Lenticulostriate Arteries Research Articles

Visualisation of lenticulostriate arteries using contrast-enhanced time-of-flight magnetic resonance angiography at 7 Tesla

7 Tesla-field-strength (7 T) Magnetic Resonance Imaging allows the small perforating arteries in the brain to be visualised, and this modality may allow visualisation of the arterial pathology in cerebral small vessel disease. Most studies have used standard Time-of-Flight (ToF) Magnetic Resonance Angiography (MRA). Whether the use of contrast enhancement improves perforating artery visualisation at 7 T remains unclear. In a prospective study, we compared standard ToF MRA with contrast-enhanced (CE) ToF MRA at 7 T for the visualisation of the lenticulostriate arteries (LSAs). Ten patients with symptomatic lacunar stroke were recruited (mean age, SD, 64 ± 9.9 years). Visualisation was assessed using a visual rating scale administered by two independent expert readers and length of the LSAs visible. Visualisation of the LSAs was improved with CE ToF MRA. The mean Visibility and Sharpness Score was higher for CE ToF MRA over standard ToF MRA (2.55 ± 0.64 vs. 1.75 ± 0.68; P = 0.0008). The mean length of LSA visualised was significantly longer with CE ToF MRA compared to standard ToF MRA (24.4 ± 4.5 vs. 21.9 ± 4.0 mm; P = 0.01). CE ToF MRA offers improved visualisation of the LSAs over standard ToF MRA. The addition of contrast may improve the ability to visualise cerebral small vessel disease arterial pathology.

Mineralizing Microangiopathy of Lenticulostriate Arteries with Basal Ganglia Infarct in an Infant Following Trivial Trauma: A Case Report

Association between trivial head trauma and basal ganglia infarct has been reported frequently in the recent years. We present the case of an infant who presented with neurological deficits following trivial head trauma and in whom all the routine hematological and laboratory investigations were unremarkable. Nonenhanced computed tomography imaging of the brain demonstrated calcification of lenticulostriate arteries in bilateral gangliothalamic complexes with a hypodense area in the left lentiform nucleus centered around one of the calcified vessels consistent with an infarct. It is hypothesized that a severe persistent form of fetal sonographic lenticulostriate vasculopathy that later undergoes mineralization predisposes infants to thrombosis following infarct, precipitating an infarct. Mineralizing microangiopathy is an underlying cause of infantile stroke and generally carries a good prognosis.

Incidence of ischemic complications and technical nuances of arteries preservation for insular gliomas resection.

IntroductionInsular gliomas have complex anatomy and microvascular supply that make resection difficult. Furthermore, resection of insular glioma is associated with a significant risk of postoperative ischemic complications. Thus, this study aimed to assess the incidence of ischemic complications related to insular glioma resection, determine its risk factors, and describe a single surgeon’s experience of artery-preserving tumor resection.MethodsWe enrolled 75 consecutive patients with insular gliomas who underwent transcortical tumor resection. Preoperative and postoperative demographic, clinical, radiological [including diffusion-weighted imaging (DWI)], intraoperative neurophysiological data, and functional outcomes were analyzed. Motor evoked potentials (MEPs) and radiological characteristics like the relationship between the proximal segment of the lateral lenticulostriate arteries (LLSAs) and the tumor, the flat inner edge sign (the inner edge of the insular glioma is well-defined) or obscure inner edge sign, the distance between the lesion and posterior limb of the internal capsule and the invasion of the superior limiting sulcus by the tumor were analyzed. Strategies such as “residual triangle,” “basal ganglia outline reappearance,” and “sculpting” technique were used to preserve the LLSAs and the main branches of M2 for maximal tumor resection according to the Berger–Sinai classification.ResultsPostoperative DWI showed acute ischemia in 44 patients (58.7%). Moreover, nine patients (12%) had developed new motor deficits, as determined by the treating neurosurgeons. The flat inner edge sign [odds ratio (OR), 0.144; 95% confidence interval (CI), 0.024–0.876) and MEPs (>50%) (OR, 18.182; 95% CI, 3.311–100.00) were significantly associated with postoperative core ischemia, which affected the posterior limb of the internal capsule or corona radiata.ConclusionsInsular glioma resection was associated with a high incidence of ischemia, as detected by DWI, as well as new motor deficits that were determined by the treating neurosurgeons. Insular glioma patients with obscure inner edge signs and intraoperative MEPs decline >50% had a higher risk of developing core ischemia. With our strategies, maximal safe resection of insular gliomas may be achieved.

