Middle Cerebral Artery Region Research Articles

Dl-3-n-Butylphthalide Alleviates Secondary Brain Damage and Improves Working Memory After Stroke in Cynomolgus Monkeys.

Remote secondary neurodegeneration is associated with poststroke cognitive impairment (PSCI). Dl-3-n-butylphthalide (NBP) improves PSCI clinically. However, whether it ameliorates PSCI by alleviating secondary neurodegeneration remains uncertain. Nonhuman primates provide more relevant models than rodents for human stroke and PSCI. This study investigated the effects of NBP on PSCI and secondary neurodegeneration in cynomolgus monkeys after permanent left middle cerebral artery occlusion (MCAO). Thirteen adult male cynomolgus monkeys were randomly assigned to sham (n=4), MCAO+placebo (n=5), and MCAO+NBP groups (n=4). The MCAO+placebo and MCAO+NBP groups received saline and NBP injections intravenously, respectively, starting at 6-hour postsurgery for 2 weeks, followed by soybean oil and NBP orally, respectively, for 10 weeks after MCAO. Infarct size was assessed at week 4 by magnetic resonance imaging. Working memory and executive function were evaluated dynamically using the delayed response task and object retrieval detour task, respectively. Neuron loss, glia proliferation, and neuroinflammation in the ipsilateral dorsal lateral prefrontal cortex, thalamus, and hippocampus were analyzed by immunostaining 12 weeks after MCAO. Infarcts were located in the left middle cerebral artery region, apart from the ipsilateral dorsal lateral prefrontal cortex, thalamus, or hippocampus, with no significant difference between the MCAO+placebo and MCAO+NBP group. Higher success in delayed response task was achieved at weeks 4, 8, and 12 after NBP compared with placebo treatments (P<0.05), but not in the object retrieval detour task (all P>0.05). More neurons and less microglia, astrocytes, CD68-positive microglia, tumor necrosis factor-α, and inducible NO synthase were observed in the ipsilateral dorsal lateral prefrontal cortex and thalamus after 12 weeks of NBP treatment (P<0.05), but not in the hippocampus (P>0.05). Our findings indicate that NBP improves working memory by alleviating remote secondary neurodegeneration and neuroinflammation in the ipsilateral dorsal lateral prefrontal cortex and thalamus after MCAO in cynomolgus monkeys.

Poststroke Mania During the COVID-19 Pandemic.

The pandemic of coronavirus infection 2019 (COVID-19) is stressing people's daily lives and making them more susceptible to various mental illnesses. Depression and suicide attempt as well as, strangely enough, manic patients are on the rise. The main complication of COVID-19 infection is ischemic stroke. Multiple lacunar infarcts in the white matter of the right middle cerebral artery region induce an imbalance of blood flow in the left and right cerebral cortex and risk causing mania. The increase in mania during the COVID-19 must be considered not only a primary increase due to stress but also poststroke mania secondary to COVID-19 infection.

Abstract 105: Limb Shaking Transient Ischemic Attack: A Rare Presentation of Internal Carotid Artery Occlusion

