Middle Cerebral Artery Stroke Research Articles

Case Report – Successful Thrombectomy After Critical Resuscitation Following a Cardiac Arrest

Sparse evidence exists to support a delayed attempt at thrombectomy after a periprocedural cardiac arrest or acute medical decompensation. This case highlights the presentation of a 23‐year‐old woman with dilated cardiomyopathy, who initially presented with a left middle cerebral artery stroke syndrome, but who had a cardiac arrest in the angiogram suite prior to the procedure starting. After aggressive resuscitation in the critical care unit, repeat imaging showed a persistent perfusion deficit in the left middle cerebral artery territory and she successfully underwent a thrombectomy. The case highlights that critical care efforts, even after a severe initial presentation, and significant resuscitative efforts in the intensive care unit setting, can still lead to a successful thrombectomy, and that eligibility for thrombectomy can be reassessed as the patient stabilizes.

Dual αV-integrin and neuropilin-1 targeting peptide CEND-1 plus nab-paclitaxel and gemcitabine for the treatment of metastatic pancreatic ductal adenocarcinoma: a first-in-human, open-label, multicentre, phase 1 study

CEND-1 is a novel cyclic peptide that targets αV integrins and neuropilin-1 and enhances tumour delivery of co-administered anticancer drugs. We investigated the safety, tolerability, and biological activity of CEND-1 in patients with metastatic pancreatic ductal adenocarcinoma in combination with nab-paclitaxel and gemcitabine. This open-label, multicentre, phase 1 study, conducted at three hospitals in Australia, enrolled participants aged 18 years or older with histologically confirmed metastatic pancreatic ductal adenocarcinoma who had one or more lesions measurable on MRI or CT, an Eastern Cooperative Oncology Group performance status score of 0 or 1, and a life expectancy of at least 3 months. Exclusion criteria included previous chemotherapy and brain metastases or other malignancy (unless receiving curative intent). There was no randomisation or masking. CEND-1 monotherapy was given as an intravenous fluid bolus on day 1 of a run-in phase of 7 days (0·2-3·2 mg/kg) followed by CEND-1 plus intravenous gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) on days 1, 8, and 15 of 28-day treatment cycles until disease progression. The primary safety endpoints were incidence, severity, and duration of treatment-emergent and treatment-related adverse events; overall survival; and clinical laboratory results, which were all assessed in the safety population. This study is registered with ClinicalTrials.gov, NCT03517176, and the Australian New Zealand Clinical Trials Registry, ACTRN12618000804280. Between Aug 13, 2018, and Nov 30, 2019, 31 patients were enrolled (eight in the dose-escalation phase [cohort 1a] and 23 in the expansion phase [cohort 1b]). Two patients were excluded from the efficacy population. No CEND-1 dose-limiting toxicities were observed in the safety population (n=31). The most common grade 3 or 4 events were neutropenia (17 [55%] patients), anaemia (eight [26%]), leukopenia (five [16%]), and pulmonary embolism (four [13%]). Serious adverse events occurred in 22 (71%) patients, mostly related to disease progression. Ten deaths occurred during the study due to progression of metastatic pancreatic cancer (n=9) and a left middle cerebral artery stroke (n=1). In the efficacy population (n=29), 17 (59%) patients had an objective response, including one complete response and 16 partial responses. After a median follow-up of 26 months (IQR 24-30), median overall survival was 13·2 months (95% CI 9·7-22·5). CEND-1 with nab-paclitaxel and gemcitabine has an acceptable safety profile, with no dose-limiting toxicities and encouraging activity. Adverse events were generally consistent with those seen with nab-paclitaxel and gemcitabine. Further randomised trials to determine the efficacy of CEND-1 are warranted. DrugCendR Australia Pty.

