Internal Carotid Artery Territory Research Articles

Cerebral ptosis: An ominous sign in stroke—A retrospective study

AbstractIntroductionCerebral ptosis is defined as the drooping of eyelids due to lesions in the cerebral hemispheres. Cerebral ptosis is due to either unilateral or bilateral hemispheric damage without brainstem involvement. Ischemic strokes are the most common etiology leading to hemispheric damage.AimsTo assess the prevalence of cerebral ptosis in ischemic strokes and to correlate the presence of cerebral ptosis with the outcome of the patients. To also assess the demographic profile of these patients.Materials and MethodsThis is a retrospective study from June 2022 to August 2024. All patients diagnosed as acute stroke presenting with cerebral ptosis within day 3 of stroke were included. Patients with a reduced level of consciousness, brainstem involvement, and those with signs of impending herniation were excluded. The modified Rankin scale (mRS) on the day of admission and the day of discharge were compared.ResultsThere were 26 patients with cerebral ptosis among 649 patients admitted with anterior circulation stroke (prevalence 4.01%). 84.6% (n = 12) had right hemisphere involvement and 15.4% (n = 4) had left side involvement. 88.5% (n− = 23) had middle cerebral artery territory involvement and 7.7% (n = 2) had internal carotid artery territory involvement. The mean mRS on admission was 4.42 and 4.81 on discharge (paired t‐test 0.015). mRS 6 (death) was observed in four patients.ConclusionCerebral ptosis is a supranuclear disorder with the most common etiology being vascular insult to the cerebral hemisphere. It is an ominous and rare clinical sign. Identification of this entity is important, and it is not to be confused with a reduced level of consciousness.

Safety and Efficacy of Injection Tenecteplase in 4.5 to 24 Hours Imaging Eligible Window Patients with Acute Ischemic Stroke (EAST-AIS) - Study Protocol.

Tenecteplase is used as the standard of care treatment for thrombolysis in acute ischemic stroke (AIS) patients within 4.5 h of symptom onset. Documented reports were less certain to claim the benefits of it in an extended window period. EAST-AIS (CTRI/2022/03/040718) trial is designed to determine the success rate of thrombolysis in an extended window period for good clinical outcomes. It is a randomized, placebo-controlled trial of tenecteplase administered within 4.5-24 h of stroke onset (with or without large vessel occlusion) based on evidence of salvageable tissue through baseline computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) scan. Criteria of patient inclusion are as follows: patients of both genders (male and female), age >18 years, pre-stroke modified Ranking Scale (mRS) <2, baseline NIHSS >5, CTP showing penumbra-ischemic core ratio >1.8, absolute difference in volume >10 ml, and ischemic core volume <70 ml. The sample size for the study is 100 patients: 50 in the tenecteplase arm (0.25 mg/kg body weight; maximum- 25 mg) and 50 in the placebo arm (controls). The study's primary objective is safety endpoints along with the efficacy of tenecteplase assessed using the mRS score at 90 days of stroke onset. The result obtained from EAST-AIS will determine the safety and efficacy of tenecteplase injection administered 4.5-24 h following the symptom onset for AIS patients within the territory of Internal Carotid Artery (ICA), Middle Cerebral Artery (MCA), or Anterior Cerebral Artery (ACA) occlusion.

Relationship between carotid web morphology on CT angiography and stroke: A pooled multicenter analysis.

