MCA Infarction Research Articles

Reliable infarction of the middle cerebral artery territory in C57BL/6 mice using pterygopalatine artery ligation and filament optimization - The PURE-MCAo model.

Current techniques for inducing intraluminal filamentous middle cerebral artery occlusion (fMCAo) in mice produce highly variable results and often cause additional infarcts in the posterior cerebral artery (PCA) territory. The aim of the current study was to develop a novel procedure to overcome these shortcomings. Male C57BL/6 mice were subjected to 60 min of fMCAo with cerebral blood flow monitored by laser Doppler flowmetry. The influence of the length of the occlusion filament coating and the combination of common carotid artery (CCA) or pterygopalatine artery (PPA) ligation on lesion volume and functional outcome 24 h after reperfusion was evaluated. The use of appropriate filament and PPA ligation while maintaining CCA perfusion prevented the development of infarcts in the PCA area, resulted in pure MCA infarcts (68.3 ± 14.5 mm3) and reduced the variability of infarct volumes by more than half (from 26-38% to 14% standard deviation/mean). Using an improved fMCAo procedure, we were able to produce PCA area-unaffected reproducible (PURE) infarcts exclusively in the MCA territory. Thus PURE-MCAo reduced outcome variability by more than 50%. Our results may thus help to reduce the number of animals in preclinical stroke research and to increase the reproducibility of the fMCAo model.

Early Surgical Intervention In Large Mca Infarction: Meta-Analysis Report

Objective: To assess the effectiveness and safety of early surgical intervention, specifically decompressive craniectomy (DC), in patients with large middle cerebral artery (MCA) infarction. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing early surgical intervention with medical management. Results: Early surgical intervention demonstrated a significant reduction in mortality and improved functional outcomes, particularly in younger patients. However, it was associated with increased complication rates. Conclusion: Early surgical intervention can benefit select patients with large MCA infarctions, but careful patient selection is essential.

42. Territorial MCA Infarction with Hemorrhagic Transformation as a Complication of Percutaneous Coronary Intervention

42. Territorial MCA Infarction with Hemorrhagic Transformation as a Complication of Percutaneous Coronary Intervention

The Relationship between CT Angiography Collateral Score and Biochemical Parameters during Acute Ischemic Stroke Caused by Middle Cerebral Artery Infarct.

Background/Objectives: Collateral development after AIS is important for prognosis and treatment. In this study, we aimed to investigate the relationship and correlation between biochemical parameters and CT angiography collateral score within the first 9 h and its effect on the neurological outcomes of patients with AIS due to MCA infarction. Methods: A total of 98 patients with MCA infarction were hospitalized for diagnosis and treatment after undergoing CT angiography within 9 h of suffering a stroke. Demographic data, admission biochemical parameters, hospitalization data, and discharge NIHSS scores were recorded. Souza's scoring system for collateral distribution was used to evaluate collaterals. Souza CS system and clinical disability comparison outcomes identified. Results: According to the Souza CS system, 13 patients were in the malignant profile category, and 85 patients were in the good profile category. The NIHSS value of patients with a malignant profile was 27, while the mean NIHSS value of patients with a good profile was 9. There was a statistically significant difference in uric acid, total cholesterol, triglyceride, HDL cholesterol, CRP, hsCRP, D-Dimer, troponin I, vitamin B12, fibrinogen, NSE, homocysteine, aPTT, and INR levels according to collateral distribution. Conclusions: This study demonstrates that biochemical parameters can influence the distribution of malignant and benign collaterals in AIS independent of age and gender.

Performance evaluation of two different software programs for automated ASPECTS scoring in patients with suspected stroke.

The range of software available to radiologists has increased enormously with the advancement of AI. A good example of this is software to determine ASPECTS in the treatment of potential stroke patients. In this study, two software packages (eASPECTS from Brainomix and VIA_ASPECTS from Siemens) were tested and compared for their performance in the daily clinical routine of a maximum care provider with a 24/7 stroke unit. A total of 637 noncontrast CT images were obtained from consecutive patients with suspected stroke, of whom 73 were finally diagnosed with MCA infarction. Differences in agreement and quantification of agreement were analysed, as well as the correlation and sensitivity, specificity and accuracy compared to raters. Compared to VIA_ASPECTS, eASPECTS shows good agreement and strong correlation with the raters. VIA_ASPECTS has lower accuracy and low specificity than eASPECTS but a higher sensitivity. Both software products have the potential to be decision support tools for radiologists. There are, however, differences between the two software products in terms of their intended use.

