Middle Cerebral Artery Stroke Research Articles

Dose reduction in perfusion CT in stroke patients by lowering scan frequency does not affect automatically calculated infarct core volumes

Background and purposeCT Perfusion technique (CTP) is a quantitative, easily performed, accepted and reliable method for detection of ischemic brain changes. Based on calculated parameters, the size of ischemic penumbra and irreversibly damaged infarct core can be determined which helps guide treatment decisions. However, due to the dynamic nature of the CTP study, it is dose intensive. This study determines the consequences of retrospectively reducing the number of scans in the dynamic acquisition by half on the volume of the automatically calculated infarct core (non-viable tissue) and penumbra (tissue at risk) volumes. Our hypothesis was that equivalent volumetric information could be obtained at a substantial dose savings. Materials and methodsFifty one consecutive patients with occlusion of M1 and/or M2 segment of the middle cerebral artery and ischemic stroke proven by follow-up MRI were included. CTP scans were first analyzed in a standard fashion and automatically generated volumes measured in milliliters were recorded in a database. A second analysis was conducted after removing every second data acquisition from the sequential CTP scans. Automatic volume measurements were repeated, recorded and compared to the initial values obtained using the full dataset. ResultsThe two CTP protocols were statistically equivalent pertaining to automatic infarct core volume calculation but a case-by-case analysis revealed substantial overestimation in some cases. ConclusionReduction of radiation exposure in CTP without objective loss of accuracy of automatically calculated infarct core volume is feasible but might lead to clinically relevant infarct core overestimation in individual cases.

Acute middle cerebral artery stroke in a patient with a patent middle cerebral artery.

Knowledge of cerebrovascular anatomical variants is vital for clinicians working with patients presenting with signs and symptoms of cerebral infarction, particularly in the era of endovascular clot retrieval. We provide an overview of a cerebrovascular anatomical variation and detail a patient presenting with cerebral infarction secondary to occlusion of their anomalous vessel who underwent successful endovascular clot retrieval with excellent functional outcome. We also include technical descriptions. Given the clinical importance of the areas supplied by the accessory middle cerebral artery, knowledge of this vessel is not only important for diagnosis but also for neurosurgical or endovascular management of patients with this variant.

Acute cerebellar stroke and middle cerebral artery stroke exert distinctive modifications on functional cortical connectivity: A comparative study via EEG graph theory

ObjectiveWe tested whether acute cerebellar stroke may determine changes in brain network architecture as defined by cortical sources of EEG rhythms. MethodsGraph parameters of 41 consecutive stroke patients (<5 days from the event) were studied using eLORETA EEG sources. Network rearrangements of stroke patients were investigated in delta, alpha 2, beta 2 and gamma bands in comparison with healthy subjects. ResultsThe delta network remodeling was similar in cerebellar and middle cerebral artery strokes, with a reduction of small-worldness. Beta 2 and gamma small-worldness, in the right hemisphere of patients with cerebellar stroke, increase respect to healthy subjects, while alpha 2 small-worldness increases only among patients with a middle cerebral artery stroke. ConclusionsThe network remodeling characteristics are independent on the size of the ischemic lesion. In the early post-acute stages cerebellar stroke differs from the middle cerebral artery one because it does not cause alpha 2 network remodeling while it determines a high frequency network reorganization in beta 2 and gamma bands with an increase of small-worldness characteristics. SignificanceThese findings demonstrate changes in the balance of local segregation and global integration induced by cerebellar acute stroke in high EEG frequency bands. They need to be integrated with appropriate follow-up to explore whether further network changes are attained during post-stroke outcome stabilization.

Efficiently Recording the Eye-Hand Coordination to Incoordination Spectrum.

