Complete Middle Cerebral Artery Infarction Research Articles

Clarion call for histopathological clot analysis in "cryptogenic" ischemic stroke: implications for diagnosis and treatment.

Diagnosis, treatment, and secondary management of cryptogenic stroke patients pose a formidable challenge. The scenario is further complicated in patients with native and prosthetic valvular heart disease. We present a case study of a 36‐year‐old man who received intravenous thrombolysis (IV‐tPA) and endovascular thrombectomy (EVT) for presumed “cryptogenic” complete middle cerebral artery infarction who made a surprisingly excellent clinical recovery despite poor baseline and postintervention neuroimaging. Retrospective gram stain of his clot confirmed a diagnosis of infective endocarditis. This raises an important issue regarding need for more routine histopathological analysis of clot retrieved after EVT in “cryptogenic” stroke patients particularly those with valvular heart disease.

A multiparameter model predicting in-hospital mortality in malignant cerebral infarction

The early identification of patients with large hemisphere infarctions (LHIs) at risk of fatal brain edema may result in better outcomes. A quantitative model using parameters obtained at admission may be a predictor of in-hospital mortality from LHI.This prospective study enrolled all patients with LHI involving >50% of the middle cerebral artery (MCA) admitted to our neurological intensive care unit within 48 hours of symptom onset. Early clinical and radiographic parameters and the baseline CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke [double weight]) were analyzed regarding their ability to predict patient outcomes.Seventy-seven patients with LHIs were identified, 33 (42.9%) with complete MCA infarction (CMCA), and 44 (57.1%) with incomplete MCA infarction (IMCA). The predictors of CMCA score included: >1/3 early hypodensity in computed tomography findings, hyperdense MCA sign, brain edema, initial National Institutes of Health Stroke Scale (NIHSS) score ≥17, and stroke in progression during the 1st 5 days of admission. The cutoff CMCA score was 2, with a sensitivity of 81.8% and specificity of 70.5%. Mortality score 1, used for predicting in-hospital mortality from LHI, included CMCA and CHADS2 scores ≥4 (sensitivity 100.0%, specificity 57.4%), and mortality score 2 included CMCA and CHADS2 scores ≥4, and NIHSS score ≥26, during the 1st 5 days (sensitivity 100.0%, specificity 91.7%).Patients qualifying for a mortality score of 2 were at high-risk of in-hospital mortality from LHI. These findings may aid in identifying patients who may benefit from invasive therapeutic strategies, and in better describing the characteristics of those at risk of mortality.

Predictors of in-hospital mortality and prognosis in patients with large hemispheric stroke receiving decompressive craniectomy

Objective. Decompressive craniectomy reduces fatality in patients with space-occupying infarctions. However, mortality remains high. We aimed to identify predictors of in-hospital mortality and outcomes in a cohort of patients with large hemispheric stroke receiving decompressive craniectomy. Methods. We retrospectively reviewed all patients diagnosed with complete middle cerebral artery infarction and receiving decompressive craniectomy. Hospital characteristics were compared among different groups (survivors versus non-survivors, good outcome versus poor outcome). A total of 71 consecutive patients were enrolled. Results. From 2004 January to 2010 April, 71 patients were enrolled whose mean age was 65.11 ± 13.13 years and 33 (46.5%) of these were men. The in-hospital mortality was 28.2% overall. Of the patients who survived and were discharged, 37 (77.1%) had poor outcome (mRS 4–6) and 11 (22.9%) had good outcome (mRS 0–3). Pre-operation brain computed tomography (CT) hypodensity volume (p = 0.001) was significantly associated with mortality. In binary logistic regression model, pre-operation brain CT hypodensity volume (OR = 1.015; 95% CI, 1.001 to 1.030) and age (OR = 1.112; 95% CI, 1.017 to 1.215) were both significantly associated with outcomes. Conclusions. In patients with large hemispheric stroke receiving decompressive craniectomy, pre-operation brain CT hypodensity volume was significantly associated with in-hospital mortality whereas age was not. Pre-operation brain CT hypodensity volume and age were predictors of outcomes in those who survived the acute phase.

