14 symptomatic patients with ICA >50% stenosis – Group II. PWI was evaluated qualitatively and quantitatively in 5 cerebral territories with: mean transit time (MTT), cerebral blood volume (CBV) and cerebral blood flow (CBF). Mean values of perfusion parameters were measured before and after stenting ΔMTT, ΔCBV, ΔCBF were calculated as subtraction of after-treatment values from those before treatment. ResultsIn qualitative evaluation after ICA stenting perfusion was normalized in 21 patients (80.8%) in Group I and in 8 patients (80%) in Group II.In quantitative estimation MTT decreased significantly after CAS on stented side vs. non-stented side in all examined patients regardless of the group, p<0.05. MTT decreased more in Group II than in Group I in all territories (p<0.05) with the exception of temporal lobe. CBV and CBF have shown insignificant differences. Conclusions1.In MRI the most useful parameters to assess brain perfusion are MTT and ΔMTT: regardless whether patients are asymptomatic or symptomatic.2.There were no significant differences in CBV and CBF after stenting in both groups of patients.3.The positive effect of ICA stenting measured with decrease of MTT, CBV values and increase of CBF value is more prominent in symptomatic patients.

Brain oxygenation responses to an autonomic challenge: a quantitative fMRI investigation of the Valsalva manoeuvre.

In late age, the autonomic nervous system (ANS) has diminished ability to maintain physiological homeostasis in the brain in response to challenges such as to systemic blood pressure changes caused by standing. We devised an fMRI experiment aiming to map the cerebral effects of an ANS challenge (Valsalva manoeuvre (VM)). We used dual-echo fMRI to measure the effective transverse relaxation rate (R2*, which is inversely proportional to brain tissue oxygenation levels) in 45 elderly subjects (median age 80 years old, total range 75-89) during performance of the VM. In addition, we collected fluid-attenuated inversion recovery (FLAIR) data from which we quantified white matter hyperintensity (WMH) volumes. We conducted voxelwise analysis of the dynamic changes in R2* during the VM to determine the distribution of oxygenation changes due to the autonomic stressor. In white matter, we observed significant decreases in oxygenation levels. These effects were predominantly located in posterior white matter and to a lesser degree in the right anterior brain, both concentrated around the border zones (watersheds) between cerebral perfusion territories. These areas are known to be particularly vulnerable to hypoxia and are prone to formation of white matter hyperintensities. Although we observed overlap between localisation of WMH and triggered deoxygenation on the group level, we did not find significant association between these independent variables using subjectwise statistics. This could suggest other than recurrent transient hypoxia mechanisms causing/contributing to the formation of WMH.

Outcomes of Patients With Acute Type B (DeBakey III) Aortic Dissection: A 13-Year, Single-Center Experience.

Background—Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period.Methods and Results—We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD–thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation.Conclusions—In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.

A Thrombotic Stroke Model Based On Transient Cerebral Hypoxia-ischemia

Stroke research has endured many setbacks in translating neuroprotective therapies into clinical practice. In contrast, the real-world therapy (tPA thrombolysis) rarely produces benefits in mechanical occlusion-based experimental models, which dominate preclinical stroke research. This split between the bench and bedside suggests the need to employ tPA-responsive models in preclinical stroke research. To this end, a simple and tPA-reactive thrombotic stroke model is invented and described here. This model consists of transient occlusion of the unilateral common carotid artery and delivery of 7.5% oxygen through a face mask in adult mice for 30 min, while maintaining the animal rectal temperature at 37.5 ± 0.5 °C. Although reversible ligation of the unilateral carotid artery or hypoxia each suppressed cerebral blood flow only transiently, the combination of both insults caused lasting reperfusion deficits, fibrin and platelet deposition, and large infarct in the middle cerebral artery-supplied territory. Importantly, tail-vein injection of recombinant tPA at 0.5, 1, or 4 hr post-tHI (10 mg/kg) provided time-dependent reduction of the mortality rate and infarct size. This new stroke model is simple and can be standardized across laboratories to compare experimental results. Further, it induces thrombosis without craniectomy or introducing pre-formed emboli. Given these unique merits, the tHI model is a useful addition to the repertoire of preclinical stroke research.

