Middle Cerebral Artery Circulation Research Articles

Abstract TMP11: Cerebral Visual Impairment in Pediatric Stroke Patients Assessed by Virtual Reality Testing

Introduction: Pediatric stroke is one of the leading causes of disability in children, many of whom incur brain injury affecting critical visual anatomical networks. Dedicated ophthalmologic examinations that detect cerebral visual impairment (CVI) - the leading cause of congenital visual impairment in developed countries - are not standard of care and can delay diagnosis and interventions. There is limited CVI data in pediatric stroke patients, and in this work we present data defining visual processing deficits in pediatric stroke patients. Hypothesis: We hypothesize that pediatric stroke patients will (1) demonstrate greater visual-spatial processing impairments than controls and (2) demonstrate increasing performance impairment as a function of increasing visual task demands. Methods: Using a virtual reality (VR) based visual search task system, we characterized significant deficits in higher-order visual processing of pediatric stroke patients (n = 17) as compared to healthy controls (n = 13). Stroke patients suffered from a perinatal (n = 8) or pediatric (n = 9) stroke - confirmed with brain MRI - affecting various vascular territories of the anterior and posterior circulations. The task required searching for on-screen targets with increasing visual complexity. Metrics such as reaction time, gaze error, shifted ellipse area, success rate, and pursuit saccade ratio were analyzed using unpaired group-level t-tests and considered significant if p < 0.05. Results: Stroke patients took longer to identify the target (p = 0.001), were less accurate in finding it (p = 0.007), and exhibited greater impairment in performance with an increasing number of distractors compared to healthy children. Groups had comparable task compliance, as indexed by an off-screen count metric. Conclusion: This original work demonstrates that pediatric stroke patients, particularly those with strokes affecting the middle cerebral artery and posterior circulation vascular territories, exhibit impaired higher-order visual processing. This highlights the urgent need for standardized clinical testing to provide quantitative performance measures of cortical visual processing. This will allow timely detection and implementation of interventional therapies.

Initial Infarct location of Acute Stroke in Middle Cerebral Artery Circulation and Its Clinical Outcome using modified rank in scale

Abstract Introduction: Functional outcome after ischemic stroke is influenced by a variety of factors such as injured brain regions, extend and volume of the infarct. This study aim to correlate the infarct location and functional outcome of the patient. Materials and Method: This is a Prospective study done at MES Medical College, between December 2020 to June 2022, total 44 patients were admitted and taken MRI with a diagnosis of acute middle circulation ischemic stroke within 48 hours of symptom onset. Location of infarct is correlated with clinical outcome using a modified Rankin score taken at 45 days follow up. Results: Most of the infarct were located in the right hemisphere. A considerably high impact on functional outcome was found at the insula and surrounding opercular cortex.

Variants of anomalies in the structure of the Willis circle in patients with acute cerebrovascular accident in various vascular beds

Background. The frequency and severity of acute cerebrovascular accident depend on the variants of the anomaly in the structure of the Willis circle.
 Aim. To identify the frequency and variants of the Willis circle anomaly in patients with acute cerebrovascular accident with an assessment of the severity of neurological disorders according to the National Institutes of Health Stroke Scale (NIHSS).
 Material and methods. The study included 47 patients with acute cerebrovascular accident in conditions of the Willis circle anomaly: 21 male and 26 female, mean age was 67.0816.03 years. All patients underwent magnetic resonance imaging, magnetic resonance angiography of the brain, neurological examination using NIHSS.
 Results. Patients with the absence of one posterior communicating artery had a significant stroke severity according to the NIHSS: 9.4295.840 points (moderate neurological disorders), p=0.016. The results in patients with the absence of both posterior communicating arteries were 5.6674.410 (p=0.939), in patients with posterior trifurcation 5.2006.058 (p=0.864), the group with an anomaly in the form of the absence of all communicating arteries had 4.0002.828 points (mild neurological disorders), p=0.602. The group of patients with anterior trifurcation showed the lowest results: 3.5002.121 points (p=0.492). Circulatory disorders in the posterior circulation system were significantly more common in the pathologies of the Willis circle consisting of trifurcation, and less common in other pathologies of the Willis circle, consisting in trifurcation, compared with the group of patients with the absence of at least one communicating artery (p=0.037).
 Conclusion. Patients with stroke and the absence of one posterior communicating artery had neurological disorders of moderate severity according to the NIHSS, with the localization of the catastrophe mainly in the left middle cerebral artery circulation; in patients with the absence of both posterior communicating arteries, neurological disorders were of mild severity; patients with stroke in the posterior circulation system more often had an anomaly of the Willis circle in the form of a trifurcation.