CT and MR imaging of primary cerebrovascular complications in pediatric head trauma

The incidence of severe traumatic head injury in children has constantly increased over the last years. Diagnostic imaging has become an unrenounceable tool for the documentation and follow-up of intracranial lesions. The use of magnetic resonance imaging (MRI) in the early posttraumatic phase has led to a more thorough understanding of intracranial injuries. We retrospectively analyzed the cranial computed tomography (CCT) and magnetic resonance (MR)-studies of patients with traumatic head injuries for primary cerebrovascular complications. In 64 children (45 male, 19 female) with traumatic head injuries, CCT and MR examinations were available for analysis. The children's age ranged from 3 months to 15 years with a median age of 7 years. All patients had initial CCT on admission to the hospital with follow-up examinations depending on clinical state and initial imaging findings. All patients had at least one MR examination between 0 to 120 days after the trauma with a median time interval of 17 days. In five of 64 (7.8%) patients, cerebrovascular complications were found on imaging studies. Initial imaging within the first 24 h after the trauma detected a complete middle cerebral artery infarction in one patient and extensive sinus thrombosis after a complex skull fracture in another. In two patients, thrombosis of the transverse sinus appeared on MRI 4 to 6 days after the trauma. In another patient with open-skull injury, a posttraumatic aneurysm of the pericallosal artery was diagnosed on MRI 30 days after the trauma. Our study shows that, although primary cerebrovascular lesions after traumatic head injuries in children are rare, the radiologist should be aware of the characteristic injury patterns and the time appearance of imaging findings on CT and MRI.

Recovery From Aphasia After Decompressive Surgery in Patients With Dominant Hemispheric Infarction

HomeStrokeVol. 36, No. 10Recovery From Aphasia After Decompressive Surgery in Patients With Dominant Hemispheric Infarction Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBRecovery From Aphasia After Decompressive Surgery in Patients With Dominant Hemispheric Infarction Talip Asil, Ufuk Utku and Kemal Balci Cumhur Kilincer Talip AsilTalip Asil University of Trakya, Faculty of Medicine, Department of Neurology, Edirne, Turkey Search for more papers by this author , Ufuk UtkuUfuk Utku University of Trakya, Faculty of Medicine, Department of Neurology, Edirne, Turkey Search for more papers by this author and Kemal BalciKemal Balci University of Trakya, Faculty of Medicine, Department of Neurology, Edirne, Turkey Search for more papers by this author Cumhur KilincerCumhur Kilincer University of Trakya, Faculty of Medicine, Department of Neurosurgery, Edirne, Turkey Search for more papers by this author Originally published1 Oct 2005https://doi.org/10.1161/01.STR.0000182258.70796.8dStroke. 2005;36:2071To the Editor:The stroke patients with space occupying supratentorial lesions have poor prognosis. Despite the treatment procedures, the mortality of such patients is up to 80%, and the survivors usually have severe morbidity such as aphasia.1 In recent years, decompressive surgery was used for the treatment of space occupying supratentorial infarctions.2Kastrau et al reported recovery from aphasia in 13 of 14 patients with large hemispheric infarctions after decompressive surgery.3 However, the study was performed by a neurolinguistic center, and the patients were first evaluated 538 days (ranges 105 to 1207 days) after the decompressive surgery, then the recovery from aphasia was determined within the following period. Same authors also reported that most of the recovery from aphasia occurs within the early period after the event. In our hospital (University of Trakya, School of Medicine), 29 patients underwent decompressive craniectomy between August 1999 and December 2003, 8 of the patients who survived had dominant hemispheric infarction, and all had recovery from aphasia within the six-month period after the event. Initial neurological examination of the 8 patients revealed global aphasia. Six months after surgery, 5 of the patients had Broca aphasia and the remaining 3 patients had slight recovery from global aphasia. We think that evaluating recovery from aphasia may have great value if performed in the early stages after stroke.The authors reported that the contralateral activation in homologous areas of speech processing and the perilesional activation in the ipsilateral speech areas may have value for recovery from aphasia, and we also have the same opinion about the improvement process.Age was reported the most valuable parameter for recovery from aphasia by Kastrau et al, but the mean age of the elderly patients was 43.9±5.2 years. Although the mean age of our patients (53.7±7.5 years) was older than Kastrau’s patients, evident recovery from aphasia was observed in our patients after six months.Although the study of Kastrau et al is the first study about the recovery from aphasia after decompressive surgery, a study that also evaluates the other factors affecting cerebral perfusion (eg, the duration from the event to the surgery, stroke severity at the time of surgery, and the discovery of herniation) may have more value.1 Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996; 53: 309–315.CrossrefMedlineGoogle Scholar2 Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998: 29: 1888–1893.CrossrefMedlineGoogle Scholar3 Kastrau F, Wolter M, Huber W, Block F. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke. 2005; 36: 825–829.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By (2006) Current awareness: Pharmacoepidemiology and drug safety, Pharmacoepidemiology and Drug Safety, 10.1002/pds.1177, 15:4, (i-xii), Online publication date: 1-Apr-2006. October 2005Vol 36, Issue 10 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000182258.70796.8dPMID: 16192466 Originally publishedOctober 1, 2005 PDF download Advertisement