The objective analysis of eye movements has a significant history and has been long proven to be an important research tool in the setting of brain injury. Quantitative recordings have a strong capacity to screen diagnostically. Concurrent examinations of the eye and upper limb movements directed toward shared functional goals (e.g., eye-hand coordination) serve as an additional robust biomarker-laden path to capture and interrogate neural injury, including acquired brain injury (ABI). While quantitative dual-effector recordings in 3-D afford ample opportunities within ocular-manual motor investigations in the setting of ABI, the feasibility of such dual recordings for both eye and hand is challenging in pathological settings, particularly when approached with research-grade rigor. Here we describe the integration of an eye tracking system with a motion tracking system intended primarily for limb control research to study a natural behavior. The protocol enables the investigation of unrestricted, three-dimensional (3D) eye-hand coordination tasks. More specifically, we review a method to assess eye-hand coordination in visually guided saccade-to-reach tasks in subjects with chronic middle cerebral artery (MCA) stroke and compare them to healthy controls. Special attention is paid to the specific eye- and limb-tracking system properties in order to obtain high fidelity data from participants post-injury. Sampling rate, accuracy, permissible head movement range given anticipated tolerance and the feasibility of use were several of the critical properties considered when selecting an eye tracker and an approach. The limb tracker was selected based on a similar rubric but included the need for 3-D recording, dynamic interaction and a miniaturized physical footprint. The quantitative data provided by this method and the overall approach when executed correctly has tremendous potential to further refine our mechanistic understanding of eye-hand control and help inform feasible diagnostic and pragmatic interventions within the neurological and rehabilitative practice.

Middle cerebral artery stroke following massive hornet sting: a case report

Hornet stings are frequently encountered in practice in Nepal. Majority of patients sustain minor illness. However, complications like anaphylactic shock and the rare acute kidney injury, multiple organ dysfunction and acute myocardial infarction have been reported. Ischemic stroke following hornet stings has been reported infrequently in scientific publications. We report a case of fatal right Middle Cerebral artery territory ischemic stroke and acute kidney injury in a 40-year farmer.

Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion-based Ischemic Core in Acute Ischemic Stroke.

Background Recent studies have proven the effectiveness of thrombectomy up to 24 hours after stroke onset for patients with specific criteria at advanced CT or MRI. Clinical implementation of treatment in this extended time window remains a challenge, as many stroke centers do not routinely use advanced imaging. Purpose To determine whether automated cerebral x-ray attenuation measurements at noncontrast CT provide information on the presence of CT perfusion-defined ischemic core as applied in late time windows for thrombectomy. Materials and Methods In this retrospective study, patients with middle cerebral artery stroke due to proximal occlusion from 2009 to 2017 were included. All patients underwent noncontrast CT and CT perfusion. Automated software was used to calculate relative Hounsfield unit (rHU) values for Alberta Stroke Program Early CT Score (ASPECTS) regions on noncontrast CT images as the ratio of x-ray attenuation between ischemic versus non-ischemic hemispheres. Sensitivity, specificity, and diagnostic performance of rHU and composite rHU-ASPECTS, a score incorporating rHU from all regions, were analyzed for the classification of regional ischemic core and late time window thrombectomy criteria at CT perfusion. Results Data in a total of 200 patients were evaluated (105 women [mean age, 74 years ± 14 {standard deviation}] and 95 men [mean age, 76 years ± 14]). There were 121 patients in the validation cohort and 79 patients in the independent test cohort. Compared among all examined regions, rHU values yielded the best classification of ischemic core for the caudate nucleus, the lentiform nucleus, and the insula (with areas under the receiver operating characteristic curve [AUCs] ranging from 0.70 to 0.77; P < .001 for each). The composite rHU-ASPECTS score allowed classification of CT perfusion imaging selection criteria of ischemic core sizes of less than 70 mL and target mismatch of greater than 1.8 with AUCs of 0.80 (P = .001; 75% sensitivity and 83% specificity) in the test cohort and 0.74 (P < .001; 58% sensitivity and 82% specificity) in the validation cohort. Conclusion Noncontrast CT x-ray attenuation measurements identify Alberta Stroke Program Early CT Score regions classified as ischemic core at CT perfusion. This approach may serve as a selection criteria surrogate for thrombectomy in late time windows. © RSNA, 2019 Online supplemental material is available for this article.