Free-floating thrombus and a fragment of atherosclerotic plaque in the lumen of the internal carotid artery – review of 2 cases

Free-floating thrombus or a fragment of atherosclerotic plaque (mobile plaque) in the lumen of the carotid artery is extremely rare. Atherosclerosis is the most common cause underlying their occurrence. The optimal treatment strategy has not been developed, at least in part due to the rarity of observations, as well as the lack of comparative studies between conservative and surgical treatment (carotid artery stenting, endovascular thrombectomy, endarterectomy). We present two cases that demonstrate the treatment tactics of these rather rare pathologies. Patient Yu., 62 years old, was hospitalized with focal neurological symptoms, National Institutes of Health Stroke Scale of 12. According to the CT of the brain, signs of an ischemic stroke in the right middle cerebral artery circulation were detected. Selective cerebral angiography diagnosed thrombosis of the arteries of the precentral and central sulcus of the right middle cerebral artery, critical stenosis of the mouth of the right internal carotid artery, and a free-floating thrombus in its lumen with a fixation point at the level of atherosclerotic plaque, which blocked the lumen of the artery by more than 60 %. Endovascular aspiration of a free-floating thrombus was performed, followed by angioplasty and stenting of critical stenosis with a favorable clinical outcome. Patient L., 73 years old, applied for carotid ultrasonography, during which a mobile atherosclerotic plaque was diagnosed at the level of the bifurcation of the right common carotid artery. Digital selective cerebral angiography confirmed a plaque fragment floating in the lumen of the artery. After applying a loading dose of ticagrelor without complications, an emergency implantation of a carotid stent was performed at the level of the bifurcation of the right common carotid artery.Taking into account the modern possibilities of interventional radiology and a wide range of tools, the endovascular approach to the treatment of complicated atherosclerotic plaque with a floating component or a formed blood clot is the best treatment option with a good safety profile.

Prediction of outcomes in stroke patients from radiological findings – A hospital-based retrospective cohort study from a comprehensive stroke care center in Kerala, India

Introduction: Functional outcome after stroke can be improved by early and accurate diagnosis with the help of imaging techniques such as computed tomography (CT) and magnetic resonance imaging. Alberta Stroke Program Early CT Score (ASPECTS) calculated from the CT image infarct areas of middle cerebral artery (MCA) circulation is supposed to be a reliable outcome predictor. Methodology: A retrospective cohort study was conducted in the Comprehensive Stroke Care Center for a period of 6 months. All adult patients (18–90 years) who had visited the hospital from January 2014 to December 2017 were enrolled for the study. Patients with MCA strokes were only included in the study since the ASPECTS is defined for this territory. The data were gathered from the electronic format of the patient information system in the institution and were entered in a structured proforma specifically designed for the study. ASPECTS was calculated from the CT findings of the patient. The modified Rankin Scale (mRS) scores were calculated for every patient at four different time points. The collected data were compiled in a Microsoft Excel sheet and were analyzed using IBM Statistical Package for Social Sciences (SPSS version 21). The summary statistics for categorical variables were reported using frequency and percentage and continuous variables as mean (standard deviation). We reported the association of the ASPECTS with mRS at different time points using the Chi-Square test. Results: A total of 132 adult patients were enrolled in the study. The mean age of the study population was 60.72 (±13.99) years, and among them, 93 (70.45%) were males. Majority of the patients were nonvegetarians (99.92%). The most prevalent risk factor found was hypertension (62.1%). The most common symptom presented by the patients was facial palsy (28%). When the ASPECTS was calculated for 132 patients, 62 patients fell in the high ASPECTS category (8–10), 45 patients had a moderate ASPECTS (5–7), and 25 had low ASPECTS (0–4). mRS scores calculated for four different time points showed a decline in disability in most of the patients. ASPECT and mRS had a negative association signifying, as the ASPECTS increases the number of functional disability decreases. Conclusions: Our study results show that ASPECTS can be a definite outcome predictor in MCA stroke patients.

