Left Middle Cerebral Artery Infarction Research Articles

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.

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

All Trans Retinoic Acid: A Cerebral Friend or Foe? (P3-5.002)

<h3>Objective:</h3> NA <h3>Background:</h3> All-trans retinoic acid (ATRA) is an initial treatment for acute promyelocytic leukemia (APL). Studies suggest that ATRA has neuroprotective effects since it reduces atherosclerosis and neural inflammation. We present a case series of patients that developed acute recurrent ischemic strokes and demonstrated rapid progression of intracranial and extracranial stenosis in the setting of ATRA therapy. <h3>Design/Methods:</h3> NA <h3>Results:</h3> <h3>Case 1:</h3> A 47-year-old female with a history of hypertension presented with symptoms concerning for myocardial infarction, deep venous thrombosis, and thrombocytopenia which led to a diagnosis of APL. She was treated with ATRA and two days later developed left gaze deviation, facial droop, and left hemiparesis. Vessel imaging revealed a right middle cerebral artery (MCA) occlusion. Despite successful thrombectomy, the patient continued to decline. Repeat imaging showed re-occlusion of the right MCA as well as a new left MCA infarct. She later developed diffuse cerebral edema and fatal herniation. <h3>Case 2:</h3> A 41-year-old female with a history of hypertension and APL treated with ATRA had multiple recent strokes involving bilateral frontal, left occipital and watershed territories. Vessel imaging during the first admission did not show any stenosis. Over the course of the next seven months, she had multiple admissions for recurrent strokes with rapid progression and worsening of her intracranial stenosis despite dual antiplatelet and statin therapy. Cerebrospinal fluid analysis including cell count, protein, cytology and flow cytometry was unremarkable. She subsequently developed extensor posturing with paraparesis due to malignant cerebral edema and died. <h3>Conclusions:</h3> The underlying mechanism of accelerated vessel stenosis in the above cases is unknown. Further research should explore whether ATRA use in APL is indeed associated with the progression and/or poor clinical outcomes in the setting of acute ischemic stroke. Clinicians should remain vigilant about the concomitant use of ATRA in patients with a history of vascular risk factors. <b>Disclosure:</b> Mannyam, MD (Jackson, MS); Maryam

The Effect of Effortful Swallow with Progressive Resistance on Swallow Function in Post-Stroke Dysphagia: A Case Study

Background: Dysphagia management is vital in individuals reporting swallowing difficulties post-stroke. The literature review recommends the effortful swallow maneuver as a simple technique with multiple benefits for treating patients with oropharyngeal dysphagia due to stroke. No studies have documented the effect of effortful swallow and progressive resistance in individuals with swallowing difficulties post-stroke. Aim: To investigate whether the effortful swallow with added progressive resistance helps alleviate the swallowing function in individuals with dysphagia following stroke. Case report: In this case report, we describe a 30-year-old male who presented with left middle cerebral artery infarction and subsequent swallowing difficulty. The treatment procedure included 20 sessions of swallowing therapy incorporating effortful swallow with progressive resistance. Conclusion: Following 20 sessions of swallow treatment, significant improvement was seen in oro-facial measurements such as anterior and posterior tongue strength, anterior and posterior tongue endurance, and typical and effortful swallow tongue pressure. Functional oral intake level, dysphagia outcome and severity levels also improved significantly, contributing to better quality of life. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) examination showed improved swallow safety and efficiency post-therapy. Conclusion: Effortful swallow with progressive resistance effectively improved oro-pharyngeal swallow functions in an individual who presented with dysphagia following stroke. The case study highlights the effect of effortful swallow with progressive resistance in treating swallowing difficulties in a participant who presented with dysphagia following stroke.

Petrous Carotid Artery Thrombosis in an Immunocompromised Patient Presenting With Mastoiditis, A Case Report.