The Carotid web (CaW) is a cause of stroke, particularly in younger individuals. However, the frequency and the radiological features of the web's morphology associated with stroke risk are uncertain. We determined the CaW radiological features on computed tomography (CT) angiography associated with ipsilateral stroke. Data from six studies of patients with acute ischemic stroke were pooled. Identification and measurement of CaWs were performed by experienced readers using baseline neck CT angiography. We assessed six 2D CaW radiological features on sagittal oblique images, namely, main axis length, thickness, height, base width, distance to wall, and angle between the web main axis and carotid wall, and CaW volume on 3D images. CaWs were divided into symptomatic if acute ischemic stroke was in the ipsilateral internal carotid artery territory and its etiology was undetermined and asymptomatic if one condition was unmet. Univariable and multivariable analyses were conducted to assess the association between each radiological CaW feature and symptomatic CaW. Of the 3442 patients in the pooled data with assessable CTAs, 60 (1.7%) had CaW. In patients with CaW, median age was 59 (interquartile range [IQR]: 50-68) years, 60% were women, and 3 patients had bilateral CaWs. There were 39 (62%) symptomatic and 24 (38%) asymptomatic CaWs. Patients with symptomatic CaW were younger (55 (IQR: 49-61) years versus 69 (IQR: 52-75) years), had lower rates of hypertension (9 (25.0%) versus 12 (57.1%)) and more intracranial large vessel occlusions compared to patients with asymptomatic CaWs. After adjusting for age, hypertension, and occlusion location, CaW length (adjusted odds ratio (aOR) 1.84 (95% confidence interval [CI]: 1.03-3.28)), thickness (aOR: 2.31 (95% CI 1.08-4.97)), volume (aOR: 1.07 per 1 mm3 increment (95% CI: 1.01-1.12)), and angle relative to the carotid wall (aOR: 0.95 (95% CI: 0.91-0.99)) were associated with symptomatic CaW. Radiological assessment of CaW morphology may determine its potential causal role in ischemic stroke etiology. Symptomatic CaWs tend to be longer, larger, and oriented at more acute angles relative to the carotid wall as compared to asymptomatic CaWs.

Clinical case of bridged reperfusion therapy in massive ischemic stroke in the territory of left internal carotid artery on the background of dissection

Stroke remains the most common cause of death and permanent disability in the developed countries of the world. One of the main predictors of a good outcome is both mostly fast and safety recanalization of the occluded vessel of the brain. Over the past decade, endovascular therapy became a promising therapeutic approach for patients with acute ischemic stroke in combination with early usage of high-resolution methods of neuroimaging. This article discusses a clinical case of severe ischemic stroke due to occlusion of a major artery, confirmed by CT angiography. The efficacy of reperfusion therapy with intravenous administration of alteplase in combination with thrombectomy was demonstrated, the most common intra-arterial recanalization complications were pointed out. The early recognition of sudden complications with rapid decision-making for therapy modification during bridged reperfusion therapy is important for improving results of trearment.

Carotid free-floating thrombus stemming from carotid web: co-occurrence of two rare causes of ischemic stroke

BackgroundCarotid web (CaW) and carotid free-floating thrombus (CFFT) are rare yet critical causes of ischemic stroke in young adults.Case presentationA 54-year-old woman presented with a fluctuating right sensory-motor faciobrachial syndrome. A brain MRI scan revealed multiple small recent asynchronous cortico-subcortical ischemic foci in the vascular territory of the left internal carotid artery. A CT angiography identified a CFFT in the left internal carotid artery arising from an underlying CaW. The patient was treated with excellent clinical outcomes with carotid artery stenting and dual antiplatelet therapy.ConclusionsWe provide a structured pathophysiological rationale connecting CaW and CFFT and highlight pivotal therapeutic implications. Further studies are needed to investigate this relationship and guide assessment and treatment.

Abstract 110: Autoangiogenesis Secondary to Chronic Cocaine Use Mimicking Moya‐Moya

