Middle Cerebral Artery Distribution Research Articles

Transcranial Doppler ultrasonography can predict inpatient rehabilitation functional outcome in patients with stroke.

Despite advances in imaging techniques and treatment modalities, tools to predict recovery after stroke remain limited. The objective of the study was to determine if transcranial Doppler (TCD) mean flow velocities were predictive of functional recovery following ischemic stroke. Data were collected from patients with stroke admitted to an academic tertiary care facility in the southeastern region of the United States between 2012 and 2019 who had a middle cerebral artery distribution ischemic stroke, TCD, and were discharged to our inpatient rehabilitation facility. Mean flow velocities were categorized as low (<40 cm/s), normal (40-80 cm/s), or high (>80 cm/s). Functional Independence Measure (FIM) scores were collected on admission to and discharge from IPR. Multiple linear regression models were used to assess the differences in mean FIM score changes by categories of mean flow velocities. We enrolled 57 patients, mean age 60 years, 73.7% male. Compared to the normal velocity group, those with abnormally low velocities had a significantly smaller change in their FIM score (adjusted β = -8.42; p = .01). Compared to the normal velocity group, those with abnormally high velocities experienced a greater change in FIM score, but this association was not statistically significant (beta = 1.12; p = .77). In this limited population, we found that low mean flow velocity as measured by TCD ultrasonography after a middle cerebral artery stroke is associated with poorer functional recovery following inpatient rehabilitation. Our results suggest that the value of TCD ultrasonography as a tool to predict motor recovery after stroke warrants further investigation.

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.

INNV-25. PROLONGED FOLLOW-UP OF AN OLIGODENDROGLIOMA PATIENT WITH HISTORY OF TUMOR TREATING FIELDS (TTF) AS POST CHEMO-RADIATION MAINTENANCE THERAPY

Abstract INTRODUCTION: Recurrence of low and high-grade gliomas are common after radiation and chemotherapy. Despite continued research on glioma’s management, there is limited knowledge regarding the role of maintenance treatment after standard radiation and chemotherapy therapy. Tumor Treating Fields as maintenance therapy after radiation and chemotherapy may potentially help prevent recurrence of oligodendroglioma. Case Report: A 35-year-old male developed headaches and a non-enhancing mass was detected on his brain MRI in 2011. Observation was advised by his surgeon. The patient presented with seizures in early 2014, and his brain MRI found the mass developed new enhancement. In late 2014, the patient had multiple seizures, and significant progression of the tumor was discovered. The patient underwent craniotomy and biopsy in the middle cerebral artery distribution area in early 2015. Pathology reported grade II oligodendroglioma; however, a biopsy might have missed the high-grade glioma region. His brain MRI showed a significant enhancing lesion, which was clinically also consistent with grade III oligodendroglioma due to rapid growth. Radiation was conducted followed by 6 cycles of PCV chemotherapy throughout 11 months. Post-radiation-chemotherapy brain MRI was stable with a moderate size residue tumor at the right insula region. Following patient wishes, NovoTTF-100A, or Optune, was administered 6 weeks after completion of chemotherapy as maintenance therapy for 2 years to prevent tumor progression. Now, after 5 years being off Optune, the patient is full-functional, and his brain MRI is stable without tumor progression. Discussion: Our case highlights the potential effect of Tumor Treating Fields as maintenance therapy after initial radiation and chemotherapy for lower and higher grade oligodendrogliomas. The patient had rapid tumor progression on brain MRI prior to treatment and only underwent a biopsy without resection, yet uncommonly, remains survival and full functional since initial image diagnosis 12 years ago and tissue diagnosis 8 years ago.

Differences in distribution and features of carotid and middle cerebral artery plaque in patients with pial infarction and perforating artery infarction: A 3D vessel wall imaging study

PurposeAtherosclerotic plaques of carotid artery (CA) and middle cerebral artery (MCA) are important causes of acute ischemic stroke (AIS). This study was designed to jointly assess the plaque distribution and features of CA and MCA in AIS patients with pial infarction (PI) and perforating artery infarction (PAI), and to investigate the associations between plaque characteristics and ischemic infarction patterns. MethodsImaging data of sixty-five patients from a cross-sectional study were reviewed. All the patients had acute infarction in the MCA territory on diffusion weighted imaging (DWI) and underwent CA and MCA vessel wall imaging (VWI). The CA and MCA plaque presence and high-risk features on the ipsilateral side of infarction were analyzed. The brain infarction lesions were divided into PI group vs. non-PI group, and PAI group vs. non-PAI group. Different plaque distribution types and plaque features were compared in each two groups, and their associations were investigated using binary logistic regression. ResultsSixty-five patients (mean age, 54.6 ± 10.1 years; 61 men) were included. The CA high-risk plaque (OR: 5.683 [1.409–22.929], P = 0.015) and MCA plaque presence (OR: 3.949 [1.397–11.162], P = 0.010) were significantly associated with PI. MCA plaques that involved the orifice of the perforating arteries were significantly associated with PAI (OR: 15.167 [1.851–124.257], P = 0.011). ConclusionCA and MCA plaques show distinct distribution and high-risk features in patients with PI and PAI. Combined intracranial and extracranial arteries imaging should be considered for the evaluation of the symptomatic ischemic patients.

