Left Middle Cerebral Artery Research Articles

Serial dilation to enable ulnar artery access for endovascular neurointervention: Technical report and systematic review of the literature

BackgroundFor rare neuro-endovascular cases in which transfemoral access is not feasible and the palmar circulation is insufficient for radial artery access, ulnar artery access may be considered. Materials and methodsMechanical thrombectomy via ulnar artery access was performed to preserve the dominant radial artery. The ulnar artery was serial dilated to 7-French with microdilator. Angiography was performed using a diagnostic catheter. The sheath was exchanged for a guide catheter, and a triaxial system was inserted. A mechanical thrombectomy was performed. The systematic literature review included all studies pertaining to techniques for ulnar artery access for neurointervention in the last 20 years (2003–2023) published in the PubMed, Web of Science, and Embase databases. Results67-year-old male developed left MCA syndrome in the setting of an infected abdominal aortic endograft. A transfemoral approach was ruled out due to concern for crossing the infected endograft. Allen test and ultrasound demonstrated that the right radial artery was of adequate size for access, but the ulnar artery was insufficient to support the palmar arch. Mechanical thrombectomy resulted in TICI 3 reperfusion. Systematic review of the literature yielded 2 case series and 1 case report of transulnar neurovascular procedures. Access site complications were rare and included 3 access site hematomas and 1 ulnar artery occlusion. ConclusionWe report our technique of serial dilation of the ulnar artery for neuroendovascular procedures and provide a systematic review of the literature for complication avoidance in ulnar artery access.

Using High-Resolution Vessel Wall Magnetic Resonance Images in a Patient of Intracranial Artery Dissection Related Acute Infarction.

Acute ischemic stroke in young adults typically carries significant implications for morbidity, mortality, and long-term disability. In this study, we describe the case of a 34-year-old male with no prior medical history who presented with symptoms of right-sided weakness and slurred speech, suggesting an acute ischemic stroke. Initial CT angiography revealed an occlusion in the left M2 segment middle cerebral artery (MCA). The occlusion was successfully recanalized through emergent endovascular thrombectomy, which also identified a dissection as the cause of the stroke. Follow-up assessments at 3 days and three months, which included advanced vessel wall MRI, highlighted the critical role of intracranial artery dissection in strokes among young adults and provided essential images for ongoing evaluation.

Cerebral arterial blood flow, attention, and executive and cognitive functions in depressed patients after acute hypertensive cerebral hemorrhage.

Intracerebral hemorrhage mainly occurs in middle-aged and elderly patients with hypertension, and surgery is currently the main treatment for hypertensive cerebral hemorrhage, but the bleeding caused by surgery will cause damage to the patient's nerve cells, resulting in cognitive and motor dysfunction, resulting in a decline in the patient's quality of life. To investigate associations between cerebral arterial blood flow and executive and cognitive functions in depressed patients after acute hypertensive cerebral hemorrhage. Eighty-nine patients with depression after acute hypertensive cerebral hemorrhage who were admitted to our hospital between January 2019 and July 2021 were selected as the observation group, while 100 patients without depression who had acute hypertensive cerebral hemorrhage were selected as the control group. The attention span of the patients was assessed using the Paddle Pin Test while executive function was assessed using the Wisconsin Card Sorting Test (WCST) and cognitive function was assessed using the Montreal Cognitive Assessment Scale (MoCA). The Hamilton Depression Rating Scale (HAMD-24) was used to evaluate the severity of depression of involved patients. Cerebral arterial blood flow was measured in both groups. The MoCA score, net scores I, II, III, IV, and the total net score of the scratch test in the observation group were significantly lower than those in the control group (P < 0.05). Concurrently, the total number of responses, number of incorrect responses, number of persistent errors, and number of completed responses of the first classification in the WCST test were significantly higher in the observation group than those in the control group (P < 0.05). Blood flow in the basilar artery, left middle cerebral artery, right middle cerebral artery, left anterior cerebral artery, and right anterior cerebral artery was significantly lower in the observation group than in the control group (P < 0.05). The basilar artery, left middle cerebral artery, right middle cerebral artery, left anterior cerebral artery, and right anterior cerebral artery were positively correlated with the net and total net scores of each part of the Paddle Pin test and the MoCA score (P < 0.05), and negatively correlated with each part of the WCST test (P < 0.05). In the observation group, the post-treatment improvement was more prominent in the Paddle Pin test, WCST test, HAMD-24 score, and MoCA score compared with those in the pre-treatment period (P < 0.05). Blood flow in the basilar artery, left middle cerebral artery, right middle cerebral artery, left anterior cerebral artery, and right anterior cerebral artery significantly improved in the observation group after treatment (P < 0.05). Impaired attention, and executive and cognitive functions are correlated with cerebral artery blood flow in patients with depression after acute hypertensive cerebral hemorrhage and warrant further study.