The neurotologic literature commonly describes venous sinus thrombosis as a complication of mastoiditis. However, thrombosis of the internal carotid artery in the setting of mastoiditis is rarely described. We aim to document a case of carotid artery thrombosis in a patient presenting with mastoiditis. We describe this case and review relevant literature. A renal transplant patient was transferred to our hospital with a left middle cerebral artery (MCA) infarct due to acute mastoiditis. Examination demonstrated middle ear effusion and radiologic workup confirmed mastoid infection adjacent to the site of arterial thrombosis. During cortical mastoidectomy and facial recess approach to the middle ear, the petrous carotid bone was found to be dehiscent with pneumatization of the petrous apex. Thrombosis was found to resolve following surgery, IV antibiotics and anticoagulation. Clinically, his focal neurological deficits improved. Proximity of the infectious process to an exposed petrous carotid artery supports the hypothesis that this patient's thrombus was a product of infectious spread and extra-luminal compression. To our knowledge, this is the first report of MCA infarction due to petrous ICA arterial thrombus in the setting of mastoid infection. The patient's immunocompromised state may have predisposed and contributed to the adverse outcome. We advocate for aggressive management of acute mastoiditis in the immunocompromised to prevent or manage complications (such as venous thrombophlebitis as well as ICA thrombus) as these patients don't show typical signs of infection and inflammation.

64-Year-Old Woman With Aphasia and Troponin Elevation

64-Year-Old Woman With Aphasia and Troponin Elevation

Differential Effects of Speech and Language Therapy and rTMS in Chronic Versus Subacute Post-stroke Aphasia: Results of the NORTHSTAR-CA Trial

Background & objective Contralesional 1-Hz repetitive transcranial magnetic stimulation (rTMS) over the right pars triangularis combined with speech-language therapy (SLT) has shown positive results on the recovery of naming in subacute (5–45 days) post-stroke aphasia. NORTHSTAR-CA is an extension of the previously reported NORTHSTAR trial to chronic aphasia (>6 months post-stroke) designed to compare the effectiveness of the same rTMS protocol in both phases. Methods Sixty-seven patients with left middle cerebral artery infarcts (28 chronic, 39 subacute) were recruited (01-2014 to 07-2019) and randomized to receive rTMS (N = 34) or sham stimulation (N = 33) with SLT for 10 days. Primary outcome variables were Z-score changes in naming, semantic fluency and comprehension tests and adverse event frequency. Intention-to-treat analyses tested between-group effects at days 1 and 30 post-treatment. Chronic and subacute results were compared. Results Adverse events were rare, mild, and did not differ between groups. Language outcomes improved significantly in all groups irrespective of treatment and recovery phase. At 30-day follow-up, there was a significant interaction of stimulation and recovery phase on naming recovery (P <.001). Naming recovery with rTMS was larger in subacute (Mdn = 1.91/IQR = .77) than chronic patients (Mdn = .15/IQR = 1.68/P = .015). There was no significant rTMS effect in the chronic aphasia group. Conclusions The addition of rTMS to SLT led to significant supplemental gains in naming recovery in the subacute phase only. While this needs confirmation in larger studies, our results clarify neuromodulatory vs training-induced effects and indicate a possible window of opportunity for contralesional inhibitory stimulation interventions in post-stroke aphasia. NORTHSTAR trial registration https://clinicaltrials.gov/ct2/show/NCT02020421.

Fetal posterior communicating artery as a conduit for concurrent anterior and posterior circulation infarct: A case report

Fetal type posterior cerebral artery (FTPCA) is a variant of posterior circulation of brain, in which the distal part of posterior cerebral artery (PCA) is perfused by a branch of internal carotid artery (ICA) via fetal posterior communicating artery (fetal PCOM). In the presence of fetal PCOM, a paradoxical concurrent infarction of anterior and posterior circulation may happen. We report a 67-year-old man who presented with sudden onset right sided weakness and aphasia, with National Institutes of Health Stroke Scale (NIHSS) score of 22 and clinically diagnosed to have left total anterior circulation infarct (TACI). Subsequently, he received IV Alteplase as a standard hyperacute ischemic stroke treatment. Computed tomography angiography (CTA) of brain showed left FTPCA with prominent left fetal PCOM. Subsequent computed tomography (CT) of brain showed concurrent left middle cerebral artery (MCA) and PCA territories infarct. CTA brain is commonly done in ischemic stroke cases to assess presence of large vessel occlusions and intracranial or extracranial atherosclerotic disease. However, this case depicts its additional role in detecting anatomical variants of cerebral circulation. In terms of clinical importance, presence of multiple territories infarction portends a poorer neurological outcome.