Introduction We present the case of a young male presenting with syncope who was found to have incidental hypodensities on computed tomography (CT) of his head, with magnetic resonance imaging (MRI) concerning for Moya‐Moya related occlusion of the right internal carotid artery, but with digital subtraction angiography (DSA) showing extensive autoangiogenesis and collateralization from all other intracranial vascular territories, without Moya‐Moya related changes. This presumably developed as reactive changes to severe chronic cocaine use. Methods We present a case from a tertiary care center in the borough of Manhattan, New York City, USA. All information is deidentified and exempt from IRB approval. Results A 36‐year‐old man with history significant for asthma, active smoker status, and active cocaine use, presented for loss of consciousness. The patient reported 3 days of upper respiratory symptoms and decreased oral intake with subsequent loss of consciousness immediately preceded by lightheadedness and nausea, and without any post‐event confusion, lacerations, or incontinence. Neurologic history is significant for right upper extremity weakness from 9/2022‐12/2022 that self‐resolved and was believed to be a peripheral nerve pathology. Admission exam without focal deficits. Admission CT of his head showed multifocal confluent hypodensities in the subcortical right frontal lobe. CT Angiogram of head and neck showed severe narrowing at right Internal Carotid Artery (ICA) terminus and right M1 segment with lenticulostriate arterial collateralization, severe bilateral A1 stenosis with distal Anterior Cerebral Artery (ACA) flow suggestive of chronic collateralization, and significant right Posterior Cerebral Artery (PCA) collateralization. Given concern for Moya‐Moya disease, MRI of the brain was obtained and despite no acute infarct, MRI was significant for multifocal white matter T2/FLAIR hyperintensities with the largest in the right frontal lobe. The patient subsequently underwent digital subtraction angiography (DSA) to assess collaterals and stratify for possible need for future encephaloduroarteriosynangiosis (EDAS). DSA showed significant auto‐angiogenesis between numerous vascular territories, including recruitment of right Posterior Cerebral Artery and External Carotid Artery branches to perfuse the territory of the severe right ICA terminus steno‐occlusive disease. With minimal anterograde flow into the right Anterior Choroidal Artery and none to the right Middle Cerebral Artery (MCA), the characteristic Moya‐Moya appearance was not appreciated on DSA given minimal anigogenesis around the right ICA occlusion site. Rather, distal perfusion of the R ICA territory was dependent on collaterals from the right PCA, right ACA via the Anterior Communicating Artery, angiogenesis between the right Anterior Falcine Artery and R ACA, and angiogenesis between the right MCA and ACA/MCA cortical branches. These proliferative changes involved all cranial vascular territories, including those without steno‐occlusive disease. Conclusion Acute cocaine use is associated with increased risk of acute ischemic stroke[1], due in part to its sympathomimetic effects causing vasospasm and to its arrhythmic properties[2]. Neuroadaptation after chronic cocaine use is less well understood though rat models suggest that as cerebral ischemia develops from chronic cocaine use, the HIF‐VEGF pathway is activated to promote angiogenesis to restore local blood flow[3]. We present this case as evidence of a similar angiogenic physiologic response in humans to minimize the microvascular ischemic injury from chronic cocaine use.

Abstract 097: Un‐stumped by Carotid Stump Syndrome: Use of External Carotid Stenting in Preventing Ischemic Stroke

Introduction Recurrent infarcts to the internal carotid artery territory in the setting of a corresponding occlusion raises concern for carotid stump syndrome. Over time, robust anastomoses may develop between the patent ipsilateral external carotid artery and the anterior circulation distal to the site of occlusion. A carotid stump’s disturbance of flow uncommonly can form emboli that travel via retrograde flow from the occluded internal carotid artery to the ipsilateral external carotid artery and its collaterals. Stenosis of the external carotid artery in such patients can be a source of atheroembolism or hypoperfusion. We describe a case of external carotid stenting with carotid stump coil occlusion. Methods We present a case report. Verbal consent to share this information was obtained directly from the patient. Results A 75‐year‐old man with aortic stenosis, atrial arrhythmia, multiple prior bi‐hemispheric strokes, on aspirin and clopidogrel, presented with left facial droop, arm weakness, and slurred speech. Magnetic resonance imaging revealed embolic appearing strokes in the right middle cerebral artery territory (Figure 1A). Cerebral angiography revealed complete occlusion of the right internal carotid artery with perfusion of the right middle cerebral artery by external carotid artery anastomoses, and the external carotid was found to be stenosed proximally. Digital subtraction angiography revealed right external carotid – middle cerebral artery anastomoses via the right sphenopalatine artery, middle meningeal artery, internal maxillary artery, and ophthalmic collaterals (Figure 1B). The patient underwent coiling of the right internal carotid artery stump (Figure 1C) followed by stenting of the right external carotid using a 9 mm x 40 mm Cordis precise Pro stent. Post‐stenting angiogram demonstrated good apposition of the stent to the parent vessel walls and improvement of flow into the right external carotid and intracranial circulation (Figure 1D). The patient was treated with aspirin and ticagrelor for 3 months. Repeat imaging at follow up did not show further embolic episodes, with improvement in the patient’s deficits. After three months, he was continued on aspirin alone. Conclusion In patients with an occluded internal carotid artery and recurrent embolic infarcts ipsilateral to the side of the occlusion, carotid stump syndrome may be considered. In this case, we believe the patient’s carotid occlusion served as a nidus for emboli formation, or that there was atheroembolism from the stenosed external carotid artery despite adherence to dual antiplatelet therapy. By coiling the stump, we addressed a possible source of emboli, and stenting of the proximal external carotid optimized anterograde flow and prevented further atheroembolism. Our case showcases an interventional neuroradiology approach to carotid stump emboli and external carotid artery stenosis.

