Left Middle Cerebral Artery Territory Research Articles

Stroke Due to Orthognathic Surgery: Case Report of a Rare Complication

Summary:Le Fort I osteotomy is a frequent surgical procedure used in orthognathic surgeries to treat severe malocclusions and is associated with relatively rare surgical complications. Here, the authors report a case of thrombotic ischemic stroke as a result of this procedure, a complication still not described in the literature. A 19-year-old man with class II malocclusion and retrognathia underwent orthognathic surgery for aesthetic purposes. The surgery included a Le Fort I maxillary osteotomy with vertical impaction, bilateral sagittal split ramus osteotomy for mandibular advancement, and genioplasty. Postoperatively, the patient developed left eye blindness, headache, somnolence, aphasia, and right hemiplegia. Medical imaging showed the Le Fort I line of fracture extending from the maxillary osteotomy to the left optic canal and to the left carotid canal, with osseous fragments impinging the petrous segment of the internal carotid artery, left carotid artery occlusion and associated to an ischemic stroke at the left middle cerebral artery territory. Treatment required decompressive craniectomy and later focused on clinical stabilization, infection management, orthognathic care, neurorehabilitation, and cranioplasty. The hemiplegia and aphasia partially recovered during 12 months, and final dental occlusion was appropriate. Our report demonstrates that an unfavorable Le Fort I fracture trajectory can lead to ischemic stroke and severe neurological deficits.

Case Report – Successful Thrombectomy After Critical Resuscitation Following a Cardiac Arrest

Sparse evidence exists to support a delayed attempt at thrombectomy after a periprocedural cardiac arrest or acute medical decompensation. This case highlights the presentation of a 23‐year‐old woman with dilated cardiomyopathy, who initially presented with a left middle cerebral artery stroke syndrome, but who had a cardiac arrest in the angiogram suite prior to the procedure starting. After aggressive resuscitation in the critical care unit, repeat imaging showed a persistent perfusion deficit in the left middle cerebral artery territory and she successfully underwent a thrombectomy. The case highlights that critical care efforts, even after a severe initial presentation, and significant resuscitative efforts in the intensive care unit setting, can still lead to a successful thrombectomy, and that eligibility for thrombectomy can be reassessed as the patient stabilizes.

Development of a carotid artery thrombolysis stroke model in mice

AbstractRecanalization with restored cerebral perfusion is the primary goal of thrombolytic therapy in acute ischemic stroke. The identification of adjunctive therapies that can be safely used to enhance thrombolysis in stroke remains an elusive goal. We report here the development of a mouse in situ carotid artery thrombolysis (iCAT) stroke model involving graded cerebral ischemia to induce unihemispheric infarction after thrombotic occlusion of the common carotid artery (CCA). Electrolytic-induced thrombotic occlusion of the left CCA enabled real-time assessment of recanalization and rethrombosis events after thrombolysis with recombinant tissue-type plasminogen activator (rtPA). Concurrent transient stenosis of the right CCA induced unihemispheric hypoperfusion and infarction in the left middle cerebral artery territory. Real-time assessment of thrombolysis revealed recanalization rates <30% in rtPA-treated animals with high rates of rethrombosis. Addition of the direct thrombin inhibitor argatroban increased recanalization rates to 50% and reduced rethrombosis. Paradoxically, this was associated with increased cerebral ischemia and stroke-related mortality (25%-42%). Serial analysis of carotid and cerebral blood flow showed that coadministration of argatroban with rtPA resulted in a marked increase in carotid artery embolization, leading to distal obstruction of the middle cerebral artery. Real-time imaging of carotid thrombi revealed that adjunctive anticoagulation destabilized platelet-rich thrombi at the vessel wall, leading to dislodgement of large platelet emboli. These studies confirm the benefits of anticoagulants in enhancing thrombolysis and large artery recanalization; however, at high levels of anticoagulation (∼3-fold prolongation of activated partial thromboplastin time), this effect is offset by increased incidence of carotid artery embolization and distal middle cerebral artery occlusion. The iCAT stroke model should provide important new insight into the effects of adjunctive antithrombotic agents on real-time thrombus dynamics during thrombolysis and their correlation with stroke outcomes.