METHODS OF LABOR ANALGESIA BY DETERMING THE LEVEL OF CHILDBIRTH SATISFACTION

Introduction. Paroxysmal sympathetic hyperactivity (PSH) can occur as a result of brain injury, hypoxic brain damage, acute cerebrovascular accident (ACVA). The clinical picture of PSH is caused by excessive sympathetic activity and includes transient paroxysms of tachycardia, hypertension, hyperventilation, hyperthermia, and diaphoresis. PSH is a neurological emergency, which in the vast majority of cases is a diagnosis of exclusion. Lack of adequate detection and treatment of the disease leads to a high mortality rate. The diagnosis is exclusively clinical, so other pathologies must be excluded. Currently, the most widely accepted diagnostic criteria for PSH are the criteria proposed by Baguley et al. Case description. Patient D., 29 years old, was hospitalized with a diagnosis of middle cerebral artery stroke. The patient had attacks which were characterized by tachycardia, hypertension, tachypnea with asynchrony with the ventilator, diaphoresis and hypertension every day with a frequency of 2-3 times per day and were ending approximately 30-40 minutes after the onset. The diagnosis of PSH was established according to the score on the scale proposed by Baguley et al., 25 points (17 or more points – a probable diagnosis of PSH). Conclusions. It is believed that the cause of PSH is a violation of the inhibition function of the cortex on the brain structures located below, as a result of which paroxysms of sympathetic activation occur, manifested by tachycardia, hypertension, hyperventilation, diaphoresis, and hyperthermia. In this clinical case, resolution of paroxysms was observed faster with the combination of morphine and propofol. An important aspect of therapy is adequate rehydration therapy to compensate for fluid losses due to hyperthermia and diaphoresis, as well as the administration of beta-blockers on an ongoing basis

Left Hemisphere Bias of NIH Stroke Scale Is Most Severe for Middle Cerebral Artery Strokes.

NIHSS score is higher for left vs. right hemisphere strokes of equal volumes. However, differences in each vascular territory have not been evaluated yet. We hypothesized that left vs. right differences are driven by the middle cerebral artery (MCA) territory, and there is no difference between hemispheres for other vascular territories. This study is based on data from 802 patients with evidence of acute ischemic stroke in one major arterial territory (MCA, n = 437; PCA, n = 209; ACA, n = 21; vertebrobasilar, n = 46). We examined differences in patients with left or right strokes regarding to lesion volume, NIHSS, and other covariates (age, sex, race). We used linear models to test the effects of these covariates on NIHSS. We looked at the whole sample as well as in the sample stratified by NIHSS (≤5 or >5) and by lesion location (MCA or PCA). Patients with left MCA strokes had significantly higher NIHSS than those with right strokes. Only patients with MCA strokes showed NIHSS score affected by the hemisphere when controlling for stroke volume and patient's age. This difference was driven by the more severe strokes (NIHSS>5). It is important to consider this systematic bias in the NIHSS when using the score for inclusion criteria for treatment or trials. Patients with right MCA stroke may be under-treated and left with disabling deficits that are not captured by the NIHSS.

Cortico-Cerebellar Connectivity Underlying Motor Control in Chronic Poststroke Individuals.

The robust, reciprocal anatomic connections between the cerebellum and contralateral sensorimotor cerebral hemisphere underscore the strong physiological interdependence between these two regions in relation to human behavior. Previous studies have shown that damage to sensorimotor cortex can result in a lasting reduction of cerebellar metabolism, the magnitude of which has been linked to poor rehabilitative outcomes. A better understanding of movement-related cerebellar physiology as well as cortico-cerebellar coherence (CCC) in the chronic, poststroke state may be key to developing novel neuromodulatory techniques that promote upper limb motor rehabilitation. As a part of the first in-human phase I trial investigating the effects of deep brain stimulation of the cerebellar dentate nucleus (DN) on chronic poststroke motor rehabilitation, we collected invasive recordings from DN and scalp EEG in participants (both sexes) with middle cerebral artery stroke during a visuo-motor tracking task. We investigated the excitability of ipsilesional cortex, DN, and their interaction as a function of motor impairment and performance. Our results indicate the following: (1) event-related oscillations in the ipsilesional cortex and DN were significantly correlated at movement onset in the low beta band, with moderately and severely impaired participants showing desynchronization and synchronization, respectively; and (2) significant CCC was observed during the isometric hold period in the low beta band, which was critical for maintaining task accuracy. Our findings support a strong coupling between ipsilesional cortex and DN in the low beta band during motor control across all impairment levels, which encourages the exploitation of the cerebello-thalamo-cortical pathway as a neuromodulation target to promote rehabilitation.SIGNIFICANCE STATEMENT Cerebral infarct because of stroke can lead to lasting reduction in cerebellar metabolism, resulting in poor rehabilitative outcomes. Thorough investigation of the cerebellar electrophysiology, as well as cortico-cerebellar connectivity in humans that could provide key insights to facilitate the development of novel neuromodulatory technologies, has been lacking. As a part of the first in-human phase I trial investigating deep brain stimulation of the cerebellar dentate nucleus (DN) for chronic, poststroke motor rehabilitation, we collected invasive recordings from DN and scalp EEG while stroke survivors performed a motor task. Our data indicate strong coupling between ipsilesional sensorimotor cortex and DN in the low beta band across all impairment levels encouraging the exploration of electrical stimulation of the DN.

