Middle Cerebral Artery Infarction Research Articles

Safety and efficacy of internal carotid artery infusion of autologous bone marrow-derived stem cells in subacute middle cerebral artery infarct

Objective: To evaluate the safety and the efficacy of internal carotid artery (ICA) infusion of autologous bone marrow-derived stem cells (BMSC) in subacute middle cerebral artery (MCA) infarct. Subject and method: A prospective, open-label, non-randomized was conducted in patients with MCA infarct, within 7-40 days from onset. Sixty-two patients satisfying the inclusion criteria were enrolled and allocated into either BMSC group (n = 31) or control group (n = 31). Follow-ups were performed at 6 months and 1 year after therapy. Adverse events were noted to conclude safety outcome. The primary efficacy outcomes were percentages of recovered patients with a score of 0 to 2 on the modified Rankin Scale (mRS). The secondary efficacy outcomes were evaluated by the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Brunnstrom stages of hand (BRS-H), and infarct volume on head MRI. Result: There were no significant differences in the percentages of noted adverse events. The percentages of the mRS 0-2 in BMSC group were remarkably higher as compared to control group at both 6-month and 1-year follow-up, but not statistically significant (25.8% vs 6.9%, p=0.08 and 26.7 vs 9.7, p=0.1, respectively). BI at 6 months was significantly better in the BMSC group, however no significant differences on other secondary efficacy measures. Conclusion: ICA infusion of BMSC was safe and tolerated in patients with subacute MCA infarct. Although the difference in the primary efficacy outcomes was not statistically significant, a favorable trend was found in BMSC group representing by the BI at 6 months and the percentages of mRS 0-2 at both main follow-ups.

Significant improvement of Barthel index scores in patients with subacute middle cerebral artery infarct after intravenous autologous bone marrow-derived stem cells infusion

Objective: To assess the safety and the efficacy of intravenous infusion of autologous bone marrow-derived stem cells (BMSC) in subacute middle cerebral artery (MCA) infarct. Subject and method: A prospective, open-label, non-randomized was performed in patients with MCA infarct, within 7-40 days from onset. Sixty-three patients, satisfying the inclusion criteria, were enrolled, and allocated into the IV-BMSC group (n = 32) or into control group (n = 31). Main follow-ups were at 6 months and 1 year after therapy. Adverse events were noted to conclude safety outcome. The primary efficacy outcomes were proportions of patients achieving a score of 0 to 2 on the modified Rankin Scale (mRS). The secondary efficacy outcomes were evaluated by the National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI), Brunnstrom stages of hand (BRS-H), and infarct volume on head MRI. Result: There were no statistically significant differences in the rates of noted adverse events. There were no significant differences between the two groups on the proportions of the mRS 0-2 at both 6-month and 1-year follow-up (3.2% vs 6.9% with p=0.6, and 6.9 vs 9.7 with p=1.0, respectively). The improvement of BI at 6 months was significantly better in the IV-BMSC group compared to control group, however no significant differences on other secondary efficacy measures. Conclusion: Intravenous infusion of BMSC was safe in patients with subacute MCA infarct. Although the difference in the primary efficacy outcomes was not statistically significant, a favorable secondary outcome was observed in IV-BMSC group, presenting by the statistically significant improvement of the Barthel index at 6-month follow-up.

Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years.

The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years. Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months. In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed. As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Worsened Stroke Outcome in a Model of Preeclampsia is Associated With Poor Collateral Flow and Oxidative Stress.