Abstract 9332: A Case of Fulminant Vasculitis Complicated by ST-Elevation Myocardial Infarction and Stroke

Introduction: Acute coronary syndrome is a rare complication of vasculitis. We present a case of fulminant medium-vessel vasculitis complicated by ST-elevation myocardial infarction (STEMI) and stroke. Case report: A 30-year-old woman with a history of painful skin lesions presented with acute headache, neck pain, and right arm weakness with paresthesia. CT angiography revealed high-grade stenosis of the internal carotids. Subsequently, she reported acute chest pain and dyspnea. ECG revealed anterior STEMI (Figure 1). She underwent emergent coronary angiography that revealed an acute occlusive thrombus of the proximal LAD that was successfully treated with aspiration thrombectomy and drug-eluting stent deployment (Figure 1). The patient was transferred to our institution with concern for fulminant vasculitis complicated by STEMI and stroke. Upon arrival to our hospital, CT and MRI revealed severe occlusions of the bilateral internal carotid arteries and a left middle cerebral artery infarct (Figure 1). Echocardiogram demonstrated severe left ventricular systolic dysfunction with regional wall motion abnormalities. Additional imaging demonstrated inflammation of the thoracic aorta, common iliac, and renal arteries, as well as occlusions of the inferior mesenteric and infratibial arteries. An extensive serologic evaluation for rheumatologic disease was negative. The patient was treated with IV corticosteroids and cyclophosphamide for fulminant medium-vessel vasculitis. Discussion: This report provides a rare opportunity to consider the management of fulminant vasculitis, most likely polyarteritis nodosa, presenting as STEMI and acute stroke. The patient’s presentation, imaging, and laboratory findings were inconsistent with alternative diagnoses such as Tayakasu’s arteritis, Behçet’s disease, or a systemic rheumatologic condition. The patient improved with immunosuppression and follows with cardiology for chronic heart failure.

P.115 Vessel Wall Imaging of Unusual Childhood Strokes: a Pediatric Case Series

Background: MR-based vessel wall imaging (VWI) has gained influence in the clinical investigations, and management of pediatric strokes. Limitations still exist in interpreting it as a singular modality. Methods: We present 4 pediatric stroke cases with VWI enhancement. Results: Case 1. 4-year old boy with sickle cell anemia, who developed encephalopathy during a hemolytic crisis. MR-VWI revealed bilateral extracranial internal carotid enhanced narrowing, deemed a secondary vasculopathy, with resolution upon follow-up. Case 2. 16-year old male presented with left middle cerebral artery (MCA) infarction. VWI revealed left internal carotid terminus and proximal MCA enhancement. Conventional angiography showed abnormalities in mesentric and hepatic arteries. Stability sustained on anticoagulation and immunosuppressive therapy. Case 3. 10-year old girl, developed bilateral MCA infarctions with enhanced extracranial segments of both ICAs, and narrow PCAs, consistent with Moyamoya vasculopathy. Improved on combined immunosuppressive and anticoagulation therapy. Case 4. 13-year old boy had an episode of right facial weakness, with a normal neurological exam; with enhancement and narrowing in the left extracranial ICA, likely an intramural hematoma from dissection. He responded to dual anticoagulation therapy. Conclusions: In conclusion, these cases illustrate similarities in vessel wall imaging abnormalities under different clinical contexts, with practical utility in longitudinal follow-up and prognostication.

ISCHEMIC STROKE IN COVID-19 PATIENT: A RARE CASE REPORT.