A Thrombotic Stroke Model Based On Transient Cerebral Hypoxia-ischemia.

Stroke research has endured many setbacks in translating neuroprotective therapies into clinical practice. In contrast, the real-world therapy (tPA thrombolysis) rarely produces benefits in mechanical occlusion-based experimental models, which dominate preclinical stroke research. This split between the bench and bedside suggests the need to employ tPA-responsive models in preclinical stroke research. To this end, a simple and tPA-reactive thrombotic stroke model is invented and described here. This model consists of transient occlusion of the unilateral common carotid artery and delivery of 7.5% oxygen through a face mask in adult mice for 30 min, while maintaining the animal rectal temperature at 37.5 ± 0.5 °C. Although reversible ligation of the unilateral carotid artery or hypoxia each suppressed cerebral blood flow only transiently, the combination of both insults caused lasting reperfusion deficits, fibrin and platelet deposition, and large infarct in the middle cerebral artery-supplied territory. Importantly, tail-vein injection of recombinant tPA at 0.5, 1, or 4 hr post-tHI (10 mg/kg) provided time-dependent reduction of the mortality rate and infarct size. This new stroke model is simple and can be standardized across laboratories to compare experimental results. Further, it induces thrombosis without craniectomy or introducing pre-formed emboli. Given these unique merits, the tHI model is a useful addition to the repertoire of preclinical stroke research.

Asymptomatic carotid artery stenosis--is screening useful?

Stenoses of the carotid artery are associated with an increased stroke risk. Duplex ultrasound is the method of choice for screening for carotid artery stenosis. Unselected screening for carotid stenosis in unselected persons is not efficient and cannot be recommended. Screening by vascular ultrasound, however, is indicated in patients with neurologic symptoms from cerebral territories supplied by the anterior or mid cerebral artery, and in asymptomatic patients with carotid bruits, atherosclerotic disease in other vascular territories, after contralateral carotid artery revascularization, and after radiation therapy of the neck.

Fast cerebral flow territory mapping using vessel encoded dynamic arterial spin labeling (VE-DASL).

Whole-brain territory mapping using planning-free vessel-encoded pseudocontinuous arterial-spin-labeling (VE-pCASL) takes approximately 5 min, which is frequently considered too long for standard clinical protocols. In this study, vessel-encoded dynamic-ASL (VE-DASL) is optimized to achieve fast (< 30 s) cerebral flow territory mapping, especially aimed for the acute setting. VE-DASL is based on the creation of a continuous stream of magnetically labeled or unlabeled blood with different encoding patterns for each feeding artery, whose inflow into the brain tissue is monitored continuously. This approach leads to unique signal fluctuation within each flow territory, enabling reconstruction of individual flow territories by means of clustering techniques followed by linear regression. VE-DASL was implemented and validated both as single slice and whole-brain method. In vivo results showed reasonable agreement with the "gold-standard" reference maps obtained from VE-pCASL. The Dice similarity coefficient which represents the fractional overlap between VE-DASL and "gold-standard" VE-pCASL territories ranged from 83.4% to 87.7% for the right internal cerebral artery (RICA), 81.7% to 83.1% for the left internal cerebral artery (LICA) and 64.3% to 71.8% for the vertebral arteries. VE-DASL has the potential to map the main flow territories with whole-brain coverage in a short scan duration (∼30 s).

Ischemic cardiomyopathy and cerebral infarction in a young patient associated with khat chewing.