Anterior ischemic stroke: Analysis of the multivariable CT-based models for prediction of clinical outcome

ObjectiveTo determine the predictive value of multiple CT-based measurements, individually and collectively, including arterial collateral filling (AC), tissue perfusion parameters, as well as cortical venous (CV) and medullary venous (MV) outflow, in patients with acute ischemic stroke (AIS). MethodsWe retrospectively reviewed a database of patients with AIS in the middle cerebral artery distribution, who underwent evaluation by multiphase CT-angiography and perfusion. AC pial filling was evaluated using a multiphase CTA imaging. The CV status was scored using the adopted PRECISE system based on contrast opacification of the main cortical veins. The MV status was defined by the degree of contrast opacification of medullary veins in one cerebral hemisphere as compared to the contralateral hemisphere. The perfusion parameters were calculated using FDA-approved automated software. A good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. ResultsA total of 64 patients were included. Each of the CT-based measurements could predict clinical outcomes independently (P<0.05). AC pial filling and perfusion core based models did slightly better compared to each of the other models (AUC = 0.66). Among models with two variables, the perfusion core combined with MV status had the highest AUC=0.73 followed by a combination of MV status and AC (AUC=0.72). Multivariable modeling with all four variables resulted in the highest predictive value (AUC=0.77). ConclusionThe combination of arterial collateral flow, tissue perfusion, and venous outflow provides a more accurate prediction of clinical outcome in AIS than each variable alone. This additive effect of these techniques suggests that the information collected by each of these methods only partially overlaps.

Bilateral Hypoplasia of the Cervical Internal Carotid Arteries in a Pregnant Patient with Patent Foramen Ovale – A Case Report and Discussion

Introduction: Congenital hypoplasia or aplasia of the internal carotid artery (ICA) is believed to affect less than 0.01% of the population, with fewer than 200 unilateral and 30 bilateral cases reported in the literature. While often asymptomatic, they have been associated with stroke, transient ischemic attack (TIA), and other neurovascular pathologies. Case Report: We describe a 33-year-old 28 weeks pregnant female with a history of patent foramen ovale (PFO) and ischemic stroke in the right middle cerebral artery (MCA) distribution three years prior who experienced new onset transient right upper extremity weakness and numbness. Duplex sonography revealed bilateral hypoplasia of the internal carotid arteries (HICA), confirmed by CT and MR angiography of the head and neck. Discussion: To our knowledge, this is the first reported case of bilateral HICA with concurrent PFO and pregnancy presenting with TIA. All three conditions are associated with stroke and TIA. HICA should be included in the differential diagnosis of neurologic deficit despite its rarity.

Abstract Number ‐ 225: COVID‐19 As A Potential Inducer Of Antiphospholipid Syndrome In A Patient With Acute Ischemic Stroke