Spontaneous Ruptured Brain Arteriovenous Malformation In Adolescent Patient: Case Report

Introduction: Brain arteriovenous malformations (bAVMs) are one of the most common causes of intracranial hemorrhage in the adolescent. AVMs are relatively rare as congenital intracranial abnormalities but these lesions are becoming frequently reported. AVMs generally has no any symptoms and only recognized after intracranial or subarachnoid hemorrhage occurs. This disease usually gives symptoms of headaches and seizures without cause. However, along with the development of medical technology, arteriovenous malformation lesions are common. Case report: This 24 year old woman in unconscious with right hemiparesis and atypical chronic progressive headache with vas 8-9, without aura. Previously the patient had a seizure with a duration of 5 minutes, rigid all over body. The patient had no prior history of trauma, infection, hypertension, diabetes or stroke. GCS E2M5Vaphasia with motoric aphasia, motoric and sensory deficits in the form of right hemiparesis, paresis of N. VII, increased physiological reflexes, and positive Babinsky reflex. CT-Scan Angiography imaging of the head showed intraparenchymal bleeding in the left temporoparietal lobe with perifocal edema, AVM in the left temporalis region with a nidus with a feeding artery from the left MCA and a draining vein from the left transverse sinus. The patient was referred for further vascular intervention. Discuss: AVMs was previously considered a congenital malformation with risk of bleeding in anomalous tissue or nidus occurring within the brain parenchyma. Rupture of the artery and discharge into the subarachnoid space causes a sudden increase in ICP, cerebral vascular vasospasm resulting in global and focal brain dysfunction. In addition, with the increasing use of non-invasive intracranial imaging, AVMs can be detected directly.

Newly formed and ruptured infectious intracranial aneurysm in few days following first intracranial aneurysm embolization concurrent with middle cerebral artery occlusion: A regrettable case in a baby child

AbstractInfectious intracranial aneurysm (IIA) and embolic cerebral infarction are well‐known devastating complications of children suffering infective endocarditis. In this report, we describe a successfully embolized IIA concurrent with bilateral middle cerebral artery (MCA) occlusion. Unfortunately, a newly formed IIA located in the contralateral MCA bifurcation ruptured at the seventh day following embolization. A 6‐month‐old female child was admitted to hospital 3 days following acute right limb mobility disorder. An interventional surgery history of congenital heart disease was confirmed. She was immediately started on antibiotic therapy and the computed tomography agiography (CTA) scan showed occlusion of the upper branch of the left MCA. Unfortunately an IIA was located in the distal artery region (DAR) of the ipsilateral anterior cerebral artery. Angiography (digital subtraction angiography) was performed and the DAR IIA was embolized by OnyX‐18 with Magic 1.2 Fr. microcatheter. On the sixth day, magnetic resonance imaging during the hospital stay showed reduced infarction area with no other special sign. Desperately, a major seizure with opisthotonos attacked the baby on the seventh day after embolization. An immediate CTA scan showed massive hematoma in the right basal ganglia and a ruptured bifurcate aneurysm of the right MCA. The parents refused positive treatment and discharged in considering the critical situation. It should be noted that IIA can be fast formed anywhere in cerebral artery and dynamic angio‐image should be performed as supervision.