Preeclampsia increases the incidence of maternal stroke, a devastating condition that is on the rise. We investigated stroke outcome in a model of experimental preeclampsia with and without treatment with clinically relevant doses of magnesium sulfate (experimental preeclampsia+MgSO4) compared to normal late-pregnant and nonpregnant rats. Transient middle cerebral artery occlusion was used to induce focal stroke for either 1.5 or 3 hours. Infarct volume and hemorrhagic transformation were determined as measures of stroke outcome. Changes in core middle cerebral artery and collateral flow were measured by dual laser Doppler. The relationship between middle cerebral artery perfusion deficit and infarction was used as a measure of ischemic tolerance. Oxidative stress and endothelial dysfunction were measured by 3-nitrotyrosine and 8-isoprostane, in brain and serum, respectively. Late-pregnant animals had robust collateral flow and greater ischemic tolerance of brain tissue, whereas experimental preeclampsia had greater infarction that was related to poor collateral flow, endothelial dysfunction, and oxidative stress. Importantly, pregnancy appeared preventative of hemorrhagic transformation as it occurred only in nonpregnant animals. MgSO4 did not provide benefit to experimental preeclampsia animals for infarction. Stroke outcome was worse in a model of preeclampsia. As preeclampsia increases the risk of future stroke and cardiovascular disease, it is worth understanding the influence of preeclampsia on the material brain and factors that might potentiate injury both during the index pregnancy and years postpartum.

Abstract WMP95: External Validation Of Acute Atherosclerotic Ischemic Stroke Radiological Markers

Introduction: Intracranial atherosclerosis-related acute large vessel occlusion (ICAS-LVO) is the dominant cause of acute middle cerebral artery (MCA) occlusions that can be passed with wire or microcatheter but cannot be completely opened (5-15% of all middle cerebral artery (MCA) infarcts). The major challenge of ICAS-LVO is the tendency of reocclusion or cause a residual, fixed severe stenosis rendering the vessel with suboptimal revascularization. These patients carry a poor functional outcome and high mortality despite mechanical thrombectomy (MT). We aimed to externally validate three preidentified markers of ICAS-LVO on early non-contrast computed tomography (NCCT) and CT Angiogram (absent hyperdense MCA sign (HMCAS), Hounsfield measurements (HU ratio≤1.1 and Delta HU<6) and CTA truncal occlusion). Methods: We conducted a retrospective analysis of 77 consecutive patients presenting with acute M1 occlusions undergoing MT. Based on our previous observational experiences, NCCT and CTA patterns that had been associated with ICAS-LVO included the absent HMCAS, HU ratio and Delta HU between site of occlusion and contralateral MCA and CTA truncal occlusion. ICAS-LVO was identified if an occlusion was difficult to cross, had tendency to reocclude after successful recanalization or demonstrated residual fixed severe stenosis. These markers were also compared with reperfusion rates and functional outcomes at 3 months. Results: Out of 77 patients, 13 (16%) had suspected ICAS-LVO. Absent HMCAS had a sensitivity of 91% and specificity of 90% (AUC 0.91), HU ratio ≤1.1 and delta HU <6 had sensitivity of 100% and specificity of 98% (AUC 0.992) and CTA truncal occlusion had sensitivity of 91% and specificity of 97% (AUC 0.943), in predicting ICAS-LVO. These radiological markers were also significantly associated with unsuccessful reperfusion (TICI 0-2a) and poor functional outcomes (mRS>2) at 3 months. Conclusion: Initial non-contrast CT and CTA markers are highly sensitive and specific in predicting atherosclerotic M1 occlusions and significantly associated with failed reperfusion, and poor functional outcomes after mechanical thrombectomy.

Abstract TMP9: Covid-19 Increases The Risk Of Malignant Middle Cerebral Artery Infarction In Acute Stroke