Paraclinoid internal carotid artery aneurysm with delayed stent occlusion after deployment of a flow diverter stent involving the orifice of the anterior cerebral artery: illustrative case.

In-stent thrombotic occlusion is a serious ischemic complication that can also result in ischemia in the distal perfusion territory and the territory of side branches for the artery in which the flow diverter (FD) stent is deployed. A 49-year-old female with a large paraclinoid internal carotid artery (ICA) aneurysm was treated with an FD involving the orifice of the anterior cerebral artery (ACA). The antiplatelet dose was reduced because of an increased clopidogrel response postintervention. The patient developed aphasia 2 months later. Emergency magnetic resonance imaging and digital subtraction angiography of the brain indicated FD stent occlusion and a small infarct in the distal vascular territory of the ipsilateral ICA, but the anterior choroidal artery (AChoA) territory was preserved by collateral flow. Emergency superficial temporal artery to middle cerebral artery anastomosis was performed, and she was discharged without neurological deficit 2 weeks after the second operation. In-stent occlusion after FD deployment involving the orifice of the ACA can cause severe cerebral ischemia that requires an adequate antiplatelet effect and careful follow-up. The AChoA territory can be preserved by collateral blood flow even in cases of in-stent occlusion.

Single-Stage Extracranial and Intracranial Stenting of the Internal Carotid Artery in a Patient with Open Circle of Willis and Associated Renovascular Hypertension

We describe a case of 72-year-old patient with recurrent transient ischemic attacks in the right internal carotid artery (ICA) territory associated with uncontrolled hypertension. Duplex ultrasonography und carotid angiography showed a 60% stenosis with signs of a vulnerable plaque in the cervical segment, as well as a 90% stenosis in the cavernous segment of the right ICA. After further examination the patient was diagnosed with an 80% renal artery stenosis. First, the patient had a single-stage stenting for extracranial and intracranial stenoses of the right ICA, then left renal artery stenting. No intraoperative and postoperative complications were observed. These results show that this surgical treatment is minimally invasive, safe, and effective in symptomatic patients and may be considered for the disease.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Clinicoetiological Profile of Acute Ischemic Stroke Patients in the Therapeutic Window in a Tertiary Care Hospital in Northern India

Background: A stroke is defined by the rapid emergence of clinical symptoms and focuses on evidence (applicable to individuals in a deep coma and those with subarachnoid hemorrhage) or widespread brain damage. The study aimed to evaluate the clinical characteristics of patients with acute ischemic stroke in a tertiary care hospital in North India. Methods: By analyzing case files and conducting patient interviews, information on the patients was gathered and evaluated. The study's inclusion and exclusion criteria were based on the 2018 American Heart Association and American Stroke Association (AHA/ASA) thrombolysis guidelines for acute ischemic stroke. Recent major trauma or major surgery within 14 days not involving the head, seizure at the onset of stroke, systemic malignancy, and pregnancy were excluded. Results: The study enlisted the participation of 76 patients who were divided into two groups. Patients in the one group were given tenecteplase, whereas the other group were given alteplase. Patients in the tenecteplase and alteplase groups were of different ages and had various other risk factors for hypertension, atrial fibrillation, diabetes, smoking, and previous stroke or transient ischemic attack. The risk factor distribution in both the groups was statistically significant for variables such as hypertension and diastolic blood pressure (P &lt; 0.05). Stroke in internal carotid artery territory was present in 3 out of 42 in the tenecteplase group and 2 out of 32 in the alteplase group. Most patients in both the groups had a stroke of undetermined cause. Small vessel and large vessel strokes were found in 9.5% and 14.7%, respectively. Conclusion: In the development of stroke, there is a definite relationship between age and gender. A sedentary lifestyle, food, and obesity are risk factors for stroke. According to an AHA/ASA drug utilization analysis, most medicines were appropriate for stroke patients.

Distribution of amyloid-β precursor protein-immunoreactive axons differs according to the severity of cerebral ischemia in autopsy brains.