Ischemic stroke in neurosarcoidosis: A retrospective cohort analysis

BackgroundCerebrovascular disease is rarely reported in neurosarcoidosis and constitutes one of its least well-described forms, though recognition for it has grown in the last decade with recent studies estimating a higher frequency of occurrence than previously known. MethodsPatients with ischemic stroke were included if the mechanism was directly attributable to sarcoidosis of the CNS. Patients were excluded if an alternative stroke etiology was of equal or higher likelihood than CNS sarcoidosis. ResultsNeurologic disease was the initial presenting manifestation of sarcoidosis in 8/11 (72.7%), and ischemic stroke was an inaugural manifestation of sarcoidosis in 4/11 (36.4%). Small vessel disease was the predominant ischemia subtype (10/11, 90.9%) with pontine perforating vessels (6/11, 54.5%) and lenticulostriate arteries (3/11, 27.3%) being the vasculature most often affected. Vessels with a more rostral supratentorial distribution were uncommonly affected. Common neuroinflammatory accompaniments included leptomeningitis (10/11, 90.9%) and cranial nerve disease (3/11, 27.3%). Recurrent strokes occurred in 8/11 (72.7%), and recurrent neuroinflammation occurred in 7/11 (63.6%). Antiplatelet drugs were used in 6/11 (54.5%) patients. Most (10/11, 90.9%) required at least two lines of immunosuppression to achieve inflammatory disease remission in this context; infliximab was the most successfully employed immunosuppressant (7/8 treatment courses, 87.5%). Recurrent strokes occurred in 8/11 (72.7%) patients, and a second inflammatory attack occurred in 7/11 (63.6%) patients. The presenting median modified Rankin Scale score of 4.0 improved to 2.0 over a median period of follow-up of 52.0 months. ConclusionIschemic strokes in neurosarcoidosis occur in a caudal-to-rostral distribution, tend to affect small caliber blood vessels that lack collateral blood flow, and typically associate with inflammatory leptomeningeal disease. The risk for relapse in the forms of stroke or neuroinflammation are high in this neurosarcoidosis phenotype.

Awake Craniotomy without Invasive Blood Pressure Monitoring

To assess the safety of foregoing invasive monitoring in a select group of patients undergoing awake craniotomy for supratentorial tumor resection. Awake craniotomies were performed for tumor resection without invasive blood pressure monitoring when there was no preexisting cardiopulmonary indication as determined by the attending anesthesiologist according to institutional protocol. Noninvasive monitoring was performed every 3-5 minutes intraoperatively and then every 15 minutes in the recovery room for 4 hours before transfer to the ward. At a single tertiary care hospital, 74 consecutive awake surgeries were performed with noninvasive blood pressure monitoring. Among patients, 39 (52.7%) were male, 42 (83.8%) had infiltrative primary brain tumors, 2 (2.7%) had a history of coronary artery disease, 6 (8.1%) were diabetics, 10 (29.7%) were smokers, and 22 (29.7%) were on antihypertensive medications preoperatively. American Society of Anesthesiologists classification was I in 1.4% of patients, II in 36.4%, III in 60.8%, and IV in 1.4%. Intraoperative vasoactive medications were administered in 21 (28.4%) patients; 8 (38%) of these were on antihypertensive agents preoperatively. Vasodilators were administered in 13 (61.9%) patients, vasopressors were given in 6 (28.6%) patients, and both vasodilators and vasopressors were given in 2 (9.5%) patients. One patient experienced a lenticulostriate artery stroke intraoperatively, and 1 patient experienced atrial fibrillation 1 week postoperatively. There were no other perioperative anesthetic, hemorrhagic, renal, or cardiopulmonary complications. Intraoperative physiologic control and surgical site complication avoidance do not warrant routine invasive blood pressure monitoring during awake craniotomy for tumor resection.