Ischemic stroke in the setting of supratherapeutic International Normalized Ratio following coronavirus disease 2019 infection: a case report

BackgroundSARS-CoV-19 infection is associated with an increased risk of thrombotic events. We present a case of acute middle cerebral artery ischemic stroke in a patient with SARS-CoV-19 infection despite being on warfarin with supratherapeutic INR (International Normalized Ratio).Case presentationA 68-year-old Caucasian female with multiple comorbidities was admitted to the hospital with symptoms of upper respiratory tract infection. A rapid antigen test confirmed the diagnosis of COVID-19 pneumonia, and intravenous remdesivir was initiated. On the fifth day of admission, the patient experienced sudden onset confusion, slurred speech, left-sided hemiplegia, right-sided eye deviation, and left-sided facial droop. Imaging studies revealed an occlusion of the distal anterior M2 segment of the right middle cerebral artery, and an MRI of the brain confirmed an acute right MCA infarction. Notably, the patient was receiving warfarin therapy with a supratherapeutic INR of 3.2.ConclusionsThis case report highlights the potential for thromboembolic events, including stroke, in patients with COVID-19 infection, even when receiving therapeutic anticoagulation therapy. Healthcare providers should be vigilant for signs of thrombosis in COVID-19 patients, particularly those with pre-existing risk factors. Further research is necessary to understand the pathophysiology and optimal management of thrombotic complications in COVID-19 patients.

Early versus late decompressive craniectomy in large middle cerebral arterial infarct- A stitch in time saves nine

Introduction: The etiology of malignant MCA infarctions is mostly due to thrombosis or embolic occlusion of either the internal carotid artery or the proximal MCA. The cornerstone of ischemic stroke diagnosis remains the history and neurological examination. A prospective study to compare outcome of early verses late decompression craniotomy was done at a tertiary care hospital in India. Materials and methods: A prospective observational study in the neurosurgical department of a tertiary care hospital of India, for a period of 3 years from 2018-2021. A total of 30 patients (15 each for early and late decompressive craniectomy respectively) were included in study after fulfilling inclusion criteria. The patients were followed up for next 6 months with neuro examination and score making done after every 1 month, 3 months and 6 months of-decompressive craniotomy. To find the significance between early and late group of patients we have used 2 independent sample t-test for age. For MRS and Barthal index at 1st month, 3rd month and 6th month, Hospital stay we have used Mann-Whitney U test (Non-parametric test) because the data type is ordinal or not following normal Distribution/ skewed. All statistical test performed at 5% level of significance so the p-value < 0.05 considered as significant. Results: The majority of patients were male in both the groups – early group 9 (60%) and late group 12 (80%). The mean age group for early and late groups was 44.07 and 42.87 years respectively. The comparison of MRS score in early and late group was not statistically significant at 1st month of follow up, however it showed significant difference at 2nd and 6th month respectively. MRS score with respect to affected side, in both the early and late group showed statistically significant difference at 6 months of follow up respectively. The Barthel index with respect to affected side showed significant difference in early group whereas in the late group significant difference was seen at 6th month of follow up only. The outcome of patients was not affected by side of involvement in both groups early as well as late. The mean hospital stay in early group was 14.8 days in comparison to late group where it was 42.47 days. Conclusion: The results of the present study indicate that early surgical intervention for decompression craniectomy in cases of MCA infarct have better outcome than late intervention with shorter hospital stay better functional outcome at discharge and 6 months post discharge.

Decompressive Hemi Craniectomy in Malignant Middle Cerebral Artery Infarction: Adding Years of Quality Life or Mere Existence?

In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient's proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. In-hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow-up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right-sided lesion. None of the patients could perform well in MOCA. DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers.

