Left Middle Cerebral Artery Research Articles

Study of Cerebral Hemispheric Lateralization in Stroke and the Arterial Territories Involved in High-risk Patients

Introduction: According to WHO, Stroke is the 2nd leading cause of death and disability after Ischemic heart disease. Prevalence rate of stroke in India varies from 44.45 to 150 per lakh population. Studies have reported a higher frequency of stroke of the left hemisphere. The artery reported to be the most affected is Left Middle Cerebral artery(MCA) followed by Right Middle Cerebral artery. The aim of this study is to determine the side of cerebral hemisphere most affected by stroke and the arterial territories involved in high-risk patients aged above 35 years presenting to the tertiary healthcare centre, as well as to study the sex predilection of stroke. Materials and Methods: A cross-sectional prospective study of 50 high risk stroke patients with Diabetes Mellitus(DM) and /or Hypertension(HTN) presenting to General medicine OPD of a tertiary healthcare centre were investigated with CT/MRI for the side of the cerebral hemisphere affected and the arterial territories involved. The data was tabulated over the course of three months and statistical analysis was carried out. Results: The left cerebral hemisphere was affected in 50%, right in 40% and bilateral involvement was found in 10% patients. Slight predilection of stroke towards the left was seen, however it was not found to be statistically significant (P-value= 0.249). MCA territory was involved in 66% of the patients, Posterior Cerebral Artery(PCA) territory in 8%, Vertebrobasilar Artery(VB) territory in 8%, Anterior Cerebral Artery(ACA) territory in 6% and MCA+ACA in 4%, MCA+VB in 2% and MCA-PCA watershed in 6% patients. Conclusions: We found a slight predilection of stroke towards the left, which was however, not found to be statistically significant. We also found that Middle Cerebral Artery(MCA) territory is the most commonly involved in stroke.

Paracentral acute middle maculopathy as the first sign of internal carotid artery dissection

Purpose: It is proposed to present a clinical case of a patient with a paracentral acute middle maculopathy (PAMM) as the first sign of presentation of severe internal carotid artery (ICA) dissection.Methods: An initial basic ophthalmologic examination of the patient was performed, followed by an optical coherence tomography (OCT) and an OCT‐angiography (OCT‐A) of each eye. Finally, the patient was evaluated by a neurologist, performing a cerebral and supra‐aortic trunks (SAT) computed tomography (CT) angiography.Results: We present a 54‐year‐old patient who came to the emergency room complaining of central blurred vision in his left eye (OS) during 24 h. On ophthalmological examination, it is remarkable a visual acuity (VA) of counting fingers at 1 m in OS. Eye fundus (EF) of OS showed small oval whitish macular lesions. Macular OCT of OS revealed hyperreflective bands in the internal nuclear layer (INL) and OCT‐A showed areas with low flow at deep capillary plexus (DCP) and macular vascular density (MVD) parameters decreased compared to the right eye (OD). During the examination, the patient began to feel a slight loss of strength in his right hemibody with dizziness, so he was explored by a neurologist and a cerebral and SAT CT angiography was performed, which reported severe left ICA dissection with an area of hypoperfusion in the territory of the left middle cerebral artery, but without intracranial vascular occlusion. Since there was no image of occlusion and given the mild neurological symptoms, endovascular treatment was rejected and anticoagulation with enoxaparin was established. Two months later, VA of OS improved to 1, with no significant lesions in the EF. The OCT of OS showed a slight thinning of the INL and the OCT‐A revealed a greater flow in the DCP with better MVD values.Conclusions: This entity should be considered in patients with visual disturbances. PAMM may be the first sign of ICA pathology.