Background: COVID-19 is shown to be associated with hypercoagulable state which may cause neurological and cardiovascular complications. COVID-19 has been represented as an independent risk factor for acute ischemic stroke. Objective:We report a case of acute ischemic stroke as a COVID-19 complication. Material and methods: A 62-year-old known hypertensive male was diagnosed with COVID-19. He developed neurological symptoms 10 days after being tested positive. On doing an NC-CT head, a large acute ischemic stroke involving left Middle Cerebral Artery infarct was detected. Result and Conclusion: Our case represents the development of acute ischemic stroke as a neurological manifestation in patient with COVID-19. Early evaluation for acute neurological changes and timely management may reduce morbidity and mortality in such cases.

A CASE OF MIDDLE CEREBRAL ARTERY INFARCT FOLLOWING UNEVENTFUL CLIPPING OF ANTERIOR COMMUNICATING ARTERY ANEURYSM

Background: Aneurysms of the anterior communicating artery are the most frequently encountered intracerebral aneurysms in routine neurosurgical practice. Management of intracerebral aneurysm involves aneurysm clipping or endovascular coil aneurysm embolisation. However, to the best of our knowledge, there is no reported case of an isolated ipsilateral middle cerebral artery infarction following clipping of anterior communicating artery aneurysm. Case Description: A 65-year-old female with hypertension presented with a history of giddiness, fall and altered sensorium. The patient had a Glasgow Coma Scale (GCS) score of 12, and further investigation of the magnetic resonance imaging on suspicion of stroke revealed subarachnoid haemorrhage in the bilateral parietal sulcus, left Sylvain ssure, left ambient and quadrigeminal cisterns with intra-ventricular extension. The patient was subsequently referred for neurosurgery consultation. Computed tomography (CT) angiogram conrmed the presence of a ruptured anterior communicating artery aneurysm. The neurological assessment showed reduced responsiveness to verbal commands, with a Hunt and Hess score of 3. The patient underwent uneventful clipping of the aneurysm. Postoperatively, the patient did not wake up from anaesthesia and had persistently elevated blood pressure and right-sided hemiplegia. On the third day of postoperative care, a CT head scan revealed a left middle cerebral artery infarction with a midline shift. Decompressive craniotomy was performed, and following this procedure, the patient improved in sensorium with residual right-sided hemiplegia Conclusion: This case report presents an undetected new micro embolism or postoperative cerebral vasospasm as possible causes for the development of cerebral infarct in patients with subarachnoid haemorrhage following an aneurysm rupture.

Triggered by Covid-19? Large Vascular Occlusion Resulting in Cytokine Storm Syndrome and Kounis Syndrome: A Case Report

It has been widely reported that infections caused by coronaviruses, especially SARS-CoV-2 (Covid-19), can result in cytokine storm syndrome, one of the causes of acute cerebrovascular disease and ‘kounis syndrome’. An 87-year-old male patient, who did not have any chronic diseases apart from hypertensions, was admitted to our emergency department with mental fog and right-sided weakness in the absence of the typical symptoms of Covid-19 (such as fever, cough). In addition to evidence of left middle cerebral artery infarction in Computerized Tomography (CT) of the brain, there were infiltrative findings compatible with Covid-19 in thorax CT. Here, we discuss this case in the light of the literature, assuming that inflammation (cytokine storm) and hypercoagulopathy induced by Covid-19 may have presented with large vessel occlusion and kounis syndrome as a result of increased risk of arterial thrombosis.

Post-stroke cognitive impairment on the Mini-Mental State Examination primarily relates to left middle cerebral artery infarcts.