Introduction COVID‐19 has been linked to hypercoagulability and acute ischemic stroke, though the precise mechanism is not well understood [1]. Various mechanisms have been suggested, including the potential release of autoantibodies‐ either via self‐production or exacerbation of the release of already produced autoantibodies [2‐3]. Antiphospholipid antibodies have been identified in severe disease [3‐4] and implicated in thrombosis [1‐2], though the significance is unclear. In this report, we describe a young woman with asymptomatic COVID‐19 presenting with acute ischemic stroke and postulate it was a manifestation of activated autoimmunity from COVID‐19. Methods Case Report Results A 22 year‐old previously healthy woman presented with acute onset dysarthria and right upper extremity weakness and numbness. On presentation, blood pressure was 158/101. NIHSS was 2 for right upper extremity drift and decreased sensation. Neurologic exam was otherwise unremarkable. Thrombolytic therapy was not administered given presentation outside the time window. CT head showed scattered left centrum semiovale hypodensities without hemorrhage. MRI brain demonstrated multifocal areas of diffusion restriction in the left centrum semiovale, anterior frontal lobe, and parietal lobe. CT angiogram demonstrated a possible thrombus at the left carotid bifurcation which was redemonstrated on MR angiography of the neck. No atherosclerotic plaque, hemodynamically significant stenosis, nor other vascular abnormality were appreciated. Heparin drip was started. Hemoglobin was 6.9 for which 1 unit of packed red blood cells was transfused. White blood cell count was 9.02. Platelet count was 761. PT/INR and PTT were 13.4/1.2 and 30.1. HIV was negative, RPR was positive at 1:128 titer, and COVID PCR was positive. She did not experience respiratory symptoms. Urine drug screen was positive for cannabinoids. LDL was 66. Transthoracic echo demonstrated minimal right to left shunting, suggesting patent foramen ovale. Ejection fraction was 60–65% and chamber sizes were normal. Bilateral lower extremity ultrasound was negative for deep vein thrombosis as a potential embolic source given cardiac shunt. Given history of miscarriage and extensive family history of sickle cell trait, possible lupus anticoagulant, and thrombosis at young ages, hypercoagulable workup was sent. Sickle cell preparation and ANA were negative. ESR was 12. High sensitivity CRP was 2.71. Anticardiolipin IgM antibody was elevated significantly at 125.9 MPL and IgG antibody was indeterminately elevated at 19.2 GPL. Beta‐2 glycoprotein IgM antibodies were also elevated at 42 SMUnits. Atypical neurosyphilis was considered given positive titer, middle cerebral artery distribution, and young age, but deemed unlikely given embolic rather than inflammatory stroke pattern [5]. Ultimately, with a possible diagnosis of antiphospholipid syndrome, anticoagulation was transitioned to warfarin via enoxaparin bridge with plan for repeat hypercoagulable workup as outpatient. Conclusions COVID‐19 has been observed in association with hypercoagulable states such as deep venous thrombosis and stroke. Here we present a case of COVID‐19 associated ischemic stroke with concomitant antiphospholipid antibodies. This case highlights the potential for even asymptomatic/mild COVID‐19 to induce autoimmunity through modulation of host antibody activity. This may be more profound in those with a predisposition to thrombosis. Autoimmunity should be considered in cases of concurrent COVID‐19 and acute ischemic stroke without clear etiology.

Abstract Number ‐ 147: Rescue bailout repair of a direct carotid‐cavernous fistula using drug eluding coronary stent

Introduction Direct carotid‐cavernous fistula (DCCF) during neurosurgical procedures or trauma are repaired with flow diverters via trans‐arterial approach and/or transvenous embolization of the cavernous sinus. There are reports of using balloon mounted bare platinum coronary stent in the treatment of DCCF prior to the era flow diverters. There are limited data on the use of drug eluding stent in the repair of DCCF. We are presenting an unusual case of DCCF developed during Neurointerventiona in an acute ischemic stroke patient with severe intracranial atherosclerotic disease that was emergently repaired using a Medtronic resolute prelude drug eluding. Additionally, cause of DCCF and rational of balloon drug eluding stent was expalined. Methods case report Results 54 years old women with multiple cerebrovascular risk factors including prior stroke presented with right middle cerebral artery (MCA) stroke which improved to NIHSS 2. CT head demonstrated old strokes in the right MCA distributions and CT angiogram was consistent with severe intracranial atherosclerotic disease (ICAD) with 90% stenosis of right supraclynoid internal carotid artery (SICA). Patient was loaded with brilinta and aspirin. Cerebral angiogram confirmed focal ICAD and presence of ahteresclorotic pouches (AP) at the Pero‐cavernous junction with poor perfusion. Parent artery diameter was 2.2 mm and stenotic section 0.5 mm. Planned was to do balloon angioplasty and a possible stent. Endovascular strategies: 6 French guiding sheath was placed to RICA and CAT5 to protect ICA pouches, and be placed beyond the ophthalmic artery for navigation of balloon delivery system. Baseline activated coagulation time (ACT) was 168 and received 4000 units of heparin with 5 mg of intraarterial integrilin. During advancement of 2×20 mm maverick balloon, the CAT5 prolapsed back below the petrous ICA. Attempts were made to reposition the CAT5 over the wire without microcatheter resulting in injury to the AP with CAT5 forming DCCF. Immediately, balloon was navigated without manipulation of CAT5 and angioplasty of SICA with reduction of stenosis from 90% to less than 50%. Repeat angiogram demonstrated high‐flow DCCF. Because of ICAD and small ICA diameter, a flow‐diverter was not considered. A Medtronic resolute drug eluding 2×34 mm stent was advanced emergently through CAT5 and placed the injured area by withdrawing CAT5 and deployment of resulting in good apposition. Subsequent angiographies revealed gradual decrease of DCCF to complete obliteration. Repeat ACT was above 400 which was not reversed. Neurological examination remained unchanged without ophthalmic sign of DCCF. Patient was sent home in 48 hours with NIHSS 0 on brilinta and aspirin. Conclusions A flexible Medtronic resolute drug eluding could be used emergently to repair traumatic DCCF which is delivered over CAT5. An intermediate guiding catheter CAT5 or others must be advanced over a microcatheter alone with microwire carefully to prevent vessel injury especially, if there are existing disease in the wall of the artery. Brilinta load may potentially increase the baseline ACT, therefore a small bolus of heparin may be considered first if the baseline ACT is high to prevent supratherapeutic ACT. Further studies are required