Cognitive Reserve Modifies the Relationship Between Neural Function, Neural Injury and Upper-Limb Recovery After Stroke

ObjectiveTo investigate whether cognitive reserve modifies the relationship between functional connectivity, lesion volume, stroke severity and upper-limb motor impairment and recovery in stroke survivors. MethodsTen patients with first-ever ischemic middle cerebral artery stroke completed the Cognitive Reserve Index Questionnaire at baseline. Upper-limb motor impairment and functional connectivity were assessed using the Fugl-Meyer Assessment and electroencephalography respectively at baseline and 3-months post-stroke. A debiased weighted phase lag index was computed to estimate functional connectivity between electrodes. Partial least squares (PLS) regression identified a connectivity model that maximally predicted variance in the degree of upper-limb impairment. Regression models were generated to determine whether cognitive reserve modified the relationship between neural function (functional connectivity), neural injury (lesion volume), stroke severity (National Institutes of Health Stroke Scale) and upper-limb motor impairment at baseline and recovery at 3-months (Fugl-Meyer Assessment). ResultsThe addition of cognitive reserve to a regression model with a dependent variable of upper-limb motor recovery and independent variables of functional connectivity between the ipsilesional motor cortex and parietal cortex, stroke severity and lesion volume improved model efficiency (∆BIC=-7.07) despite not reaching statistical significance (R2=0.90, p=0.07). Cognitive reserve did not appear to improve regression models examining motor impairment at baseline. ConclusionsPreliminary observations suggest cognitive reserve might modify the relationship between neural function, neural injury, stroke severity and upper-limb motor recovery. Further investigation of cognitive reserve in motor recovery post-stroke appears warranted.

Systemic White Blood Cell Count as a Biomarker for Malignant Cerebral Edema in Large Vessel Ischemic MCA Stroke

ObjectivesLarge middle cerebral artery (MCA) strokes remain a major cause for mortality and morbidity all over the world, and therefore early identification of patients with the highest risk for malignant cerebral edema is crucial for early intervention. Neutrophils to lymphocytes ratio (NLR) and peripheral total white blood cell (WBC) count are inflammatory markers done routinely for all patients, and this study evaluated the use of NLR and elevated white blood cell count within the first 24 h of MCA ischemic stroke onset, with the absence of significant hemorrhagic transformation, to predict malignant cerebral edema. Materials and methodsA total of 156 patients with large MCA strokes were included. We collected demographic, clinical, radiological data, and NLR and WBCs within the first 24 h from admission.We excluded patients who had any underlying infections diagnosed 7 days before or within 72 h after admission. We used a body temp of 38 C or more, abnormal CXR or abnormal urine analysis within the first 72 h to exclude patients with possible infections.We excluded immune-compromised patients and patients on steroid therapy. We compared the NLR and WBC count in patients who developed malignant cerebral edema versus the patients who did not. NLR > 3.5 and < 3.5 was used for comparison. We then conducted multivariate logistic regression models to explore the relationship between cerebral edema, WBCs and NLR count simultaneously. ResultsNLR, WBC, radiological involvement of more than 50% of MCA territory infarction on presentation, hyperdense MCA sign, and NIH stroke scale were all significantly higher in patients with malignant cerebral edema within the first 24 h. Using univariate logistic regression, NLR performs better than WBC when predicting the occurrence of malignant cerebral edema (AUC = 0.74 vs. 0.62). However, NIH stroke scale scores, and radiological involvement of more than 50% of MCA territory infarction on the first 24 h of presentation on CT scan both showed better discriminative performance for malignant cerebral edema than NLR (AUC = 0.84 and 0.76, respectively). When combined, NLR > 3.5 paired with the NIH stroke scale score had the best predictive performance (AUC = 0.87). ConclusionNLR > 3.5 can be used for early prognostication in patients with large vessel MCA ischemic strokes with no significant hemorrhagic transformation within the first 24 h regardless if they had reperfusion therapy or not. Combining NLR of > 3.5 in addition to high NIHSS provided the best predictive model in our study. Further studies are needed to further develop the best predictive model in diverse populations.