Factors associated with two different stroke mechanisms in perforator infarctions regarding the shape of arteries

Two different stroke mechanisms are involved in small vessel disease: branch atheromatous disease (BAD) and lipohyalinotic degeneration (LD). We compared mechanisms of stroke in lenticulostriate arteries (LSA) vs. anterior pontine arteries (APA) and verified factors associated with stroke mechanisms, including shape of middle cerebral artery (MCA) and basilar artery (BA). We retrospectively reviewed patients with acute ischemic stroke with penetrating artery territory confirmed by MRI. The mechanisms of stroke were categorized based on diffusion-weighted imaging; BAD was defined as lesion larger than 10 mm in LSA and lesions involving basal pontine in APA. Other lesions were classified as LD. The shapes of MCA and BA were classified as straight, with one angle, or with two angles (U, C or S shape, respectively) using anterior–posterior view. The study included 221 patients. LD was more common in LSA infarcts, but BAD was more common in APA infarcts (p < 0.001). Low initial National Institutes of Health Stroke Scale [Adjusted Odds ratio (aOR) = 0.78; p < 0.001], absence of hyperlipidemia [aOR = 0.31; p = 0.002], previous statin use [aOR = 4.35; p = 0.028] LSA infarcts [reference = APA territory; aOR = 11.07; p < 0.001], and S-shaped vessels (reference = straight shaped vessels; aOR = 3.51; p = 0.004) were independently associated with LD. Angulations in the mother vessels may be more associated with true small vessel disease more with LD than BAD.

Transanterior Limiting Sulcus of the Insula Approach: Novel Surgical Approach to the Ventral Striatum Region

Lesions in the ventral striatum region (above the anterior perforated substance) are a challenge for neurosurgeons due to their direct relationship with the lenticulostriate arteries, which difficult the surgical access. The standard approaches for this region include thefollowing: 1) transfrontal approach, 2) transanterior perforating substance approach, 3) transcallosal transventricular approach, and 4) pterional transsylvian-transinsular route. In this study, we aimed to describe a novel anatomical approach through the anterior limiting sulcus of the insula in order to access the ventral striatum. We reviewed the literature and performed a detailed dissection of this region by using Klingler's technique with brain specimens injected with silicone, paying special attention to the white fibers and lenticulostriate arteries, and provided a description of an illustrative case of a cavernous malformation. Neuroanatomical dissections showed that the lenticulostriate arteries had an inverted C-shaped anterior concavity, leaving less significant vascular relationships in the depth of the anterior limiting sulcus of the insula. In the case we described, the cavernous malformation was completely resected and the patient was discharged without any neurological deficits. The transanterior limiting sulcus of the insula approach to the ventral striatum offers a safe access route for selected cases and can be performed on the basis of anatomical references. Three-dimensional understanding of the intrinsic brain architecture and its relationships with vascular structures in this specific area is important and can be acquired mainly through laboratory training.