Introduction: Stroke as a presenting feature of COVID-19 infection is being increasingly recognized. The prevalence of malignant middle cerebral artery syndrome (MMC) in acute stroke associated with COVID-19 is yet unknown. Methods: This is a retrospective cohort study of ischemic stroke patients admitted in a health center in Brazil. We investigated the prevalence of malignant middle cerebral artery syndrome in COVID-19 and associated stroke patients. Results: We included 881 ischemic stroke patients (53% male). COVID-19 patients represented 5.3% (N = 47). Mean age was 65.6 years (SD 13.2). COVID-19 patients were significantly younger (mean: 61.4 years; SD: 13.5; p = 0.025) and disclosed a higher odds of previous ischemic heart disease (OR: 4.1 - CI: 1.98-8.16). The frequency of main stroke risk factors was similar for both groups. COVID-19 patients had significantly higher NIHSS (11 points vs 8.2 in non-Covid-19 group - p = 0.006). MMC occurred more frequently in COVID-19 patients (19.5% vs 4.1% of non-covid-19 group - p < 0.001) (Risk ratio: 5.1; CI: 2.63-10.01 - p < 0.001). COVID-19 stroke patients had a longer hospital stay (p < 0.001) and disclosed a higher risk for in-hospital infection (Risk ratio: 4.3 - CI: 2.47-7.53). Rankin scale at 90 days was significantly higher for COVID-19 patients (p <0.001). Case-fatality was higher among COVID-19 stroke patients (49.4% vs 2.5% in non-covid-19 group; p < 0.0001). Among those patients with MMC, the lethality was significantly higher among COVID-19 patients (66.6% vs 41.3% in non-covid-19 group; p< 0.0001). Multivariate logistic regression with MMC as outcome and adjusted for age, sex, NIHSS and comorbidity index, disclosed COVID-19 infection as the main independent preditor for MMC (OR: 6.3 - CI: 2.26-17.52 - p < 0.0001 - adjusted R2 = 0.2623). Conclusion: In this cohort study, COVID-19 infection was an independent predictor for malignant middle cerebral artery syndrome in ischemic stroke.

Machine learning prediction of malignant middle cerebral artery infarction after mechanical thrombectomy for anterior circulation large vessel occlusion

ObjectivePrediction of malignant middle cerebral artery infarction (MMI) could identify patients for early intervention. We trained and internally validated a ML model that predicts MMI following mechanical thrombectomy (MT) for ACLVO. MethodsAll patients who underwent MT for ACLVO between 2015 – 2021 at a single institution were reviewed. Data was divided into 80% training and 20% test sets. 10 models were evaluated on the training set. The top 3 models underwent hyperparameter tuning using grid search with nested 5-fold CV to optimize the area under the receiver operating curve (AUROC). Tuned models were evaluated on the test set and compared to logistic regression. ResultsA total of 381 patients met the inclusion criteria. There were 50 (13.1%) patients who developed MMI. Out of the 10 ML models screened on the training set, the top 3 performing were neural network (median AUROC 0.78, IQR 0.72 – 0.83), support vector machine ([SVM] median AUROC 0.77, IQR 0.72 – 0.83), and random forest (median AUROC 0.75, IQR 0.68 – 0.81). On the test set, random forest (median AUROC 0.78, IQR 0.73 – 0.83) and neural network (median AUROC 0.78, IQR 0.73 – 0.83) were the top performing models, followed by SVM (median AUROC 0.77, IQR 0.70 – 0.83). These scores were significantly better than those for logistic regression (AUROC 0.72, IQR 0.66 – 0.78), individual risk factors, and the Malignant Brain Edema score (p < 0.001 for all). ConclusionML models predicted MMI with good discriminative ability. They outperformed standard statistical techniques and individual risk factors.

How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery

IntroductionDecompressive hemicraniectomy (DCE) is routinely performed for intracranial pressure control after malignant middle cerebral artery (MCA) infarction. Decompressed patients are at risk of traumatic brain injury and the syndrome of the trephined until cranioplasty. Cranioplasty after DCE is itself associated with high complication rates. Single-stage surgical strategies may eliminate the need for follow-up surgery while allowing for safe brain expansion and protection from environmental factors. Research questionAssess the volume needed for safe expansion of the brain to enable single-stage surgery. Materials and methodsWe performed a retrospective radiological and volumetric analysis of all patients that had DCE in our clinic between January 2009 and December 2018 and met inclusion criteria. We investigated prognostic parameters in perioperative imaging and assessed clinical outcome. ResultsOf 86 patients with DCE, 44 fulfilled the inclusion criteria. Median brain swelling was 75.35 mL (8.7–151.2 mL). Median bone flap volume was 113.3 mL (73.34–146.1 mL). Median brain swelling was 1.62 mm below the previous outer rim of the skull (5.3 mm to –2.19 mm). In 79.6% of the patients, the volume of removed bone alone was equivalent to or larger than the additional intracranial volume needed for brain swelling. Discussion and conclusionThe space provided by removal of the bone alone was sufficient to match the expansion of the injured brain after malignant MCA infarction in the vast majority of our patientsA subgaleal space-expanding flap with a minimal offset can provide protection from trauma and atmospheric pressure without compromising brain expansion.