Transbrachial access for mechanical thrombectomy in a case of acute ischemic stroke with aortic bifurcation occlusion

Objective: To report successful mechanical thrombectomy through transbrachial route in a patient with left middle cerebral artery (MCA) stroke and aortic bifurcation occlusion. Background: Mechanical thrombectomy is the standard therapeutic approach for eligible candidates of acute ischemic stroke according to American Heart Association/American Stroke Association guidelines. Mostly, a transfemoral approach is used to perform mechanical thrombectomy. Few studies have shown use of radial route for this procedure. Few reports have shown alternate access routes for performing mechanical thrombectomy when transfemoral or radial routes are not accessible. Design/Methods: Case report and literature review. Results: A 51-year-old female presented with left MCA stroke. Computed tomography angiography showed left internal carotid artery T occlusion extending into left MCA. Associated left atrial thrombus and occlusion at the aortic bifurcation were diagnosed in this patient. A transbrachial route was taken to perform mechanical thrombectomy in this patient resulting in complete recanalization. Conclusion: This case emphasizes the role of alternate access routes to perform mechanical thrombectomy in challenging situations.

Falsely normal CT perfusion ischemic core readings are common and often associated with deep infarcts

BackgroundProper identification of infarct extent is crucial for thrombectomy and prognostication. We sought to study the frequency and topographic aspects of those cases in which CT perfusion (CTP) misses a...

Automatic CT Angiography Lesion Segmentation Compared to CT Perfusion in Ischemic Stroke Detection: a Feasibility Study

In stroke imaging, CT angiography (CTA) is used for detecting arterial occlusions. These images could also provide information on the extent of ischemia. The study aim was to develop and evaluate a convolutional neural network (CNN)–based algorithm for detecting and segmenting acute ischemic lesions from CTA images of patients with suspected middle cerebral artery stroke. These results were compared to volumes reported by widely used CT perfusion–based RAPID software (IschemaView). A 42-layer-deep CNN was trained on 50 CTA volumes with manually delineated targets. The lower bound for predicted lesion size to reliably discern stroke from false positives was estimated. The severity of false positives and false negatives was reviewed visually to assess the clinical applicability and to further guide the method development. The CNN model corresponded to the manual segmentations with voxel-wise sensitivity 0.54 (95% confidence interval: 0.44–0.63), precision 0.69 (0.60–0.76), and Sørensen–Dice coefficient 0.61 (0.52–0.67). Stroke/nonstroke differentiation accuracy 0.88 (0.81–0.94) was achieved when only considering the predicted lesion size (i.e., regardless of location). By visual estimation, 46% of cases showed some false findings, such as CNN highlighting chronic periventricular white matter changes or beam hardening artifacts, but only in 9% the errors were severe, translating to 0.91 accuracy. The CNN model had a moderately strong correlation to RAPID-reported Tmax > 10 s volumes (Pearson’s r = 0.76 (0.58–0.86)). The results suggest that detecting anterior circulation ischemic strokes from CTA using a CNN-based algorithm can be feasible when accompanied with physiological knowledge to rule out false positives.

Case Report: True Motor Recovery of Upper Limb Beyond 5 Years Post-stroke

Most of motor recovery usually occurs within the first 3 months after stroke. Herein is reported a remarkable late recovery of the right upper-limb motor function after a left middle cerebral artery stroke. This recovery happened progressively, from two to 12 years post-stroke onset, and along a proximo-distal gradient, including dissociated finger movements after 5 years. Standardized clinical assessment and quantified analysis of the reach-to-grasp movement were repeated over time to characterize the recovery. Twelve years after stroke onset, diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS) analyses of the corticospinal tracts were carried out to investigate the plasticity mechanisms and efferent pathways underlying motor control of the paretic hand. Clinical evaluations and quantified movement analysis argue for a true neurological recovery rather than a compensation mechanism. DTI showed a significant decrease of fractional anisotropy, associated with a severe atrophy, only in the upper part of the left corticospinal tract (CST), suggesting an alteration of the CST at the level of the infarction that is not propagated downstream. The finger opposition movement of the right paretic hand was associated with fMRI activations of a broad network including predominantly the contralateral sensorimotor areas. Motor evoked potentials were normal and the selective stimulation of the right hemisphere did not elicit any response of the ipsilateral upper limb. These findings support the idea that the motor control of the paretic hand is mediated mainly by the contralateral sensorimotor cortex and the corresponding CST, but also by a plasticity of motor-related areas in both hemispheres. To our knowledge, this is the first report of a high quality upper-limb recovery occurring more than 2 years after stroke with a genuine insight of brain plasticity mechanisms.