Amyloid-β precursor protein (APP) immunohistochemistry has been used to detect axonal injury in forensic neuropathology. However, axonal injury caused by cerebral ischemia has not been investigated by APP immunohistochemistry in detail. In particular, it is unknown if there is a correlation between the prognosis of cerebral ischemia and the distribution of axonal injury detected by APP immunohistochemistry. To address this issue, we compared the distribution of APP-immunoreactive axons in autopsy brains including lesions of acute phase of cerebral infarction in the territory of the middle cerebral artery (MCA) or internal carotid artery (ICA) with the degree of severity. The presence or absence of a midline shift was used as an indicator of the severity of cerebral ischemia. We identified a difference in the distribution of APP-immunoreactive axons between cases with and without a midline shift. In both the groups, APP-immunoreactive axons were detected at the margin of the ischemic lesions; however, only in cases with a midline shift, intense APP-immunoreactive axons were also found in areas other than the MCA and ICA territories, including the white matter of the cerebral hemispheres ipsilateral and contralateral to the ischemic lesions. This distribution was different from that of acute global cerebral ischemia cases reported previously. Our results indicate that the distribution of APP-immunoreactive axons differs according to the severity and type of cerebral ischemia, suggesting that the distribution of APP-immunoreactive axons is associated with the prognosis of cerebral ischemia.

Correlation of the degree of carotid stenosis and area of cerebral infarct in ischaemic stroke patients

Context: To evaluate the degree of internal carotid artery stenosis in acute cerebral infarcts and to correlate it with the area of infarct. Aims: A) To calculate the area of acute cerebral infarct by manual tracing and the degree of internal carotid artery stenosis using NASCET score. B) To calculate the ASPECT score of the cerebral infarct. C) To correlate degree of internal carotid artery stenosis, the area of infarct and ASPECT score. Settings and Design: Hospital based retrospective study. Methods and Material: A retrospective study from January 2018 to January 2020 was conducted on 51 patients with acute ischemic infarct involving the internal carotid artery territory (ICA) due to stenosis of the intra or extracranial ICA. In this study we correlated the infarct area as measured by diffusion weighted magnetic resonance (DWI MRI), Alberta Stroke Program Early CT Score (ASPECTS) and degree of carotid stenosis on MR angiography and carotid doppler using North American Symptomatic Carotid Endarterectomy Trial (NASCET) score. Statistical analysis used: Mc Nemar test was used to correlate ICA stenosis by NASCET score with the area of infarct. Pearson’s correlation was used to correlate ASPECT score and infarct volume.

Recanalization of the middle cerebral artery after prolonged induced hypertensive therapy to rescue early neurologic deterioration: a case report

Background: Although decades have passed since the introduction of pharmacologically induced hypertensive therapy (PIHT) against early neurologic deterioration (END) in acute ischemic stroke, the optimal duration of PIHT remains elusive. Case Report: A 70-year-old man developed right hemiplegia and aphasia 25 hours before arrival. Computed tomography angiography (CTA) revealed acute infarction in the left middle cerebral artery (MCA) territory and occlusion of the left internal carotid artery. He experienced END 36 hours after admission, and CTA revealed a newly developed proximal MCA occlusion. PIHT was initiated to augment cerebral perfusion. As his neurologic symptoms were highly dependent on blood pressure, PIHT was inevitably sustained for over 3 weeks. Follow-up CTA revealed recanalization of the MCA.Conclusion: Although further investigation is required to expedite the future clinical application, prolonged PIHT may serve as a viable collateral-enhancing treatment for a certain subset of patients with END without alternative treatment options.

Non-contrast hemodynamic imaging of Moyamoya disease with MR fingerprinting ASL: A feasibility study

