Middle Cerebral Artery Syndrome Research Articles

Thrombectomy using Zoom Reperfusion System in pediatric acute ischemic strokes: Case series and literature review.

Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively. Case report and literature review. A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively. The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

Abstract 198: Case Report: Thrombectomy using Zoom Reperfusion System In Pediatric Acute Ischemic Strokes

Introduction Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in mechanical thrombectomies in adults but has not been described in pediatrics to our knowledge. We present two cases of a 14‐year‐old boy with acute right middle cerebral artery (MCA) syndrome and a 10‐year‐old boy with acute left MCA syndrome who underwent mechanical thrombectomy using Zoom Reperfusion System safely with TICI 2B and 3 recanalization respectively. Methods Case report and review of literature Results Case 1: 14‐year‐old previously healthy boy presented to our facility for acute right MCA syndrome secondary to right supraclinoid internal carotid artery (ICA) occlusion. After receiving alteplase, patient was taken for mechanical thrombectomy. After femoral access was obtained, an 8‐French sheath was introduced into the right femoral artery through which a Zoom 88 catheter and 5‐French BERN catheter (Terumo) were coaxially advanced over a Terumo Glidewire into the right common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the lacerum ICA segment with BERN catheter and Glidewire then removed. Angiogram demonstrated complete occlusion of the ICA just past the origin of the ophthalmic artery. Via Zoom 88 catheter, a Zoom 71 catheter was then navigated to the face of clot over a velocity microcatheter (Penumbra) and synchro 2 wire system (Stryker) which was then removed. The vacuum manifold was then attached to Zoom 71 catheter and allowed to engage with the clot for 3 minutes prior to withdrawal into the Zoom 88 catheter. TICI 2B recanalization was achieved with sub‐occlusive thrombus within the proximal M1 segment. Retrieval of the sub‐occlusive thrombus in the M1 segment was performed with TREVO stentriever (Stryker). Procedure was complicated by vasospasm in the A1 and M2 segments which resolved with milrinone and verapamil infused through the Zoom 88 catheter. Case 2: 10‐year‐old with left hypoplastic heart syndrome presented to our facility for acute left MCA syndrome due to left ICA terminus occlusion. Mechanical thrombectomy was performed after receiving alteplase. Femoral artery access was obtained with a 8‐French sheath, through which Zoom 88 catheter and 5‐French select catheter (Penumbra) were advanced over Terumo Glidewire into the left common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the ophthalmic segment of ICA with select catheter and Glidewire then removed. Angiogram demonstrated complete occlusion at the ICA terminus. Zoom 71 catheter was introduced through Zoom 88 catheter and navigated to the face of clot at the ICA terminus over velocity microcatheter (Penumbra) and synchro wire system (Stryker) which was then removed. Zoom 71 was then attached to a vacuum manifold to engage with the clot for 90 seconds. TICI 2A recanalization after first pass was achieved with flow restoration in anterior cerebral artery but none in the MCA.TICI 3 recanalization was achieved after second pass. Conclusion The use of Zoom reperfusion system potentially proves to be safe for use in the pediatric age group with good recanalization results and no intraoperative or postoperative complications.

Systemic Neoplastic Cryoglobulinemic Vasculitis Mimics Large Vessel Occlusion: A Case Report.

We describe a systemic neoplastic cryoglobulinemic vasculitis presenting as a large vessel occlusion (LVO) syndrome. We focus on a rare presentation of a rare condition. A 68-year-old man was admitted to the Stroke Unit of Padova with a right middle cerebral artery syndrome. A cerebrovascular event was suspected and protocol for revascularization treatment was performed. Neuroimaging provided no evidence for infarcted tissue or medium-large vascular occlusion but hypothesized a vasculitic involvement of the small vessels of the right hemisphere. Further diagnostics demonstrated a microangiopathic involvement of the heart, kidneys, and lungs. Blood tests showed circulating cryoglobulins and further hematological investigation identified a chronic lymphatic leukemia-like lymphoproliferative disorder. High-dose steroid therapy improved the patient's clinical status and no neurological symptoms remained at discharge. We discuss the clinical-radiologic presentation of a small vessel vasculitis that mimics an LVO stroke. This case focuses on the relevance of concomitant multiorgan manifestations in the hyper-acute evaluation of LVO stroke, suggesting the clinical neurologist should consider alternative etiologies as these could provide important clinical implications.

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

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

Determination of an intracontinental transform system along the southern Central Asian orogenic belt in the latest Paleozoic

Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.