A Tetrad Cognitive Presentation of Gerstmann Syndrome: A Rare Manifestation of Stroke

Gerstmann Syndrome is a rare neurological presentation due to a lesion in the left dominant parietal lobe, manifesting as a tetrad of agraphia, acalculia, finger agnosia and right-left disorientation. We present a case of a 52-year-old man, right hand dominant, who presented to the Emergency Department with acute confusion for one day. He was disorientated to time, place and person. Focused neurological examination revealed atypical signs of acute stroke, comprising agraphia, acalculia, finger agnosia and right-left disorientation. Stroke protocol was activated and he underwent computed tomography brain perfusion, which confirmed a large penumbra area at the left middle cerebral artery territory. Computed tomography angiogram of the carotid arteries showed a long segment thrombosis in the left internal carotid artery. Emergency thrombectomy was abandoned due to impenetrable hard thrombus. He was treated with dual antiplatelet therapy and discharged after three days with partial improvement in terms of following commands, simple calculations and reduced finger agnosia. He was scheduled for outpatient follow up. This case highlights Gerstmann syndrome as an atypical manifestation of acute stroke.

Malignant cerebral infarction after COVID-19 myocarditis in 22-year-old female: a case report

Background: Ischemic stroke is one of the serious neurological complications of coronavirus disease 2019 (COVID-19). However, ischemic stroke can develop secondary complications after cardiac involvement in COVID-19. Case Report: We report the case of a 22-year-old patient who presented with malignant cerebral infarction 10 months after COVID-19-related myocarditis. A 22-year-old woman was referred to the emergency room because of abnormal mental status changes. She developed heart failure and arrhythmia after COVID-19-related myocarditis. Brain magnetic resonance imaging (MRI) revealed high signal intensity on diffusion-weighted imaging that was indicative of acute cerebral infarction in the left middle cerebral artery (MCA) and left anterior cerebral artery (ACA) territory. In addition, occlusion of both the left MCA and ACA was observed on brain MRI. Craniectomy with therapeutic hypothermia was performed to treat the cerebral edema. Conclusion: This case suggests that caution is needed in survivors with secondary complications after COVID-19.

Spatially separate cerebral infarction in the posterior cerebral artery territory after combined revascularization of the middle cerebral artery territory in an adult patient with moyamoya disease and fetal-type posterior communicating artery: illustrative case.

BACKGROUNDRemote cerebral infarction after combined revascularization of the middle cerebral artery (MCA) territory is rare in patients with moyamoya disease (MMD) with a fetal-type posterior communicating artery (PCoA).OBSERVATIONSA 57-year-old woman developed numbness in her right upper limb and transient motor weakness and was diagnosed with MMD. She also had a headache attack and a scintillating scotoma in the right visual field. Preoperative magnetic resonance angiography (MRA) showed stenosis of the left posterior cerebral artery (PCA). Combined revascularization was performed for the left MCA territory. No new neurological deficits were observed for 2 days after the operation, but right hemianopia, alexia, and agraphia appeared on postoperative day (POD) 4. Magnetic resonance imaging showed a new left occipitoparietal lobe infarction, and MRA showed occlusion of the distal left PCA. After that point, the alexia and agraphia gradually improved, but right hemianopia remained at the time of discharge on POD 18.LESSONSCerebral ischemia in the PCA territory may occur after combined revascularization of the MCA territory in patients with fetal-type PCoA. For these cases, a double-barrel bypass or indirect revascularization to induce a slow conversion could be considered on its own as a treatment option.

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.

Sporadic Hemiplegic Migraine Presenting ATP1A2 Mutation in Korea

Hemiplegic migraine (HM) is a rare form of migraine, characterized by migraine with reversible motor weakness. HM can be divided into sporadic and familiar HM based on familiarity. Mutations in CACNA1A, ATP1A2 and SCN1A were identified in familiar HM. We present a patient with sporadic HM exhibiting recurrent hemiplegia, mental change and fever along with headache attacks. During the hemiplegia, he showed perfusion delay in left middle cerebral artery territory. Genetic panel test revealed a likely pathogenic varia nt in ATP1A2.

Deep Learning Approach Using Diffusion-Weighted Imaging to Estimate the Severity of Aphasia in Stroke Patients.