Anti-myelin oligodendrocyte glycoprotein (MOG) antibody-associated cortical encephalitis with low signal in subcortical white matter on MRI FLAIR imaging

A 32-year-old male presented with unilateral orbital-temporal pulsatile headache, followed by fever in the 38°C range and nausea. The patient experienced two episodes of transient dysarthria and tinnitus, each lasting several minutes. MRI revealed swelling of the left cerebral cortex, enhancement of the leptomeninges, dilation of the left middle cerebral artery, and subcortical FLAIR hypointensity. The clinical presentation and MRI findings raised suspicions of myelin oligodendrocyte glycoprotein (MOG) antibody-associated cortical encephalitis. After two courses of steroid pulse therapy, the patient's headache subsided, and there was a significant improvement in the swelling of the left cerebral cortex. Subsequently, serum MOG antibody positivity was confirmed. While unilateral cortical FLAIR hyperintensity and increased blood flow can be observed in various diseases, MOG antibody-associated cortical encephalitis is notably characterized by subcortical FLAIR hypointensity, a finding more frequently observed in this condition compared to other diseases. In this case, the findings were useful for early diagnosis and intervention.

A case of left middle cerebral artery occlusion during catheter ablation for paroxysmal ventricular tachycardia

A case of left middle cerebral artery occlusion during catheter ablation for paroxysmal ventricular tachycardia

Клиническое разнообразие афатических нарушений у больных в остром периоде ишемического полушарного инсульта. Взгляд невролога

Aphasia syndrome is a frequently diagnosed disorder in patients with acute cerebrovascular accident (ACVA), which is of great interest for study, since it affects all areas of human mental activity and has a number of distinctive features from aphasias of other etiologies. The article presents a literature review of speech disorders and describes the authors’ own observations of patients in the acute period of ischemic hemispheric stroke in the left middle cerebral artery basin suffering from various types of aphasic disorders.

Computerized Tomographic Brain Findings in Hypertensives with Stroke in Abuja, Nigeria

Abstract Background: Stroke has become an increasingly significant health problem, and early diagnosis of the stroke type with prompt management improves prognosis. Neuroimaging is crucial to the management of stroke, and computed tomography (CT) scan is a cardinal diagnostic tool in identifying the subtypes, the knowledge of which will improve the management of the patients. Aims and Objectives: The study was aimed at establishing the cranial CT findings in hypertensives with stroke, ascertain the type of stroke, frequency of specific features, such as sites, vascular territories, and secondary effects of the primary lesion. Associations of CT findings with variables such as age and coexisting risk factors were also explored. Materials and Methods: Eighty-four adult hypertensive patients with clinical diagnosis of stroke were serially recruited and cranial CT scan was performed, using 16-slice multidetector CT machine (Toshiba Activion 16®), within 24 h of presentation at the emergency department. All clinical findings, demographic parameters, and radiological findings were documented. The data obtained were analyzed using the Statistical Package for Social Sciences (IBM SPSS version 23.0. Armonk, NY, USA). Results: The mean age of the patients was 57.94 ± 12.05 (mean ± standard deviation) and females were more than males with a male:female ratio of 1:1.3. Ischemic stroke constituted 59.5% while hemorrhagic stroke was 40.5%, and the left middle cerebral artery territory was the most common area affected by both stroke types (P < 0.01). Most of the intracerebral bleed occurred in the basal ganglia (50%), and hemorrhagic stroke was more associated with severe neurological deficits (67.6%) (P < 0.001). Conclusion: Ischemic stroke was more common than hemorrhagic stroke, and more women were affected on a general note. The middle cerebral artery territory is the most common site of affectation, and positive association was established between noncompliance with anti-hypertensive medication and stroke.

A Cerebral Embolism Caused by a Malignant Peripheral Nerve Sheath Tumor in a Patient with Neurofibromatosis Type 1.

A 31-year-old man with neurofibromatosis type 1 (NF-1) had undergone resection of a malignant peripheral nerve sheath tumor (MPNST) on the buttock 3 months previously. He subsequently underwent mechanical thrombectomy for a hyperacute left middle cerebral artery embolism. Histopathologically, the emboli comprised neurofilament-positive pleomorphic tumor cells with geographic necrosis and conspicuous mitosis and were identified as MPNST. The patient died of respiratory failure due to lung MPNST metastasis on day 15 of hospitalization. To our knowledge, this is the first report of a spontaneous cerebral embolism due to MPNST in a NF-1 patient.