Bedside neurophysiological tests can identify neonates with stroke leading to cerebral palsy

ObjectiveThe unspecific symptoms of neonatal stroke still challenge its bedside diagnosis. We studied the accuracy of routine electroencephalography (EEG) and simultaneously recorded somatosensory evoked potentials (EEG-SEP) for diagnosis and outcome prediction of neonatal stroke. MethodsWe evaluated EEG and EEG-SEPs from a hospital cohort of 174 near-term neonates with suspected seizures or encephalopathy, 32 of whom were diagnosed with acute ischemic or hemorrhagic stroke in MRI. EEG was scored for background activity and seizures. SEPs were classified as present or absent. Developmental outcome of stroke survivors was evaluated from medical records at 8- to 18-months age. ResultsThe combination of continuous EEG and uni- or bilaterally absent SEP (n = 10) was exclusively seen in neonates with a middle cerebral artery (MCA) stroke (specificity 100%). Moreover, 80% of the neonates with this finding developed with cerebral palsy. Bilaterally present SEPs did not exclude stroke, but predicted favorable neuromotor outcome in stroke survivors (positive predictive value 95%). ConclusionsAbsent SEP combined with continuous EEG background in near-term neonates indicates an MCA stroke and a high risk for cerebral palsy. SignificanceEEG-SEP offers a bedside method for diagnostic screening and a reliable prediction of neuromotor outcome in neonates suspected of having a stroke.

Cerebral infarct topography of atrial fibrillation and Chagas disease

BackgroundChagas disease (CD) and ischemic stroke (IS) have a significant but poorly understood correlation. There is paucity of evidence regarding secondary prophylaxis of IS and etiological causes. ObjectivesTo compare arterial stroke topography and the respective morbidities and mortality in patients with CD of undetermined and cardioembolic etiologies and with cardioembolic IS (atrial fibrillation [AF]). MethodsWe compared vascular topography and outcomes using data obtained from the electronic medical records of all patients with IS with either CD (with cardioembolic or undetermined etiology) or AF, admitted to SARAH Hospital Brasilia between 2009 and 2013. ResultsA total of 115 patients were investigated: 49 involving AF, 23 involving CD of unclear etiology, and 43 involving CD of cardioembolic etiology. Middle cerebral artery stroke was predominant in all groups, although more frequent in patients with CD of undetermined etiology. No significant difference was found in the arterial territories. Hemodynamic stroke was predominant among CD patients who experienced cardioembolic events. AF patients had worse modified Rankin scale scores upon admission and a higher mortality rate than CD patients in both categories. ConclusionsStroke topography is not useful in determining the etiological diagnosis. Patients with AF and IS are more likely to have worse outcomes than are those with CD and IS. The autonomic nervous system could be affected in patients with CD.

The effect of unilateral stroke on autonomic function in the term newborn.

The mature cerebral cortex has a topographically organized influence on reflex autonomic centers of the brainstem and diencephalon and sympathetic activation coming primarily from the right hemisphere and parasympathetic activation from the left. In the term newborn, the maturational status of this central autonomic system remains poorly understood. Sixteen term newborns admitted to Children's National with unilateral middle cerebral artery (MCA) strokes (n = 8 left, n = 8 right) had archived continuous electrocardiograph (EKG) signals available. We compared stroke laterality and severity with indices of autonomic function, as measured by heart rate variability. We performed both time- and frequency-domain analyses on the R-R interval (RRi) over 24h of continuous EKG data at around 7 days of age. Right MCA stroke significantly increased sympathetic tone, while left MCA stroke increased parasympathetic tone. Regardless of laterality, stroke severity was associated inversely with sympathetic tone and positively with parasympathetic tone. Surprisingly, injury to either insular region had no significant autonomic effect. Phenobarbital blood levels were positively associated with sympathetic tone and inversely related to parasympathetic tone. Based on these findings, it is difficult to reconcile the functional topography of the central autonomic system in term newborns with that currently proposed for the normal mature brain. Further investigation is clearly needed.