A Hybrid Approach for the Treatment of a Pure Arterial Malformation Located at an Accessory Middle Cerebral Artery. Cerebral Revascularization Followed by Endovascular Occlusion Using nBCA: Case Report

BACKGROUND AND IMPORTANCE: Pure arterial malformations (PAMs) are rare vascular lesions with unknown natural history. Described in 2013 and initially considered benign, recent evidence of ruptured cases and progressive angioarchitectural changes may support the need for interventional treatment for selected patients. We present the first case of an accessory middle cerebral artery PAM successfully treated using a hybrid approach, including microsurgical revascularization and endovascular occlusion using Glubran2/Lipiodol. CLINICAL PRESENTATION: A 58-year-old woman with a history of spontaneous basal ganglia hemorrhage 2 years before presented to our clinic with a dilated, multilobulated, and overlapping lesion located at a dominant left accessory middle cerebral artery, compatible with the diagnostic criteria of a PAM. The lesion was near the previous bleeding site, and since perforating and cortical vessels arose from its distal lobule, a safeguarding superficial temporal artery-MCA bypass was considered necessary before the successful endovascular embolization of the malformation using nBCA (Glubran2/Lipiodol). CONCLUSION: PAMs can be associated with intracranial bleeding; thus, active treatment is warranted for selected patients. A hybrid microsurgical-endovascular approach is feasible and can be considered the optimal treatment for specific complex anatomies.

Synthesizing 4D Magnetic Resonance Angiography From 3D Time-of-Flight Using Deep Learning: A Feasibility Study.

Objective and background This study aimed to develop a deep convolutional neural network (DCNN) model capable of generating synthetic 4D magnetic resonance angiography (MRA) from 3D time-of-flight (TOF) images, allowing estimation of temporal changes in arterial flow. TOF MRA provides static information about arterial structures through maximum intensity projection (MIP) processing, but it does not capture the dynamic information of contrast agent circulation, which is lost during MIP processing. Considering the principles of TOF, it is hypothesized that dynamic information about arterial blood flow is latent within TOF signals. Although arterial spin labeling (ASL) can extract dynamic arterial information, ASL MRA has drawbacks, such as longer imaging times and lower spatial resolution than TOF MRA. This study's primary aim is to extend the utility of TOF MRA by training a machine-learning model on paired TOF and ASL data to extract latent dynamic information from TOF signals. Methods A DCNN combining a modified U-Net and a long-short-term memory (LSTM) network was trained on a dataset of 13 subjects (11 menand two women, aged 42-77 years) using paired 3D TOF MRA and 4D ASL MRA images. Subjects had no history of cerebral vessel occlusion or significant stenosis. The dataset was acquired using a 3T MRI system with a 32-channel head coil. Preprocessing involved resampling and intensity normalization of TOF and ASL images, followed by data augmentation and arterial mask generation. The model learned to extract flow information from TOF images and generate 8-phase 4D MRA images. The precision of flow estimation was evaluated using the coefficient of determination (R²) and Bland-Altman analysis. A board-certified neuroradiologist validated the quality of the images and the absence of significant stenosis in the major cerebral arteries. Results The generated 4D MRA images closely resembled the ground-truth ASL MRA data, with R² values of 0.92, 0.85, and 0.84 for the internal carotid artery (ICA), proximal middle cerebral artery (MCA), and distal MCA, respectively. Bland-Altman analysis revealed a systematic error of -0.06, with 95% agreement limits ranging from -0.18 to 0.12. Additionally, the model successfully identified flow abnormalities in a subject with left MCA stenosis, displaying a delayed peak and subsequent flattening distal to the stenosis, indicative of reduced blood flow. Visualization of the predicted arterial flow overlaid on the original TOF MRA images highlighted the spatial progression and dynamics of the flow. Conclusions The DCNN model effectively generated synthetic 4D MRA images from TOF images, demonstrating its potential to estimate temporal changes in arterial flow accurately. This non-invasive technique offers a promising alternative to conventional methods for visualizing and evaluating healthy and pathological flow dynamics. It has significant potential to improve the diagnosis and treatment of cerebrovascular diseases by providing detailed temporal flow information without the need for contrast agents or invasive procedures. The practical implementation of this model could enable the extraction of dynamic cerebral blood flow information from routine brain MRI examinations, contributing to the early diagnosis and management of cerebrovascular disorders.