Abstract 16: Inhibiting Ezh2 Is Neuroprotective After Stroke In Aged Mice

Introduction: Ischemic stroke results in activation of microglia, which may polarize towards a pro-inflammatory (M1) phenotype and/or an anti-inflammatory (M2) phenotype. Enhancer of zeste homolog (EZH) 2 is a histone-lysine N-methyltransferase enzyme, a key modulator of microglia polarization. We here investigated whether microglial-specific deletion of EZH2 leads to a beneficial protective effect in stroke and microglial over-expressing microglial EZH2 exacerbates stroke outcome in vivo . Methods: Aged male mice were subjected to 60-minutes middle cerebral artery stroke. Tamoxifen administration was started 30 days prior to stroke to induce genetic deletion of microglial EZH2 in CX3CR1-creER/EZH2-floxed mice. EZH2 floxed mice were used as controls. Microglial EZH2 over-expressing was performed using lentiviral vectors. Mice were sacrificed for immunohistochemistry and crystal violet staining (brain infarct assay) after behavior tests at 3 days after stroke. Results: The expression of microglial EZH2 was significantly abrogated with tamoxifen injection in KO mice compared to the control floxed mice (144±15.43 vs. 50.65±4.99 cells/mm 2 , P&lt;0.01, N=5/each group). EZH2 deletion reduced brain infarct volume (29.27±2.23% vs. 6.07±0.88%, P&lt;0.001, N=7/each group) and improved functional outcome assayed by adhesive removal test (59±13.1 seconds, N=7 in control vs. 26.28±4.1 seconds, N=12 in KO, P&lt;0.01). Mechanistically, microglial EZH2 deletion led to a decrease in expression of M1 marker iNOS (170±14.78 vs. 76.65±11.38 cells/mm 2 , P&lt;0.05, N=4/each group), an increase in M2 marker Arg1 (96.64±11.48 vs. 203.3±22.02 cells/mm 2 , P&lt;0.05, N=4/each group) co-stained in microglia (Iba1). We additionally found over-expressing EZH2 in microglial cells exacerbated stroke outcome including performance in adhesive tape removal and hang-wire tests 3 days after stroke. We observed decreased Arg1 and increased iNOS in stroke mice with over-expression of EZH2 (n= 5/6, p=&lt;0.05). Conclusions: Genetic deletion of EZH2 in microglia improved stroke outcome in aged while overexpression of EZH2 exacerbated stroke outcome. The effect of protective effect of EZH2 inhibition may be due to limiting microglial M1 polarization and enhancing M2 polarization.

Long-Term Functionality Prediction for First Time Ischemic Middle Cerebral Artery Stroke Patients Receiving Conventional Medical Treatment.

BackgroundMiddle cerebral artery (MCA) ischemic stroke poses a major threat to human beings and prompts intravenous thrombolytic and/or thrombectomy management remains the gold standard treatment. However, not all MCA stroke patients fit in the inclusion and exclusion criteria that many patients only receive conventional medical therapy. We attempt to seek the baseline parameters that can effectively predict patients’ long-term functionality, as well as hypothesizing that the carotid duplex derived resistance/pulsatility index might be capable of fulfilling this purpose.MethodsThe 741 MCA ischemic stroke patients have been retrospectively recruited for the project. Under the initial screening, matching the inclusion and exclusion criteria, there are 471 participants to be enrolled in the study. The patients’ basic information, along with outcome assessments, pre-admission Barthel index and NIHSS score, and pre- and post-treatment mRS are recorded. All statistical analyses were performed using R for Windows (version 3.6.3). The significance level was set at P < 0.05 for all analyses.ResultsOf the 471 patients, 239 participants show a net mRS improvement, whereas the other 232 show deterioration. Hyperlipidaemia, chronic kidney disease, and dementia are related to long-term functionality improvement. The multivariate logistic regression analysis shows that right common carotid artery (CCA) resistance index (RI) and ischemic heart disease play a significant role in favourable outcome functionality. The ROC and Youden Index models are formulated, and it shows that Barthel Index and the NIHSS are most significant in the outcome measurement group (AUC: 0.675, 0.653; cut-off point: 57.5, 3.5, respectively). The right-side CCA RI is the solely important outcome predictor for the baseline carotid duplex study (AUC: 0.5; cut-off point: 0.785).ConclusionThe favourable long-term functionality of MCA ischemic stroke patients receiving conventional medical treatment seems to correlate fairly with pre-admission NIHSS and Barthel index scores. Underlying hyperlipidaemia, chronic kidney disease, and dementia are conversely associated with favourable long-term capability. Moreover, the value of CCA RI appears to significantly alter the long-term outcomes in this group of patients.