Abstract TMP26: Age Exacerbates the Pathogenicity of Neutrophils in Ischemic Stroke

Introduction: Ischemic stroke is a major cause of disability and mortality worldwide. Neutrophils may exacerbate stroke-related injury via the release of reactive oxygen species (ROS) and granule proteins. As age is the strongest risk factor for poor outcomes after ischemic stroke, we hypothesized that age exacerbates the deleterious functions of neutrophils after brain ischemia. Methods and Results: Young (3 month) and aged (20-22 month) mice were subjected to middle cerebral artery (MCAO) stroke. Aged mice had higher mortality than young mice at 7 days (0% young, 60% aged, p&lt;0.05, n=5/group). Aged mice also had greater neurodeficits than young mice (p&lt;0.05). Flow cytometry showed that aged animals display an increase in neutrophil proportions in the blood, spleen, lung and bone marrow (p&lt;0.001) after ischemic stroke compared to young. Furthermore, flow cytometry demonstrated that neutrophils from the blood of aged animals produced ROS at higher levels than neutrophils from young animals (p&lt;0.05). Aged stroke animals had higher serum IL-6 (p&lt;0.0001) and CXCL1 (p&lt;0.01), two powerful neutrophil activating cytokines, at 24 hours after stroke. Follow-up serum measurements in human ischemic stroke patients (n=143) demonstrated that increased age was associated with higher levels of IL-6 (p=0.014) and IL-8 (p&lt;0.0001) at 24 hours. We then used anti-Ly6G, a neutrophil specific monoclonal antibody, to deplete circulating neutrophils as a potential treatment for ischemic stroke. Mice were randomized to receive 500ug anti-Ly6G IP or control at 4, 24 and 48 hours after stroke (n=6-7/group). Treatment conferred no benefit to young mice, but resulted in a significant improvement in behavioral recovery in aged mice as measured by adhesive test at 7 days (p&lt;0.01), corner test at 14 days (p&lt;0.001) and hangwire test at 14 days (p&lt;0.05). Conclusions: Neutrophils from aged animals exhibit altered organ trafficking and a higher reactive oxygen species generation. Elevated levels of neutrophil-activating cytokines were seen in both aged animals and aged ischemic stroke patients at 24 hours. Finally, anti-neutrophil depletion therapy had no effect in young animals, but resulted in significantly enhanced behavioral recovery in aged animals.

Abstract TP413: Prediction of Dysphagia Using the Alberta Stroke Program Early CT Score

Background: Dysphagia is common in patients with acute middle cerebral artery (MCA) stroke, and associated with malnutrition, pneumonia and mortality. Hence, identification of patients with swallowing disorder early after stroke onset is important. Besides bedside screening tools, brain imaging findings including lesion size and location may be of value. We investigated whether The Alberta stroke program early CT score (ASPECTS) can be used to predict dysphagia, and whether differences exist herein between the left and the right hemisphere. Methods: The analysis was based on a prospective dataset of 113 patients with acute ischemic stroke in the MCA territory. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 24 h after admission for validation of dysphagia. Brain imaging (CT or MRI) was rated for ischemic changes according to the ASPECT score. Results: 62 patients (54.9%) had FEES-proven dysphagia. In left hemispheric strokes the strongest associations between the ASPECTS sectors and dysphagia were found for the lentiform nucleus (ExpB 0.113 [CI 0.028-0.433; p=0.001), the insula (0.275 [0.102-0.742]; p=0.011) and the frontal operculum (0.280 [CI 0.094-0.834]; p=0.022). For right hemispheric strokes, only non-significant associations were found which were strongest for the insula region (0.385 [0.107-1.384]; p=0.144). For the left hemisphere multivariate logistic regression analysis revealed lower ASPECT scores to be independently associated with dysphagia, whereas for the right hemisphere this association was not present. Conclusion: The distribution and extent of early ischemic changes in brain imaging according to ASPECTS allows a reliable prediction of dysphagia in MCA-stroke patients, particularly for the left hemisphere.

Abstract WMP23: Automated Regional Density Measurements on Baseline Non-Contrast CT Predict Final Infarction in Acute Ischemic Stroke Patients