Ischemic and haemorrhagic stroke: pathomorphology,diagnosis, treatment and prevention

Purpose of the work - analyze the bases of the pathomorphology of ischemic and haemorrhagic stroke, as well as the principles of diagnosis, prophylaxis and treatment that will prevent the secondary development of the corresponding pathologies. The analysis is done on the basis of articles review and research of 2010-2017, using the databases Pubmed, eLIBRARY.RU, Web of Science. According to the latest data, 16 million people suffer from brain disorders annually, 6 million of them die. Mostly, low- and medium-income countries are vulnerable to strokes. In Ukraine, this problem has been underestimated for a long time in comparison with the developed world's countries, where the prevention and control of the effects of acute cerebrovascular diseases have long been recognized as the most important tasks of modern medicine. A few decades ago, the proportion of patients under 60 among the patients with a diagnosed stroke made up not more than 20%; today, this figure increased to 35%, and in some regions of Ukraine - up to 40. The mortality rate reaches 40 % during a month and 54% during a year, but half of the deaths occur in the first two days. The onset of the ischemic stroke, which may cause thrombosis, thromboembolism or obliteration with an atherosclerotic plaque, is very common. In 60% of cases, a stroke or cerebral infarction is a consequence of atherosclerosis. Mostly, the localization site is the middle cerebral artery circulation. The infarction is characterized, first of all, by ischemic changes of nerve cells and glia, the vessels are most resistant to ischemia. The changes by hyperchromic type, accompanied by pycnosis and destruction of cellular elements, are most typical for neurons. Then the process extends to glia. A haemorrhagic stroke, as opposed to the ischemic one, occurs in the setting of a high blood pressure. Arterial hypertension leads to the change in the permeability of vessel walls, the occurrence of plasmorrhagia, necroses and microaneurysms, which develop, and, as a result, hemorrhage. The localization site is associated with the peculiarities of the angioarchitectonics - basal ganglia and the optic nerve. A cavity, filled with blood, may be formed, or a swelling of the brain matter, which gradually increases up to the formation of a gliomezodermal scar or a cyst, may occur. It is important to timely diagnose this type of pathology. The diagnosis is based on a clinical picture, anamnesis, cerebrospinal fluid analysis and instrumental methods of examination. Urgent hospitalization of patients is necessary. In case of an ischemic stroke, the treatment is aimed at increasing blood flow to the brain, and in case of haemorrhagic stroke - at reducing blood pressure, eliminating cerebral edema and increasing the blood-clotting abilities. In case of prevention of cerebrovascular diseases, the correction of risk factors is of great importance. Thus, the pathologic picture of stroke`s different types is quite diverse. Lesions of nerve cells and glia are presented in ischemia. Damage of the vessels walls, which leads to hemorrhages with necrosis of the tissues, is inherent while hemorrhagic stroke. Using of precisely modern instrumental methods of research is fundamental in the diagnosis of cerebrovascular diseases. Timely prophylaxis of cardiovascular diseases and correction of risk factors prevents the occurrence of stroke.