Newborn with a Large Intracranial Mass.

Newborn with a Large Intracranial Mass.

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review.

BACKGROUND:Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants.METHODS:Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 –2019. Results were combined using descriptive statistics.RESULTS:Fourteen studies encompassed 546 stroke cases in preterm infants between 23 –36 weeks gestational ages and birth weights between 450 –3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis.CONCLUSION:This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.

Optic Nerve Sheath Diameter Detects Intracranial Hypertension in Acute Malignant Middle Cerebral Artery Infarction

ObjectivesTo evaluate optic nerve sheath diameter in the acute phase of patients with malignant ischemic middle cerebral artery stroke submitted or not to decompressive craniectomy surgery. Materials and MethodsForty patients participated in the study and were evaluated bilaterally by ultrasound on admission and at 24h, 48h and 72 h after admission. Optic nerve sheath diameter values were correlated with tomographic and/or clinical criteria compatible with severe intracranial hypertension. ResultsA Receiver Operating Characteristic curve was drawn for each eye, determining a cut-off value for severe intracranial hypertension in the right eye of 5.4 mm (sensitivity: 62%; specificity: 100%; AUC: 0.82) and in the left eye 5.4 mm (sensitivity: 76%; specificity: 84%; AUC: 0.77). In patients undergoing craniectomy, there was a decrease in the mean value of 1.04mm in the right eye (pre: 5.84 ± 0.47 mm; post: 4.80 ± 0.84 mm; p = 0.001), while in the left, it decreased around 0.86mm (pre: 5.59 ± 0.69 mm; post: 4.73 ± 0.74 mm; p = 0.003). Patients with fatal outcome showed a persistent high mean ocular nerve sheath diameter. ConclusionsMonitoring optic nerve sheath by ultrasound can be considered a reliable method for identifying severe intracranial hypertension in patients with large vessel occlusion, as well as for monitoring patients undergoing craniectomy. Additional studies will be necessary to include this parameter in craniectomy indication algorithms in the future.

Recovery of social and everyday skills after a complex of functional spatially oriented rehabilitation in elderly patients with cerebral stroke

To analyze the effectiveness of social recovery (trip to the store by bus and making purchases) in elderly patients with stroke in the right middle cerebral artery undergoing a course of specialized trainings in a complex of functional spatially oriented rehabilitation. The study involved 44 patients with previous stroke (mean age 70.8±3.1 years) randomized into 2 equal groups: main group - basic standard of rehabilitation (exercises with instructor, mechanotherapeutic technique with cyclic simulators, massage of paretic limbs) and training of social adaptation in a complex of functional spatially oriented rehabilitation; control group - basic standard of rehabilitation alone. Duration of rehabilitation course was 14 days. To determine mean norm of timing of complex training of socially significant skill, we asked 23 volunteers without severe comorbidities to perform tasks of functional spatially oriented rehabilitation. After complex rehabilitation program, we found significant dynamics of time necessary for the following actions: "take a bag and hang it over shoulder", "open the pockets of the bag with a zipper (2 pockets)", "take the jacket off the hanger and put it on", "take the products from the basket and put in the pocket". Moreover, the main group was characterized by significantly lower impairment of daily activity (Barthel score 66.3±4.5 vs. baseline 45.7±4.9, p<0.05), improvement of functional independence (FIM score 76.7±1.5 vs. baseline 65.2±3.1, p>0.05). These values turned out to be significantly better than in the control group. These results indicate the effectiveness of functional spatially oriented rehabilitation in elderly patients with cerebral stroke. This approach increases personal independence in daily life and improves overall quality of life.