Introduction: Early ischemic changes on non-contrast CT (NCCT) can be visually assessed using the Alberta Stroke Program Early CT Score (ASPECTS). We sought to determine if automated regional density quantification provides additional information on the development of final infarction. Methods: We selected 121 patients with middle cerebral artery stroke due to large vessel occlusion out of a consecutive cohort. Densities in ASPECTS regions were quantified as average Hounsfield Unit (HU) values using automated segmentation (Fig. 1). Relative HU (rHU) values were calculated dividing absolute regional densities of ischemic by non-ischemic hemispheres. Final infarction was quantified semi-automatically as total volume and was defined visually per ASPECTS region in a dichotomized fashion. A composite rHU score incorporating values from all ASPECTS regions weighted by regional relevance was calculated. ROC analysis was performed to calculate AUC values. Linear regression analysis was used for multivariable adjustment. Results: Median visual ASPECTS on NCCT was 8 (IQR: 6-9). Automated density measurements were feasible in all 121 patients within one minute of post-processing time. rHU values yielded significant regional classification of final infarction in ROC analyses for all ASPECTS regions except M3 and M6. Best classifications were achieved for lentiform nucleus (AUC=0.810, p&lt;0.001), caudate nucleus (AUC=0.777, p&lt;0.001), and insula (AUC=0.764, p&lt;0.001). The composite rHU score was independently associated with final infarction volume (β=-0.353, p&lt;0.001), outperforming visual ASPECTS assessment (β=-0.190, p=0.062) in multivariable regression analysis. Conclusions: Automated NCCT density changes identify ASPECTS regions that develop final infarction in stroke patients. The composite rHU score outperformed visual ASPECTS interpretation in the prediction of final infarction volumes and may serve as an observer-independent imaging biomarker.

Abstract 53: Reorganization of Functional Language Networks Following Neonatal Arterial Ischemic Stroke

Introduction: Neonatal arterial ischemic stroke (NAIS) is the most common form of childhood stroke. Unlike adults with stroke, children with left middle cerebral artery (MCA) NAIS seldom become aphasic, although adolescence often reveals the emergence of higher-order language deficits. Functional language networks may be predictive of later-emerging language outcomes, and can aid to identify at-risk children with NAIS. Methods: Five neurotypical children (2F; 5 RH; mean 12.7 ± 2.6 years), and five children with unilateral-MCA NAIS (3F; 5 RH; mean 11.3 ± 2.0 years) listened to semantically correct and incorrect sentences while magnetoencephalography (MEG) was recorded. Task-related functional connectivity was calculated using the phase lag index (PLI) across regions of interest. The relationship between the functional brain networks and language skill was examined. Results: Neurotypical children showed increased global functional connectivity for semantically correct sentences 1.8 to 2.0 seconds from stimulus onset in the theta band (4-7 Hz; p &lt;0.05). The top connections in the theta band and time window of interest involved a significantly greater number of nodes in the left frontal lobe for controls compared to patients ( p &lt;0.05), while patients recruited a greater number of temporal lobe nodes than controls ( p &lt;0.05). Furthermore, patient language networks demonstrated a more bilateral distribution than those of typically-developed children (37.5% vs. 30% of top connections). The mean connectivity strength in the language network was positively correlated with vocabulary skill (r=0.84) for patients, and with word reading ability for both patients and neurotypical children (r=0.95, r=0.88, respectively). Conclusions: These results suggest reorganization of expected unilateral and frontal language networks towards a bilateral and temporal distribution following stroke, with less reliance on traditional language nodes. Such reorganization may underlie the language ability trajectory of children with neonatal MCA stroke. Reorganization of functional brain networks may be used as a predictive marker for language development following neonatal stroke, which can ultimately guide precision medicine and improve long-term outcomes.

Outcomes of Hypothermia in Addition to Decompressive Hemicraniectomy in Treatment of Malignant Middle Cerebral Artery Stroke