Cerebral hemodynamics during atrial fibrillation: computational fluid dynamics (CFD) analysis of lenticulostriate arteries using 7T high-resolution magnetic resonance imaging

Abstract Background Lenticulostriate arteries (LSAs) are small perforating arteries (0.1–1 mm diameter), perpendicularly departing from middle cerebral artery (MCA) and supplying blood flow to important cerebral subcortical and basal ganglia areas. LSAs are involved in silent strokes and cerebral small vessel disease, potentially leading to cognitive decline and vascular dementia. There is growing evidence that atrial fibrillation (AF), the most common cardiac arrhythmia, increases the risk of dementia even in the absence of clinical strokes. AF also increase the risk of small vessel disease. AF may alter deep cerebral hemodynamics per se, however no data exists regarding a possible impact of AF on MCA-LSA branching sites hemodynamics. Purpose To use computational fluid dynamics (CFD) analysis to study the hemodynamics of LSAs-MCA branching sites. Methods 7T high-resolution magnetic resonance imaging (HR-MRI) brain scans (Figure 1, panel a) were used to derive detailed geometrical models of LSAs-MCA branching sites. CFD analysis was then conducted, simulating AF conditions as well as sinus rhythm (SR), at different ventricular rates (from 50 to 130 bpm). Results Geometrical models were retrieved from HR-MRI scans of 7 patients. By means of the most significant metrics, such as wall shear stress (WSS; Figure 1, panel b), wall shear stress gradient (WSSG), and flow velocity (FV), a comparison between SR and AF was performed. Conclusion CFD analysis of LSAs-MCA branching sites using geometrical models derived from HR-MRI brain scans was feasible and allows to quantify the impact of AF on these critical ramifications of the MCA. Funding Acknowledgement Type of funding sources: None.

Lesion Location Predicts Early Neurological Deterioration in Single Subcortical Infarction.

A certain number of patients with single subcortical small infarction (SSSI) in the lenticulostriate artery (LSA) territory present with early neurological deterioration (END). We sought to identify a more specific predicting imaging marker for END in lenticulostriate SSSI patients. We screened patients in a prospective hospital-based registry of stroke in the first Affiliated Hospital of Zhengzhou University from January 2015 to December 2020. Lesion locations were defined as posterior type when more than half of the lesion was located in the posterior part of the corona radiata divided by the midline, which was drawn between the tangents of the anterior and posterior horns of the lateral ventricle and was adjacent to the lateral ventricle at the same time. END was defined as an increase of ≥2 points in total National Institutes of Health Stroke Scale score or ≥1 point. A multivariate logistic analysis was used to assess the imaging predictors for END. 418 patients were enrolled in the final data analysis. Among them, 206 (49. 3%) cases were rated as the posterior type and71 (17.0%) cases had to END. A multivariate logistic analysis showed that only the posterior type (adjusted odds ratio, 2. 126; 95% confidence interval, 1. 250-3. 614; P = 0. 005) was independently associated with the risk of END. The posterior type of lesion location represented an imaging marker predicting END in lenticulostriate SSSI patients.

Stroke Literature Synopsis (Preclinical).

Stroke Literature Synopsis (Preclinical).

Usefulness of Orbitocranial Approach in Neck Clipping of Aneurysms Arising from Middle Cerebral Artery Proximal to the Limen Insulae: A Case Series

Neck clipping of the aneurysms arising from the middle cerebral artery (MCA) proximal to the limen insulae is often difficult because of difficulties in securing a bright and wide operative field to observe the aneurysms and surrounding structures, such as the anterior perforated substance, lenticulostriate arteries, and early frontal branch. Our objective was to determine the usefulness of the orbitocranial approach in neck clipping of the aneurysms arising from the MCA proximal to the limen insulae. This prospective study included 7 patients who underwent neck clipping of aneurysms arising from the MCA proximal to the limen insulae through the orbitocranial approach. In addition to conventional pterional craniotomy, the superiolateral orbital rim was resected with a 1-piece fashion. Its procedures, complications, and outcomes were reviewed. Removal of the superolateral orbital rim facilitated a bright and wide observation from the skull base side. It was much easier to identify the anterior perforated substance, lenticulostriate arteries, and early frontal branch around the aneurysm through the orbitocranial approach than through the conventional pterional approach. Neck clipping could be performed completely and safely in all cases. The orbitocranial approach to aneurysms arising from the MCA proximal to the limen insulae provides us a bright and wide operative field compared with the conventional pterional approach, which is useful to secure complete and safe neck clipping by avoiding cerebral contusion and unexpected obstruction of the early frontal branch.