FMRI informed voxel-based lesion analysis to identify lesions associated with right-hemispheric activation in aphasia recovery

Several mechanisms have been attributed to post-stroke loss and recovery of language functions. However, the significance and timing of domain-general and homotopic right-hemispheric activation is controversial. We aimed to examine the effect of left-hemispheric lesion location and time post-stroke on right-hemispheric activation. Voxel-based lesion analyses were informed by auditory language-related fMRI activation of 71 patients with left middle cerebral artery stroke examined longitudinally in the acute, subacute and early chronic phase. Language activation was determined in several right-hemispheric regions of interest and served as regressor of interest for voxel-based lesion analyses. We found that an acute to chronic increase of language activation in the right supplementary motor area was associated with lesions to the left extreme capsule as part of the ventral language pathway. Importantly, this activation increase correlated significantly with improvement of out-of-scanner comprehension abilities. We interpret our findings in terms of successful domain-general compensation in patients with critical left frontotemporal disconnection due to damage to the ventral language pathway but relatively spared cortical language areas.

Differences in Dual Task Performance After Robotic Upper Extremity Rehabilitation in Hemiplegic Stroke Patients

Background: Cognitive–motor interference is a phenomenon in which the concomitant performance of cognitive and motor tasks results in poorer performance than the isolated performance of these tasks. We aimed to evaluate changes in dual-task performance after robotic upper extremity rehabilitation in patients with stroke-induced hemiplegia.Methods: This prospective study included patients with left upper limb weakness secondary to middle cerebral artery stroke who visited a rehabilitation hospital. Participants performed a total of 640 robot-assisted planar reaching movements during a therapist-supervised robotic intervention that was conducted five times a week for 4 weeks. Cognitive and motor performance was separately evaluated in single- and dual-task conditions. The digit span test and Controlled Oral Word Association Test (COWAT) were used to assess cognitive performance, whereas motor performance was evaluated through kinematic assessment of the motor task.Results: In single-task conditions, motor performance showed significant improvement after robotic rehabilitation, as did the scores of the COWAT subdomains of animal naming (p < 0.001), supermarket item naming (p < 0.06), and phonemes (p < 0.05). In dual-task conditions, all motor task performance variables except mean velocity showed improvement after robotic rehabilitation. The type of cognitive task did not affect the dual-task effect, and there were no significant differences in the dual-task effects of motor, cognitive, or the sum of motor and cognitive performance after robotic rehabilitation.Conclusion: Post-stroke robotic rehabilitation has different effects on motor and cognitive function, with more consistent effects on motor function than on cognitive function. Although motor and cognitive performance improved after robotic rehabilitation, there were no changes in the corresponding dual-task effects.

Detection and vascular territorial classification of stroke on diffusion-weighted MRI by deep learning

PurposeRapid detection and vascular territorial classification of stroke enable the determination of the most appropriate treatment. In this study, we aimed to investigate the performance of convolutional neural network (CNN) models in the detection and vascular territorial classification of stroke on diffusion-weighted images (DWI). MethodsDWI of 421 cases (271 acute ischemic stroke patients and 150 cases without any ischemia findings on DWI) obtained between January 2017 to April 2020 were reviewed. We created two custom datasets. A stroke detection dataset was created with 1800 slices (900 S and 900 normal) consisting of 1400 for training, 200 for validation, 200 for test. A vascular territorial type dataset was created with 1717 slices (883 middle cerebral artery stroke, 416 posterior circulatory stroke, and 418 watershed stroke) consisting of 1117 slices for training, 300 for validation, 300 for test. A transfer learning approach based on MobileNetV2 and EfficientNet-B0 CNN architecture was used. The performance of the models was evaluated. ResultsModified MobileNetV2 and EfficientNet-B0 models achieved 96% (κ: 0.92) and 93% (κ: 0.86) accuracy in stroke detection, respectively. In vascular territorial classification of stroke as middle cerebral artery, posterior circulation, or watershed infarction, an accuracy of 93% (κ: 0.895) was achieved with modified MobileNetV2 model and 87% (κ: 0.805) with modified EfficientNet-B0 CNN model. ConclusionTransfer learning approach with custom top CNN models achieve sufficiently high performance for both the detection of ischemic stroke and the classification of its vascular territorial type on DWI.