The Utility of Vessel Wall Imaging in the Postulation of Acute Ischemic Stroke With Spontaneous Recanalization Pathophysiology

:Recent advances in technology, particularly in the field of magnetic resonance imaging, have brought forth new sequences, including vessel wall imaging (VWI). Traditionally, the workup for intracranial vascular pathology has always turned to luminal imaging using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Since its introduction, VWI has enabled researchers and practicing clinicians to better understand disease processes and manage patients to the best standard of care possible. Spontaneous recanalization in acute ischemic stroke (AIS) is a known but understudied phenomenon. Available literature has looked at this phenomenon and postulated the occurrence based on conventional cross-sectional imaging and angiography; however, objective evidence pointing to the occurrence of this phenomenon is scarce. We would like to share our experience using VWI in a patient who was clinically suspected to have a middle cerebral artery syndrome at onset, with resolution of the symptoms 3 hours after initial presentation. VWI showed vessel wall enhancement at the suspected vessel involved, with evidence of acute infarcts at the vascular territory supplied. A presumptive diagnosis of AIS with spontaneous recanalization was made. Our experience could potentially aid in the understanding of spontaneous recanalization in patients with AIS, particularly in the postulation of the pathophysiology.

Embolic MCA Stroke Treated With tPA and TICI-3 Mechanical Thrombectomy Complicated by Hemiballismus: A Case Study and Literature Review.

This report examines the etiology of hemiballistic movements that began 24 hours after a 63-year-old male with vascular risk factors received tissue plasminogen activator (tPa) and thrombolysis in cerebral ischemia 3 (TICI3) thrombectomy for a left middle cerebral artery (MCA) ischemic stroke. The clinical course was reviewed from an admission at a large academic institution where assessments included physical exams, head and neck computed tomography angiography (CTA), and head magnetic resonance imaging (MRI) without contrast. The patient's initial physical exam was consistent with a left MCA syndrome and included a National Institute of Health Stroke Scale (NIHSS) of 20. CTA showed an embolic M2 occlusion. After tPA and TICI 3 thrombectomy, NIHSS improved to 3 for dysarthria, facial weakness, and language deficits. MRI showed left insular diffusion restriction. New right-sided hemiballistic movements began 24 hours after treatment. At his six-week follow-up outpatient appointment, the movements were no longer present, and his neurologic exam was unremarkable, including an NIHSS of zero. No prior cases of hemiballism have been reported as a likely complication of treatment with tPa and thrombectomy. The globus pallidus is the suspected origin of the ballistic movements either from a decreased insular signal or embolic event during treatment. As stroke interventions improve, the susceptibility of certain tissues to brief ischemic events during treatment must be assessed.

The Deception of Mass Effect: Subacute Posterior Cerebral Artery Infarction Presenting as a Mimic of Acute Middle Cerebral Artery Syndrome

Clinical data from 3 related cases sheds light on the complex presentation of subacute posterior cerebral artery strokes mimicking acute middle cerebral artery (MCA) syndrome. An expert witness in the field of interventional and diagnostic radiology defended a primary care physician against litigation for an alleged missed diagnosis using multimodality imaging to age a cerebrovascular event. The use of basic computerized tomography and magnetic resonance imaging physics principles are applied to determine whether a patient is outside the treatment window for thrombolytic administration or endovascular intervention. In the defended case, earlier stroke recognition would not have changed the patient’s outcome under question as he was deemed to have a completed infarct prior to presenting to the primary care physician’s (PCP’s) office, making the patient ineligible from acute stroke thrombolytic or endovascular treatment.

Malignant middle cerebral artery syndrome with thrombotic thrombocytopenia following vaccination against SARS-CoV-2.

Cases of thromboses at unusual sites with thrombocytopenia have been reported following vaccination against Sars-CoV-2. This new syndrome, christened vaccine-induced thrombotic thrombocytopenia (VITT), mainly results in venous thromboses. We report the case of a young woman with a right middle cerebral artery stroke following vaccination with ChAdOx1 nCoV-19. A diagnosis of VITT was made and platelet counts began to recover shortly after commencing treatment with argatroban, intravenous immunoglobulins and corticosteroids. On day 6 following admission, the patient deteriorated neurologically and decision made to proceed with decompressive hemicraniectomy. There were no perioperative complications and anticoagulation with argatroban was reinitiated on the first postoperative day. VITT is a rare condition resembling auto-immune heparin-induced thrombocytopenia. All critical care staff should be aware of the rare link between vaccination against SARS-CoV-2 and VITT and the need to rapidly commence both anticoagulation, using heparin alternatives, and immunomodulation.