Changes in periventricular anastomosis after indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic moyamoya disease.

Periventricular anastomosis in moyamoya disease (MMD) is an unusual angiographic finding that arises from perforating arteries such as the lenticulostriate artery (LSA), thalamic artery (THA), and anterior choroidal artery (AChA). This anastomosis is associated with increased hemorrhagic risk in MMD and can be corrected by direct revascularization surgery. The present supplementary analysis on a prospective cohort aimed to elucidate changes in periventricular anastomosis after indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic MMD. Twenty-two patients with misery perfusion in the symptomatic cerebral hemisphere who underwent indirect revascularization surgery alone also underwent six-vessel cerebral angiography via arterial catheterization before and at 6months after surgery. Before surgery, two patients (9%) had positive periventricular anastomosis from the LSA and another (5%) from the AChA; all three of these periventricular anastomoses regressed after surgery, but these changes were not statistically significant (p = 0.0833). The degree of formation of collateral vessels from the LSA significantly decreased after surgery (p = 0.0143), but the degree of collateral vessels from the THA or AChA did not differ between pre- and postoperative conditions. Eight patients with postoperative regression of the collateral vessels from any perforating artery exhibited postoperative rich collateral flow from indirect revascularization. Periventricular anastomosis tended to regress after indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic MMD. Collateral vessels formed from the LSA likely regressed after indirect revascularization surgery alone for such patients, but those vessels from the THA or AChA seldom changed.

Time-of-Flight Intracranial MRA at 3 T versus 5 T versus 7 T: Visualization of Distal Small Cerebral Arteries.

Background Three-dimensional (3D) time-of-flight (TOF) MR angiography (MRA) at 7 T has been reported to have high image quality for visualizing small perforating vessels. However, B1 inhomogeneity and more physiologic considerations limit its applications. Angiography at 5 T may provide another choice for intracranial vascular imaging. Purpose To evaluate the image quality and cerebrovascular visualization of 5-T 3D TOF MRA for visualizing intracranial small branch arteries. Materials and Methods Participants (healthy volunteers or participants with a history of ischemic stroke undergoing intracranial CT angiography or MRA for identifying steno-occlusive disease) were prospectively included from September 2021 to November 2021. Each participant underwent 3-T, 5-T, and 7-T 3D TOF MRA with use of customized MR protocols within 48 hours. Radiologist scoring from 0 (invisible) to 3 (excellent) and quantitative assessment were obtained to evaluate the image quality. The Friedman test was used for comparison of characteristics derived from 3 T, 5 T, and 7 T. Results A total of 12 participants (mean age ± SD, 38 years ± 9; nine men) were included. Visualizations of the distal arteries and small vessels at 5-T TOF MRA were significantly higher than those at 3 T (median score: 3.0 vs 2.0, all P < .001 for distal segments and lenticulostriate artery; median score: 2.0 vs 0, P < .001 for pontine artery). The total length of small vessel branches detected at 5 T was larger than that at 3 T (5.1 m ± 0.7 vs 1.9 m ± 0.4; P < .001). However, there was no evidence of a significant difference compared with 7 T in either the depiction of distal segments and small vessel branches (average median score, 2.5; all P > .05) or the quantitative measurements (total length, 5.6 m ± 0.5; P = .41). Conclusion Three-dimensional time-of-flight MR angiography at 5 T presented the capability to provide superior visualization of distal large arteries and small vessel branches (in terms of subjective and quantitative assessment) to 3 T and had image quality similar to 7 T. © RSNA, 2022 Online supplemental material is available for this article. An earlier incorrect version appeared online. This article was corrected on September 14, 2022.