Management of a Case of Acute Ischaemic Stroke with Large Vessel Occlusion in an LVAD Patient; A UK Secondary Medical Center Experience

Introduction: Left ventricular assist devices (LVADs) are getting more popular in managing advanced heart failure patients. The implantation of LVADs is associated with neurological complications, including ischemic stroke or intracranial hemorrhage. There are no current guidelines on how to manage these neurological complications. In this report, we presented an LVAD patient with a large ischemic cerebral infarct and subarachnoid hemorrhage simultaneously and outlined our approach to managing these complications without affecting the LVAD function. Case presentation: A 34- year-old gentleman with an LVAD to bridge him to heart transplantation presented with acute left-sided body weakness of an undetermined time of onset. His CT head showed a large right middle cerebral artery infarct. He was not a thrombolysis candidate due to the undetermined onset of his stroke, the anticoagulation he was on for the LVAD, and the signs of infarct maturation in the CT head. We managed him in a multidisciplinary team approach holding the Aspirin and Warfarin he was taking and doing serial CT imaging of his brain to monitor the development of brain edema. The patient developed a small subarachnoid hemorrhage on day 2, that spontaneously resolved on day 5. We started him on unfractionated heparin on day 7 and Warfarin on day 10. We made an excellent recovery of his neurological function without impairment of the function on the LVAD. Conclusion: Simultaneous ischemic stroke and brain hemorrhage are a challenge in LVAD patients. A closely monitored stoppage of antithrombotics and serial brain imaging can guide the treatment. Regular assessment of LVAD function is mandated. Antithrombotics could be carefully reintroduced under surveillance brain scanning to maintain the LVAD function.

Effect of decompressive hemicraniectomy performed within the first 48 hours on mortality in the treatment of malignant infarction of the middle cerebral artery

To evaluate the clinical outcomes of patients with malignant middle cerebral artery (MCA) infarction who underwent wide decompressive hemicraniectomy. Fifty-two patients with large MCA infarcts were retrospectively evaluated, and 12 patients who underwent extensive decompressive hemicraniectomy and duraplasty with a bone flap extending beyond the infarct borders were included in the study. The degree of stroke (stroke volume), preoperative and postoperative midline shift of the craniectomy area and improvement in midline shift were calculated on computed tomography. Preoperative and postoperative neurologic examination scores were determined using the modified Rankin Scale. The mean age was 63 (min: 41, max: 79) years. There was left MCA infarction in one patient and right MCA infarction in 11 patients. The postoperative follow-up period of the operated patients ranged from 14 to 90 days. The neurological examination of seven patients (58.3%) showed significant improvement. Eight (66.6%) patients survived. Postoperatively, the mean midline deviation value of 12 patients decreased from 11.04 to 4.8. It is considered that wide decompressive craniectomy performed in young patients in the early period with strict radiological and clinical follow-up can increase survival and functional recovery.

Retracted: Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction.

[This retracts the article DOI: 10.1155/2022/4373404.].

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.