PurposeMR Fingerprinting (MRF) Arterial Spin Labeling (ASL) is a non-contrast technique to estimate multiple brain hemodynamic and structural parameters in a single scan. The purpose of this study is to examine the feasibility and initial utility of MRF-ASL in Moyamoya disease. MethodsMRF-ASL, conventional single-delay ASL, Time-of-flight (TOF) MR angiography, and contrast-based dynamic-susceptibility-contrast (DSC) MRI were prospectively collected from a group of Moyamoya patients in North America (N = 21, 4 men and 17 women). Sixteen healthy subjects (7 men and 9 women) also underwent an MRF-ASL scan. Cerebral blood flow (CBF), bolus arrival time (BAT), and tissue T1 were compared between Moyamoya patients and healthy controls. Perfusion parameters from MRF-ASL were compared to those from other MRI sequences. Multi-linear regression was used for comparisons of parameter values between Moyamoya and control groups. Linear mixed-effects models was used when comparing MRF-ASL to PCASL and DSC parameters. Spearman's Rank Correlation Coefficient was calculated when comparing MRF-ASL to and MRA grades. A P value of 0.05 or less was considered significant. ResultsBAT in stenotic internal carotid artery (ICA) territories was prolonged (P < 0.001) in Moyamoya patients, when compared with healthy controls. CBF in stenotic ICA territories of Moyamoya patients was not different from CBF in healthy controls; but in the PCA territories, CBF in Moyamoya patients was higher (P < 0.01) than controls. Quantitative T1 values in the stenotic ICA territories was longer (P < 0.05) than that in controls. Hemodynamic parameters estimated from MRF-ASL were significantly correlated with single-delay ASL and DSC. Longer BAT was associated with more severe intracranial artery stenosis in ICA. ConclusionsMRF-ASL is a promising technique to assess perfusion and structural abnormalities in Moyamoya patients.

Newborn with a Large Intracranial Mass.

Newborn with a Large Intracranial Mass.

Mapping the Perfusion Territory of Internal Carotid Artery with Digital Distraction Angiography

Mapping the Perfusion Territory of Internal Carotid Artery with Digital Distraction Angiography

Ischaemic stroke and oral inflammatory diseases

The aim of this study was to establish clinical significance of oral inflammatory diseases in ischaemic stroke (IS), how aware doctors and nurses are of this problem, and the safety and possibility of performing dental hygiene in patients with acute IS.&#x0D; Materials and methods. We examined 100 patients who had suffered an ischaemic stroke in the internal carotid artery territory within 6 to 48 hours. The efficacy of dental hygiene and the risk of developing chronic oral sepsis were evaluated using the Patient Hygiene Performance Index (PHP) and Chronic Oral Sepsis Risk index (COSR). Quality of life was assessed using the short version of the Oral Health Impact Profile (OHIP-14). The sociological study included 100 patients with ischaemic stroke, 38 nurses, and 18 neurologists.&#x0D; Results. The severity of IS at study inclusion was 8 (3; 15) points on the NIHSS, while the Barthel Index score was 70 (45; 90) points. The modified Rankin Scale score was 13 points. The PHP index was 2.28 0.05 and the COSR index was 20.13 0.50. The OHIP-14 results (a total score of 28.1 6.8 points) also indicated unsatisfactory quality of dental health. The results of sociological studies revealed low level of awareness regarding dental care during acute IS among doctors. After professional oral care, treatment of oral inflammatory diseases, and removal of significantly damaged teeth, patients with IS had a decrease in the PHP index to 1.17 0.05 and the COSR index to 7.36 0.50, which corresponds to a satisfactory level of dental hygiene by the end of the acute stroke period. The impact of dental health on quality of life parameters as measured by the OHIP-14 scale (22.4 7.2 points) was satisfactory.&#x0D; Conclusion. The most important aspect of early dental care in patients with IS is increasing the quality of oral health.

Giant cell arteritis presenting as a stroke in the internal carotid artery territory: a case-based review.

Giant cell arteritis (GCA) is a large-vessel vasculitis, typically affecting the aorta and its branches. The involvement of vertebral and internal carotid arteries occurs in a limited number of cases, and stroke as a presenting symptom of GCA is extremely unusual: this subset of the disease has a poor prognosis and rarely responds to immunosuppression.We report the case of a 70-year-old woman, who presented to the Emergency Department for ischemic stroke, which appeared to be the first and only symptom of GCA. The prompt administration of steroids and tocilizumab (TCZ) led to clinical and radiological resolution, with no residual disability at 6-month follow-up.Our case-based review, highlighting the rarity of a large vessel vasculitis presenting only with a cerebrovascular accident, provides new evidence for the efficacy of TCZ even in more unusual varieties of GCA: in these cases, TCZ should be immediately prescribed, in order to prevent mortality and severe long-term morbidity.

Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients.

Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.