Introduction Limb‐shaking transient ischemic attack (LS‐TIA) is a rare disorder characterized by brief, irregular, involuntary movements of the extremities with or without loss of consciousness. Associated paroxysmal hyperkinetic extremity movements often described by patients as “shaking,” “tremors,” or “twitching” are an uncommon and under‐reported presentation of cerebral hypoperfusion. Vascular etiology must remain on the differential as these transient but hemodynamically significant episodes are associated with severe carotid steno‐occlusive disease and carry an elevated risk for stroke. Methods The patient was evaluated in routine clinical practice. Results A man in his 50s with medical history of chronic right internal carotid artery (ICA) occlusion, coronary artery disease and tobacco use disorder presented with two months of intermittent, progressive worsening of left extremity tremors associated with ipsilateral weakness and mild confusion during the spells. These involuntary paroxysmal spells—precipitated by standing up, exertion and neck hyperextension—initially occurred 4 to 5 times per week in left upper extremity but progressed to 4 to 5 times per day with prolonged durations reaching 20 minutes and involving the left lower extremity. The initial event involved loss of consciousness, but no further syncopal episodes were noted. While ipsilateral hemiparesis and mild confusion occurred during the spells, spontaneous resolution and immediate return to baseline were reported afterward. On presentation, the National Institutes of Health Stroke Scale (NIHSS) was zero. Computed tomography (CT) head did not show acute intracranial process. CT angiography (CTA) re‐demonstrated right ICA occlusion at its origin. A load of Clopidogrel 300 mg and Aspirin 325 mg was administered. Orthostatic blood pressure measurements were normal. CT perfusion of brain demonstrated a perfusion decrease within the right frontoparietal lobes in the right middle cerebral artery (MCA) region. Routine EEG was performed, and it did not show interictal discharges. Brain MRI did not show acute infarcts. Catheter cerebral angiogram was then pursued, confirming right ICA occlusion at its origin and additionally showed mild atherosclerosis of the left ICA without flow‐limiting stenosis. After thorough evaluation, these events of unilateral extremity shaking and hemiparesis were deemed to be LS‐TIA. Neurosurgery was consulted and offered extracranial‐intracranial (EC‐IC)/ superficial temporal artery‐MCA bypass surgery. He was discharged in stable condition to continue DAPT and high‐dose statin while pending surgical intervention. Conclusion This case not only provides a descriptive narration of the presentation of LS‐TIA along with the steps in management undertaken but also encourages the consideration of vascular etiology as a potential cause for acute onset paroxysmal hyperkinetic movements. Early diagnosis and appropriate treatment are crucial to reduce burden of poor outcomes and prevention of stroke.

A Rare Case of Ischemic Optic Chiasmopathy Following Left Ventricular Dysfunction in a Patient with Coronary Artery Disease

We report a case of transient bitemporal hemianopia following a hypotensive episode in a patient of coronary artery disease (CAD). A 51-year-old male presented with anterior wall myocardial infarction (AWMI) and underwent percutaneous coronary artery intervention (PCI). On the second day post procedure, he developed an acute ischemic event following a cardioembolic infarct to the left middle cerebral artery (MCA) region. Over the next few days, the patient had persistent drop in blood pressure, during which he developed a transient bitemporal hemianopia, which improved after blood pressure correction, consistent with ischemic chiasmopathy. As such in literature, ischemic optic chiasmopathy is a very rare entity. This case report emphasizes that clinicians should consider that sustained hypotension associated with a cardiac event may lead to transient ischemic phenomenon such as the witnessed visual impairment due to hypoperfusion of the optic chiasm.

Deep medullary veins as an important imaging indicator of poor prognosis in acute ischemic stroke: a retrospective cohort survey.

The deep medullary veins (DMVs), which constitute a component of the intracerebral venous circulation system and are part of intracerebral reperfusion mechanisms, have been suggested as a novel imaging marker for cerebral white matter hypersignal and cerebral small vessel disease based on their discontinuous and reduced visual representation. However, the correlation between the number and continuity of visible DMVs and the poor prognosis of acute ischemic stroke (AIS) remains undefined. Magnetic susceptibility-weighted imaging was applied in this study to assess the distribution and structural characteristics of DMVs in patients with AIS and to investigate its relationship with the poor prognosis of those with AIS. This retrospective study included 90 patients diagnosed with AIS in the middle cerebral artery region by the Neurology Department of Liaoning Provincial People's Hospital. Clinical, laboratory, and cranial magnetic resonance imaging data were collected. After the 3-month follow-up visit, patients were dichotomized into good (0-2 points) and poor (≥3 points) prognosis groups based on the modified Rankin Scale score, and the DMV imaging characteristics were evaluated using a 3-level visual rating scale. The association between DMV and AIS prognosis was determined through Mann-Whitney test and multivariate logistic regression analysis. In univariate analysis, factors that were statistically significant between the different prognostic groups were DMV score (P=0.007), DMV symmetry (P=0.016), infarct size (P=0.029), and admission National Institutes of Health Stroke Scale (NIHSS) score (P<0.001). DMV score had a positive correlation with NIHSS score, (rs=0.209; P=0.048). Logistic regression analysis showed that the DMV score [odds ratio (OR), 1.356; 95% confidence interval (CI): 1.114-1.650; P=0.002], NIHSS score (OR, 1.280; 95% CI: 1.117-1.466; P<0.001), and fasting glucose (OR, 1.220; 95% CI: 1.023-1.456; P=0.027) were risk factors for poor prognosis in those with AIS. Discontinuity in DMV visualization was found to be associated with an unfavorable prognosis for patients AIS. The visual assessment of DMV through susceptibility-weighted imaging has the potential to predict AIS prognosis and furnish valuable insights for clinical treatment.