Abstract WP9: Direct Aspiration (ADAPT) and Primary Stent Retriever Thrombectomy for Acute Ischemic Stroke: A Systematic Review of Radiographic and Clinical Outcomes in 3339 Patients

Introduction: Endovascular stroke therapy has been revolutionized by the advent of modern devices for thrombectomy. It remains to be determined what is the most safe and effective way to perform stroke thrombectomy. The two most common approaches to thrombectomy currently include: 1-direct aspiration with the additional use of a stent retriever if needed (ADAPT), 2 - primary stent retriever thrombectomy. We aimed to compare radiographic and clinical outcomes in patients with acute stroke from large vessel occlusion (LVO) treated with these two approaches. Methods: Using the PubMed database, we searched for studies that included patients with acute ischemic stroke from LVO treated with direct aspiration (ADAPT) or primary stent retriever thrombectomy. The literature search included 294 studies, excluding 122 manuscripts. Statistical analysis was performed on 36 publications with a total of 2656 patients that underwent thrombectomy using a stent retriever device and 11 publications with a total of 683 patients that underwent thrombectomy using ADAPT. We compared the proportions of patients with successful recanalization, favorable functional outcomes, intracranial hemorrhage, mortality rates and occurrence of distal embolization in the two treatment groups by calculating chi 2 and confidence intervals for odds ratios. Results: 3339 patients from 47 publications were included in final analysis. There was no difference in age (p=0.7625, 95% CI -2.91–3.94), NIHSS (p=0.1135, 95% CI -3.55-0.39), the use of intravenous thrombolysis (p=0.9631, 95% CI -29.46-30.85), or location of occlusion (internal carotid artery, middle cerebral artery or posterior circulation; p=0.9679) between the two groups. We found no difference in rates of successful recanalization TICI 2b/3 (79.9% with ADAPT vs. 74.9% with primary stent retriever; p=0.4771, 95% CI -0.091-0.191) or good clinical outcome at 3 months defined as mRS 0-2 (51.0% with ADAPT vs. 46.8% with primary stent retriever; p=0.4814, 95% CI -0.161-0.077). Conclusion: According to our systematic review, endovascular treatment with direct aspiration (ADAPT) and primary stent retriever thrombectomy approaches results in similar radiographic and clinical outcomes in patients with acute stroke from LVO.

Assessment of clot length with multiphase CT angiography in patients with acute ischemic stroke

Introduction Existing stroke literature demonstrates that rapid recanalization of vessels improves long-term prognosis after acute ischemic stroke. However, further optimization of the speed of the thrombectomy procedure, used to recanalize a blocked vessel, is limited by our minimal knowledge of the clot dimensions pre-procedure. Knowing the clot dimensions would allow planning of the thrombectomy procedure with the appropriate size and length of stent retriever, and determination of the correct site of the stent deployment ensuring total coverage of the clot by the stent retriever. Methods We performed a feasibility study to assess if multiphase computed tomography angiography (mCTA) can be used to estimate clot length by comparing CTA imaging data with imaging data obtained from conventional digital subtraction angiography (DSA). A retrospective chart review was performed of patients with clots in the proximal middle cerebral artery and adequate collateral circulation, who underwent both mCTA and DSA. Results Clot length was not significantly different on 3D mCTA versus mCTA MIPs, nor was it significantly different on MIP mCTA versus DSA. Pathological evidence also supported our ability to measure clot length on mCTA. Conclusions We suggest that mCTA is a reliable and valid measure of clot length in acute ischemic stroke patients.

The Impact of Risk Burden Differences between Men and Women on the Clinical Course of Ischemic Stroke

Our objective is to assess the impact of varying risk profiles in men and women on the clinical picture of ischemic stroke. The study involved 185 patients, 100 women and 85 men. We assessed the patients' neurological status upon admission, 1 and 2 weeks following stroke onset, using the Scandinavian Stroke Scale and the Barthel Index; stroke syndromes according to the Oxfordshire Classification; their etiology and pathogenesis according to the Trial of Org 10172 in Acute Stroke Treatment; and the prevalence of vascular risk factors. We used cranial magnetic resonance imaging to locate infarcts. Women had more total anterior circulation infarct subtype strokes, whereas men had more posterior circulation infarct and lacunar infarct. On neuroimaging, women had more infarcts in the middle cerebral artery circulation, whereas men had more in the brain stem and/or cerebellum. Women had a higher prevalence of atrial fibrillation (AF) and coronary artery disease, whereas men were more likely to smoke and abuse alcohol. Women had more cases of cardioembolism, whereas men had more strokes caused by atherosclerosis of large vessels. In the present study, heart diseases, such as coronary artery disease and AF, were more prevalent among women. It seems that AF is a risk factor with significant impact on the epidemiological differences regarding ischemic stroke in men and women.