Background and PurposeThis study aimed to investigate the applicability of deep learning (DL) model using diffusion-weighted imaging (DWI) data to predict the severity of aphasia at an early stage in acute stroke patients. MethodsWe retrospectively analyzed consecutive patients with aphasia caused by acute ischemic stroke in the left middle cerebral artery territory, who visited Asan Medical Center between 2011 and 2013. To implement the DL model to predict the severity of post-stroke aphasia, we designed a deep feed-forward network and utilized the lesion occupying ratio from DWI data and established clinical variables to estimate the aphasia quotient (AQ) score (range, 0 to 100) of the Korean version of the Western Aphasia Battery. To evaluate the performance of the DL model, we analyzed Cohen’s weighted kappa with linear weights for the categorized AQ score (0–25, very severe; 26–50, severe; 51–75, moderate; ≥76, mild) and Pearson’s correlation coefficient for continuous values. ResultsWe identified 225 post-stroke aphasia patients, of whom 176 were included and analyzed. For the categorized AQ score, Cohen’s weighted kappa coefficient was 0.59 (95% confidence interval [CI], 0.42 to 0.76; P<0.001). For continuous AQ score, the correlation coefficient between true AQ scores and model-estimated values was 0.72 (95% CI, 0.55 to 0.83; P<0.001). Conclusions DL approaches using DWI data may be feasible and useful for estimating the severity of aphasia in the early stage of stroke.

Is COVID-19 infection also a silent killer?: A case of acute stroke

A 59-year-old male had multiple comorbidities such as diabetes, dilated cardiomyopathy, hypertension, ischemic heart disease, and chronic obstructive pulmonary disease. He presented with dyspnea and had ground-glass opacity in the lungs. It was during the pandemic of COVID-19 so repeated Reverse transcription polymerase chain reaction (RT-PCR) was done, but all were negative. He got stabilized within 5 days and we planned discharge. Suddenly, he had right hemiplegia and developed altered sensorium. He had NIH Stroke Scale/Score of 28 and computed tomography-Alberta Stroke Program Early Computed Tomography Score of 10. We used tenecteplase (0.25 mg/kg bodyweight) for thrombolysis within 20 min of onset and planned mechanical thrombectomy for the occlusion of internal carotid artery and beyond. However, in magnetic resonance imaging of the brain, he had an established infarct in the left middle cerebral artery (MCA) territory (within this short time) without significant DWI/FLAIR mismatch. Hence, we continued conservative management. We incidentally detected him to have COVID-19 infection positivity on that day, but all inflammatory and coagulation parameters were normal on that day and later. His monitor did not reveal arrhythmia (during the event and later) and echocardiography failed to reveal evidence of culprit lesion. He had a rapid clinical decline, required hemicraniectomy but expired within 2 days. COVID-19 infection may have negative reports initially, but malignant MCA infarct with normal inflammatory markers makes our case special. The rapidity with which stroke developed underscores the severe nature of the disease process, the absence of arrhythmias (in this in-house stroke), and normal coagulation parameters hints that the exact mechanism of stroke in this type of infection is still an enigma.

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 1122‐000021: Delayed Vasospasm and Cerebral Ischemia Following Mild Traumatic Brain Injury

Introduction : Post‐traumatic vasospasm (PTV) is a significant cause of morbidity and mortality following traumatic brain injury (TBI). 1 Delayed PTV is thought to occur due to inflammation from SAH. 1 The risk of symptomatic PTV is associated with the severity of TBI. 1,2,3 Treatment of PTV traditionally involves agents used in aneurysmal vasospasm such as Nimodipine. Intra‐arterial and intravenous verapamil and milrinone have been utilized to treat PTV. 4 We present a rare case of delayed cerebral ischemia caused by PTV without SAH treated with intra‐arterial milrinone and oral verapamil. Methods : This is a case report of a case of a 16‐day delay of cerebral ischemia secondary to PTV. Results : A 19‐year‐old female without significant medical history presented to the emergency room as the restrained driver in a motor vehicle collision involving a car versus a tree. The patient’s Glasgow Coma Scale score was 13 and the initial head CT did not demonstrate SAH with a Rotterdam score of 0. There were multiple fractures and soft tissue contusions noted on imaging which required surgical correction and splinting. The patient’s hospital stay was complicated by a large retroperitoneal hematoma requiring blood transfusions and surgical evacuation. 16 days after admission, the patient experienced sudden‐onset right upper extremity paralysis and weakness of the right leg. CT head demonstrated loss of gray‐white differentiation in the left middle cerebral artery (MCA) territory and CT angiography demonstrated 70% stenosis of the left supra‐clinoid internal carotid artery (ICA) and proximal left MCA. Cerebral angiography demonstrated 60% stenosis left supra‐clinoid ICA and 60% stenosis at the origin of the left MCA consistent with PTV. Left MCA stenosis improved to 20% post 10 mg intra‐arterial milrinone in the left ICA (Figure 1). The patient also received verapamil orally. Transcranial doppler demonstrated elevated peak systolic velocities at 298 cm/s in the left MCA and 276 cm/s in the left ICA. Six days later this improved to 150 cm/s in the left MCA and 151 cm/s in the left ICA. The patient continued to be unable to move her right side against gravity with dense expressive aphasia and dysarthria at discharge to inpatient rehabilitation. At follow‐up 4 weeks later, her right hemiparesis had improved significantly to being able to stand with assistance and her expressive aphasia had improved from one word to occasionally forming several word sentences. Conclusions : PTV is a potentially devastating complication of TBI. As our case demonstrates, the presence of mild TBI and absence of SAH may be falsely reassuring. 2 Additionally, our case report demonstrates that intra‐arterial milrinone causes radiographic improvement in PTV. Further studies are needed for the best screening and diagnostic exams for PTV and therapeutic interventions.