Non-Ketotic Hyperglycemia Presenting as a Left Middle Cerebral Artery Syndrome in a 68-Year-Old Male (4802)

Non-Ketotic Hyperglycemia Presenting as a Left Middle Cerebral Artery Syndrome in a 68-Year-Old Male (4802)

Measuring the Optic Nerve Sheath Diameter with Ultrasound in Acute Middle Cerebral Artery Stroke Patients

BackgroundMeasurement of the optic nerve sheath diameter (ONSD) with ultrasound enables non-invasive and indirect assessment of increased intracranial pressure (ICP). Although most of the studies were employed with traumatic brain injury patients, it's increasingly popular in acute ischemic stroke (AIS) studies. ObjectivesEvaluating whether using ONSD as a follow-up measurement would help monitor the thrombolytic therapy (TT) effectiveness and determine the high-risk patients for malignant middle cerebral artery (MCA) syndrome. MethodsThis prospective observational study was conducted between August 1, 2019, and February 1, 2020, in a tertiary hospital. Forty-four patients were eligible. We determined the TT moment as the time when the first ocular ultrasound measurement would be made (time 0). Also, we decided on the 24th h after the treatment as the time to perform the second ocular ultrasound measurement (time 24). The National Institute of Health Stroke Scale (NIHSS), the Glasgow Coma Scale (GCS), and the Alberta Stroke Program Early Computed Tomography (ASPECT) scores were evaluated blindly at the time-0 and the time-24. The cut-off value of ONSD was 0.55 mm. ResultsThere was no difference in ONSD results before and after the TT (p = 0.414). But, patients with an equal or higher value than cut-off had an increased risk for complications such as malignant-MCA, bleeding, seizure, etc. (p = 0.05). Malignant-MCA was observed in four patients with higher ONSD values. At the time-24, NIHSS decreased, GCS and ASPECT scores increased. Finally, ONSD was positively correlated with the NIHSS and negatively correlated with the GCS at the time-24. ConclusionsMonitoring ONSD values in both the emergency department and the intensive care unit may be useful in the early diagnosis of MCA stroke complications and the follow-up of TT's effectiveness.

Management of Tumor- and Nontumor-related Aorto-esophageal and Aorto-bronchial Fistulas

This study aims to review and compare the clinical presentation, management, and outcome in patients with tumor-related (TR) and nontumor-related (NTR) aorto-esophageal fistula (AEF) and aorto-bronchial fistula (ABF) with particular focus on the thoracic endovascular aortic repair. We retrospectively reviewed a series of 16 consecutive patients with TR (n=8) and NTR (n=8), ABF (n=6), and AEF (n=10) admitted to our hospital from 2011 to2019. The median age was 62years (range 46-81), with 11 men. The most common predisposing factor was esophageal or gastric cardia cancer (n=6), followed by open repair of the thoracic aorta (n=5). Endoluminal vacuum therapy (Endo-SPONGE®) accounted for 3 cases of AEFs. Thoracic endovascular aortic repair (TEVAR) was applied in 13 patients (4 with ABFs and 9 with AEFs). The primary technical success of the TEVARs was 100%. One patient (8%) was complicated with postoperative middle cerebral artery syndrome and left-sided hemiparesis. The respective in-hospital, 6-month, and 1-year mortality rates were 0% (n=0), 25% (n=2), and 25% (n=2) for the NTR group and 63% (n=5), 88% (n=7), and 100% (n=8) for the TR group. After a mean period of 13months, 5 (31%) patients were still alive, and one patient lost to follow-up after 11months. The survivors (n=5) had all nontumor-related ABF. Progression of underlying cancer and hemodynamic shock were the most common causes of death. TEVAR represents a reliable option in the treatment of NTR ABFs. In the cases of TR fistulas and NTR AEFs, TEVAR should be applied more selectively. The associated mortality remains very high.

Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage

The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients. We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved. IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.

Recombinant Tissue Plasminogen Activator Use in an Acute Stroke Patient With Tuberous Sclerosis