BackgroundPost-stroke cognitive impairment can occur after damage to various brain regions, and cognitive deficits depend on infarct location. The Mini-Mental State Examination (MMSE) is still widely used to assess post-stroke cognition, but it has been criticized for capturing only certain cognitive deficits. Along these lines, it might be hypothesized that cognitive deficits as measured with the MMSE primarily involve certain infarct locations.AimsThis comprehensive lesion-symptom mapping study aimed to determine which acute infarct locations are associated with post-stroke cognitive impairment on the MMSE.MethodsWe examined associations between impairment on the MMSE (<5th percentile; normative data) and infarct location in 1198 patients (age 67 ± 12 years, 43% female) with acute ischemic stroke using voxel-based lesion-symptom mapping. As a frame of reference, infarct patterns associated with impairments in individual cognitive domains were determined, based on a more detailed neuropsychological assessment.ResultsImpairment on the MMSE was present in 420 patients (35%). Large voxel clusters in the left middle cerebral artery territory and thalamus were significantly (p < 0.01) associated with cognitive impairment on the MMSE, with highest odds ratios (>15) in the thalamus and superior temporal gyrus. In comparison, domain-specific impairments were related to various infarct patterns across both hemispheres including the left medial temporal lobe (verbal memory) and right parietal lobe (visuospatial functioning).ConclusionsOur findings indicate that post-stroke cognitive impairment on the MMSE primarily relates to infarct locations in the left middle cerebral artery territory. The MMSE is apparently less sensitive to cognitive deficits that specifically relate to other locations.

Non-invasive brain stimulation as add-on therapy for subacute post-stroke aphasia: a randomized trial (NORTHSTAR).

Non-invasive brain stimulation (NIBS) with speech therapy might improve recovery from post-stroke aphasia. This three-armed sham-controlled blinded prospective proof-of-concept study tested 1 Hz subthreshold repetitive transcranial magnetic stimulation (rTMS) and 2-mA cathodal transcranial direct current stimulation (ctDCS) on the right pars triangularis in subacute post-stroke aphasia. Sixty-three patients with left middle cerebral artery infarcts were recruited in five hospitals (Canada/United States/Germany, 01-2014/03-2018) and randomized to receive rTMS (N = 20), ctDCS (N = 24) or sham stimulation (N = 19) with ST for 10 days. Primary outcome variables were Z-score changes in naming, semantic fluency and comprehension tests and adverse event frequency. Secondary outcome variable was the percent change in the Unified Aphasia Score. Intention-to-treat analyses tested between-group effects at days 1 and 30 post-treatment with a pre-planned subgroup analysis for lesion location (affecting Broca's area or not). Naming was significantly improved by rTMS (median = 1.91/interquartile range = 0.77/p = .01) at 30 days versus ctDCS (median = 1.11/interquartile range = 1.51) and sham stimulation (median = 1.02/interquartile range = 1.71). All other primary results were non-significant. The rTMS effect was driven by the patient subgroup with intact Broca's area where NIBS tended to improve UnAS (median = 33.2%/interquartile range = 46.7%/p = .062) versus sham stimulation (median = 12.5%/interquartile range = 7.9%) at day 30. Conversely, in patients with infarcted Broca's area, UnAS tended to improve more with sham stimulation (median = 75.0%/interquartile range = 86.9%/p = .053) versus NIBS (median = 12.7%/interquartile range = 31.7).Conclusion: We found a delayed positive effect of low-frequency rTMS targeting the right pars triangularis on the recovery of naming performance in subacute post-stroke aphasia. This intervention may be beneficial only in patients with morphologically intact Broca's area.

Acil Servise Başvuran İskemik İnme ve Geçici İskemik Atak Hastalarının Değerlendirilmesi