Acute Ischemic Stroke in a Young Child and Its Association with SARS-CoV-2 Infection

AbstractThe coronavirus disease 2019 (COVID-19) in children has been shown to have lower morbidity and mortality in children as compared with adults. The neurological complications related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly reported in children, yet the cerebrovascular complications are rare. We report a case of a toddler who presented with right-sided hemiparesis and motor aphasia, with an antecedent history suggestive of COVID-19 infection. The child tested negative on the nasopharyngeal swab for real-time reverse transcription-polymerase chain reaction (RT-PCR), but the serology for anti-SARS-CoV-2 IgG assay was positive. The neuroimaging showed an acute infarct in the left middle cerebral artery territory. A detailed evaluation for causes of childhood stroke was unrevealing, except for the presence of severe iron deficiency anemia (IDA). The child was diagnosed as acute ischemic stroke (AIS) most probably secondary to mild COVID-19 infection. The objective of this case report is to explain the possibility of AIS after a mild COVID-19 infection, complicated by the underlying severe IDA. Therefore, an association between COVID-19 and stroke in children needs to be emphasized and RT-PCR for SARS-CoV-2 as well as serological assay must be included in the workup of stroke in the young.

Cerebrovascular Events Complicating Cardiac Catheterization - A Tertiary Care Cardiac Centre Experience

Background:Cerebrovascular events (CVEs) are one of the rare complications of cardiac catheterization. This prospective single-center study was conducted to assess the incidence, presentations, and outcomes of CVEs in patients undergoing cardiac catheterization.Methods:Patients undergoing cardiac catheterization who developed CVEs within 48 h of procedure were analyzed prospectively with clinical assessment and neuroimaging.Results:Out of 55,664 patients, 35 had periprocedural CVEs (0.063%). The incidence of periprocedural CVEs with balloon mitral valvotomy, percutaneous coronary intervention, and coronary angiography was 0.127%, 0.112%, and 0.043%, respectively. A larger proportion of periprocedural CVEs occurred in patients with acute coronary syndrome (ACS, 77.1%) than in patients with stable coronary artery disease (CAD). The majority of CVEs were ischemic type (33 patients, 94.3%). It was most commonly seen in the left middle cerebral artery (MCA) territory. Hemorrhagic CVEs were very rare (2 patients, 5.7%). The majority of the CVEs manifested during or within 24 h of the procedure (31 patients, 88.6%). Neurodeficits persisted during the hospital stay in 20 patients (57.2%), who had longer duration of procedure compared to those with recovered deficits (P = 0.0125). In-hospital mortality occurred in three patients (8.5%) and post-discharge mortality in another 3 (8.5%).Conclusions:Periprocedural CVEs are rare and have decreased over time. They occur in a greater proportion in patients with ACS than in patients with stable CAD, more with interventional than diagnostic procedures. Ischemic event in the left MCA territory is the most common manifestation, commonly seen within 24 h of the procedure. Longer duration of procedure was a risk factor for larger infarcts and hence persistent neurodeficit at discharge. Although a substantial number of patients recover the neurodeficits, periprocedural CVEs are associated with adverse outcomes.