Avoiding vascular complications in insular glioma surgery - Amicrosurgical anatomy study and critical reflections regarding intraoperative findings.

IntroductionVascular lesions in insular glioma surgery can severely impact patients' quality of life. This study aims to present the results of our dissections and authors’ reflections on the insular vascular anatomy.Matherials and MethodsThe insular vascularization was examined using ×3 to ×40 magnification in 20 cadaveric cerebral hemispheres in which the arteries and veins had been perfused with colored silicone.ResultsIn insular gliomas, this individualization of the anatomical structures is rarely possible, as the gyri are swollen by the tumor and lose their individuality. In the transsylvian approaches, the anatomical parameters for delimiting the insula in tumors are best provided by the superior and inferior circular sulci. The branches of the MCA are easily identified in the transcortical approach, but only at the end of the surgery after the tumor is resected.). One of the factors under-discussed in the literature is the involvement of the lenticulostriate arteries by the medial part of the tumor. In our experience of 52 patients (article submitted to publishing), LSTa were founded to be involved by the tumor in 13 cases. In 39 patients, there was no involvement of the LSTa, which allowed a more aggressive resection. Early preoperative identification of the anterior perforated substance on the MRI and its proximity to the tumor may help determine the route of the LSTa over the medial tumor boundaries.DiscussionOur reflections introduced our imaging and anatomical concept regarding LSTa in insular glioma surgery. Accurate identification of origin, route, and distribution of the LSTa is pivotal to surgical success, especially in the lateral group. The anatomical knowledge of their path directly impacts the extent of tumor resection and functional preservation.ConclusionKnowledge of microsurgical anatomy, brain mapping, and surgical experience counts a lot in this type of surgery, creating a reasonable procedure flowchart to be taken intraoperatively.

Morphological characteristics of lenticulostriate arteries in a large age-span population: Results from 7T TOF-MRA.

Lenticulostriate arteries (LSAs) originate from the middle cerebral artery (MCA) and supply blood to the basal ganglia. The evaluation of its structure and function is essential for the etiological diagnosis of subcortical infarction. However, the characteristics of LSA in a healthy population remain poorly described. Our study aims to acquire morphological measurements of LSA by 7T TOF-MRA on 140 healthy volunteers with a large age range (21–68 years). The results show that the number of branches of LSA gradually decreases with age (r = −0.328, p < 0.001), and the maximum visible length becomes shorter (r = −0.385, p < 0.001). Moreover, there is a significant correlation between the volume of the basal ganglia nuclei and the morphology of LSA. The volume of the putamen is associated with the number of stems (r = 0.267, p < 0.001) and branches (r = 0.236, p < 0.001) of LSAs, while the volume of caudate is closely related to the maximum visible length of LSAs (r = 0.199, p = 0.001). In conclusion, this study is the first in-vivo study to report the morphology of LSA with a large sample size of more than one hundred cases. These findings are valuable in understanding the degeneration of LSAs during aging.

Imaging features of adult moyamoya disease patients with anterior intracerebral hemorrhage based on high-resolution magnetic resonance imaging

This study aimed to identify the high-resolution magnetic resonance imaging (HRMRI) features of moyamoya disease (MMD) patients with anterior intracerebral hemorrhage (ICH) and attempted to reveal potential mechanisms of anterior ICH. Eligible adult MMD patients were consecutively included, and the morphological features of lenticulostriate arteries (LSAs), vessel wall structure of terminal internal carotid artery (ICA) and periventricular anastomosis were evaluated by HRMRI. 78 MMD patients containing 21 patients with anterior ICH, 31 ischemic patients and 26 asymptomatic patients were included. The mean value of total length of LSAs in anterior ICH group (90.79 ± 37.00 mm) was distinctively lower (p < 0.001) compared with either ischemic group (138.04 ± 46.01 mm) or asymptomatic group (170.50 ± 39.18 mm). Lumen area of terminal ICA was significantly larger (p < 0.001) in hemorrhagic group (4.33 ± 2.02 mm2) compared with ischemic group (2.29 ± 1.17 mm2) or asymptomatic group (3.00 ± 1.34 mm2). Multivariate analysis revealed the total length of LSAs (OR 0.689, 95%CI, 0.565–0.840; p < 0.001) and lumen area of terminal ICA (OR 2.085, 95%, 1.214–3.582; p = 0.008) were significantly associated with anterior ICH. Coexistence of reduced LSAs and relatively preserved lumen area of terminal ICA with an AUC of 0.901 (95%CI, 0.812–0.990) could be a potential predictor of anterior ICH in MMD patients.