Amaç: Acil servise başvuran iskemik inme ve geçici iskemik atak hastalarını değerlendirerek, demografik özelliklerini araştırmayı ve acil serviste kalma sürelerini belirlemeyi amaçladık.Gereç ve Yöntem: Bu çalışma Acil Servise 01.01.2015 ile 31.12.2015 tarihleri arasında başvuran iskemik inme ve geçici iskemik atak hastaları değerlendirilerek yapılmıştır. Çalışmayı kabul eden, 18 yaş ve üzerinde, iskemik serebrovasküler olay ve geçici iskemik atak tanısı alan hastalar prospektif olarak incelenmiştir. Hastaların demografik özellikleri, vital bulguları, iskemik inme ile ilgili özellikler, yapılan tetkikler ve tetkik sonuçları, yapılan tedaviler, acil serviste yatış süreleri ve sonlanım durumları değerlendirilmiştir.Bulgular: Çalışmaya toplam 122 hasta dâhil edilmiştir. Hastaların 52 tanesi kadın, 70 tanesi erkek cinsiyettedir. Tüm hastaların yaş ortalamaları 66,25±13,51 yıldır. Hastaların acil servise şikâyetlerinin başlanmasından en sık 3-6 saat ve ikinci sıklıkta 24 saatten sonra başvurmuşlardır. En sık eşlik eden kronik hastalıklar hipertansiyon (%63) ve takiben de diyabettir (%49). Çalışmamızdaki hastaların %32,8’sinin sigara kullandığı, %67,2’ sinin sigara kullanmadığı saptanmıştır. Hastaların 45’inde (%36,9) atriyal fibrilasyon vardır. Sol orta serebral arter infarktının kadınlarda erkeklere göre daha sık görülmesi istatistiksel olarak anlamlı bulunmuştur (p&amp;lt;0,05). Nörologların acil konsültasyonuna cevap verme süreleri ortalama 68,91±68,90 dakikadır. Hastaların acil serviste ortalama kalış süresi 2,55±2,07 gündür. Hastalıkların en yoğun olarak görüldüğü dönem Ocak (%22) ve Şubat (%13,1) aylarıdır.Sonuç: Erkek cinsiyet, ileri yaş ve hipertansiyon, diyabet gibi eşlik eden hastalıklar iskemik inme ve geçici iskemik atak geçirme açısından risk oluşturmaktadır. Kadınlarda sol orta serebral arter sulama alanında iskemik infarkt daha fazla görülmektedir. Hastalıklar daha çok kış aylarında görülmektedir. Hastalar acil servise geç başvurmaktadır. Bu konuda toplumu bilgilendirici çalışmalara ihtiyaç vardır. Hastaların acil serviste bekleme süreleri 24 saatin üzerindedir ve konsültasyonlara yeteri kadar hızlı cevap verilmemektedir. Servislerde yatak açılamama sorununun çözümü gerekmektedir.

Hemispheric lateralization of depression and attention deficit

Objective: There is a complex interaction among to the ischemic cerebrovascular diseases, cognition and depression. The aim of present study is to investigate the relationship between lesion side and depression and attention deficit in patients with Middle Cerebral Artery (MCA) infarction.&#x0D; Methods: This study was conducted on 41 patients with right and left MCA infarction. Beck Depression Inventory (BDI) was used for determination of depression severity of patients and Montreal Cognitive Assessment (MoCA) scoring was used for evaluation of cognitive status. Attention sub-test of MoCA score was also examined.&#x0D; Results: 20 patients had right MCS. The mean age of the patients was 72.21 years. 51.2% of the patients were male. BDI mean score was found to be 11.25 in patients with right MCA infarction and 16.9 in patients with left MCA infarction (p:0.04). The total MoCA scores between two groups were similar (right/left MCA infarction: 20.8/21.3). It was seen to be lower attention sub-score in patients with right hemisphere effects compared to patients with left hemispheric lesion (3.1/5.9; p:0.00).&#x0D; Conclusion: According to our findings, it is understood that attention of patients with right MCA infarction is more affected and patients with left MCA infarction is more depressed. In future studies, depression and attention affects which are at risk of developing after MCA infarctions should be evaluated in detail and should be put emphasis to rehabilitation of these areas.

Poor Outcomes Related to Anterior Extension of Large Hemispheric Infarction: Topographic Analysis of GAMES-RP Trial MRI Scans