Abstract Number ‐ 218: Mechanical Thrombectomy in a HIV Patient with Staphylococcus Lugdunensis Bacteremia: A Case Report.

Introduction Occlusion of cerebral arteries account for 40–50% of neurological complications of infective endocarditis with the emboli most commonly lodging in the middle cerebral artery. The management of these occlusions with the use of thrombolytic therapies are associated with intracranial hemorrhage whereas outcomes with endovascular thrombectomy, while still under investigation, appear to be more favorable. In this case report, we present a HIV patient with persistent staphylococcus lugdunenesis bacteremia of unknown origin and acute left middle cerebral artery occlusion, who underwent endovascular thrombectomy. Methods Case Report Results A 66‐year‐old male past medical history of HIV on Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir, pancytopenia and treated hepatitis C who presented for malaise, back pain, and urinary symptoms for 1 week. Initial labs remarkable for pancytopenia, CD4 count 44 and positive urinalysis. Ceftriaxone was started for UTI and Trimethoprim/Sulfamethoxazole for PJP prophylaxis. Urine and multiple blood cultures were positive for staphylococcus lugdunensis. Vancomycin was added to antibiotic therapy. On day two of hospitalization, patient developed new onset aphasia, right facial droop, and right hemiparesis. Upon evaluation, NIHSS was 14. CT head was negative. CTA head and neck showed left M1 occlusion. CT perfusion showed an infarct core of 20cc and 144cc of penumbra. Due to concern for possible infective endocarditis, thrombolytics were not administered but he was taken for thrombectomy. Emboli retrieval was successful with mTICI‐2c reperfusion. During thrombectomy, clot noted to have septic emboli appearance. Post thrombectomy, patient had complete resolution of neurological deficits. MRI brain showed multiple punctate foci of restricted diffusion in the left middle cerebral artery distribution consistent with embolic process. TTE was inconclusive. Intraoperative cultures of the clot resulted positive for staphylococcus lugdunensis and pathology examination detailed clot with bacterial colonization. TEE was performed and negative for valvular vegetations, mass, thrombus, or endocarditis but there was an intrapulmonary shunt. Patient later developed a small acute left parietal lobe parenchymal hematoma and basal ganglia infarct. His neurological status remained unchanged. He completed 6 weeks of IV antibiotic therapy upon discharge. Conclusions This case illustrates the importance of timely endovascular thrombectomy in suspected cerebral septic emboli as outcomes are favorable. It supports prompt recognition of septic emboli bacterial species for targeted antibiotic therapy along with further investigation into staphylococcus lugdunensis and its relation with cerebral septic emboli. This case urges additional exploration into the relationship between HIV patients and cerebrovascular disease including cerebral septic emboli.

Misery Perfusion and Tau Deposition in Atherosclerotic Major Cerebral Artery Disease: A 18F-Florzolotau Positron Emission Tomography Study.

Studies using animal models have shown that cerebral hypoperfusion causes hyperphosphorylation of tau protein, leading to neuronal damage. However, the relationship between hypoperfusion and tau deposition in humans is unclear. Hence, we aimed to determine whether cerebral hypoperfusion leading to decreased blood flow relative to metabolic demand [increased oxygen extraction fraction (OEF), misery perfusion] is associated with increased tau deposition in patients with atherosclerotic internal carotid artery or middle cerebral artery disease. We prospectively evaluated the distribution of tau aggregate deposition using positron emission tomography and 18F-florzolotau (PMPBB3 [1-fluoro-3-((2-((1E,3E)-4-(6-(methylamino)pyridine-3-yl)buta-1,3-dien-1-yl)benzo[d]thiazol-6-yl)oxy)propan-2-ol)]) in 8 patients with atherosclerotic disease of the internal carotid artery or middle cerebral artery. The standardized uptake value ratio of 18F-florzolotau at 100 to 110 minutes after injection was calculated using the cerebellar cortex as a reference region and was correlated with OEF obtained from 15O-gas positron emission tomography in the middle cerebral artery distributions. Significant decreases in cerebral blood flow and cerebral metabolic rate of oxygen and increases in OEF were found in the hemisphere ipsilateral to the arterial lesion. 18F-florzolotau standardized uptake value ratio in this region was also greater than that in the contralateral hemisphere. In the ipsilateral hemisphere, 18F-florzolotau standardized uptake value ratio positively correlated with OEF values. This pilot study with a small sample size suggests that increases in OEF-misery perfusion-may be associated with increased tau aggregates deposition in atherosclerotic internal carotid artery or middle cerebral artery disease.

Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease.

PurposeTo investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis.Materials and MethodsPatients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting.ResultsForty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches.ConclusionThe iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.

High platelet to lymphocyte ratio as a risk factor for poor outcome in acute ischemic stroke patient

Background &amp; Objective: Stroke is one of the leading causes of death and disability worldwide. The incidence of ischemic stroke in the anterior circulation is greater in the middle cerebral artery (MCA) distribution. A high level of platelet to lymphocyte ratio (PLR) has been widely studied as a predictor of poor outcomes in various conditions, such as cardiovascular disease and malignancy. However, the significance of PLR as a predictor of outcome in stroke patients, especially the ischemic type, are still uncertain. This study aimed to determine whether increased PLR was a risk factor for poor outcomes in acute ischemic stroke patients. Methods: This is a single-center case-control study. The data of acute ischemic stroke patients in MCA territory admitted from January 2019 to April 2020, who met the inclusion and exclusion criteria, were collected. The stroke outcome was defined by NIHSS upon discharge. The Control group was those with NIHSS &lt;10 and Case group with NIHSS≥10 or death. The determinant of this study as a risk factor was PLR with a cut-off ratio of 148. Results: Ninety- three subjects with 47 cases (mean age 65.51±11.73) and 46 controls (mean age 57.78±11.39) were collected. In adjusted multivariate analysis, independent risk factor was high PLR (p=0.008) and high CRP (p=0.008). Meanwhile, in bivariate analysis, significant risk factors for poor outcome of acute ischemic stroke were high PLR (odds ratio [OR], 4.88; 95% confidence interval [CI], 2.02-11.73, p&lt;0.01), elderly (OR, 4.02; 95% CI, 1.48-10.87, p=0.05), embolic stroke type (OR, 2.85; 95% CI, 1.21-6.76, p=0.01), and high CRP (OR, 5.13; 95% CI,2.09-12.57, p&lt;0.01). Conclusions: High PLR is an independent risk factor for poor outcomes in acute MCA ischemic stroke.

Recovery from aphasia in the first year after stroke.

Most individuals who experience aphasia after a stroke recover to some extent, with the majority of gains taking place in the first year. The nature and time course of this recovery process is only partially understood, especially its dependence on lesion location and extent, which are the most important determinants of outcome. The aim of this study was to provide a comprehensive description of patterns of recovery from aphasia in the first year after stroke. We recruited 334 patients with acute left hemisphere supratentorial ischaemic or haemorrhagic stroke and evaluated their speech and language function within 5 days using the Quick Aphasia Battery (QAB). At this initial time point, 218 patients presented with aphasia. Individuals with aphasia were followed longitudinally, with follow-up evaluations of speech and language at 1 month, 3 months, and 1 year post-stroke, wherever possible. Lesions were manually delineated based on acute clinical MRI or CT imaging. Patients with and without aphasia were divided into 13 groups of individuals with similar, commonly occurring patterns of brain damage. Trajectories of recovery were then investigated as a function of group (i.e. lesion location and extent) and speech/language domain (overall language function, word comprehension, sentence comprehension, word finding, grammatical construction, phonological encoding, speech motor programming, speech motor execution, and reading). We found that aphasia is dynamic, multidimensional, and gradated, with little explanatory role for aphasia subtypes or binary concepts such as fluency. Patients with circumscribed frontal lesions recovered well, consistent with some previous observations. More surprisingly, most patients with larger frontal lesions extending into the parietal or temporal lobes also recovered well, as did patients with relatively circumscribed temporal, temporoparietal, or parietal lesions. Persistent moderate or severe deficits were common only in patients with extensive damage throughout the middle cerebral artery distribution or extensive temporoparietal damage. There were striking differences between speech/language domains in their rates of recovery and relationships to overall language function, suggesting that specific domains differ in the extent to which they are redundantly represented throughout the language network, as opposed to depending on specialized cortical substrates. Our findings have an immediate clinical application in that they will enable clinicians to estimate the likely course of recovery for individual patients, as well as the uncertainty of these predictions, based on acutely observable neurological factors.