Khat is a stimulating agent used by many people in the Horn of Africa and the Arabian peninsula. Khat chewing is a known cardiovascular risk factor and is thought to cause vasoconstriction, systemic hypertension, and thrombogenicity. A 33-year-old Somalian man initially presented with loss of neurological function of the left arm, hazy vision, and headache. He smokes tobacco and chews two bundles of khat a week for more than 10 years. His ECG on admission showed a Q wave in V1 and V2 and 2 mm ST-elevations in V1, V2, and V3 and a terminal negative T wave in I, aVL, V2, V3, and V4, consistent with a recent, evolving anterior infarction. A noncontrast enhanced CT of the brain showed ischemia in the right middle cerebral artery vascular territory. An MRI showed recent ischemia in the vascular territory of the posterior division of the right middle cerebral artery. Coronary angiography showed a 70% stenosis with haziness of the proximal left anterior descending artery. Diagnostic tests and imaging are consistent with recent myocardial infarction in the LAD vascular territory because of coronary spasm and cerebral infarction in the middle cerebral artery vascular territory probably related to khat chewing.

The Significance of Cerebral Hemodynamics Imaging in Carotid Endarterectomy: A Brief Review

The indication of carotid endarterectomy (CEA) is principally determined by the presence or absence of symptoms and the degree of stenosis. However, the results of recent studies have implicated the usefulness of cerebral hemodynamics imaging for perioperative assessments. Many studies using single-photon emission computed tomography (SPECT) have demonstrated that cerebral hemodynamics imaging assessments are useful in the prediction and assessment of post-CEA hyperperfusion. In studies using transcranial Doppler ultrasonography, SPECT, or positron-emission tomography (PET), cerebral hemodynamic impairment is highly likely to increase the risk of cerebral infarction in patients with asymptomatic carotid artery stenosis. In other studies using the same modalities, cerebral hemodynamic impairment might be related to cognitive impairment in carotid artery stenosis, and this cognitive impairment might be improved with CEA. Nuclear medicine techniques involve the injection of radioactive tracers. Arterial spin labeling (ASL) is an emerging technique of perfusion magnetic resonance imaging (MRI) for the noninvasive measurement of cerebral perfusion. ASL could detect pathologic states such as hypoperfusion, impaired vasoreactivity, and postoperative hyperperfusion activities that are equivalent to SPECT. In addition, regional perfusion imaging visualizes cerebral perfusion territories by selective ASL. In conclusion, cerebral hemodynamic imaging would be useful for the perioperative assessment of CEA. However, there is a lack of sufficient scientific evidence to confirm the benefits, necessitating further study.

Systematization, distribution and territory of the caudal cerebral artery on the brain's surface of the turkey (Meleagris gallopavo)

Thirty Meleagris gallopavo heads with their neck segments were used. Animals were contained and euthanized with the association of mebezonium iodide, embutramide and tetracaine hydrochloride (T 61, Intervet ) by intravenous injection. The arterial system was rinsed with cold saline solution (15°C), with 5000IU heparin and filled with red-colored latex. The samples were fixed in 20% formaldehyde for seven days. The brains were removed with a segment of cervical spinal cord and after, the dura-mater was removed and the arteries dissected. The cerebral carotid arteries, after the intercarotid anastomosis, were projected around the hypophysis, until they reached the tuber cinereum and divided into their terminal branches, the caudal branch and the rostral branch. The rostral branch was projected rostrolateralwards and gave off, in sequence, two collateral branches, the caudal cerebral and the middle cerebral arteries and the terminal branch was as cerebroethmoidal artery. The caudal cerebral artery of one antimere formed the interhemispheric artery, which gave off dorsal hemispheric branches to the convex surface of both antimeres. Its dorsal tectal mesencephalic branch, of only one antimere, originated the dorsal cerebellar artery. In the interior of the cerebral transverse fissure, after the origin of the dorsal tectal mesencephalic artery, the caudal cerebral artery emitted occipital hemispheric branches, pineal branches and medial hemispheric branches, on both antimeres. The caudal cerebral artery's territory comprehended the entire surface of the dorsal hemioptic lobe, the rostral surface of the cerebellum, the diencephalic structures, the caudal pole and the medial surface of the cerebral hemisphere and in the convex surface, the sagittal eminence except for its most rostral third. Due to the asymmetry found in the caudal cerebral arteries' ramifications, the models were classified into three types and their respective subtypes.