Neuroprotective Effects of Tryptanthrin-6-Oxime in a Rat Model of Transient Focal Cerebral Ischemia.

The activation of c-Jun N-terminal kinase (JNK) plays an important role in stroke outcomes. Tryptanthrin-6-oxime (TRYP-Ox) is reported to have high affinity for JNK and anti-inflammatory activity and may be of interest as a promising neuroprotective agent. The aim of this study was to investigate the neuroprotective effects of TRYP-Ox in a rat model of transient focal cerebral ischemia (FCI), which involved intraluminal occlusion of the left middle cerebral artery (MCA) for 1 h. Animals in the experimental group were administered intraperitoneal injections of TRYP-Ox 30 min before reperfusion and 23 and 47 h after FCI. Neurological status was assessed 4, 24, and 48 h following FCI onset. Treatment with 5 and 10 mg/kg of TRYP-Ox decreased mean scores of neurological deficits by 35-49 and 46-67% at 24 and 48 h, respectively. At these doses, TRYP-Ox decreased the infarction size by 28-31% at 48 h after FCI. TRYP-Ox (10 mg/kg) reduced the content of interleukin (IL) 1β and tumor necrosis factor (TNF) in the ischemic core area of the MCA region by 33% and 38%, respectively, and attenuated cerebral edema by 11% in the left hemisphere, which was affected by infarction, and by 6% in the right, contralateral hemisphere 24 h after FCI. TRYP-Ox reduced c-Jun phosphorylation in the MCA pool at 1 h after reperfusion. TRYP-Ox was predicted to have high blood-brain barrier permeability using various calculated descriptors and binary classification trees. Indeed, reactive oxidant production was significantly lower in the brain homogenates from rats treated with TRYP-Ox versus that in control animals. Our data suggest that the neuroprotective activity of TRYP-Ox may be due to the ability of this compound to inhibit JNK and exhibit anti-inflammatory and antioxidant activity. Thus, TRYP-Ox may be considered a promising neuroprotective agent that potentially could be used for the development of new treatment strategies in cerebral ischemia.

[Exploration of the effect of blood lipids on the lesion distribution pattern in acute ischemic stroke based on MRI study with population standard spatial analysis].

Objective: To explore the effect of blood lipids on the lesion distribution pattern in patients with acute ischemic stroke by using MRI technology based on population standard spatial analysis. Methods: The MRI data of 1 202 patients with acute ischemic stroke in General Hospital of Eastern Theater Command from January 2015 to December 2020 and Nanjing First Hospital from January 2013 to December 2021 were retrospectively collected, including 871 males and 331 females, aged 26 to 94 (64±11) years. According to the condition of blood lipids, they were divided into the dyslipidemia group (n=683) and the normal blood lipids group (n=519). After the automatic segmentation of diffusion-weighted imaging (DWI) images by artificial intelligence, the infarct sites were registered to the standard space which was used to draw the frequency heat map. The chi-square test was used to compare the difference in lesion location between the two groups. Generalized linear model regression analysis was used to observe the correlation between each blood lipid index and lesion site, and inter-group comparison and correlation analysis were used to observe the relationship between each blood lipid index and lesion volume. Results: Compared with the normal blood lipid group, the lesions in the dyslipidemia group were more extensive, mostly distributed in the occipital temporal region of the right posterior cerebral artery and the frontal region of the left middle cerebral artery. The brain regions of higher triglyceride(TG) and higher low-density lipoprotein cholesterol(LDL-C) groups were concentrated in the posterior circulation. The brain regions in the higher total cholesterol(TC) and lower high-density lipoprotein cholesterol(HDL-C) groups were concentrated in the anterior circulation(all P<0.05). In the anterior circulation infarct volume, the higher TC group was significantly higher than the normal TC group[(27.58±5.34) vs (17.73±1.18)ml, P=0.029]. In the posterior circulation infarct volume, the higher LDL-C group and the TG group were significantly higher than the normal LDL-C and TG groups[(7.55±2.51) vs (3.55±0.31) ml; (5.76±1.19) vs (3.36±0.30) ml](both P<0.05). Correlation analysis showed that TC and LDL-C were non-linearly (U-shaped) correlated with anterior circulation infarct volume (both P<0.05). Conclusions: Different blood lipids have effects on the distribution pattern and volume of ischemic stroke infarcts. Different hyperlipidemia is related to the specific distribution site and the larger extent of infarction.