496: REVERSIBLE MALIGNANT CEREBRAL EDEMA FOLLOWING CRANIOPLASTY

Introduction: Cranioplasty is a low-risk procedure and is performed for improving hydrocephalus and cerebral protection after decompressive craniectomy. Until recently, a complication that received little attention despite the devastating consequences is malignant cerebral swelling occurring after cranioplasty. There is limited knowledge regarding the pathophysiology or prevention of this condition. We present a novel case wherein a patient developed malignant cerebral swelling and fully recovered from the event. Description: 44-year-old female initially hospitalized in January 2021 for a right MCA occlusion; she received Alteplase and thrombectomy was performed. Hospital course was complicated by post procedure CT head showing midline shift and mass effect for which she was taken for right sided hemicraniectomy and right temporal lobectomy. She underwent tracheostomy, PEG and was discharged. She presented back in August 2021 for an elective right sided cranioplasty. The operative course was uneventful, a hemovac was placed with a subgaleal drain and a postoperative CT head showed cranioplasty in good position. That evening, the patient became increasingly lethargic, and was intubated. She was given hyperosmotic therapy and a repeat CT head showed newly evolving right PCA infarct, cerebellar infarcts with edema, worsening subdural hematoma and left MCA infarcts. While obtaining the repeat CT head, the patient developed seizures with progression to status epilepticus and was started on a midazolam infusion. CEEG showed epileptiform potentials in the right posterior quadrant and left hemisphere, without seizures. Two days later, on a repeat CT head there were no new findings. Patient began to improve clinically, and MRI brain on day 3 didn’t show new infarct or lesion other than encephalomalacia. She was transferred out of the ICU on day 6, a stability CT head three weeks later was stable, and she was discharged to acute rehab. Discussion: Transient malignant swelling followed cranioplasty is a high risk complication and possibly related to severe TBI, SSFS and vacuum suction drainage. Our patient is the first reported survivor from this. Further research and investigation of other cases should be identified to assess for commonalities and interventions to provide the best chance of recovery.

Tissue Healing in Hemicraniectomy.

IntroductionDecompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse “question mark” (“Dandy flap”) incision. The goal of this study was to analyze the details of tissue healing problems in DHC. Materials and methodsA total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the “Dandy flap” incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05.ResultsThe most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins).ConclusionA noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic “Dandy flap” incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

Early experience with patient-specific low-cost 3D-printed polymethylmethacrylate cranioplasty implants in a lower-middle-income-country: Technical note and economic analysis

Background: Polymethyl methacrylate (PMMA) cranioplasty, while widely prevalent, has limitations associated with freehand manual intraoperative molding. PMMA has been superseded by titanium or Polyetheretherketone implants, prefabricated commercially from preoperative CT scans, and boasting superior clinical and cosmetic outcomes. However, such services are extremely inaccessible and unaffordable in the lower-middle-income country (LMIC) settings. The study aims to describe, in detail, the process of making ultra-low-cost patient-specific PMMA cranioplasty implants with minimum resources using open-access software. We report the first such service from the public health-care system within Pakistan, a LMIC.Methods: Using open-source software, preoperative CT heads were used to prefabricate three-dimensional implants. Both implant and cranial defects were printed using polylactic acid (PLA) to assess the implant’s size and fit preoperatively. From the PLA implant, we fashioned a silicon mold that shapes the PMMA implant. Ten patients who underwent cranioplasty using our technique for various cranial defects with at least a 12-month follow-up were retrospectively reviewed. Clinical, cosmetic, and radiological outcomes were objectively assessed.Results: Etiology of injury was trauma (8), malignant MCA infarct (1), and arteriovenous fistula (1). We produced seven frontotemporal-parietal implants, one bifrontal, one frontal, and one frontoparietal. At 1 year, eight patients reported their cosmetic appearance comparable to before the defect. Radiological outcome was classified as “excellent” for eight patients. No postoperative complications were encountered, nor did any implant have to be removed. One patient’s implant involving the orbital ridge had an unsatisfactory cosmetic outcome and required revision surgery. The average cost per implant to the National Health Service was US$40.Conclusion: Prefabricated patient-specific PMMA cranioplasty implants are cost-effective. A single surgeon can fashion them in a limited resource setting and provide personalized medicine with excellent clinical/cosmetic-radiological results. Our method produces patient-specific cranioplasty implants in an otherwise unaffordable LMIC setting.

Sphenoid wing meningiomas: peritumoral brain edema as a prognostic factor in surgical outcome.