Relationship of Pressure Reactivity Index and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage.

Patients with aneurysmal subarachnoid hemorrhage (SAH) continue to have poor functional outcome due to the occurrence of delayed cerebral ischemia (DCI). Although vasospasm represents the primary therapeutic target for mitigating DCI, DCI occurs through multifocal etiologies that involve impaired cerebral autoregulation. Worse pressure reactivity index (PRx) values, which consists of a moving correlation coefficient between intracranial pressures and mean arterial pressures, have been shown to be associated with DCI in non-randomized clinical trials. We discuss two patients that presented with high-grade SAH and comatose exams. Patient one was a 34-year-old male diagnosed with SAH from a ruptured right middle cerebral artery aneurysm. He had intact PRx values (Mean: -0.07 during hospital days 9-19), while having severe, refractory vasospasm. At the conclusion of his hospitalization, he was functionally independent, had negligible DCI, and was successfully discharged home. Patient two was a 78-year-old female diagnosed with SAH from a ruptured anterior communicating artery aneurysm. She had an improving PRx ranging from -0.1 to 0.1 early in her hospitalization. However, upon developing severe vasospasm, her PRx increased to 0.6 (overall PRx from hospital days 4-16 was 0.3), and she suffered from extensive DCI in bilateral middle cerebral and anterior cerebral artery distributions that ultimately resulted in malignant cerebral edema and brain death. Cerebral autoregulation as measured by PRx may represent a viable target for neuroprognostication by evaluating DCI risk in patients with SAH who develop severe or refractory vasospasm. Further studies evaluating the role of cerebral autoregulation, PRx, and its pathophysiological role in DCI are warranted.

INNV-10. TUMOR TREATING FIELDS (TTF) AS MAINTENANCE THERAPY FOR AN OLIGODENDROGLIOMA CASE AND LONG-TERM FOLLOW-UP

Abstract INTRODUCTION Recurrence of low- and high-grade gliomas is observed often after radiation and chemotherapy. Despite continued research on glioma management, there is limited knowledge regarding maintenance treatment after standard care. Tumor Treating Fields as maintenance therapy after radiation and chemotherapy may potentially help prevent recurrence. CASE REPORT In 2011, a 35-year-old male reported headaches to a local ED. A non-enhancing mass was detected on his brain MRI. Observation was advised by his local surgeon. The patient presented with seizures in early 2014, and his brain MRI found the mass developed new enhancement. In late 2014, the patient had multiple seizures, and significant progression of the tumor was discovered. The patient underwent craniotomy and biopsy in the middle cerebral artery distribution area in early 2015. Pathology reported grade II oligodendroglioma; however, the patient only underwent a biopsy, which might have missed the high-grade glioma region. His brain MRI showed a significant enhancing lesion with rapid growth, which was clinically more consistent with grade III oligodendroglioma. Radiation therapy was conducted followed by 6 cycles of PCV chemotherapy throughout 11 months. Post-radiation-chemotherapy brain MRI was stable with a moderate size residual tumor at the right insula region. Following patient wishes, NovoTTF-100A, or Optune, was administered 6 weeks after completion of chemotherapy as maintenance therapy for 2 years to prevent tumor progression. Now, after 3 years being off Optune, the patient is stable without new neurological symptoms or tumor progression. DISCUSSION: Our case highlights the potential effect of Tumor Treating Fields as maintenance therapy after initial radiation and chemotherapy for low- and high-grade oligodendrogliomas. The patient had rapid tumor progression prior to diagnosis and only underwent a biopsy without resection, yet uncommonly, has survived since initial image diagnosis 10 years ago and tissue diagnosis 6 years ago and is fully functional currently.

Treatment of a Giant Thrombotic M1 Segment Middle Cerebral Artery Aneurysm With Radial Artery Bypass and Distal Occlusion to Create a "Blind Sac" Following Endovascular Failure: 2-Dimensional Operative Video.