BackgroundWe aimed to assess the correlation of lesion location and clinical outcome in patients with large hemispheric infarction (LHI). MethodsWe analyzed admission MRI data from the GAMES-RP trial, which enrolled patients with anterior circulation infarct volumes of 82-300 cm3 within 10 hours of onset. Infarct lesions were segmented and co-registered onto MNI-152 brain space. Voxel-wise general linear models were applied to assess location-outcome correlations after correction for infarct volume as a co-variate. ResultsWe included 83 patients with known 3-month modified Rankin scale (mRS). In voxel-wise analysis, there was significant correlation between admission infarct lesions involving the anterior cerebral artery (ACA) territory and its middle cerebral artery (MCA) border zone with both higher 3-month mRS and post-stroke day 3 and 7 National Institutes of Health Stroke Scale (NIHSS) total score and arm/leg subscores. Higher NIHSS total scores from admission through poststroke day 2 correlated with left MCA infarcts. In multivariate analysis, ACA territory infarct volume (P = .001) and admission NIHSS (P = .005) were independent predictors of 3-month mRS. Moreover, in a subgroup of 36 patients with infarct lesions involving right MCA-ACA border zone, intravenous (IV) glibenclamide (BIIB093; glyburide) treatment was the only independent predictor of 3-month mRS in multivariate regression analysis (P = .016). ConclusionsAnterior extension of LHI with involvement of ACA territory and ACA-MCA border zone is an independent predictor of poor functional outcome, likely due to impairment of arm/leg motor function. If confirmed in larger cohorts, infarct topology may potentially help triage LHI patients who may benefit from IV glibenclamide. Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01794182.

Cardiac papillary fibroelastoma, a cause of acute embolic stroke: Report of two cases

Cardiac Papillary Fibroelastoma (PFE) is a rare benign cardiac tumor mainly clinically asymptomatic that unexpectedly can cause a wide variety of embolic manifestations in heart and brain. Our first case was a 27 years old Indian man, with no previous cardiac or cerebral diseases history, presented in emergency department (ED) with sudden onset of acute nausea, vomiting, vertigo and imbalance. The neurological exam (NE) showed cerebellar ataxia. Brain imaging showed acute right cerebellar infarct. The transesophageal echocardiogram (TEE) showed a cardiac mass of the mitral valve that was subsequently defined as PFE by the cardiac MRI. The second case was a 50 years old Arabic male with no previous cardiac or cerebral diseases history, presented at our ED with acute onset of aphasia and right sided weakness. NE confirmed the aphasia and right hemiparesis. Brain imaging showed patchy left middle cerebral artery infarction. TEE showed mobile echo density noted attached to the aortic valve which was consistent with the PFE. Evidence of large vessels occlusion and post infective vegetation were excluded in both cases. We have presented two cases of PFEs associated with cerebral embolic stroke. These clinical cases strengthen the notion that cardiac tumors carried a high risk of cerebral embolic presentation and emphasize the need to suspect their presence at every age in the event of an embolic stroke. Advanced imaging use is important for a correct diagnosis and management.

Case Series of Adolescents With Stroke-Like Symptoms Following Head Trauma.

Studies cite the incidence of pediatric blunt cerebrovascular injuries (BCVI) ranges from 0.03% to 1.3%. While motor vehicle incidents are a known high-risk mechanism, we are the first to report on football injuries resulting in BCVI. Case 1 is a 14-year-old male football player who presented with slurred speech and facial droop 16h after injury that had resulted in unilateral stinger on the field. The patient had a negative brain computed tomography (CT) at the onset of symptoms. Given progression of symptoms over the next 24h, re-evaluation with CT angiography (CTA) of brain and neck showed left internal carotid artery (ICA) dissection, and magnetic resonance imaging of the brain showed left middle cerebral artery infarct. Case 2 is a 16-year-old male football player who presented with headache and right hemiparesis immediately following a tackle injury. CT brain and neck were negative at an outside hospital, but he was transferred to us for progressive symptoms, and then CTA showed a left ICA dissection with distal emboli, including occlusive involvement of the intracranial left ICA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of BCVI requires a high level of suspicion. Focal neurologic deficits are consistently a risk factor across all screening criteria, including the Denver, Utah, Memphis, and Eastern Association for the Surgery of Trauma. These current screening criteria, however, may not be sufficient to diagnosis BCVI in children. The addition of the mechanism of injury and attention to the patient's clinical presentation and examination are important to prevent missed diagnosis and poor neurologic outcomes.