Sphenoidal meningiomas constitute 18% of intracranial masses, and still present a difficult surgical challenge. PTBE has been associated with several complications and future recurrence. This study aims to evaluate the outcome of the operatively treated sphenoid wing meningiomas in relation to PTBE as a prognostic factor in a series of 65 patients. The clinical materials of 65 patients with SWM treated microsurgically between 2007 and 2020 were analyzed retrospectively. Follow-up ranged from 6 to 156months (median, 86). Clinical outcomes include postoperative major neurological deficit, quality of life using KPS, recurrence, and mortality rates. The mean age of patients was 53.9years (range 20-74), males 24.6% and females75.4%. An edema index (EI) of 1 (40%) was considered as absent edema, and EI > 1 (60%) indicated present edema. Total resection (Simpson I-II) was achieved in 64.6% and subtotal (Simpson IV) in 13.8%. Postoperative complications included vision impairment in 3 patients, motor weakness 6, third nerve palsy 6, intraoperative bleeding and edema 5, and MCA infarct 2, recurrence in 17% and 7.7% died. In univariate analysis, we found that the PTBE is one of the serious risk factors in the immediate surgical outcomes and complication, though more data is needed to support this claim, while having a negative effect on postoperative KPS at short-term follow up (χ2 = 6.44, p = 0.011). PTBE was associated with decline in KPS and quality of life in the early postoperative period (three months) while showing no significant effect at long-term outcomes.

Abstract 272: Infective Endocarditis Of Unicuspid-unicommisural Aortic Valve

Approximately, 75% of patients with infective endocarditis have underlying structural heart disease at the time of diagnosis. Aortic valve disease is associated with up to a quarter of patients, with aortic regurgitation being the most common abnormality. A unicuspid aortic valve (UAV) is an extremely rare congenital anomaly with a prevalence of 0.02%. We present a unique case of UAV with a devastating association. Case Summary: A 32-year-old male intravenous drug abuser presented with weakness after 18-hours of symptom onset. He was afebrile but tachycardic, with left-sided hemiparesis and sensory loss. Brain CT-scan revealed a hypodensity within the right cerebral hemisphere, a CTA of head-neck revealed an acute right MCA infarct with malignant cerebral edema. Due to deteriorating clinical condition, he was intubated for airway protection and underwent emergent hemi-craniectomy. Blood cultures grew enterococcus faecalis. Transthoracic echocardiogram showed abnormal aortic valve with severe regurgitation. Transesophageal echocardiography (TEE) demonstrated unicuspid unicommissural aortic valve with a small mobile echodensity attached to the left ventricular outflow tract aspect. Decision Making: He received a 6-weeks course of ceftriaxone and vancomycin with negative repeat blood cultures. Given poor clinical state, he was deemed poor candidate for valve replacement and was discharged to long-term rehabilitation facility. Four-months later, he was re-admitted with fevers. Repeat TEE demonstrated multiple aortic valve vegetations. He subsequently underwent successful minimally invasive aortic valve replacement. Conclusion: Unicuspid unicommisural aortic valve is an extremely rare condition that can be complicated by aortic stenosis more often than regurgitation. Infective endocarditis has been reported in 11% among UAV patients and can lead to valvular destruction with severe regurgitation which can be catastrophic in some patients

Abstract 17180: Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion: COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.