The case is of a 36-yr-old male with a previously coiled aneurysm arising from the proximal M1 segment of the middle cerebral artery (MCA) just beyond the internal carotid artery (ICA) bifurcation who presented to our institution with subjective left hemiparesis, headache, and vomiting. Physical exam revealed a left facial droop, but neurological exam was otherwise normal, including full motor strength. Neuroimaging showed a large partially thrombosed aneurysm recurrence, measuring 5.2 cm, with obstructive hydrocephalus. Cerebral angiogram showed filling within a small portion of the aneurysm and marked stenosis of the MCA beyond the neck. A ventriculostomy was placed, and he underwent a pterional craniotomy for high-flow radial artery bypass from the common carotid artery to an M2 branch of the MCA and clip placement. This case demonstrates the creation of a blind sac by placing a clip on the MCA distal to the aneurysm and proximal to the lenticulostriate arteries for the treatment of a giant proximal M1 segment aneurysm. Postoperative digital subtraction angiography shows the MCA distribution, including the lenticulostriate arteries, filling through the radial artery bypass, and anterograde flow through the ICA, which perfuses up to and including the anterior choroidal artery. There is no residual filling of the aneurysm. The patient remained at his neurological baseline postoperatively and required ventriculoperitoneal shunt placement for hydrocephalus. At outpatient follow-up, computed tomography imaging showed decreased size of the thrombosed aneurysm, measuring 4.5 cm, and he had no neurological deficits. The patient gave informed consent for surgery and deidentified video recording of this case.

Optic Nerve Infarction in a Patient With Coronavirus Disease 2019.

Severe acute respiratory syndrome 2 (SARS-CoV2), also called coronavirus disease 2019 (COVID-19), has spread worldwide and affected millions of lives. Although there are many unaddressed questions about the pathogenesis of the virus and the best treatment, it is known that the virus affects several organ systems, including respiratory, gastrointestinal, and neurologic (1–4). Neurologic manifestations reported in COVID-19 patients include headache, anosmia, seizure, stroke, encephalitis, and Guillain–Barre syndrome (4); However, neuro-ophthalmic manifestations have infrequently been reported (5–8). We describe a patient with COVID-19 who developed thrombosis of the left internal carotid artery leading to infarction of the left optic nerve. A 50-year-old man was found to have a positive polymerase chain reaction (PCR) test for COVID-19. Twelve days later, he developed fever, cough, and dyspnea. His respiratory symptoms worsened, and 2 days later, he was admitted to hospital for acute onset of aphasia and right hemiparesis. After computed tomography (CT) of the brain excluded a hemorrhagic stroke, the patient was given intravenous tissue plasminogen activator and referred to our medical center. His medical history included poorly controlled diabetes mellitus, hypertension, and hyperlipidemia. On admission, the patient was lethargic, oriented to self, aphasic, and not following commands. He had right hemiplegia and left gaze preference. Nasal and oropharyngeal swabs for real-time PCR confirmed infection with SARS-CoV2, and due to his respiratory failure, he was intubated and transferred to the intensive care unit. His hematologic studies included white blood cells of 12.6 × 103/µL (normal, 4–11/µL) with 4% lymphocyte (normal, 15%–52%), C-reactive protein 214 mg/L (normal, 0–10.9 mg/L), d-dimer >20,000 ng/mL (normal, 0–240 ng/mL), lactate dehydrogenase 280 U/L (normal, 120–240 U/L), and fibrinogen 1,228 mg/dL (normal, 220–498 mg/dL). Neuroimaging studies were obtained. CT angiography (CTA) was consistent with occlusion of the cervical and intracranial portion of the left internal carotid artery (Fig. 1). Subsequent brain MRI demonstrated scattered acute infarcts in the distribution of the left middle cerebral artery. Diffusion-weighted imaging (DWI) showed restricted diffusion along the intraorbital portion of the left optic nerve (Fig. 2).FIG. 1.: CTA. Sagittal and axial images reveal total occlusion of the left internal carotid artery (A, arrow) and absent flow in the artery at the skull base (B, arrow).FIG. 2.: A. Diffusion-weighted scan shows multiple areas of ischemia in the left cerebral hemisphere. B. Diffusion-weighted scan demonstrates restricted diffusion in the left intraorbital optic nerve (arrow). C. The apparent diffusion coefficient (ADC) map confirms restricted diffusion of the left optic nerve (arrow).After 3 weeks, as the patient's respiratory condition and mental status improved, he reported loss of vision in his left eye. At that time, visual acuity was 20/50 in the right eye and no light perception in the left eye. There was a left relative afferent pupillary defect, eye movements were intact, and the fundi were unremarkable. Six weeks later, visual function was unchanged, but the left optic disc was now pale. Cerebrovascular ischemia is a recognized complication of the COVID-19. A series of 219 patients with COVID-19 from Wuhan, China, revealed a 4.6% rate for acute ischemic stroke (1). In this series, patients with COVID-19 who developed stroke were significantly older than non-COVID-19 stroke patients (75.7 ± 10.8 vs 52.1 ± 15.3 years) and had other cardiovascular risk factors. In contrast, Oxley et al (2) reported 5 patients younger than 50 years with COVID-19 who were diagnosed with acute stroke; 2 had no cardiovascular risk factors. Our patient had several risk factors for stroke, including diabetes mellitus, hypertension, and hypercholesterolemia. The mechanism of thromboembolic events in COVID-19 is controversial. Connor and colleagues (3) suggested that a contributing factor is the elevated level of coagulative factors, including platelet, fibrinogen, and d-dimer. Vascular endothelial dysfunction that impairs its antithrombotic properties is another proposed mechanism (4). There are few reports of visual loss associated with COVID-19 disease. Four patients have been documented with profound visual loss due to bilateral parieto-occipital or bilateral occipital lobe infarctions (5–7). In addition, Zhou et al (8) described a patient with COVID-19 who developed bilateral myelin oligodendrocyte glycoprotein (MOG)–associated optic neuritis. The authors speculated that COVID-19 provided a “potential connection” between the viral disease and central nervous system demyelination. DWI in our patient demonstrated acute infarction of the intraorbital portion of the left optic nerve due to thrombosis of the left internal carotid artery. Our report expands the spectrum of neuro-ophthalmic findings in patients with COVID-19.