Early Clinical Signs, Lesion Localization, and Prognostic Factors in Unilateral Symptomatic Internal Carotid Artery Occlusion

The aim of this study was to assess infarct localization, clinical signs, and prognostic factors in cases with unilateral symptomatic total internal carotid occlusion. In total, 101 patients who had a diagnosis of symptomatic unilateral carotid occlusion in the Department of Neurology, Trakya University Faculty of Medicine, between January 2008 and May 2012, were included in this study. The relationship between infarct localizations and prognosis of patients was evaluated by cranial magnetic resonance imaging (MRI) and diffusion-weighted MRI. The condition of ipsilateral middle cerebral artery (MCA) and posterior communicating arteries (PCoAs) was assessed by cranial and cervical magnetic resonance angiography besides opposite carotid. Patients were evaluated by modified Rankin Scale in terms of prognosis at discharge and after 3months. Furthermore, they were evaluated in terms of risk factors, such as cigarette and alcohol use, presence of temporary ischemic attack and stroke history, hypertension, diabetes mellitus, coronary artery disease, previous myocardial infarction, hyperlipidemia, and peripheral vascular disease. Territorial infarct was commonly seen as acute ischemic stroke pattern especially in cases with a poor MCA circulation and insufficient collateral circulation. Development of territorial stroke, occlusion of MCA, and nonvisualization of PCoA were found to be associated with poor prognosis. In unilateral symptomatic intracranial carotid artery occlusion, poor prognosis and high mortality-associated territorial stroke pattern is frequently observed. Besides, presence of severe stenosis or occlusion and absence of collateral circulation in MCA are associated with poorprognosis.

Fetus Sound Stimulation: Cilia Memristor Effect of Signal Transduction

Background. This experimental study evaluates fetal middle cerebral artery (MCA) circulation after the defined prenatal acoustical stimulation (PAS) and the role of cilia in hearing and memory and could explain signal transduction and memory according to cilia optical-acoustical properties. Methods. PAS was performed twice on 119 no-risk term pregnancies. We analyzed fetal MCA circulation before, after first and second PAS. Results. Analysis of the Pulsatility index basic (PIB) and before PAS and Pulsatility index reactive after the first PAS (PIR 1) shows high statistical difference, representing high influence on the brain circulation. Analysis of PIB and Pulsatility index reactive after the second PAS (PIR 2) shows no statistical difference. Cilia as nanoscale structure possess magnetic flux linkage that depends on the amount of charge that has passed between two-terminal variable resistors of cilia. Microtubule resistance, as a function of the current through and voltage across the structure, leads to appearance of cilia memory with the “memristor” property. Conclusion. Acoustical and optical cilia properties play crucial role in hearing and memory processes. We suggest that fetuses are getting used to sound, developing a kind of memory patterns, considering acoustical and electromagnetically waves and involving cilia and microtubules and try to explain signal transduction.

Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression.

ObjectiveIn addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression.Materials and MethodsIn 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality.ResultsAneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05).ConclusionIn this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.

Carotid Stump Syndrome: Pathophysiology and Endovascular Treatment Options

Carotid stump syndrome is one of the recognised causes of recurrent ipsilateral cerebrovascular events after occlusion of the internal carotid artery. It is believed that microemboli arising from the stump of the occluded internal carotid artery or the ipsilateral external carotid artery can pass into the middle cerebral artery circulation as a result of patent external carotid-internal carotid anastomotic channels. Different pathophysiologic causes of this syndrome and endovascular options for treatment are discussed.