Abstract 1122‐000037: LVO in the Setting of TTP

Introduction : Thrombotic Thrombocytopenic Purpura (TTP) is a disorder of coagulation caused by a deficiency of ADAMTS13 due to either hereditary mutations or acquired autoimmune inhibitors. Low levels of ADAMTS13 metalloprotease leads to Von Willebrand Factor (VWF)‐platelet aggregation and microvascular thrombosis when patients with TTP are exposed to high shear stress in the microcirculation. [1] Hematologic disorder or coagulopathies are the major cause of 1–4% of all ischemic strokes. [2] TTP patients usually present with small vessel strokes or sometimes very distal branches of large arteries. The gold standard treatment for acute stroke in these patients is plasma exchange, however in patients presenting with LVO strokes, recanalization therapies should be considered. [3] Here we present a case of large vessel occlusion stroke in the setting of TTP. Methods : 31‐year‐old African American female with TTP and Strokes admitted to with right sided hemiparesis, and expressive aphasia within 2h of symptom onset. National Institute of Health Stroke Scale (NIHSS) of 16. Laboratory work up significant for Platelets 114k, Hemoglobin 12, PTT 24 seconds, Serum glucose 107, ADAMTS‐13 &lt;1 IU/dL and negative COVID‐19 PCR. CTH showing ASPECTS of 9 (Picture A), CTA head and neck revealing a left MCA occlusion and intracranial vessel irregularities in the left Anterior Cerebral Artery (ACA) and bilateral Posterior Cerebral Arteries (PCA) (Picture B). CTP with 24cc core and 132 cc mismatch (Picture C). Patient was taken to the Angiogram Suite for urgent thrombectomy with a final TICI score of 3 achieved after one pass (Picture D/E). Results : Post procedure NIHSS was 1 for mild expressive aphasia. Brain MRI revealed Left MCA and right parietal territories infarct (Picture F). Transesophageal Echocardiogram was unremarkable. She underwent urgent Plasma Exchange (PLEX) for TTP flair in light of undetectable ADAMTS‐13, significant drop in platelet count and thrombotic event. After 5 PLEX sessions platelets remained stable with counts greater than 150.000. Immunotherapy with Prednisone, Caplacizumab, Atovaquone and Mycophenolate Mofetil was continued and she was discharged home on day 7 from admission. Conclusions : Our patient had severe and refractory disease presenting with LVO and underwent an unusual therapeutic approach considering the etiology of her disease. IV thrombolysis and arterial thrombectomy are well established therapies for acute strokes in the general population, but are rarely performed in patients affected by Thrombotic Microangiopathy (TMA) such as TTP. Safety and efficacy of these procedures have not been studied in this population and it is usually selected by extrapolating data from studies that used individuals without TMA. We aim to illustrate this uncommon case of LVO stroke in the setting of TTP and potentially stimulate the elaboration of studies that include these patients.

Quality of life impairment in adult Moyamoya patients\u2014preoperative neuropsychological assessment and correlation to MRI and H215O PET findings

Moyamoya angiopathy (MMA) related cerebral perfusion deficits or infarctions might influence quality of life (QoL). This study examines preoperative QoL in adult patients with MMA and correlates these with findings obtained via diagnostic imaging. Sixty-seven adult Moyamoya patients underwent preoperative neuropsychological testing including questionnaires to determine QoL, as well as psychiatric and depressive symptoms. The results were checked for correlation with territorial hypoperfusions seen in H215O PET with acetazolamide (ACZ) challenge (cerebrovascular reserve) and infarction patterns observed in MRI. Each vascular territory was analyzed separately and correlated with QoL. Physical role function was restricted in 41.0% of cases and emotional role function in 34.4% of cases (SF-36). Obsessive–compulsive disorder (39.3%) (SCL-90-R), psychoticism (34.4%) (SCL-90-R), and depression (32.7%) (BDI-II) were also very common. Psychoticism was significantly more frequent in cases where perfusion deficits in PET CT were observed in both MCA territories (left p = 0.0124, right p = 0.0145) and infarctions in MRI were present in the right MCA territory (p = 0.0232). Depression was significantly associated with infarctions in the right MCA territory (SCL-90-R p = 0.0174, BDI-II p = 0.0246). Women were affected more frequently by depression (BDI-II, p = 0.0234). Physical role function impairment was significantly associated with perfusion deficits in the left MCA territory (p = 0.0178) and infarctions in the right MCA territory (p = 0.0428). MMA leads to impairments in different areas of QoL. Approximately one-third of all adult MMA patients suffered from depression, with women being most affected. In addition to depression, presence of executive dysfunctions and mental disorders such as psychoticism, obsessive–compulsive disorder, and impaired physical and emotional role function affected QoL. These patients showed significantly more often infarctions and perfusion deficits in the right MCA territory. Long-term studies with follow-up results are necessary to clarify a possible beneficial impact of early surgical revascularization on QoL and depression in adult MMA patients.