Sex differences in stroke‐induced cognitive impairment and the impact of Mir20a‐3p treatment in middle‐aged Sprague Dawley rats

AbstractBackgroundStroke is a leading risk factor for dementia. Our previous studies show that the small non‐coding RNA, mir20a‐3p, is neuroprotective for stroke and reduces sensory‐motor impairment in the acute phase (Branyan et al., 2021). In this study, we used a battery of tests to assess the integrated functioning of affective and cognitive circuits after stroke in males and females, as well as the impact of mir20a‐3pMethodMiddle‐aged (acyclic) females and males were subject to ischemic stroke using endothelin‐1 in the left middle cerebral artery (MCA) region. Mir20a‐3p mimics or scrambled oligo was administered i.v. 4h and 24h after stroke with a supplementary dose at 60d. Long‐term cognitive changes were assessed by contextual fear conditioning (CFC) and the novel object recognition test (NORT).ResultBoth males and females showed significant sensory‐motor impairment due to stroke in the acute phase, which was attenuated by Mir20a‐3p treatment. In the chronic phase, cognitive function was assessed by cued and contextual fear conditioning, evaluated by percent freezing during acquisition, retrieval, and extinction of fear memory. When measured 30, 60 and 100d after stroke, retrieval of fear memory was significantly reduced over time in sham and stroke males and females. However, linear regression analysis revealed that among females, the rate of decline of fear memory was significantly accelerated in the stroke group that received scrambled oligo treatment, while the rate of decline in the Mir20a‐3p group was similar to the sham group, indicating a protective effect of this drug. Surprisingly, stroke+ scrambled treated male rats did not show an accelerated decline. We further examined declarative memory (as assessed by the Novel Object Recognition Task) and noted that there was a decline over time in both males and females.ConclusionThis study shows that cognitive impairment is selectively affected by stroke and that despite the fact that acute sensory‐motor impairment is seen to a similar extent in males and females, stroke significantly affected the retrieval of fear memory in females but not males. Moreover, treatment with Mir20a‐3p abrogated this effect of stroke.

Evaluation of single-delay arterial spin labeling-based spatial coefficient of variation and histogram-based parameters in relation to cerebrovascular reserve in patients with Moyamoya disease.

Single-delay Arterial Spin Labeling (ASL)-based spatial coefficient of variation (CoVCBF) has been suggested as a measure of hemodynamic disturbance in patients with cerebrovascular diseases. However, spatial CoVCBF and other histogram-based parameters such as skewness and kurtosis and the volume of the arterial transit time artefact (ATAvol), has not been evaluated in patients with MMD nor against cerebrovascular reserve (CVR). The aim of this study was to assess whether any associations between spatial CoVCBF, skewness, kurtosis, and ATAvol are present and to analyze any potential associations with CVR, derived from single-delay ASL in patients with MMD. Fifteen MMD patients were included before or after revascularization surgery. Cerebral blood flow (CBF) maps were acquired using pseudo-continuous ASL before, and 5, 15, and 25 min after an intravenous acetazolamide injection. CVRmax was defined as the highest percentual increase in CBF at any of the three post-injection time points. A vascular territory template was spatially normalized to each patient, including the bilateral anterior, middle, and posterior cerebral arteries. All affected anterior and middle cerebral artery regions and all unaffected posterior cerebral artery regions were included, based on Suzuki grading by digital subtraction angiography. Significant differences between affected and unaffected regions were found for CBF, CVRmax, and ATAvol. No association was found between CVRmax and any other parameter. High correlations were found between spatial CoVCBF, skewness and ATAvol. Spatial CoVCBF derived from single-delay ASL does not correlate with CVR in patients with MMD. Moreover, skewness and kurtosis did not provide additional information of clinical value.

Management of Cerebral 4-Vessel Disease With Anterior Circulation Symptoms by Stenting Both Vertebral Arteries at the Same Session.