Association of RNF213 Variants With Periventricular Anastomosis in Moyamoya Disease.

The pathogenic mechanisms of periventricular anastomosis (PA) in moyamoya disease remain unknown. Here, we aimed to describe the angiographic profiles of PA and their relationships with really interesting new gene (RING) finger protein 213 (RNF213) genotypes. We conducted a retrospective cohort study of moyamoya disease patients consecutively recruited between June 2019 and January 2021 in Beijing Tiantan Hospital, Capital Medical University, China. C-terminal region of RNF213 was sequenced. Angiographic characteristics of PA vessels (lenticulostriate artery, thalamotuberal artery, thalamoperforating artery, anterior choroidal artery, and posterior choroidal artery) were compared between different groups of RNF213 genotypes. The dilatation and extension of PA vessels were measured by using PA score (positive, score 1-5; negative, score 0). Multivariate regression analysis was conducted to assess variables associated with PA score. In addition, gene expression of RNF213 in human brain regions was evaluated from the Allen Human Brain Atlas. Among 260 patients (484 hemispheres), 71.2% carried no RNF213 rare and novel variants, 20.0% carried p.R4810K heterozygotes, and 8.8% carried other rare and novel variants. PA scores in patients with p.R4810K and other rare and novel variants were significantly higher than in wild-type patients (P<0.001). Age (odds ratio [OR], 0.958 [95% CI, 0.942-0.974]; P<0.001), platelet count (OR, 0.996 [95% CI, 0.992-0.999]; P=0.027), p.R4810K variant (OR, 2.653 [95% CI, 1.514-4.649]; P=0.001), other rare and novel variants (OR, 3.197 [95% CI, 1.012-10.094]; P=0.048), Suzuki stage ≥4 (OR, 1.941 [95% CI, 1.138-3.309]; P=0.015), and posterior cerebral artery involvement (OR, 1.827 [95% CI, 1.020-3.271]; P=0.043) were significantly correlated with PA score. High expression of RNF213 was detected in the periventricular area. RNF213 variants were confirmed to be associated with PA in moyamoya disease. Individuals with RNF213 p.R4810K heterozygotes and other C-terminal region rare variants exhibited different angiographic phenotypes, compared with wild-type patients.

MRI-guided thrombolysis for lenticulostriate artery stroke within 12h of symptom onset.

Stroke thrombolysis treatment is generally administered within 4.5 h, but a greater time window may be permitted depending upon the ischemic penumbra on neuroimaging. This observational cohort study investigated the outcomes of thrombolysis given within 12 h after symptom onset of lenticulostriate artery stroke. The population comprised 160 patients. Thrombolysis was administered via tissue plasminogen activator, alteplase (TPA). Thrombolysis was indicated by a mismatch between diffusion-weighted imaging (DWI) and T2-weighted imaging (T2WI), that is, an acute ischemic lesion on DWI without a corresponding lesion on T2WI. Demographics and medical history were compared with the modified Rankin scale (mRS) score, to reflect outcome. Patients with a favorable clinical outcome (mRS 0–1) had significantly lower hypertension, baseline NIH Stroke Scale (NIHSS) score, and admission systolic/diastolic blood pressure compared with patients with mRS 2–6. Lower admission systolic blood pressure and NIHSS score were significantly associated with favorable outcome. In patients either with IV-TPA within 4.5 h, or between 4.5 and 12 h, lower admission systolic blood pressure and/or NIHSS score similarly independently predict favorable outcome. However, in all groups, the onset-to-treatment time did not significantly influence the outcomes. We conclude that in our cohort higher admission systolic blood pressure and higher baseline NIHSS and not time were associated with poor outcome in patients with magnetic resonance-guided thrombolysis within 12 h of isolated lenticulostriate artery stroke, therefore loosening the traditionally perceived dependency of outcome on time.