HYPERCOAGULABLE STATE: AN ENIGMA IN COVID-19 INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state predisposing patients to both arterial and venous thrombosis. The pathophysiology is not completely understood as new data continues to emerge. Our case features a patient with multiple causes of hypercoagulability and a similar disease profile as catastrophic antiphospholipid syndrome (CAPS). CASE PRESENTATION: A 28-year-old male with a past medical history of obesity presented with dyspnea on exertion, presyncope, and bilateral lower extremity edema. Physical exam revealed jugular venous distension and 3+ bilateral pitting edema. COVID-19 PCR was positive. CTA chest showed bilateral pulmonary emboli and right lower lobe pulmonary infarcts. During the hospital course, he developed chest pain and elevated troponin. EKG revealed an anterolateral STEMI. Cardiac catheterization showed 100% LAD occlusion that was not amenable to stenting. An echocardiogram showed cardiomyopathy with an ejection fraction of 18%. Other laboratory tests revealed hypoalbuminemia and nephrotic-range proteinuria, confirming nephrotic syndrome. Renal biopsy was a limited sample but showed mild epithelial foot process effacement. Immune-complex disease was ruled out. The patient was discharged on apixaban. Two weeks later, he presented with altered mental status and right-sided weakness. CTA and CTP showed large core infarct in the left middle cerebral artery territory. Due to core infarction volume, he was not a candidate for endovascular intervention. Hypercoagulability workup revealed positive anti-cardiolipin antibody IgG and IgM, suggestive of an acquired antiphospholipid syndrome (APS) secondary to COVID-19. Other causes of hypercoagulability were ruled out. He was transitioned to warfarin outpatient. DISCUSSION: This case represents a multifactorial etiology of hypercoagulable state secondary to COVID-19-infection, antiphospholipid antibodies (APLA), and nephrotic syndrome. One mechanism of COVID-19 hypercoagulability is related to neutrophil activation and unregulated formation of neutrophil extracellular traps (NETS) which can cause platelet activation and thrombin generation. Viral infections have been associated with the production of APLA. A study among hospitalized patients with COVID-19 infection showed that more than 50% were transiently positive for APLA, which are prothrombotic. This case bears resemblance to CAPS, which is a severe form of APS with multi-organ involvement in a short period of time. CONCLUSIONS: This case highlights the need for further investigation on the pathophysiology of COVID-19 hypercoagulability state, the immunological similarities between COVID-19 and CAPS, and the population that should receive thromboprophylaxis as well as the duration of therapy. REFERENCE #1: Zuo Y, Estes S, Ali R et al. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci. Transl. OMed. 2020 Nov;12(570):eabd3876 REFERENCE #2: Tung M, Tan B, Cherian R, et al. Anti-phospholipid syndrome and COVID-19 Thrombosis: Connecting the dots. Rheumatology Advances in Practice. 2021 Feb;5(1):rkaa081 REFERENCE #3: Ortega-Paz L, Capodanno D, Montalescot G, et al. Coronavirus Disease 2019– Associated Thrombosis and Coagulopathy: Review of the Pathophysiological Characteristics and Implications for Antithrombotic Management. J Am Heart Assoc. 2021;10:e019650 DISCLOSURES: No relevant relationships by Mohammad Omar Butt, source=Web Response No relevant relationships by Lisa Ezegbu, source=Web Response No relevant relationships by Saima Mili, source=Web Response No relevant relationships by Tamim Naber, source=Web Response No relevant relationships by Azka Sadiq, source=Web Response No relevant relationships by Sivashankar Sivaraman, source=Web Response

THROMBECTOMY FOR ACUTE EMBOLIC STROKE FOLLOWING HEART SURGERY

Introduction Acute ischaemic stroke occurs in approximately 1-10% of patients undergoing cardiac surgery and can markedly impair recovery (1). Thrombolysis carries an unacceptably high risk of haemorrhage in the early postoperative period after heart surgery. Mechanical thrombectomy is becoming an increasingly preferred alternative to treat ischaemic strokes, and unlike thrombolysis, is not contraindicated in the early postoperative period. We report a patient who had witnessed onset of ischaemic stroke in the early postoperative period after aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery and was treated with mechanical thrombectomy. Discussion An 81-year-old male patient underwent elective tissue AVR and CABG (internal mammary to left anterior descending coronary artery) surgery. Surgery was uncomplicated and following weaning from mechanical ventilation, the patient's trachea was extubated on the evening of surgery. His recovery progressed uneventfully and on the day after surgery, he was moved to a high dependency unit. On the morning of the second post-operative day, the patient had a witnessed rapid deterioration in conscious level, becoming unresponsive with a divergent gaze. Urgent plain CT scan of the brain showed hyperattenuation of the left middle cerebral artery (MCA) territory consistent with acute thrombosis. The patient was granted emergency funding for a mechanical thrombectomy and was transported to the regional neurology hospital. A mechanical thrombectomy was performed successfully, with digital subtraction angiography (DSA) confirming complete occlusion of the left MCA with poor collateral cross flow. The patient failed to recover neurological function and died approximately 24 hours later. Mechanical thrombectomy is now a well-established treatment for acute ischaemic stroke. There are clear advantages with regard to functional outcome for patients undergoing mechanical thrombectomy versus best available medical therapies such as thrombolysis (2). A recent systematic review of acute ischaemic stroke post cardiac surgery showed that 50% of patients who underwent endovascular mechanical thrombectomy had a full or good neurological recovery, 36% had moderate recovery and 14% had little improvement (1). Factors that may have led to a poor outcome in this patient's case included the delay in hospital transfer, the poor cerebral cross blood flow noted on DSA and extensive comorbidities. In conclusion, although there are many reports of mechanical thrombectomy being associated with a good neurological outcome from acute ischaemic stroke associated with cardiac surgery, outcome may not be improved if there is underlying cerebrovascular disease and intervention is delayed.