Stroke is among the leading causes of mortality and morbidity worldwide. The coexistence of bilateral carotid and vertebral artery (VA) occlusion and/or stenosis is in the very rare entity group in the literature. Here, we present a case with bilateral carotid artery occlusion and bilateral VA stenosis, who presented with an atypical clinical presentation and underwent bilateral vertebral percutaneous transluminal angioplasty (PTA) and stenting in the same session. A 67 year old male patient was brought to the emergency department with complaints of inability to speak and weakness in both legs for 1 day. There were bilateral infarct areas in the anterior cerebral artery region and an additional infarct area in the left middle cerebral artery region. First, the right VA stenosis level was crossed using a 0.14 guidewire. After PTA, balloon-expandable stenting was performed with a 3.0×12 mm NC (non-compliant) balloon, and nearly complete recanalization was observed. Therefore, it was decided to perform an intervention on the left VA in the same session. As in this example case, in cases where cerebral perfusion is severely impaired, medical treatment after recanalization may be one of the best treatment options. The carotid arteries are the main arteries supplying the anterior circulation, and the vertebral arteries supply blood to the posterior circulation. However, in cases where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system. However, in cases such as this, where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system and may be responsible for anterior circulation strokes. The situation becomes more severe if both vertebral artery critical stenosis is added. Synchronous carotid and vertebral artery revascularization is not recommended in the guidelines for patients with combined carotid and vertebral artery disease. In patients with four-vessel occlusion/stenosis, as in this particular case, the intervention method and priorities are unclear. We achieved a favorable clinical outcome with simultaneous bilateral vertebral artery angioplasty and stenting, a hazardous method that can be a guide as an approach option in similar cases.

右中大脳動脈領域梗塞の慢性期に認知リハビリテーションが奏効した1例

Few reports have yet investigated adequate cognitive rehabilitation for patients with chronic cognitive disorder. In this report, we describe a case of cognitive rehabilitation 10 months after onset of cerebral infarction in the right middle cerebral artery region, resulting in a good outcome. The patient was a 44-year-old right-handed male, with primary symptoms of inattention and left hemispatial neglect. The patient had not undergone any neuropsychological evaluations or cognitive rehabilitation until 10 months after disease onset. After 30 days of both direct attention training and metacognitive strategy training, including time pressure management, improvement of his cognitive disorder was achieved. The teaching of internal methods to improve metacognition with a high level of evidence was effective even 10 months after onset. Furthermore, it is important for therapists who provide cognitive rehabilitation using metacognitive strategy training to understand patients' remaining functions based on neuropsychological assessment, and to consider and teach compensatory methods so that they can be effectively used by patients in situations of daily life.

Brain arteriovenous malformations of the middle cerebral artery region: image characteristics and endovascular treatment based on a new classification system

BackgroundTo date, few studies have investigated the use of endovascular treatment (EVT) for brain arteriovenous malformations (BAVMs) in the supplying area of the middle cerebral artery (MCA). Moreover, no suitable classification was aimed at EVT for MCA-BAVMs. Therefore, this study proposed a new classification.MethodsThis study retrospectively collected 135 MCA‑BAVMs. They were classified into four types: Type I BAVMs located above the M1 segment; Type II BAVMs located in the region around the Sylvian fissure; and Type III BAVMs located in the supplying region of the M4 segment and subdivided into types IIIa and IIIb. The relevance of various types of MCA-BAVMs and their imaging characteristics and EVT outcomes was analyzed by ordinary one-way ANOVA, Tukey's multiple comparisons test and the chi-square test.ResultsThe 135 patients averaged 33.8 ± 14.7 years and included 75 females (55.6%, 75/135). Among them, 15 (11.1%, 15/135), 16 (11.9%, 16/135), 54 (40%, 54/135), and 50 (37%, 50/135) MCA-BAVMs were type I, II, IIIa and IIIb, respectively. After EVT, a good outcome was achieved in 97% of patients. Statistical analysis showed that type I BAVMs were smaller than type II and IIIb BAVMs (P value < 0.05), and type IIIb BAVMs were larger than type I and IIIa BAVMs (P value < 0.05). Deep vein involvement in type I and IIIb BAVMs was more common than in other types (P value < 0.05), and intraventricular hemorrhage (IVH) was also more common (P value < 0.05). The normal morphology in type IIIb was less than that in the other types (P value < 0.05). Type IIIa BAVMs had a higher degree than other types (P value < 0.05).ConclusionThe present study demonstrated that the new classification of MCA-BAVMs can be used to evaluate imaging characteristics and EVT outcomes in different types. In addition, EVT may be a safe treatment modality for MCA‑BAVMs.