ДЕКОМПРЕССИВНАЯ ГЕМИКРАНИЭКТОМИЯ У ПАЦИЕНТА СО ЗЛОКАЧЕСТВЕННЫМ ИШЕМИЧЕСКИМ ИНСУЛЬТОМ В БАССЕЙНЕ СРЕДНЕЙ МОЗГОВОЙ АРТЕРИИ ПОСЛЕ НЕЭФФЕКТИВНОГО ВНУТРИВЕННОГО ТРОМБОЛИЗИСА

Methods: The gold standard treatment for patients with cerebral infarction (CI) is intravenous thrombolysis, and it is superior to standard therapy in improving functional status. Malignant middle cerebral artery infarction (MMCAI) is characterized by ischemic injury of 50% or more of the territory supplied by MCA, which, in turn, is a contraindication to thrombolytic therapy. When patients are admitted to the hospital within the therapeutic window before identification of a hypodense lesion by computed tomography, detecting the MMCAI promptly is challenging. Consequently, these patients receive intravenous thrombolysis. The article describes a successful decompressive hemicraniectomy (DHC) in a patient with MMCAI following ineffective, uncomplicated intravenous thrombolysis. Keywords: Malignant ischemic stroke, middle cerebral arter, decompressive hemicraniectomy, thrombolysis.

The Effect of Effortful Swallow with Progressive Resistance on Swallow Function in Post-Stroke Dysphagia: A Case Study

Background: Dysphagia management is vital in individuals reporting swallowing difficulties post-stroke. The literature review recommends the effortful swallow maneuver as a simple technique with multiple benefits for treating patients with oropharyngeal dysphagia due to stroke. No studies have documented the effect of effortful swallow and progressive resistance in individuals with swallowing difficulties post-stroke. Aim: To investigate whether the effortful swallow with added progressive resistance helps alleviate the swallowing function in individuals with dysphagia following stroke. Case report: In this case report, we describe a 30-year-old male who presented with left middle cerebral artery infarction and subsequent swallowing difficulty. The treatment procedure included 20 sessions of swallowing therapy incorporating effortful swallow with progressive resistance. Conclusion: Following 20 sessions of swallow treatment, significant improvement was seen in oro-facial measurements such as anterior and posterior tongue strength, anterior and posterior tongue endurance, and typical and effortful swallow tongue pressure. Functional oral intake level, dysphagia outcome and severity levels also improved significantly, contributing to better quality of life. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) examination showed improved swallow safety and efficiency post-therapy. Conclusion: Effortful swallow with progressive resistance effectively improved oro-pharyngeal swallow functions in an individual who presented with dysphagia following stroke. The case study highlights the effect of effortful swallow with progressive resistance in treating swallowing difficulties in a participant who presented with dysphagia following stroke.

Modifying skin flaps for achieving very large decompressive craniectomies in malignant middle cerebral artery territory infarcts: A technical note.

Decompressive craniectomy is a well described treatment to salvage life in large middle cerebral artery (MCA) territory infarcts. The size of the craniectomy is limited by the size of the skin incision and very large craniectomies need large skin flaps that are prone to necrosis at the wound margins. We describe two modifications in the skin flap that we have used in 7 patients to achieve very large bony decompressions in malignant MCA infarctions without compromising on flap vascularity. One consists of a linear extension posteriorly from the question mark or reverse question mark incision while the other is an "n" shaped incision. With these modifications we achieved craniectomies of size 15.6-17.8 cm in the anteroposterior and 10.7-12 cm in vertical axis of the bone flap removed in our patients. There were no additional procedural or wound related complications in a 6-month follow up. Removal of a standard size bone flap may achieve suboptimal decompression in cases of large MCA territory infarctions. Imaginative tailoring of skin flaps helps to remove larger volumes of skull with no added procedural morbidity.

Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction?

Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts. This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4). Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained. In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.