Which patient fares worse after early deterioration due to swelling from hemispheric stroke?

The authors studied 24 patients admitted to the neurointensive care unit because of clinical deterioration to drowsiness or stupor and midline shift after complete middle cerebral artery infarction (coMCAI) stroke. Fourteen (58%) experienced further deterioration and either underwent hemicraniectomy or refused surgery and died. These patients were significantly more likely to be female (72% vs 20%) and to have additional vascular territorial infarction (72% vs 0%) on initial CT. These features may help to identify patients at high risk for further deterioration after coMCAI.

Ultrasonic evaluation of pathological brain perfusion in acute stroke using second harmonic imaging

OBJECTIVETo evaluate the use of transient response second harmonic imaging (HI) by means of ultrasound to assess abnormalities of cerebral echo contrast agent enhancement in patients with acute stroke.METHODSThe study...

Mechanical ventilation in patients with hemispheric ischemic stroke.

Whether stroke patients should be ventilated mechanically is still a contentious issue, because their outcome is very poor. We wanted to investigate how often mechanical ventilation is indicated in patients with hemispheric ischemic stroke as well as the outcome of these patients and the factors by which outcome is influenced. Prospective case series. University hospital, neurocritical care unit. Subjects were 218 patients who met the following inclusion criteria: age 18-85 yrs, acute hemispheric ischemic infarction, clinical examination, and computed tomography within 6 hrs after the onset of symptoms. Mechanical ventilation was instituted with one or more of the following conditions: deterioration of consciousness with the inability to protect the airway; PaO2 of <60; P(CO2) of >60 mm Hg; breath rate of >40 breaths/min; and left heart insufficiency with definitive or impending pulmonary edema. Mechanical ventilation was indicated for 52 (24%) of the 218 patients: in 47 (90%) patients because of deterioration of consciousness, and in five (10%) patients because of heart insufficiency and/or pneumonia. In a logistic regression model, the history of hypertension and a size of infarction exceeding two thirds of the middle cerebral artery territory were independent variables for the application of mechanical ventilation. After 3 months, 42 (81%) of these 52 patients had died. The most common cause of death was fatal midbrain herniation caused by complete middle cerebral artery infarction. Patients who survived had a good-to-fair outcome. New therapeutic strategies (e.g., hemicraniectomy) must be developed to reduce mortality and improve the outcome for this subgroup of ischemic stroke patients. Mechanical ventilation is and will remain a crucial element within such new concepts.