Automated Collateral Scoring on CT Angiography of Patients with Acute Ischemic Stroke Using Hybrid CNN and Transformer Network.

Collateral scoring plays an important role in diagnosis and treatment decisions of acute ischemic stroke (AIS). Most existing automated methods rely on vessel prominence and amount after vessel segmentation. The purpose of this study was to design a vessel-segmentation free method for automating collateral scoring on CT angiography (CTA). We first processed the original CTA via maximum intensity projection (MIP) and middle cerebral artery (MCA) region segmentation. The obtained MIP images were fed into our proposed hybrid CNN and Transformer model (MPViT) to automatically determine the collateral scores. We collected 154 CTA scans of patients with AIS for evaluation using five-folder cross validation. Results show that the proposed MPViT achieved an intraclass correlation coefficient of 0.767 (95% CI: 0.68-0.83) and a Kappa of 0.6184 (95% CI: 0.4954-0.7414) for three-point collateral score classification. For dichotomized classification (good vs. non-good and poor vs. non-poor), it also achieved great performance.

Steroid-Responsive Cerebral Vasculitis in Systemic Lupus Erythematosus with Sulcal Hyperintensities

The clinical manifestations of cerebral lupus vasculitis have a wide spectrum of severity which can result in different prognoses. Therefore, its diagnosis and treatment remain challenging without specific guidelines. A 49-year-old woman with systemic lupus erythematosus presented with transient left side paresthesia and dysarthria lasting 20 minutes. Brain magnetic resonance imaging (MRI) showed a multifocal diffusion restriction and sulcal hyperintensities in the right middle cerebral artery region. Brain magnetic resonance angiography (MRA) showed multifocal steno-occlusive lesions at her intracranial arteries. Because she only showed transient symptoms, aspirin (100 mg/day), atorvastatin (20 mg/day) and an increased dose of prednisolone (5 mg/day to 10 mg/day) were started, on the suspicion of cerebral lupus vasculitis. Brain MRIs/MRAs renormalized after four months without any recurrence. Cerebral lupus vasculitis manifests diverse clinical and neuroimaging characteristics. Although brain image demonstrates devastating features, tailored immune therapy should be selected based on the severity of the patient’s symptoms.

Vascular Cross‐Section, Rather Than Tortuosity, Can Classify First‐Pass Outcome of Mechanical Thrombectomy for Ischemic Stroke

Background Vascular geometry plays an important role in stroke thrombectomy outcomes, but few studies have examined complex characteristics of vessel morphology. The authors hypothesized that engineered vessel cross‐section features could be used to predict thrombectomy first‐pass effect (FPE). Methods The authors analyzed computed tomography angiography and noncontrast computed tomagraphy from 50 patients with anterior circulation stroke thrombectomy. After segmentation, traditional metrics (vessel tortuosity and angulation) were calculated from vessel centerlines that were transformed into the same coordinate system and same region of interest. Univariate statistical analysis and geometric morphometrics were used to interrogate differences in geometry between cases that did and did not achieve FPE, which classical angulation and tortuosity did not quantify. To describe these differences, complex cross‐section features were engineered and quantified using a semiautomatic pipeline. Machine learning was used to train predictive models of FPE based on significant cross‐section features. Results Only one local tortuosity metric was significantly different ( q =0.019) between FPE and first‐pass failure cases. The most significant principal component score ( q =0.012) from geometric morphometrics highlighted the M1 segment of the middle cerebral artery and upper cavernous internal carotid artery variation as morphological indicators of first‐pass outcome. Fifteen cross‐section features, corresponding to internal carotid artery and middle cerebral artery regions, were significantly different between cases that did and did not achieve FPE. Predictive models exhibited a strong prediction of FPE (area under the curve=0.98±0.05) and outperformed models using traditional tortuosity and angulation features. Conclusion Cross‐section features are a novel class of powerful and interpretable predictors of FPE, which could assist in treatment decision‐making.