A Simple Index Using Age, Hemoglobin, and Aspartate Transaminase Predicts Increased Intracerebral Blood Velocity as Measured by Transcranial Doppler Scanning in Children With Sickle Cell Anemia

Increased intracerebral blood velocity measured by transcranial Doppler scanning identifies children with sickle cell anemia who are at increased risk of stroke. We have tried to develop an index based on routine clinical measurements that also predicts increased intracerebral blood flow. Routinely collected clinical and laboratory data were correlated with transcranial Doppler measurements on children with sickle cell anemia seen in a single institution in 2006. The index produced was validated on a second independent data set from children with sickle cell anemia. The time-averaged mean of the maximum velocity in centimeters per second in the middle cerebral artery circulation correlated significantly with age, hemoglobin, lactate dehydrogenase, and aspartate transaminase levels, white blood cell count, and creatinine level. On multiple regression, hemoglobin and aspartate transaminase levels maintained their significance, whereas age had borderline significance, and an index was developed linked to a time-averaged mean of the maximum velocity of 220 - (8 x hemoglobin) - (1.4 x age) + (0.4 x aspartate transaminase). This detected a time-averaged mean of the maximum velocity of >170 cm/second with 100% sensitivity and 58% specificity. The index was validated on the second data set and again showed 100% sensitivity with 73% specificity. This simple index has the potential to identify children who are at higher risk of cerebrovascular disease to allow them to be prioritized for transcranial Doppler scanning and other intracerebral imaging.

Transcranial Doppler scanning and the assessment of stroke risk in children with haemoglobin sickle cell disease

Objective: To assess the role of transcranial Doppler (TCD) scanning in assessing the risk of stroke in children with haemoglobin SC (HbSC) disease. TCD scanning has an established role in...

Trends in Risk Factors, Patterns and Causes in Hospitalized Strokes over 25 Years: The Lausanne Stroke Registry

Background and Objective: The Lausanne Stroke Registry includes, from 1979, all patients admitted to the department of Neurology of the Lausanne University Hospital with the diagnosis of first clinical stroke. Using the Lausanne Stroke Registry, we aimed to determine trends in risk factors, causes, localization and inhospital mortality over 25 years in hospitalized stroke patients. Methods: We assessed temporal trends in stroke patients characteristics through the following consecutive periods: 1979–1987, 1988–1995 and 1996–2003. Age-adjusted cardiovascular risk factors, etiologies, stroke localizations and mortality were compared between the three periods. Results: Overall, 5,759 patients were included. Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. After adjustment for age, hypercholesterolemia increased (p < 0.001), as opposed to cigarette smoking (p < 0.001), hypertension (p < 0.001) and diabetes and hyperglycemia (p < 0.001). In patients with ischemic strokes, there were significant changes in the distribution of causes with an increase in cardioembolic strokes (p < 0.001), and in the localization of strokes with an increase in entire middle cerebral artery (MCA) and posterior circulation strokes together with a decrease in superficial middle cerebral artery stroke (p < 0.001). In patients with hemorrhagic strokes, the thalamic localizations increased, whereas the proportion of striatocapsular hemorrhage decreased (p = 0.022). Except in the older patient group, the mortality rate decreased. Conclusions: This study shows major trends in the characteristics of stroke patients admitted to a department of neurology over a 25-year time span, which may result from referral biases, development of acute stroke management and possibly from the evolution of cerebrovascular risk factors.

Frequency and determinants of poststroke dementia in Chinese.