Transient neurological deficits in a patient with chronic subdural hematoma

A 62-year-old, right-handed man was diagnosed with asymptomatic bilateral chronic subdural hematomas and underwent hematoma removal on the left side only. At 1 month after surgery, he was admitted to our hospital because he began to have one or two attacks/day of apraxia of speech and dysesthesia of the right hand with a duration of approximately 5 ‍min. The left hematoma had not re-expanded, but fluid-attenuated inversion resonance imaging showed hyperintense lesions in the sulci adjacent to the hematoma. Moreover, single-photon emission computed tomography revealed low-uptake lesions in the left cerebrum adjacent to the hematoma. Electroencephalogram showed no abnormalities, and CT angiography showed a slight deviation of the left middle cerebral arteries due to the hematoma. The attacks disappeared within 10 days, although the volume of the hematoma was unchanged. It was suggested that his transient neurological deficits were caused by cerebral ischemia related to chronic subdural hematoma.

Intravenous Thrombolysis for Pediatric Ischemic Stroke Secondary to Cancer Therapy-related Cardiac Dysfunction: A Case Report.

An 11-year-old boy developed cardioembolic stroke (CES) and cancer therapy-related cardiac dysfunction (CTRCD). He originally developed Ewing sarcoma and was treated with high-dose chemotherapy including doxorubicin. On admission, he had severe aphasia, and magnetic resonance imaging showed occlusion of the left middle cerebral artery M3 segment. Transthoracic echocardiography revealed severe left ventricular dysfunction and a mobile thrombus at the left ventricular apex. Intravenous thrombolysis was administered, and effective recanalization was achieved. The patient did not exhibit any neurological deficits during discharge. Reperfusion therapy for pediatric patients has not yet been established; however, it may be effective for CES secondary to CTRCD.

Less invasive bonnet bypass with subcutaneous tunneling method for common carotid artery occlusion - A technical note.

Common carotid artery occlusion (CCAO) sometimes requires vascular reconstruction. Ipsilateral superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is unsuitable due to insufficient blood flow to the external carotid artery. The bonnet bypass, one treatment option for CCAO, requires a long coronal incision and bone groove to prevent malposition and collapse of an interposition graft. However, this long incision might lead to skin complications and reduced collateral blood flow. A 60-year-old man who experienced recurrent ischemic stroke presented with the right internal carotid artery occlusion and left CCAO. The left STA was unavailable; however, both branches of his right STA were well-developed. Minimizing skin invasion was a priority because the patient had diabetes mellitus. We performed a right STA parietal branch - right MCA anastomosis, followed by a right STA frontal branch - left radial artery graft (RAG) - left MCA bonnet bypass using small intermittent skin incisions. We drilled a bone groove extending across the entire length of the interposition graft through the small intermittent skin incisions. Furthermore, we applied a right STA-RAG end-to-side anastomosis instead of an endto-end anastomosis to preserve collateral skin anastomosis. Postoperatively, the bypass remained patent, and the patient was discharged without complications. The bonnet bypass is a potential treatment for CCAO, but the procedure is invasive. Our modified bonnet bypass method enables less invasive management, preventing collapse and malposition of the interposition graft and minimizing skin complications.