Abstract T P120: Clinical Demographic Effects on Functional Outcome in Patients Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Background: Malignant MCA infarction is a devastating disease representing 1-10% of strokes. Evidence from recent randomized controlled trials show improved survival and functional outcomes following decompressive hemicraniectomy (DHC) compared with optimal medical. Ideal patient selection remains somewhat controversial. The current study examines the effects of demographic and clinical variables on functional outcomes in patients surviving one or more years following DHC. Methods: We retrospectively reviewed patients who underwent DHC for malignant MCA infarction at our institution from 03/2006 to 04/2012. We collected and compared demographic and clinical variables including age, gender, race, timing of DHC, side of infarction, IV TPA administration, and additional cerebral territorial involvement (ACA or PCA). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance. Results: A total of 32 patients met inclusion/exclusion criteria. There was no statistical difference in functional outcomes between patients ≤60 years of age and those &gt;60 years (p=0.51). No statistical difference was observed between males and females (p=0.84)). Patients who received their DHC within 48 hours of their stroke were more likely to have a better outcome than patients who received DHC after 48 hours (p=0.024). Other variables including race, cerebral dominance involvement, IV TPA administration, or additional cerebral territory involvement did not show statistical significance with respect to functional outcomes (p=0.22, p=0.462, p=0.597, and p=0.614 respectively). Conclusion: In this retrospective study, early DHC done within 48 hours of stroke was the only clinical variable shown to improve functional outcomes 1 year or more later among survivors of patients receiving DHC for malignant MCA infarction. No difference in functional outcome was seen based on age, gender, race, IV TPA administration, dominant MCA involvement, and additional cerebral territorial co infarction. Patient selection should be individualized and larger studies are needed to better assess this patient population, especially in the elderly.

Study of Risk Factors Associated with Peripheral Arteriopathy in Japanese-Brazilians from Bauru (SP)

BackgroundCardiovascular diseases are the major cause of morbidity and mortality in developed and emerging countries. Their main etiology, atherosclerosis, is a disseminated disease that affects the coronary, cerebral and peripheral territories. The peripheral arterial disease (PAD), as well as its consequences, indicates the involvement of the coronary territory. Therefore, its better understanding enables proper treatment, delaying local and long-term complications, reducing the cost to the health system. Objective This study estimates the percentage of PAD in Japanese-Brazilians from Bauru (SP), recognized by the high prevalence of metabolic disorders such as hypertension (43%), diabetes mellitus (33%) and hypercholesterolemia (60%), and examines the association with risk biomarkers. MethodsThis cross-sectional population study evaluated 1,330 Japanese-Brazilians of both genders aged ≥ 30 who underwent a complete physical examination, anthropometric measurements, laboratory tests and ankle-brachial index (ABI). Participants with ABI ≤ 0.90 were diagnosed as having PAD. After applying the exclusion criteria, 1,038 individuals were part of the analysis. We used Poisson regression to analyze associations with PAD. Results The mean age was 56.8 years and the percentage of PAD was 21.1%, equal among the genders. PAD was associated with smoking (PR 2.16 [1.33 to 3.48]) and hypertension (PR 1.56 [1.12-2.22]). ConclusionThe percentage of PAD in Japanese-Brazilians was similar to other populations of adverse cardiometabolic profile (US PARTNERS and POPADAD). The independent association of PAD with smoking and hypertension, but not with other classical risk factors, may depend on the very high frequencies of metabolic disorders in this population.

Selective and superselective angiography of pediatric moyamoya disease angioarchitecture: the anterior circulation.