Balancing the Extent of Resection and Ischemic Complications in Insular Glioma Surgery: Technical Nuances and Proposal of a Novel Composite Postoperative Outcome Index.

Maximal safe resection remains the most desired goal of insular glioma surgery. Intraoperative surgical adjuncts provide better tumor visualization and real-time "safety" data but remain limited due to a high cost and limited availability. To highlight the importance of anatomical landmarks in insular glioma resection and avoidance of vascular complications. We also propose to objectify the onco-functional balance in insular glioma surgery. Forty-six insular gliomas operated upon by a single surgeon between January 2015 and February 2020 were reviewed, focusing on the operative technique and clinical outcomes. A novel composite postoperative outcome index (CPOI) was designed, comprising the extent of resection and permanent postoperative deficits, and utilized to assess the surgical outcomes. Gross-total, near-total, and subtotal resections were achieved in 10.9%, 52.1% (n = 24), and 36.9% (n = 17) patients, respectively. The median overall survival (OS) was 20 months (95% CI = 9.56-30.43). CPOI was optimal in 38 patients (82.6%). A well-defined tumor margin (P = 0.01) and surgeon's experience (P = 0.04) were significantly associated with an optimal CPOI. Out of seven (15.2%) patients who developed permanent neurological deficits, three (6.5%) patients had severe disability. Favorable prognostic factors of survival included younger age (<40 years) (P = 0.002), tumors with only frontal lobe extension (P = 0.011), tumors with caudate head involvement (P = 0.04), and non-glioblastoma histology (P = 0.006). Tumor margin and increasing surgeon experience are critical to an optimal postoperative outcome. Respecting the basi-sulcal plane is key to lenticulostriate artery preservation. Caudate head involvement is a new favorable prognostic factor in insular gliomas.

Scattered cerebral infarction in the corona radiata predicts worse outcomes.

Intracranial branch atheromatous disease often results in progressive motor deficits in the lenticulostriate arteries (LSA). In some patients with LSA infarction, magnetic resonance imaging (MRI) revealed single lesions at the LSA origin from the middle cerebral artery spreading in a scattered manner toward the distal area. This study aimed to elucidate the clinical characteristics of such cases. This was a single-center, retrospective study comprising 1,840 consecutive patients admitted to the Ina Central Hospital, Japan. Two neurologists selected patients with LSA infarctions on the basis of MRI data. Patients with a single mass of infarct lesion from the origin were classified as the single group, whereas patients with infarct lesions as a single mass at LSA origin but divided and independent as the infarct area extended distally were classified as the scattered group. We compared the clinical characteristics and outcomes in these groups. The single and scattered groups included 119 and 35 patients, respectively. We defined worsening as an increase of one point or more on the National Institute of Health Stroke Scale. Univariate analysis demonstrated that patients in the scattered group showed significantly more worsening after hospitalization compared with those in the single group (48.6% vs. 28.6%; p<.05). Moreover, this can easily lead to increased disease severity (p<.016). In a multivariate analysis, group (odds ratio, 2.5 [95% CI, 1.11-5.74], p<.03) was an independent predictor of symptom worsening. Scattered infarction in the corona radiata is an aggravating factor leading to worse outcomes.