Aneurysm Wrapping as an Adjunct of Clipping of a Premature Rupture of the Middle Cerebral Artery Aneurysm

Aneurysms, abnormal dilatations on cerebral arterial walls, pose a significant health concern due to the morbidity and mortality associated with ruptures causing subarachnoid hemorrhage. The risk of rupture is influenced by aneurysm size and location. Surgical clipping is the preferred treatment, especially for middle cerebral artery (MCA) aneurysms, despite recent endovascular advancements. Intraoperative premature rupture poses a critical challenge, requiring swift decision-making and efficient management techniques. We describe a case of an intraoperative premature aneurysm rupture managed with muscular wrapping as an adjunct to microsurgical clipping. The patient, with a history of spontaneous intracerebral hematoma, underwent urgent microsurgical clipping for a left MCA aneurysm. Premature rupture occurred during clipping, necessitating the use of a muscle patch and fibrin glue for wrapping. The wrapping technique, originally developed for unruptured aneurysms, induces fibrotic scar formation, enhancing vascular stability. Cotton, a common wrapping material, elicits chronic inflammation. Autologous tissues and synthetic materials, like muscle, offer alternatives with potential benefits. Factors associated with increased rupture risk include aneurysm location, irregular shape, and prior rupture. Vigilance and preparedness are crucial, especially for high-risk cases. As the availability of computed tomography scans increases, more aneurysm cases are diagnosed, requiring comprehensive patient assessments before interventions. The presented case demonstrates the effectiveness of on-site wrapping in controlling premature rupture. The combined use of muscle patch and fibrin glue postaneurysmal clipping may assist in preventing rebleeding events. Intraoperative ruptures demand careful consideration, and the described wrapping technique provides a valuable option for managing such complications.

НАРУЖНОЕ ВЕНТРИКУЛЯРНОЕ ДРЕНИРОВАНИЕ ПРИ ЗЛОКАЧЕСТВЕННОМ ИШЕМИЧЕСКОМ ИНСУЛЬТЕ (КЛИНИЧЕСКИЙ СЛУЧАЙ)

Malignant ischemic stroke (MIS) in the territory of the middle cerebral artery (MCA) is the most severe form of supratentorial ischemia. Its conservative therapy is accompanied by a high mortality rate, which may reach 80%. A more effective method of treatment is decompressive hemicraniectomy (DH). However, its implementation is limited by strict indications and several contraindications. In connection with the above, an urgent task is to find an effective method of treating this category of patients. The paper presents a clinical case of successful external ventricular drainage (EVD) in a patient with ischemia affecting the total left MCA territory. Keywords: External ventricular drainage, malignant ischemic stroke, middle cerebral artery, cerebral edema, clinical case.

The Music Within: A Doppler Harmonic Pattern Report in Non-Subarachnoid Hemorrhage Related Cerebral Vasospasm

A 40-year-old male presented an episode of severe thunderclap headache with right hemiparesis. Imaging revealed severe stenosis in the left middle cerebral artery, associated with increased mean velocities detected by Transcranial Doppler Ultrasound (TCD). Notably, a distinctive "tin whistle" sound, known as a doppler harmonic effect, near the highest velocity point was observed during the examination. Extensive workup was performed, including CSF analysis and laboratory investigations, and the diagnosis of Reversible Cerebral Vasoconstriction Syndrome (RCVS) was established. Treatment involving medication and daily monitoring led to a decline in the left MCA's velocity, enabling the patient's discharge with no recurrent headaches or neurological deficits. Notably, a follow-up MRI exhibited the disappearance of the left MCA stenosis. This report discusses the rare occurrence of "musical murmurs" in cerebrovascular diseases, underscoring the potential for early diagnosis using techniques like TCD in emergency settings, particularly in conditions like RCVs.

Acute ischaemic larger artery stroke presenting as a subcortical lesion with grey matter sparing: a case report

Large artery infarctions classically involve both white matter and grey matter in the distribution of the occluded artery. Rarely, large artery infarctions can present as isolated white matter lesions. We describe a 38-year-old, right-hand dominant woman, who presented with sudden onset right face-arm-leg weakness together with expressive aphasia. Neuroimaging demonstrated changes restricted to the white matter in the distribution of the left middle cerebral artery territory. Vascular imaging of her head and neck vessels showed irregular narrowing of the intracranial portions of the left internal carotid artery. Vasculitis was suspected due to these findings on imaging, and she was initially treated with steroids. However, due to the negative vasculitis work-up and an inadequate response, the steroids were discontinued, and she was treated with antiplatelets and statins. Early stroke rehabilitation commenced while inward.Large artery ischaemic strokes can rarely present as white matter lesions when there is adequate collateral circulation, which leads to the sparing of the grey matter.

Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit

Background: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.Case Report: An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.

Cerebral blood flow and white matter alterations in adults with phenylketonuria

BackgroundPhenylketonuria (PKU) represents a congenital metabolic defect that disrupts the process of converting phenylalanine (Phe) into tyrosine. Earlier investigations have revealed diminished cognitive performance and changes in brain structure and function (including the presence of white matter lesions) among individuals affected by PKU. However, there exists limited understanding regarding cerebral blood flow (CBF) and its potential associations with cognition, white matter lesions, and metabolic parameters in patients with PKU, which we therefore aimed to investigate in this study. MethodArterial spin labeling perfusion MRI was performed to measure CBF in 30 adults with early-treated classical PKU (median age 35.5 years) and 59 healthy controls (median age 30.0 years). For all participants, brain Phe levels were measured with 1H spectroscopy, and white matter lesions were rated by two neuroradiologists on T2 weighted images. White matter integrity was examined with diffusion tensor imaging (DTI). For patients only, concurrent plasma Phe levels were assessed after an overnight fasting period. Furthermore, past Phe levels were collected to estimate historical metabolic control. On the day of the MRI, each participant underwent a cognitive assessment measuring IQ and performance in executive functions, attention, and processing speed. ResultsNo significant group difference was observed in global CBF between patients and controls (F (1, 87) = 3.81, p = 0.054). Investigating CBF on the level of cerebral arterial territories, reduced CBF was observed in the left middle and posterior cerebral artery (MCA and PCA), with the most prominent reduction of CBF in the anterior subdivision of the MCA (F (1, 87) = 6.15, p = 0.015, surviving FDR correction). White matter lesions in patients were associated with cerebral blood flow reduction in the affected structure. Particularly, patients with lesions in the occipital lobe showed significant CBF reductions in the left PCA (U = 352, p = 0.013, surviving FDR correction). Additionally, axial diffusivity measured with DTI was positively associated with CBF in the ACA and PCA (surviving FDR correction). Cerebral blood flow did not correlate with cognitive performance or metabolic parameters. ConclusionThe relationship between cerebral blood flow and white matter indicates a complex interplay between vascular health and white matter alterations in patients with PKU. It highlights the importance of considering a multifactorial model when investigating the impact of PKU on the brain.

Mechanical thrombectomy for acute left middle cerebral artery occlusion in a patient with mirror- image dextrocardia

Mirror-image dextrocardia is a physiological variant in which the heart is located in a mirror position to the right of the position of the normal human heart. Mirror-image dextrocardia combined with acute large-artery occlusive stroke is extremely rare in clinical practice. We present here a 67-year- old woman with complete blockage in her left middle cerebral artery. The patient also had a mirror- image dextrocardia. In this report, we share our experience in treating the patient using mechanical thrombectomy. During her visit to the emergency department, we performed various tests to understand the patient’s anatomy. Based on the findings, we decided to approach the femoral artery. Using a combination of stent thrombectomy and intermediate catheter aspiration, we successfully restored blood flow to the patient’s left middle cerebral artery.