The angioarchitecture of the so-called moyamoya vessels in children has not been explicitly analyzed. We aimed to investigate the precise anatomy of the vascular anastomotic networks in patients with childhood moyamoya disease. Six children diagnosed with moyamoya disease for the first time underwent an angiographic investigation with selective and superselective injections. We recorded the arterial branches feeding the moyamoya anastomotic networks, their connections and the recipient vessels. Depending on the level of the steno-occlusive lesion, the feeding vessels included the medial striate arteries, the perforators of the choroidal segment of the carotid, the uncal artery, the medial and lateral branches of the intraventricular segment of the anterior choroidal artery, perforators of the communicating segment, the superior hypophyseal arteries, the prechiasmal branches of the ophthalmic artery, the ethmoidal arteries and the dural branches of the cavernous carotid. Through connections, which are described, the recipient vessels were the lateral striate arteries and the middle cerebral, the medial striate arteries and the anterior cerebral, medullary arteries around the ventricular system, anterior temporal branches of the middle cerebral, orbitofrontal and frontopolar branches of the anterior cerebral, as well as other cortical branches of the anterior and middle cerebral territories. The use of high quality selective and superselective angiography enabled us to clearly demonstrate for the first time aspects of the microangiographic anatomy of the moyamoya anastomotic network previously only vaguely or incompletely described.

MR imaging in posterior ischemic optic neuropathy

AbstractPurpose To present and explain the pathognomonic magnetic resonance (MR) findings in posterior ischemic optic neuropathy (PION).Methods Three patients with the suspicion of PION underwent a MR examination of the anterior visual pathway.Results There was a rapidly progressive unilateral (n=2) and bilateral (n=1) decline in visual function with deterioration of central visual acuity and an altitudinal visual field defect (n=2). Fundoscopy showed optic disc pallor after 6 weeks in all patients at the affected side. A relative afferent pupillary defect was seen in the patients with unilateral disease. The MR imaging findings revealed a central high signal in the chiasm (n=3) and intracranial portion of the both optic nerves (n=1)/ one optic nerve (n=2) with normal signal of the outer part of the chiasm/optic nerve.Conclusion The pattern of the lesions can be explained by the blood supply of the optic chiasm which occurs through arterioles arising from the circle of Willis entering the chiasm and forming capillaries. In vitro research revealed a poorer capillary distribution in the central parts. The central high signal represents ischaemia due to the vulnerability of the central part of the chiasm/optic nerve. These findings are important as they are almost pathognomonic for ischemic changes in the anterior visual pathway. These findings are different from those reported in inflammatory/demyelinating disorders affecting the anterior visual pathway. PION should be differentiated from stroke in the posterior cerebral circulation territory because of the possible treatment with rt‐PA in the latter. A dedicated imaging approach is necessary in patients with visual field loss of unknown origin in order to confirm or exclude ischemic changes of the anterior visual pathway.

Headache as a symptom at stroke onset in 4,431 young ischaemic stroke patients. Results from the “stroke in young fabry patients (SIFAP1) study”

Headache as symptom of stroke is linked to gender, history of migraine, younger age, cerebellar stroke, and low blood pressure. These associations have been controversial, large scale studies are missing. We used the stroke in young fabry patients study to examine the association of demographic, clinical and imaging factors with the occurrence of headache in 4,431 young ischaemic stroke patients (18-55 years; mean: 44.7 years) with an ischemic cerebrovascular event (CVE) (ischemic stroke-IS 75.9%, TIA 24.1%). Headache in males occurred more frequently in bilateral localisation (right/left/bilateral: 27.5, 24.6, 39.2%, p < 0.01), but not in females (40.3, 34.7, 39.6%). Headache occurrence was more often associated in both genders with IS or TIA in the posterior cerebral territory (male: 33.2%, p < 0.05; female: 51.0%, p < 0.01) and vertebrobasilar arteries (male: 44.8%, p < 0.001; female: 51.2%, p < 0.001). The larger the size of the most prominent lesion the more likely patients were complaining headache during the IS (≤1 cm vs. >half lobe: 19.5 vs. 28.4% in male, p < 0.001; 28.9 vs. 39.1% in female, p < 0.01). Binary logistic regression analyses revealed lower age (p < 0.001), female sex (p < 0.001), larger size of the largest lesion (p < 0.001), and localization in the vertebrobasilar territory (p < 0.001) as predictors for headache during CVE. Headache at stroke onset is more common during IS in females, younger patients, with greater size of the acute lesion, and affected in posterior cerebral artery or vertebrobasilar system. Headache is a leading symptom in specific combination of stroke factors. These factors should be taken into account when patients report headache during IS or TIA.