Both dementia and stroke are major health problems in Chinese societies. Stroke is a frequent cause of dementia. Only a few studies have been published on poststroke dementia (PSDE), none of which has investigated a consecutive stroke cohort in Asian patient populations. The objective of this study was to examine the prevalence and clinical correlates of PSDE in Chinese stroke patients in Hong Kong. Two hundred eighty stroke patients consecutively admitted to the medical wards of a university-affiliated regional hospital were interviewed by a psychiatrist 3 months after stroke. The presence of dementia and vascular dementia was diagnosed according to the Diagnostic and Statistical Manual, 4th edition. In addition, a wide range of demographic and clinical variables were examined. Fifty-five participants (20%) had PSDE. Univariate analysis found that PSDE was associated with age; level of education; prestroke Rankin Scale score; prestroke Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score; National Institutes of Health Stroke Scale (NIHSS) best language score, dysarthria score, and total score; urinary incontinence; cortical infarct; leukoaraiosis; bilateral lesions; number of lesions; involvement of middle cerebral artery circulation; and cerebral atrophy index. Multivariate logistic regression suggested that prestroke IQCODE score, NIHSS total score, leukoaraiosis, involvement of middle cerebral artery territory, and cerebral atrophy index were independent risk factors of PSDE. After removal of 22 patients with prestroke dementia, which was defined as a prestroke IQCODE score > or =4.0, the frequency of PSDE dropped to 15.5%. Furthermore, involvement of the middle cerebral artery territory and cerebral atrophy index were replaced by level of education and bilateral lesions as independent predictors in the final logistic model. PSDE is common among Chinese stroke patients in Hong Kong. Its frequency is comparable to that in white populations. The clinical determinants of PSDE, after the exclusion of patients with prestroke dementia, include premorbid level of cognitive function, severity of stroke, leukoaraiosis, level of education, and bilateral lesions.

Superficial Temporal Artery to Middle Cerebral Artery Bypass and External Carotid Reconstruction for Carotid Restenosis After Angioplasty and Stent Placement

The recent proliferation of endovascular treatment of carotid atherosclerotic disease will increase the number of patients who require treatment for recurrent carotid stenosis after angioplasty and stent placement. The optimal management of these patients has not yet been defined. We describe a 66-year-old woman who required 2 surgical procedures for recurrent in-stent carotid stenosis. She experienced numerous transient ischemic attacks 5 months after left extracranial internal carotid artery angioplasty and stenting for asymptomatic stenosis. Angiography showed high-grade in-stent restenosis, left intracranial carotid artery stenosis, and poor collateral flow to the left middle cerebral artery circulation. The patient underwent a superficial temporal artery to middle cerebral artery bypass, and the transient ischemic attacks resolved. Five months later, angiography showed progressive stenosis of the external carotid artery at the site of the stent. The patient underwent successful external carotid reconstruction with an on-lay patch. Extracranial-intracranial bypass grafting may be used successfully in the treatment of recurrent extracranial carotid artery stenosis after angioplasty and stent placement. Also, external carotid artery reconstruction at the site of an internal carotid artery stent can be performed safely.

Ruptured cerebral aneurysm in a 39-day-old infant

A case of middle cerebral artery aneurysm in a 39-day-old infant is discussed. The unique characteristics of aneurysms in the pediatric age group which distinguish them from adults are male predominance, greater frequency in middle cerebral artery and posterior circulation. In addition, they demonstrate a greater frequency of large and giant aneurysms. Theories on the etiology of cerebral aneurysms in children are discussed.

Middle Cerebral Artery Circulation During Carotid Surgery: A Transcranial Doppler Study

Objective - Perioperative carotid cross-clamping might induce low stump pressures as well as hypoperfusion of the middle cerebral artery. In this study blood flow velocities in the middle cerebral artery were compared with intraoperative measurements of the poststenotic carotid blood pressure. Design - Forty-one patients with internal carotid artery stenosis were operated on without shunting, under general anesthesia. Poststenotic carotid pressures and middle cerebral artery flow velocities were measured before and during cross-clamping. The hemodynamic responses to preoperative carotid compressions and intraoperative cross-clamping were evaluated. Results - In seven patients the poststenotic carotid blood pressure decreased on clamping despite unchanged or even increased middle cerebral artery blood flow velocities. In all other patients, pressure changes were significantly correlated to the decrease in middle cerebral artery blood flow velocities. Autoregulatory blood flow velocity responses after preoperative common carotid artery compression were not reproducible by cross-clamping. Conclusions - Stump blood pressure measurements may not reflect middle cerebral artery perfusion in about 20% of thrombendarterectomies performed under general anesthesia. A possible explanation might be dimished cerebral autoregulation and changes in collateral flow distributions.