A Case Report of an Intracranial Giant Aneurysm in a 10-Year-Old Female

Pediatric intracranial aneurysms are rare and differ from aneurysms in adults in terms of location, etiology, natural history and management. This is a case report of giant aneurysm in a 10-year-old patient presenting with symptoms of headache and vomiting. Cerebral catheter angiogram revealed a large aneurysm in the left middle cerebral artery, M1 segment. The patient underwent left pterional craniotomy, clip reconstruction of the patent artery, and aneurysmectomy. Post operatively the patient had an unremarkable course and was discharged improved after 1 week. Cerebral catheter angiogram was performed after 2 months and revealed no residual aneurysm. Intracranial aneurysms in children are rare; 0.5% to 4.6% of intracranial aneurysms occur in patients aged 18 years or younger. Aneurysms occurring in very young children and infants are exceedingly rare. Unlike their adult counterparts, pediatric aneurysms have been reported to exhibit features such as male predominance, a higher incidence in locations such as the internal carotid bifurcation and posterior circulation, and greater numbers of giant aneurysms. By far, pediatric aneurysms present more commonly as subarachnoid hemorrhage, with peaks at ages 2-5 years and in adolescents older than 15 years. However, the rate of subarachnoid hemorrhage in children is far lower than in adults. This may be due to high incidence of giant aneurysms that present as space-occupying lesions rather than hemorrhage. In the Philippines, intracranial aneurysms are more common in adults rather that in children. Moreover, there has been no published data about pediatric intracranial aneurysm. Presented here is a case of a 10-year-old female with left middle cerebral artery (MCA) giant aneurysm. This report discusses the epidemiology, signs and symptoms and management of the pediatric patient with a giant aneurysm. Conclusions: Intracranial aneurysms in children differ from those in adults in location, morphology, etiology, natural history, and management. Giant aneurysms produce neurologic compromise related to mass effect. The most efficacious form of treatment involves complete elimination of this lesion from cerebral circulation. Regardless of whether these aneurysms are treated or observed, children with intracranial aneurysms require follow-up imaging and clinical surveillance, given their expected long-life span during which treated aneurysms could recur or additional aneurysms could arise. Key words: pediatric, giant aneurysm, craniotomy, clip reconstruction, aneurysmectomy

P103: Middle Cerebral Artery Stenosis is Associated with Severity of Depression in Elderly Patients: Magnetic Resonance Angiography (MRA) Findings

Objective:Vascular abnormalities have been frequently reported in elderly adults as a potential risk factor of late-life depression. However, it is still unclear whether stenosis of cerebral arteries may increase risk of depression in the elderly.Methods:Study participants were 365 patients 65 years or older with depressive disorder who had undergone brain MRI and angiography (MRA) which were assessed by trained radiologists, and the 15-item Geriatric Depression Scale (GDS-15) and the Mini Mental State Examination (MMSE), and blood glucose and lipid profiles.Results:Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.59%). Stenosis was associated with age, marital status, infarction, and atherosclerosis. In multivariable linear regression analysis of different locations of stenosis among the whole sample, only bilateral middle cerebral artery (MCA) stenosis was found to have a significant association with higher GDS-15 score (p= 0.0138), and more than 8 scores in the GDS-15 (p= 0.0045), but no significant associations with ACA (anterior cerebral artery), PCA (posterior cerebral artery) or ICA (internal carotid artery). In multivariable linear logistic analysis of different locations among patients with at least one cerebral artery stenosis, left MCA was found to be significantly related to higher GDS-15 scores but not with right MCA (p = 0.0202).Conclusion:MCA stenosis is significantly associated with severity of depression in elderly adults with cerebral artery stenosis, especially in those with left MCA stenosis.Key pointsPatients with cerebral artery stenosis found with brain magnetic resonance angiography (MRA) were associated with higher depression severity.Stenosis of both left and right middle cerebral artery (MCA) was associated with greater depression severity, with left MCA stenosis having a greater influence on depression severity than right MCA stenosis.Higher depression severity in patients with MCA stenosis suggests that depression in elderly patients is mediated at least in part by vascular pathology of MCA supplied regions and careful investigation and management of cerebral artery stenosis and their risk factors may help reduce the severity of depression in elderly patients who visit psychiatrists.

The difference of autonomic function in acute phase between right and left middle cerebral artery stroke

The difference of autonomic function in acute phase between right and left middle cerebral artery stroke