Motor outcome prediction using diffusion tensor tractography of the corticospinal tract in large middle cerebral artery territory infarct

Middle cerebral artery (MCA) territory infarct is the most common type of cerebral vascular territory infarct. Accurate prediction of motor outcome is important for stroke rehabilitation. We conducted an investigation of prognostic factors of motor outcome in patients with a large MCAterritory infarction, using diffusion tensor tractography (DTT) of the corticospinal tract (CST). A total of 37 consecutive hemiparetic patients with a large MCA territory infarct were recruited for this study; DTT was performed within 5-30 days after onset. Patients were classified into three groups according to DTT findings: in group A - CST integrity was preserved around infarct regions, in group B - CSTs were discontinuous, and, in group C - the upper ends of CSTs did not reach infarcted regions. Fractional anisotropy (FA) ratio of the affected CST (versus the unaffected ipsilateral CST) was calculated, and evaluation of motor function was performed using the Motricity Index (MI), modified Brunnstrom classification (MBC) score, and the functional ambulation category (FAC) score at onset and at six months after onset. Significantly greater changes in motor function (MI, MBC, and FAC) were observed between onset and six months post-onset in group A, compared with groups B and C (p < 0.05). However, no significant difference was observed between groups B and C (p > 0.05). FA ratios showed positive correlation with six-month MIs, and scores for MBC and FAC (p < 0.05). Results of this study demonstrate the usefulness of early DTT findings of CSTs for prediction of motor outcome in patients with a large MCA territory infarct.

Brain injury due to anaphylactic shock as a result of formocresol used during root canal treatment

Formocresol is still used in many parts of the world despite concerns over its toxicity. A case of a 45-year-old women who experienced brain injury after an analyphlactic reaction to formocresol is presented. During routine root canal treatment, the patient experienced nausea and vomiting after formocresol was used as an antibacterial agent in the pulp chamber. The procedure was discontinued and the symptoms resolved. Four days later, the treatment was continued by a different dentist, and the patient developed anaphylactic shock within 10 min of placement of a formocresol-soaked cotton pellet. She received emergency medical treatment and magnetic resonance imaging (MRI) revealed brain injury characterized by swelling of the gyrus in the cerebral watershed territory of the left parietal-occipital lobe. The patient subsequently made a full recovery after supportive treatment. A type-I allergic reaction can be induced by formocresol. The reasons for the brain injury are thought to be cerebral hypoxia, which was induced by the anaphylactic shock and/or cerebral parenchymal oedema. All dentists should be aware of the risks involved in the use of formocresol and avoid using materials containing formocresol and related agents.

Intracerebral hemorrhage cause by a ruptured oncotic aneurysm from choriocarcinoma metastasis

Ruptured oncotic aneurysms from choriocarcioma metastasis are very rare. One rare case of metastatic cerebral choriocarcioma with an initial presentation of intracerebral hemorrhage is reported. A 25-year-old woman initially presented with sudden onset of alteration of consciousness. The computed tomography scan showed left parietal hematoma and CT angiography showed a small aneurysm of the left middle cerebral arteries territories. Her chest X-ray showed two lung masses. A craniectomy was performed to remove the hematoma and decompression following the aneurysm excision. After surgery the patient regained consciousness and had no neurological deficit. The pathology reported metastatic choriocarcioma and her beta – HCG was 73,656 units. After recovery she received chemotherapy with an etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine/oncovine (EMA-CO) regimen.