Super-selective injection of propofol into the intracranial arteries enables Patient's self-evaluation of expected neurological deficit

IntroductionIt is hard to realize the extent of the expected postoperative neurological deficit for patients themselves. The provision of appropriate information can contribute not only to examining surgical indications but also to filling the gap between patient and expert expectations. We hypothesized that propofol infusion into the intracranial arteries (ssWada) could induce focal neurological symptoms with preserved wakefulness, enabling the patients to evaluate the postsurgical risk subjectively. MethodsPresurgical evaluation using ssWada was performed in 28 patients with drug-resistant epilepsy. Based on anatomical knowledge, propofol was super-selectively infused into the intracranial arteries including the M1, M2, and M3 segments of the middle cerebral artery (MCA), A2 segment of the anterior cerebral artery, and P2 segment of the posterior cerebral artery to evaluate the neurological and cognitive symptoms. We retrospectively analyzed a total of 107 infusion trials, including their target vessels, and elicited symptoms of motor weakness, sensory disturbance, language, unilateral hemispatial neglect (UHN), and hemianopsia. We evaluated preserved wakefulness which enabled subjective evaluations of the symptoms and comparison of the subjective experience to the objective findings, besides adverse effects during the procedure. ResultsPreserved wakefulness was found in 97.2% of all trials. Changes in neurological symptoms were positively evaluated for motor weakness in 51.4%, sensory disturbance in 5.6%, language in 48.6%, UHN in 22.4%, and hemianopsia in 32.7%. Six trials elicited seizures. Multivariate analysis showed significant correlations between symptom and infusion site of language and left side, language and MCA branches, motor weakness and A2 or M2 superior division, and hemianopsia and P2. Transient adverse effect was observed in 8 cases with 12 infusion trials (11.2 %). ConclusionThe ssWada could elicit focal neurological symptoms with preserved wakefulness. The methodology enables specific evaluation of risk for cortical resection and subjective evaluation of the expected outcome by the patients.

First‐Line Treatment of Symptomatic Subocclusive Large‐Vessel Stroke: Results of a Nationwide StrokeNet Survey

Background Limited evidence is available for the treatment of acute symptomatic subocclusive lesions in ischemic stroke. We sought to identify current treatment patterns of stroke teams at academic health centers. Methods We conducted an email survey of the National Institutes of Health StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator was asked to nominate a local stroke interventionalist, or a neurologist if the RCC principal investigator was an interventionalist, most aligned with the typical practice pattern of the RCC's lead hospital, to receive a survey. The survey consisted of a clinical vignette and displayed a subocclusive lesion in the left middle cerebral artery on computed tomography angiogram followed by subsequent scenarios, revising only 1 historical, clinical, or radiographic variable at a time. Participants were asked to select initial management for each scenario. Results were reviewed and analyzed by stroke‐trained physicians. Results Responses were received from 42 (77.8%) of 54 surveyed individuals, representing 25 (92.6%) of 27 RCCs nationwide, including 25 (59.5%) interventionalists. The majority (76.2%) of respondents treated the patient in the primary clinical vignette with mechanical thrombectomy. Among all 6 clinical scenarios, respondents chose mechanical thrombectomy with or without medical management as first‐line treatment for 4 (67%) vignettes. Exceptions were low National Institutes of Health Stroke Scale score and known ipsilateral stenosis, where respondents chose medical management as first‐line treatment. Conclusion Despite limited evidence to support mechanical thrombectomy versus other treatment strategies, the majority of StrokeNet RCC respondents would use mechanical thrombectomy with or without medical therapy to treat acute ischemic stroke due to intracranial subocclusive lesions.