Hyperprolactinaemia in a Patient with Acute Ischaemic Stroke

This is a case report of a 47-year old man with an unknown medical illness, presented with neurological deficits typical of clinical stroke. The Magnetic Resonance Imaging (MRI) findings were an acute left middle cerebral artery (MCA) territory infarction and an incidental finding of a sellar mass likely pituitary origin. The pituitary hormones showed markedly hyperprolactinaemia with the level of 21146 ng/ml (n 4.04 – 15.2 ng/ml), low Follicle-stimulating hormone (FSH) with a level of 0.929 IU/L (n 1.5-12.4 IU/L), and low luteinizing hormone (LH) with a level of 1.11 IU/L (n 1.7-8.6 IU/L). Other investigations of serum cortisol, growth hormone (GH), thyroid-stimulating hormone (TSH), platelet count and coagulation profiles were normal. The patient was treated conservatively in the ward for acute ischaemic stroke and later was started on dopamine agonist cabergoline for hyperprolactinaemia.

What is the impact of head movement on automated CT perfusion mismatch evaluation in acute ischemic stroke?

ObjectivesAutomated CT perfusion mismatch assessment is an established treatment decision tool in acute ischemic stroke. However, the reliability of this method in patients with head motion is unclear. We therefore...

Transcranial Doppler Ultrasound Pre and Post Middle Cerebral Artery Stent Placement

This report describes a 42 year old male with a 5 year history of transient ischemic attacks (TIAs), migraines, previous strokes, and symptoms referable to a left middle cerebral artery (MCA) territory event. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) revealed severe stenoses in the proximal left MCA and proximal left anterior cerebral artery (ACA). Transcranial Doppler ultrasound/Transcranial Doppler imaging (TCD/TCI) and cerebral angiogram confirmed the stenoses with a mean flow velocity (MFV) at the proximal left MCA, with a velocity of 230 cm/s. A Wingspan Stent System stent was placed in the proximal left MCA. Cerebral angiogram and serial TCD examinations performed post stent placement showed a patent left MCA without stenosis and a MFV of 55 cm/s. The left ACA was occluded following proximal left MCA stent placement. This case highlights the usefulness of TCD in the assessment of the MCA and other basal cerebral arteries.

The anesthetic approach for endovascular recanalization therapy depends on the lesion site in acute ischemic stroke

PurposeEndovascular therapy (EVT) of large-vessel occlusion in acute ischemic stroke (AIS) may be performed in general anesthesia (GA) or conscious sedation (CS). We intended to determine the contribution of ischemic cerebral lesion sites on the physician’s decision between GA and CS using voxel-based lesion symptom mapping (VLSM).MethodsIn a prospective local database, we sought patients with documented AIS and EVT. Age, stroke severity, lesion volume, vigilance, and aphasia scores were compared between EVT patients with GA and CS. The ischemic lesions were analyzed on CT or MRI scans and transformed into stereotaxic space. We determined the lesion overlap and assessed whether GA or CS is associated with specific cerebral lesion sites using the voxel-wise Liebermeister test.ResultsOne hundred seventy-nine patients with AIS and EVT were included in the analysis. The VLSM analysis yielded associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas. Stroke severity and lesion volume were significantly higher in the GA group. The prevalence of aphasia and aphasia severity was significantly higher and parameters of vigilance lower in the GA group.ConclusionsThe VLSM analysis showed associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas including the thalamus that are known to cause neurologic deficits, such as aphasia or compromised vigilance, in AIS-patients with EVT. Our data suggest that higher disability, clinical impairment due to neurological deficits like aphasia, or reduced alertness of affected patients may influence the physician’s decision on using GA in EVT.