661: ROLE OF DECOMPRESSIVE HEMICRANIECTOMY IN PEDIATRIC MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION

Introduction: Malignant conversion of cerebral infarct leading to cerebral herniation is well described in adults. There is a lack of sufficient literature on malignant infarction in children. We report a rare case of middle cerebral artery infarct (MCAI) in a teenage girl with initial improvement (honeymoon period), followed by progression to malignant MCAI (MMCAI), requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement at discharge and at 4-month follow-up. Description: A 14-year-old previously healthy female presented with loss of consciousness for 45 minutes followed by right side weakness. Her MRI of the brain showed acute infarct without hemorrhage involving the territory of the left MCA requiring PICU management. The initial diagnostic workup was suggestive of idiopathic MCAI. She had right-sided hemiplegia, and National Institute of Health Stroke Scale (NIHSS) score of 19. On hospital day 3, she showed improvement with NIHSS changing from 19 to 15. On the evening of hospital day 5, she developed progressively worsening headaches, emesis, and loss of consciousness. CT head demonstrated malignant cerebral edema, midline shift and uncal and sub-falcine herniation. She was intubated and taken emergently to the operating room for a left-sided DHC. She was then managed in the PICU with neuroprotective strategies, aggressive management of her elevated intracranial pressure, and goal-directed management of her cerebral perfusion pressure. She subsequently improved with successful extubation on hospital day 21 and discharge on hospital day 66. At a 4-month follow-up in the neurosurgery clinic, she was alert, interactive, verbal with slow speech, able to identify simple objects, lift right shoulder, and extend the right lower extremity. Discussion: Our case described above is a unique report of DHC in a pediatric patient who had rare MMCAI with a positive outcome. The additional feature of our case worth reporting was the initial honeymoon period before malignant conversion. This rare presentation highlights the importance of monitoring the neurological status in a patient with an MCAI for progression to life-threatening malignant MCAI. This case report also highlights the importance of consideration of DHC for a favorable outcome of MMCAI.

ELN missense variant in patient with mid-aortic syndrome case report

BackgroundMid-aortic syndrome (MAS) is characterized by the congenital coarctation of the abdominal aorta, abdominal and limb claudication, and hypertension. The etiology of this disorder is very diverse and often manifests in conjunction with Takayasu's arteritis, Williams-Beurens syndrome, and neurofibromatosis. The isolated mid-aortic syndrome is very rare with only a few cases reported in the literature.Case presentationA 45 years old man was admitted to the Emergency Department with sudden muscle weakness and facial paralysis on the left side. Imaging studies reveal right middle cerebral artery infarction at the M1 section. Incidental findings include multiple moderate to severe stenoses in the right internal carotid artery, and total abdominal aorta occlusion. A variant at the ELN gene (Elastin, OMIM*130,160): c.1768G > A/wt (p.Ala590Thr) was identified.ConclusionThis is the first reported case of ELN related mid-aortic syndrome in Vietnam which was diagnosed through careful clinical and genetic workup. The finding of mid-aortic syndrome, in this case, was incidental and the decision to reverse the occlusion was postponed as there was no immediate risk of renal failure or reduced blood flow to the lower limb.

Blood soluble Fas concentrations and ischemic stroke patient mortality

ABSTRACT Background Fas is a major receptor for cell death by apoptosis. Higher blood concentrations of soluble Fas (sFas) have been reported in patients with ischemic stroke compared to control subjects. The aim of this study was to explore the existence or not of an association between blood sFas concentrations and mortality in patients with ischemic stroke. Methods This study included patients admitted to Intensive Care Units with severe and malignant middle cerebral artery infarction (MCAI), defined as acute infarction, in more than 50% of this territory on computed tomography and less than 9 points on the Glasgow Coma Scale (GCS). Serum sFas levels were determined at the time of diagnosis of MMCAI. Results Non-surviving severe MMCAI patients (n = 27) showed lower platelet count (p = 0.004), higher serum sFas (p < 0.001), and lower GCS (p = 0.001) compared to surviving patients (n = 27). Multiple logistic regression found an association of serum sFas levels and mortality at 30 days (OR = 1.015; 95% CI = 1.002–1.027; p = 0.02) after control for CGS and platelet count. Conclusions The main novelty of our study was the existence of an association between high blood sFas concentrations and mortality in patients with ischemic stroke.