Moderate hypothermia in addition to early decompressive hemicraniectomy has been suggested to further reduce mortality and improve functional outcome in patients with malignant middle cerebral artery (MCA) stroke. To investigate whether moderate hypothermia vs standard treatment after early hemicraniectomy reduces mortality at day 14 in patients with malignant MCA stroke. This randomized clinical trial recruited patients from August 2011 through September 2015 at 6 German university hospitals with dedicated neurointensive care units. Of the patients treated with hemicraniectomy and assessed for eligibility, patients were randomly assigned to either standard care or moderate hypothermia. Data analysis was completed from December 2016 to June 2018. Moderate hypothermia (temperature, 33.0 ± 1.0°C) was maintained for at least 72 hours immediately after hemicraniectomy. The primary outcome was mortality rate at day 14 compared with the Fisher exact test and expressed as odds ratio (ORs) with 95% CIs. Rates of patients with serious adverse events were estimated for the period of the first 14 days after hemicraniectomy and 12 months of follow-up. Secondary outcome measures included functional outcome at 12 months. Of the 50 study participants, 24 were assigned to standard care and 26 to moderate hypothermia. Twenty-eight were male (56%); the mean (SD) patient age was 51.3 (6.6) years. Recruitment was suspended for safety concerns: 12 of 26 patients (46%) in the hypothermia group and 7 of 24 patients (29%) receiving standard care had at least 1 serious adverse event within 14 days (OR, 2.05 [95% CI, 0.56-8.00]; P = .26); after 12 months, rates of serious adverse events were 80% (n = 20 of 25) in the hypothermia group and 43% (n = 10 of 23) in the standard care group (hazard ratio, 2.54 [95% CI, 1.29-5.00]; P = .005). The mortality rate at day 14 was 19% (5 of 26 patients) in the hypothermia group and 13% (3 of 24 patients) in the group receiving standard care (OR, 1.65 [95% CI, 0.28-12.01]; P = .70). There was no significant difference regarding functional outcome after 12 months of follow-up. In patients with malignant MCA stroke, moderate hypothermia early after hemicraniectomy did not improve mortality and functional outcome compared with standard care, but may cause serious harm in this specific setting. http://www.drks.de, identifier DRKS00000623.

Usefulness of Cranial Ultrasound for Detecting Neonatal Middle Cerebral Artery Stroke

Magnetic resonance imaging is the gold standard technique in establishing the diagnosis of neonatal arterial ischemic stroke (NAIS). The diagnostic value of cranial ultrasound scanning in this clinical context is controversial. We aimed to assess the current sensitivity of the cranial ultrasound scan (CUS) in detecting NAIS, as this issue has not been well described in the literature. Newborns with NAIS diagnosed by magnetic resonance imaging between 2010 and 2016 were included. All CUSs were blindly analyzed retrospectively by a neonatologist expert in neuroimaging and compared with the findings of non-expert evaluators recorded on medical charts immediately after performing the evaluation. The overall sensitivity of CUS in detecting an imaging finding suggestive of NAIS was 87% (95% confidence interval (CI): 79%–95%) for an expert evaluator, but declined to 72% (61%–83%) when performed by a non-expert evaluator (p 0.002). Sensitivity was 83% and 61% in the first 24 h and 86% and 66% at 24–48 h for expert and non-expert evaluators, respectively (p < 0.05). CUS has higher sensitivity than previously reported in the detection of a NAIS, for both expert and non-expert evaluators. These findings may be explained by the advanced technology of new ultrasound equipment. Expertise in performing CUS is useful, particularly in the first 48 h after clinical debut.

Selection of preclinical models to evaluate intranasal brain cooling for acute ischemic stroke.

Stroke accounts for a large proportion of global mortality and morbidity. Selective hypothermia, via intranasal cooling devices, is a promising intervention in acute ischemic stroke. However, prior to large clinical trials, preclinical studies in large animal models of ischemic stroke are needed to assess the efficacy, safety, and feasibility of intranasal cooling for selective hypothermia as a neuroprotective strategy. Here, we review the available scientific literature for evidence supporting selective hypothermia and make recommendations of a preclinical, large, animal-based, ischemic stroke model that has the greatest potential for evaluating intranasal cooling for selective hypothermia and neuroprotection. We conclude that among large animal models of focal ischemic stroke including pigs, sheep, dogs, and nonhuman primates (NHPs), cynomolgus macaques have nasal anatomy, nasal vasculature, neuroanatomy, and cerebrovasculature that are most similar to those of humans. Moreover, middle cerebral artery stroke in cynomolgus macaques produces functional and behavioral deficits that are quantifiable to a greater degree of precision and detail than those that can be revealed through available assessments for other large animals. These NHPs are also amenable to extensive neuroimaging studies as a means of monitoring stroke evolution and evaluating infarct size. Hence, we suggest that cynomolgus macaques are best suited to assess the safety and efficacy of intranasal selective hypothermia through an evaluation of hyperacute diffusion-weighted imaging and subsequent investigation of chronic functional recovery, prior to randomized clinical trials in humans.