The Clock is Ticking: Overcoming Time with Mechanical Thrombectomy for Middle Cerebral Artery Infarct

Coronary angiography is associated with several documented complications, and cardioembolic stroke following angiography is a rare occurrence. This letter presents a case involving thrombotic occlusion of the left middle cerebral artery (MCA) during coronary angiography. A 36-year-old female patient, presenting to the emergency department with chest pain, underwent coronary angiography due to non-ST-segment elevation myocardial infarction. While the responsible lesion underwent revascularization, the patient experienced new-onset motor deficits and aphasia. DSA imaging was conducted on the patient, whose diffusion magnetic resonance imaging and clinical findings were indicative of MCA infarction. Thrombectomy was performed on the patient with a left MCA infarction. Proficient management of neurological complications underscores the potential positive impact of interventional treatment strategies on mortality and morbidity. In this letter to the editor, the significance of early diagnosis, appropriate treatment, and multidisciplinary approach is emphasized.

Ketamine-induced prevention of SD-associated late infarct progression in experimental ischemia

Spreading depolarizations (SDs) occur frequently in patients with malignant hemispheric stroke. In animal-based experiments, SDs have been shown to cause secondary neuronal damage and infarct expansion during the initial period of infarct progression. In contrast, the influence of SDs during the delayed period is not well characterized yet. Here, we analyzed the impact of SDs in the delayed phase after cerebral ischemia and the potential protective effect of ketamine. Focal ischemia was induced by distal occlusion of the left middle cerebral artery in C57BL6/J mice. 24 h after occlusion, SDs were measured using electrocorticography and laser-speckle imaging in three different study groups: control group without SD induction, SD induction with potassium chloride, and SD induction with potassium chloride and ketamine administration. Infarct progression was evaluated by sequential MRI scans. 24 h after occlusion, we observed spontaneous SDs with a rate of 0.33 SDs/hour which increased during potassium chloride application (3.37 SDs/hour). The analysis of the neurovascular coupling revealed prolonged hypoemic and hyperemic responses in this group. Stroke volume increased even 24 h after stroke onset in the SD-group. Ketamine treatment caused a lesser pronounced hypoemic response and prevented infarct growth in the delayed phase after experimental ischemia. Induction of SDs with potassium chloride was significantly associated with stroke progression even 24 h after stroke onset. Therefore, SD might be a significant contributor to delayed stroke progression. Ketamine might be a possible drug to prevent SD-induced delayed stroke progression.

Thrombectomy using Zoom Reperfusion System in pediatric acute ischemic strokes: Case series and literature review.

Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively. Case report and literature review. A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively. The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

FIBROMUSCULAR DYSPLASIA IN CHILDREN – A SINGLE-CENTER EXPERIENCE

Objective: Fibromuscular dysplasia (FMD) is a stenotic disease of the arteries - most often renal, carotid, and cerebral. The disease can occur at any age and is the most common cause of renovascular hypertension in children. The study aimed to present the clinical course of FMD in patients of our Department. Design and method: In 2016-2023, the Department took care of 8 patients with FMD (4 boys, 4 girls). In all patients, we analyzed: age, sex, clinical symptoms, biochemical parameters, renin and aldosterone concentrations, imaging studies (ultrasonography, computed tomography), pharmacological and invasive treatment, and outcome. Results: Age at diagnosis ranged from 10/12 to 15 9/12 years. All patients were referred due to arterial hypertension (7/8 of 2nd degree). Patients presented various symptoms: hypertensive crisis with heart failure (patient 10/12 months), headache (2 patients), vomiting (1 patient), hyperactivity (1 patient), polydipsia and polyuria (1 patient). All patients had normal renal function, 5/8 hypokalemia, 1/8 hyponatremia, and 5/8 metabolic alkalosis; all had hyperreninemia with hyperaldosteronism. Imaging examinations showed critical stenosis of the renal artery trunk in 3 patients, slight stenosis in 1 patient, and stenosis of accessory arteries or branches of main arteries in the remaining patients. Stenosis in other vessels was found in 2 patients (left middle cerebral artery in one patient and abdominal aorta, celiac trunk, superior mesenteric artery, and inferior mesenteric artery in another one). Invasive treatment was performed in 6/8 patients - in 2 patients nephrectomy was necessary; in 2 – embolization of the vessel; in 2 – angioplasty, one patient is waiting for the procedure. Before the procedure, the patients required 3 (max. 5) antihypertensive drugs. After the procedure, antihypertensive treatment was discontinued in 3 patients, and the number and dose of drugs were reduced in the remaining patients. Conclusions: 1. Renal artery stenosis should be excluded in all pediatric hypertensive patients, regardless of age and symptoms. 2.Patients with FMD require an individually selected therapeutic plan. 3.Vessel embolization is an effective method of treating stenoses of the peripheral branches of the renal arteries in the course of FMD in children.