Radiographic Features and Preventive Progressive Act of MCA Sign Ischaemic Stroke: A Case Report

One in six people in worldwide tends to have a stroke in their lifetime. Of all stroke incidents, 70% are ischemic strokes. Prevalence of stroke in Indonesia has increased from 7 to 10.9 per mile 1000 population from 2013 to 2018. The middle cerebral artery region is the foremost commonly influenced region in cerebral infarction, due to the large area of vascularisation. This article aims to report the radiographic feature of a case about MCA Sign and review if thrombectomy can be another therapy option as the preventive and progressive strategy in managing MCA Sign stroke infarct. The patient, in this case, came to the hospital with clinical presentations including loss of consciousness, hemiplegia sinistra, and dysarthria. Middle cerebral artery infarction appears as a hyperdense lesion as thrombus can be found as an early sign. Unenhanced CT of the brain should be done immediately. Thrombolytic is the main pharmacotherapy. Endovascular thrombectomy is recommended to be done within 4.5 hours after onset.

Determination of language areas in patients with epilepsy using the super-selective Wada test

The Wada test is the gold standard for determining language-dominant hemisphere. However, the precise determination of language areas in each patient requires more invasive methods, such as electrocortical stimulation. Some studies have reported the use of anesthetic injection into selective cerebral arteries to predict postoperative function. To assess the function of the anterior and posterior language areas separately, we developed an advanced test named the “super-selective Wada test” (ssWada). The ssWada procedure is as follows: an endovascular neurosurgeon identifies the arterial branches of the middle cerebral artery (MCA) perfusing the anterior language area of the inferior frontal gyrus and the posterior language area of the posterior part of the superior temporal gyrus using angiography. Behavioral neurologists assess language symptoms before and after propofol administration using a microcatheter tip in the selected arterial branch. From 30 serial patients with epilepsy who underwent ssWada test at Tohoku University Hospital, we retrospectively reviewed patients in whom multiple areas in the bilateral MCA region was examined. Eight cases were identified in this study. All eight cases had been considered for resection of the area overlapping the classical language area. Three of the eight cases were left-dominant, and the within-hemisphere distribution was also considered typical. One case was determined to be left-dominant but atypical in the intra-hemispheric functional distribution. Two cases were right-dominant, and the intra-hemispheric functional distribution was considered a mirror image of the typical pattern. The remaining two cases were considered atypical, not only in terms of bilateral language function, but also in terms of anterior-posterior functional distribution. This case series demonstrates the potential utility of ssWada in revealing separate function of the anterior and posterior language areas. The ssWada allows simulation of local surgical brain resection and detailed investigation of language function, which potentially contributes to planning the resection area. Although indications for ssWada are quite limited, it could play a complementary role to noninvasive testing because it provides information related to resection using a different approach.

ASPECTS as a clinical outcome marker for MCA infarction treated with thrombolytic therapy: Non-contrast CT versus CTA source images

Background &amp; Objective: Computed tomography angiography (CTA) in acute stroke has been widely used to demonstrate arterial occlusion. Alberta Stroke Program Early CT Score (ASPECTS) is used to detect early ischemic signs in non-contrast computed tomography (NCCT) in the middle cerebral artery region. We hypothesized that computed tomography angiography source image (CTA-SI) is superior to NCCT in predicting final infarct volume, 24 hour National Institutes of Health Stroke Scale (NIHSS) score and 90-day clinical outcome. Methods: Patients who had an acute ischemic stroke due to middle cerebral artery (MCA) occlusion and treated with tissue plasminogen activator (tPA) were retrospectively evaluated. ASPECTS was evaluated by two experienced stroke neurologists in acute NCCT, CTA-SI, and follow up imaging. The final ASPECTS was compared with the mean baseline ASPECTS of NCCT and CTA-SI. The relation of both scores with 24-hour NIHSS and clinical outcome was compared. The Modified Rankin Scale (mRS) was utilized to evaluate the 90-day outcomes. mRS score of 0-2 was considered a “good outcome”. Results: Fifty-three patients were evaluated. We observed a significant relation among CTA-SI ASPECTS and after treatment 24hr ASPECTS (y= -3.9 + 1.4 x; 95% CI, -7.6 to -0.2) (y= -26.04 + 3.5 x; CI, -41 to -10). The median baseline 24-hr NHISS was 6 (0 - 22). We found a better correlation between CTA-SI ASPECTS and 24-hr NHISS (y= 363.06 + -37.03 x; CI, -148 to 864) than between NCCT ASPECTS and 24h NHISS (y=529.80 + -62.55 x; CI, 180 - 829). Median 90 days mRS score was 2 (0 - 6). According to Deming regression analysis, the CTA-SI ASPECTS (y= 76.10 + -7.69 x; 95% CI, -36 to 188) was more consistent with the 90 day mRS compared to NCCT ASPECTS (y=149.86 + -17.67 x; 95% CI, 23 - 267) CTA-SI was superior in predicting 24hr NIHSS and day 90 mRS compared to NCCT ASPECTS. Conclusion: Prediction of CTA-SI ASPECTs is better than NCCT ASPECTs at 24hr NIHSS, 3-month mRS and final infarct size in acute ischemic stroke patients treated with tPA.