Longitudinal quantitative electroencephalographic study in mono-hemispheric stroke patients.

The identification of individual factors modulating clinical recovery after a stroke is fundamental to personalize the therapeutic intervention to enhance the final clinical outcome. In this framework, electrophysiological factors are promising since are more directly related to neuroplasticity, which supports recovery in stroke patients, than neurovascular factors. In this retrospective observational study, we investigated brain neuronal activity assessed via spectral features and Higuchi’s fractal dimension (HFD) of electroencephalographic signals in acute phase (2–10 days from symptom onset, T0) and sub-acute phase (2.5 months, T1) in 24 patients affected by unilateral middle cerebral artery stroke. Longitudinal assessment of the clinical deficits was performed using the National Institutes of Health Stroke Scale (NIHSS), together with the effective recovery calculated as the ratio between difference of NIHSS at T0 and T1 over the NIHSS value at T0. We observed that delta and alpha band electroencephalographic signal power changed between the two phases in both the hemispheres ipsilateral (ILH) and contralateral (CHL) to the lesion. Moreover, at T0, bilateral higher delta band power correlated with worse clinical conditions (Spearman’s rs = 0.460, P = 0.027 for ILH and rs = 0.508, P = 0.013 for CLH), whereas at T1 this occurred only for delta power in ILH (rs = 0.411, P = 0.046) and not for CHL. Inter-hemispheric difference (ILH vs. CLH) of alpha power in patients was lower at T0 than at T1 (P = 0.020). HFD at T0 was lower than at T1 (P = 0.005), and at both phases, ILH HFD was lower than CLH HFD (P = 0.020). These data suggest that inter-hemispheric low band asymmetry and fractal dimension changes from the acute to the sub-acute phase are sensitive to neuroplasticity processes which subtend clinical recovery. The study protocol was approved by the Bioethical Committee of Ospedale San Giovanni Calibita Fatebenefretelli (No. 40/2011) on July 14, 2011.

Embolic Stroke and Carotid Artery Occlusion in an Infant with Dilated Cardiomyopathy Secondary to Acute Myocarditis

We are reporting on an 11-month-old infant girl with two interesting findings. The first is dilated cardiomyopathy following an acute clinical course, which on presentation suggested acute myocarditis; two-dimensional echocardiographic findings showed severely-dilated left atrial and ventricular chambers as well as severe ventricular dysfunction. The second is the occurrence of right-sided middle cerebral artery stroke, with clinical manifestations of sudden onset left-sided hemiparalysis, secondary to right carotid artery occlusion. To the best of our knowledge, there is no previous report in the literature of this condition within a similar age group.

Demographic characteristics of stroke in a tertiary care hospital in Nepal

Our aim is to find out the demographics of the patients with stroke who undergo in-patient rehabilitation in a tertiary care hospital setting. We also aim to find the frequency of different types of stroke and the frequency of stroke in different vascular territories.&#x0D; Using data collected prospectively over a period of 1 year, we studied 180 individuals admitted with stroke. The demographic features of patients with stroke were collected and analyzed. Stroke was broadly stratified into hemorrhagic and ischemic stroke. Furthermore, ischemic stroke was subdivided according to the vascular territories involved: anterior cerebral artery, middle cerebral artery (MCA), posterior cerebral artery, brain-stem, cerebellar, smallvessel strokes and stroke occurring in more than one vascular territory. The most common risk factor was hypertension which was present in 50% of patients.&#x0D; The most common ischemic stroke groups were MCA stroke (39.4%) and small vessel stroke (17.2%). The most common type of hemorrhage was basal ganglia hemorrhage which was present in 15% of patients.&#x0D; In regards with Western literature, patients with stroke in our setting also had similar risk factors.&#x0D; The proportion of hemorrhagic stroke in our country was higher than in the western world. A large proportion of patients were in the age group less than 65. However, the frequency of distribution of different types of stroke and frequency of stroke in different territories were similar.

The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke

Malignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome. A cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3. Median age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P= 0.0003) and was associated with a worse outcome (P<0.0001) after exceeding a cutoff volume of 300 cm3. Volumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.