Multimodal Neurologic Monitoring in Patients Undergoing Extracorporeal Membrane Oxygenation.

Introduction Extracorporeal membrane oxygenation (ECMO) is associated with a high rate of neurologic complications. Multimodal neurologic monitoring (MNM) has the potential for early detection and intervention. We examined the safety and feasibility of noninvasive MNM during ECMO. We hypothesized that survivors and non-survivors would have meaningful differences in transcranial Doppler (TCD) sonography and electroencephalographic (EEG) characteristics, which we aimed to identify. We also investigated adverse neurologic events and attempted to identify differences in EEG and TCD characteristics among patients based on the type of ECMO and the occurrence of these events. Material and methods We performed an observational study on all patients undergoing ECMO at Baylor St. Luke's Medical Center's critical care unit in Houston, Texas, United States, from January 2017 to February 2019. All patients underwent a noninvasive MNM protocol. Results NM was completed in 75% of patients; all patients received at least one component of the monitoring protocol. No adverse events were noted, showing the feasibility and safety of the protocol. The 60.4% of patients who did not survive tended to be older, had lower ejection fractions, and had lower median right middle cerebral artery (MCA) pulsatility and resistivity indexes. Patients undergoing venoarterial (VA)-ECMO had lower median left and right MCA velocities and lower right Lindegaard ratios than patients who underwent venovenous-ECMO. In VA-ECMO patients, EEG less often showed sleep architecture, while other findings were similar between groups. Adverse neurologic events occurred in 24.7% of patients, all undergoing VA-ECMO. Acute ischemic stroke occurred in 22% of patients, intraparenchymal hemorrhage in 4.9%, hypoxic-ischemic encephalopathy in 3.7%, subarachnoid hemorrhage in 2.5%, and subdural hematoma in 1.2%. Conclusion Our results suggest that MNM is safe and feasible for patients undergoing ECMO. Certain EEG and TCD findings could aid in the early detection of neurologic deterioration. MNM may not just be used in monitoring patients undergoing ECMO but also in prognostication and aiding clinical decision-making.

Left middle cerebral artery and sigmoid sinuses thrombosis in a female patient with Crohn's disease

Introduction: Neurologic manifestations in patients with inflammatory bowel disease (IBD) appear to be more common than in the past. However, vascular events in IBD are still a rare presentation and were reported in few cases. Case presentation: A 48-year-old female patient known case of Crohn’s disease presented with sudden onset aphasia, headache, blurring of vision, and decreased level of consciousness for 2 hours. The patient looked ill, confused, agitated, and aphasic. Neurologic examination shows dysarthria and 0/5 power of the right upper and lower extremity. A brain CT without contrast was ordered and showed acute ischemic stroke. The patient received tPA (alteplase) immediately in the intensive care unit and was under observation. On admission, brain CT angiography, MRI, and MRV were performed, which showed middle cerebral artery and sigmoid sinuses thrombosis. The patient has undergone cerebral catheterization, and an MCA stent was inserted. Post catheterization, the patient’s right-sided extremity power was improved to 3/5. She was discharged from the hospital after 13 days in good general condition except for her expressive aphasia. Conclusion: To the best of our knowledge, here we report the first case presented with both; cerebral venous sinus thrombosis and cerebral arteries thrombosis in a patient with IBD. Clinicians must be considered ischemic stroke in any patients with IBD presented with acute neurological manifestation, and an urgent interventional approach must be performed.

Endovascular treatment of wide-neck bifurcation aneurysms using pCONUS2 HPC bridging device with single antiplatelet: A Case Series.