Aphasia: Conversion/dissociation or organic etiology?

Aphasia: Conversion/dissociation or organic etiology?

In Reply to the Letter to the Editor Regarding ‘Transtentorial Brain Herniation After Lumbar Drainage in Patient Planned for Cranioplastic Reconstruction: Catastrophic Play Between Atmospheric and Intracranial Pressure’

Cerebral vasospasm and delayed ischemic neurologic deficits are well-known clinical aftereffects of subarachnoid hemorrhage due to rupture of an intracranial aneurysm. However, vasospasm with consequential ischemia after clipping of an unruptured aneurysm is an exceedingly rare sequela encountered in the reported neurosurgical literature.A 53-year-old woman had presented for elective craniotomy with microsurgical clipping of an unruptured left middle cerebral artery bifurcation saccular aneurysm, which was successfully treated without complications. Despite an initially benign clinical course, she experienced diffuse vasospasm with profound ischemic neurologic deficits on postoperative day 13 with a left middle cerebral artery distribution ischemic infarct. Moreover, she developed recurrent delayed spasm of the right posterior cerebral artery on postoperative day 26 and, consequentially, a left homonymous hemianopsia despite treatment with intra-arterial verapamil infusion.To the best of our knowledge, we have reported the first case of recurrent cerebral vasospasm and delayed ischemia neurologic deficits weeks subsequent to clipping of an unruptured aneurysm. The findings from the present case highlight the importance of considering delayed vasospasm as a cause of acute onset neurologic symptoms for patients who have recently undergone elective aneurysm surgery. We also reviewed the current data regarding the epidemiology, surgical factors, and proposed pathophysiologic mechanisms related to vasospasm after elective cases.

Plaque Distribution Correlates With Morphology of Lenticulostriate Arteries in Single Subcortical Infarctions.

We aimed to use novel whole-brain vessel-wall magnetic resonance imaging (WB-VWI) to investigate the association between plaque distribution of middle cerebral artery (MCA) and morphological changes of the lenticulostriate arteries (LSAs) in single subcortical infarctions. Forty single subcortical infarction patients with no relevant MCA disease on magnetic resonance angiography were prospectively enrolled. Plaque location in the MCA was dichotomized as proximal (located adjacent to the LSA origin) or distal (located distal to the LSA origin) on whole-brain vessel-wall magnetic resonance imaging. The MCAs with proximal plaques were divided into the symptomatic and asymptomatic side, and asymptomatic side MCAs without proximal plaques were the control group. The morphological characteristics of the LSAs and features of proximal plaques were analyzed. A total of 71 MCAs in 40 patients were analyzed (31 on the symptomatic side, 22 on the asymptomatic side, and 18 in the control group). Superior-wall plaques of MCAs were observed more frequently on the symptomatic side than the asymptomatic side (45.2% versus 9.1%, P=0.005). The wall area index, plaque burden, and remodeling index did not differ significantly between the symptomatic and asymptomatic side. The number of LSA branches was smaller (P=0.011) in the symptomatic side (5.48±1.88) compared with the control group (6.83±1.92). The symptomatic side exhibited shorter average length of the LSAs (23.23±3.44 versus 25.75±3.76 mm, P=0.025) and shorter average distance of the LSAs (16.47±3.11 versus 21.53±4.76 mm, P<0.001) compared with the asymptomatic side. Superiorly distributed MCA plaques at the LSA origin are closely associated with morphological changes of the LSA in symptomatic MCAs, suggesting that the distribution, rather than the inherent features of plaques, determines the occurrence of single subcortical infarctions. Our findings provide insight into the etiologic mechanism of branch atheromatous disease in single subcortical infarctions.