Factors affecting outcome of decompressive hemicraniectomy in malignant middle cerebral artery infarction

Introduction: Decompressive Hemicraniectomy (DHC) is a standard surgical management of malignant MCA (MMCA) infarction. This study was conducted to review the outcome of surgery and to find out factors associated with favorable outcomes at a tertiary level neurosurgery referral centre. Methods and Materials: This is a retrospective study conducted over a period of three years from 2017 to 2019. Patient charts were reviewed for variable like age, sex, timing of surgery, GCS at presentation, length of ventilation, length of ICU admission and length of hospital stay. Primary outcome measure was GOSE: favorable (&lt;=4) and unfavorable (&gt;=5). SPSS version 23 was used for analysis. Results: A total of 28 patients underwent DHC out of which 21 patients were available for analysis. Mean age of patients was 58.62 years. Mean GCS on arrival was 11.86. Mean interval duration between event and surgery was 51.88 hours. Mean duration of ventilation was 4.43 days. Mean length of ICU stay was 5.95 days. Mean hospital stay was 22.33 days. Mean GOSE was 2. Mean age was significantly lower in patients with favorable GOSE. Early surgery had better mean GOSE which was not significant statistically. Conclusion: Patients with age less than 50 years have favorable GOSE despite MMCA infarction if decompressive hemicraniectomy is performed to accommodate brain swelling. Early surgery at presentation rather than waiting for deterioration might improve the outcome.

Study of Carotid doppler in Patients with ischemic stroke

Introduction: Stroke is one of the major causes of increased morbidity and death. Large-vessel atherosclerosis of intracranial and extra cranial carotid vessels is an important cause of ischemic stroke. This research was undertaken to study the carotid Doppler findings in patients with acute ischemic stroke. Methods: A hospital-based prospective cross-sectional study was conducted from January 2020 till December 2020 in the department of Radio diagnosis and Imaging at Manipal Teaching Hospital, Pokhara, Nepal. Neuro-imaging and carotid Doppler findings in patients with ischemic stroke were studied. Data analysis was done using SPSS 20. Results: The mean age of subjects with ischemic stroke was 64 ± 13.4 years with the majority of cases in the age group of 51-70 years of age with male predominance (M: F= 3: 2). Lacunar infarcts (34.2%) were the most common findings followed by MCA infarct (30%) and ACA infarct (10.8%). Carotid plaques were seen in 43.3% patients. Bilateral ICA atheromatous plaque was seen in 48.1% of patients. Carotid bulb was the common site for plaque formation. Type III plaque was the commonest type. Significant ICA stenosis &gt; 50 % was observed in 24.2% patients. Age &gt;50 years, male sex, smoking, hypertension, diabetes, and hyperlipidemia were important risk factors. Conclusion: Carotid artery Doppler demonstrated atherosclerotic plaques and significant stenosis in patients with ischemic stroke. Increasing age &gt;50 years, male sex, smoking, hypertension, diabetes, and hyperlipidemia were associated with an increased rate of atherosclerosis, carotid stenosis and ischemic stroke.

Acute ischemic stroke triggers a cellular senescence-associated secretory phenotype

Senescent cells are capable of expressing a myriad of inflammatory cytokines and this pro-inflammatory phenomenon is known as senescence-associated secretory phenotype (SASP). The contribution of this phenomenon in brain ischemia was scarce. A mouse model of transient focal cerebral ischemia by compressing the distal middle cerebral artery (tMCAo) for 60 min was used. SASP, pro-inflammatory cytokines and cell cycle mRNAs levels were quantified at 30-min and 72 h post-surgery. Immunohistochemistry in paraffin embedded human brain slides and mouse brain tissue was performed. Our results showed an increase of both p16 and p21 mRNA restricted to the infarct area in the tMCAo brain. Moreover, there was an induction of Il6, Tnfa, Cxc11, and its receptor Cxcr2 mRNA pro-inflammatory cytokines with a high positive correlation with p16/p21 mRNA levels. The p16 was mainly shown in cytoplasm of neurons and cytoplasm/membrane of microglial cells. The p21 was observed in membrane of neurons and also it showed a mixed cytoplasmic and membranous pattern in the microglial cells. In a human stroke patient, an increase of P16 in the perimeter of the MCA infarct area was observed. These suggest a role of SASP in tMCAo mouse model and in human brain tissue. SASP potentially has a physiological role in acute ischemic stroke and neurological function loss.

Large left ventricular thrombus with malignant left MCA infarct for emergency decompressive craniectomy.

Large left ventricular thrombus with malignant left MCA infarct for emergency decompressive craniectomy.