Wide neck bifurcation aneurysms (WNBA) are technically challenging for both surgical and endovascular treatments. Endovascular treatment for WNBA often requires dual antiplatelet therapy (DAPT) post stent insertion. Novel devices such as the pCONUS2 HPC neck bridging device have an HPC coating which reduces the device thrombogenicity. This theoretically allows for use of single antiplatelet therapy (SAPT), which would be advantageous, particularly in treating ruptured aneurysms. This case series aims to evaluate the safety of SAPT regimen only post stent insertion, by presenting our center early clinical experience in using pCONUS2 HPC neck bridging device in patients that are not suitable for DAPT. We report the cases of 3 patients (2 females, 1 male; range: 64-71 years old) who underwent coil embolization for WNBA using the pCONUS2 HPC device (2 unruptured WNBA, and 1 ruptured WNBA). As all 3 patients were allergic to Aspirin, they could only be started on SAPT post endovascular therapy. All 3 patients were diagnosed with WNBA on angiographic studies. Patient 1 had an unruptured left middle cerebral artery aneurysm; Patient 2 had a ruptured basilar tip aneurysm; Patient 3 had an unruptured anterior communicating artery (ACOM) aneurysm. All 3 WNBA were treated with pCONUS2 HPC neck bridging device. There were no immediate complications. The immediate angiographic result of aneurysm treatment in Patient 1 and Patient 2 demonstrated incomplete occlusions, with delayed complete occlusion of aneurysm in Patient 1 and growth of aneurysmal neck in Patient 2 on follow-up angiograms (range: 6-9 months). No major thrombo-embolic or hemorrhagic complications in the first 2 patients. For Patient 3, the immediate angiographic result of the treated aneurysm demonstrated complete occlusion. However, the patient readmitted 11 days post procedure with cerebral infarction, scoring 5 on the modified Rankin scale on discharge. pCONUS2 HPC as a neck bridging device in treating WNBA has yet to be shown superior to traditional techniques and devices. The theoretical advantage of HPC coating reducing its thrombogenicity requiring only SAPT is yet to be proven safe in clinical practice.

Failure of Evolutionary Pruning: a Case Report on a Young Adult with Rare Twig-like Middle Cerebral Artery and Its Implications on Worse Outcomes

Twig-like middle cerebral artery (MCA) is a rare intracranial vascular pathology that was hypothesized to be an arrest on the evolutionary fusion of the plexiform arterial network in the forebrain into a single MCA artery. This anomaly predisposes affected individuals to worse outcomes such as intracranial hemorrhages due to its association with aneurysms and primitive plexiform arterial systems that are prone to rupture. In this case report, a 30-year-old male had a loss of consciousness after serving as a ceremonial guard for four straight days. The patient did not have any neurologic localizing signs but presented with occasional generalized headaches relieved by pain medications. Cranial MRA showed suspicious stenosis of the left MCA. A cranial computed tomography angiogram showed complete stenosis of the M1 segment of the left MCA. Digital subtraction angiography was also done, which confirmed the complete occlusion of the said segment with collaterals from the A1 of the anterior cerebral artery supplying the distal portions of the left MCA. These findings, hence, suggested the presence of a twig-like MCA. In this article, the prevalence, pathogenesis, arrival to the diagnosis, and clinical relevance shall be discussed.

Clinico-radiological factors associated with aphasia outcome in post stroke patients: A prospective follow up study from eastern part of India