Tenecteplase for Thrombolysis in Acute Ischemic Stroke and Its Outcome—An Indian Experience

Background: Stroke has been a growing concern with increasing morbidity and mortality worldwide. Tenecteplase has been approved in India as a newer thrombolytic, in acute ischemic stroke, since 2016. Very few studies have been reported to know the efficacy of Tenecteplase in AIS compared to alteplase. Aim: This study was done to understand the efficacy and related complications of Tenecteplase in AIS. Methods: In this prospective study, we took 112 people with AIS who received Tenecteplase, admitted between August 2018 and August 2020. After obtaining ethical approval, we tabulated patients’ data and did the statistical analysis using an unpaired t test, Analysis of Variance, and chi-square test. A P value of &lt;.05 using a 2-tailed test was considered significant for all statistical analyses. Results: Out of 112 patients, 67.9% were male and 32.1% were female, with a mean age of 60.7 years. We classified stroke by using the TOAST classification. About 62.5% are classified as large atherosclerotic type, 14.3% cardioembolic, and 17.0% lacunar strokes. A total of 82.1% had a middle cerebral artery region stroke. The mean door to needle time was 76.7 min with a standard deviation of 33.3. The primary outcome was met in 47.3%, and the secondary result was achieved in 59.8%. Intracerebral hematoma was the most commonly observed complication. Mortality accounted for 9.8% of the total population. Conclusions: Tenecteplase is the newer thrombolytic agent with good efficacy. More studies are needed globally to understand regional differences and effectiveness.

Feasibility and safety of intranasally administered mesenchymal stromal cells after perinatal arterial ischaemic stroke in the Netherlands (PASSIoN): a first-in-human, open-label intervention study

Perinatal arterial ischaemic stroke (PAIS) is an important cause of neurodevelopmental disabilities. In this first-in-human study, we aimed to assess the feasibility and safety of intranasally delivered bone marrow-derived allogeneic mesenchymal stromal cells (MSCs) to treat PAIS in neonates. In this open-label intervention study in collaboration with all neonatal intensive care units in the Netherlands, we included neonates born at full term (≥36 weeks of gestation) with MRI-confirmed PAIS in the middle cerebral artery region. All eligible patients were transferred to the neonatal intensive care unit of the Wilhelmina Children's Hospital. Neonates received one dose of 45-50 × 106 bone-marrow derived MSCs intranasally within 7 days of presenting signs of PAIS. The primary endpoints were acute and subacute safety outcomes, including vital signs, blood markers, and the occurrence of toxicity, adverse events, and serious adverse events. The occurrence of unexpected cerebral abnormalities by a repeat MRI at 3 months of age was a secondary endpoint. As part of standard clinical follow-up at Wilhelmina Children's Hospital, we assessed corticospinal tract development on MRI and performed motor assessments at 4 months of age. This study is registered with ClinicalTrials.gov, NCT03356821. Between Feb 11, 2020, and April 29, 2021, ten neonates were enrolled in the study. Intranasal administration of MSCs was well tolerated in all ten neonates. No serious adverse events were observed. One adverse event was seen: a mild transient fever of 38°C without the need for clinical intervention. Blood inflammation markers (C-reactive protein, procalcitonin, and leukocyte count) were not significantly different pre-administration versus post-administration and, although thrombocyte levels increased (p=0·011), all were within the physiological range. Follow-up MRI scans did not show unexpected structural cerebral abnormalities. All ten patients had initial pre-Wallerian changes in the corticospinal tracts, but only four (40%) patients showed asymmetrical corticospinal tracts at follow-up MRI. Abnormal early motor assessment was found in three (30%) infants. This first-in-human study demonstrates that intranasal bone marrow-derived MSC administration in neonates after PAIS is feasible and no serious adverse events were observed in patients followed up until 3 months of age. Future large-scale placebo-controlled studies are needed to determine the therapeutic effect of intranasal MSCs for PAIS. Netherlands Organization for Health Research and Development (ZonMw).