BackgroundAphasia is a language disorder acquired secondary to brain damage. This study aims to evaluate clinical and radiological profile of patients with post stroke aphasia and factors affecting its recovery. MethodsWe conducted a prospective study of patients with first left Middle or Anterior Cerebral Artery infarct or Intracerebral Hemorrhage (ICH) with aphasia admitted within 14 days of stroke onset. Aphasia Quotient (AQ) was assessed at 2 weeks (AQ1) and 3 months (AQ2) using Western Aphasia Battery-Hindi version. Magnetic Resonance Imaging of brain with Diffusion Tensor Imaging (DTI) of bilateral Arcuate Fasciculus (AF) and Corticospinal Tract was done at admission, and stroke volume, Laterality Indices of Fractional Anisotropy (LI-FA), Mean Diffusivity (LI-MD), Radial Diffusivity (LI-RD), Axial Diffusivity (LI-AD) and Apparent Diffusion Coefficient (LI-ADC) were obtained. Results36 patients [8 ICH and 28 Acute Ischemic Stroke (AIS)] were included. AQ1 and AQ2 were significantly higher in subcortical stroke than cortical. AQ2 and increase in AQ scores (including its subscores) were significantly higher in ICH than AIS. National Institutes of Health Stroke Scale score at admission and volume of stroke had significant negative correlation with AQ1 and AQ2. Laterality Index of Fractional Anisotropy of Arcuate Fasciculus [LI-FA (AF)] had significant positive correlation with AQ2 and naming score at 3 months. Laterality Index of Mean Diffusivity of Arcuate Fasciculus [LI-MD (AF)] had significant negative correlation with AQ1, AQ2 and all subcomponents of AQ2. Significant positive correlation was seen between improvements in Modified Rankin Scale score and AQ. ConclusionThe study shows that DTI can be used to predict severity of aphasia at follow up and recovery in language and motor functions occur in parallel

A Study of the Correlation of Pulsatility Index by Transcranial Doppler in the Clinical Outcome of Patients with Cerebral Venous Sinus Thrombosis

Background Cerebral Venous Thrombosis (CVT), accounting for 3% of strokes, can be assessed using non-invasive Transcranial Doppler (TCD) ultrasound to measure cerebrovascular function in real-time. The TCD-derived pulsatility index (PI), highly correlates with intracranial pressure (ICP) and serves as a reliable non-invasive monitoring tool. Aim This study aims to correlate PI by TCD with clinical outcomes in CVT patients. Methods A prospective observational study of 41 CVT patients admitted between June 2022 to December 2022 was conducted in the Department of Neurology of MBS Hospital. Each patient was subjected to TCD and the PI was also recorded. The results were analysed with SPSS. Results Out of the 41 patients, two patients died and 39 patients were discharged. The PI at admission in the left middle cerebral artery (MCA) was 1.19 ± 0.20 amongst discharged and 1.64 ± 0.10 amongst those who died ( p = .003). Similarly, the PI at admission in the right MCA was 1.23 ± 0.21 amongst those discharged and 1.63 ± 0.20 amongst those who died ( p = .02). Also, PI in both left and right MCA positively and significantly correlated with CVT GS score at admission (r = 0.70, p &lt; .05; r = 0.64, p &lt; .05). Conclusion PI at admission is both right and left MCA was found to be significantly higher in patients who died during the hospital stay. Also, PI significantly correlated with the CVT GS score at the presentation. Thus, PI at admission by TCD can predict the clinical outcome of patients with CVT.

Moyamoya Syndrome in a Child with Beta-Thalassemia Trait: A Case Report with Review of Literature

Background: The association of moyamoya angiopathy with hematological conditions such as sickle cell anemia and beta-thalassemia major or intermedia is well-known, but moyamoya syndrome (MMS) associated with thalassemia trait is hardly reported. We report such a rare association. Clinical Description: A 7-year-old boy presented with right-sided monoparesis with right-sided focal seizures, along with right-sided upper motor neuron type facial nerve palsy. He had a history of recurrent transient episodes of limb weakness, which were unevaluated. Examination revealed pallor and mild splenomegaly. Management and Outcome: Routine investigations revealed microcytic hypochromic anemia with normal serum iron levels. High-performance liquid chromatography was suggestive of beta-thalassemia trait. Contrast-enhanced computerized tomography of the head showed infarction in the territory of the left anterior cerebral artery (ACA) and middle cerebral artery (MCA). Magnetic resonance angiography revealed significantly attenuated bilateral internal carotid arteries in the supraclinoid region with attenuated bilateral ACA and bilateral MCA along with collateral formation suggestive of moyamoya angiopathy. The final diagnosis of MMS secondary to beta-thalassemia trait was made. The child improved with aspirin and supportive management. Conclusion: MMS can be rarely associated with the beta-thalassemia trait. Such an underlying, unsuspected heterozygous beta-thalassemia (trait) may be diagnosed only after the identification of moyamoya disease following a stroke.