Tuberous sclerosis (TS) is an autosomal dominant disease known for over a century and recognized by characteristic hamartomatous lesions involving any organ. In this report, we are presenting a patient with TS who presented with acute embolic stroke and received tissue plasminogen activator (tPA) and had a mechanical thrombectomy (MT). She had a dramatic response without any hemorrhagic complications. She is a 68-year-old Caucasian woman with the past medical history of TS since childhood who presented to the hospital with symptoms of left middle cerebral artery (MCA) syndrome (right-sided weakness, sensory loss, right facial droop, aphasia, hemianopia, and dysarthria). National Institute of Health Stroke Scale (NIHSS) score was 19. Head computed tomography (CT) was negative for any acute abnormality except cortical tubers, subependymal ventricular calcification. CT angiography of the head and neck showed proximal occlusion of the left internal carotid artery. After ruling out all exclusion criteria, the patient received tPA and had an MT with complete reperfusion (thrombolysis in cerebral infarction (TICI) 3). Brain magnetic resonance imaging (MRI) showed an acute stroke in the multivessel territories (bilateral parietal cortices, the left lentiform nucleus, medial left temporal lobe, left thalamus, and right occipital lobe) suggestive of an embolic phenomenon and did not show any hemorrhagic complication. TS patients are at increased risk of intracerebral hemorrhage either in the setting of vascular malformation or due to hemorrhage into the subependymal giant cell astrocytoma. The best explanation for the latter could be secondary to elevated venous pressure from increased intracranial pressure. Fortunately, our TS patient who presented with acute ischemic stroke was within the window and received tPA and MT. The patient not only did not have any hemorrhagic side effects afterward but also had a significant improvement in her neurologic symptoms. To our best knowledge, this is the only case report of tPA administration in a TS patient. Moreover, we need more case reports to evaluate the safety of tPA in these patients. J Neurol Res. 2020;10(4):140-143 doi: https://doi.org/10.14740/jnr595

Triage of Acute Ischemic Stroke in Confirmed COVID-19: Large Vessel Occlusion Associated With Coronavirus Infection.

The outbreak of COVID-19 has posed a significant challenge to global healthcare. Acute stroke care requires rapid bedside attendance, imaging, and intervention. However, for acute stroke patients who have a diagnosis of or are under investigation for COVID-19, the concern for nosocomial transmission moderates operational procedures for acute stroke care. We present our experience with an in-hospital stroke code called on a COVID-19-positive patient with a left middle cerebral artery syndrome and the challenges faced for timely examination, imaging, and decision to intervene. The outlook for the ongoing COVID-19 pandemic necessitates the development of protocols to sustain timely and effective acute stroke care while mitigating healthcare-associated transmission.

Abstract WP129: The Heat Grading Scale as a Neurovascular Remodeling Based Score in Aneurysms Treated With Flow Diversion

Objective: To apply principles of neurovascular remodeling in the classification of flow diverted aneurysms to predict outcomes using the HEAT (Hemodynamics, Endothelialization and Aneurysmal Thrombosis) grading scale. Introduction: The goal of flow diversion is to exclude an aneurysm from circulation through endothelialization of the aneurysmal neck and hemodynamic induction of aneurysmal thrombosis. Current grading scales do not include the above parameters to evaluate aneurysms after flow diversion. Methods: Reconstructions using 360° virtual reality (VR) models based on volumetric digital subtraction angiography (DSA) scans of unruptured, wide-neck intracranial aneurysms treated with Pipeline™ from March 2010 to May 2018 at our comprehensive stroke center were built using Surgical Theatre ® . The HEAT grading scale was used to generate a 0 to 15-point score that evaluated residual filling (none 0%, entry remnant <5%, subtotal 5-95%, total >95%), stasis phase (persistent contrast at venous phase, clearance before venous phase, arterial clearance before capillary phase), endoleak (absence, presence), free-hanging edge (absent, present without thrombus, present with thrombus), in-stent stenosis (0-29% minimal, 30-49% mild, 50-69% moderate, 70-94% severe, 95-99% critical), and branch filling (complete, partial TICI 2b >50%, partial TICI 2a <50%, insufficient). Each case was assigned a HEAT score by four neurointerventionalists using DSA, CT angiography (CTA), and the VR model. Results: Fifty out of 86 Pipeline™ cases had 3D rotational DSA and met technical standards required to build the VR model. Clinical adverse events including central retinal artery occlusion, middle cerebral artery syndrome, and amaurosis fugax were positively associated with HEAT score (n=3, p=<0.001) as were subclinical adverse events including endoleak (n=2) and free-hanging edge with thrombus (n=2) (p=<0.001). Interrater variability was high (k=0.8). Conclusion: The HEAT grading scale is sensitive, reproducible, and associated with clinical outcome. Larger prospective studies are warranted to validate our results.

Recombinant Tissue Plasminogen Activator Use in an Acute Stroke Patient With Tuberous Sclerosis

Tuberous sclerosis (TS) is an autosomal dominant disease known for over a century and recognized by characteristic hamartomatous lesions involving any organ. In this report, we are presenting a patient with TS who presented with acute embolic stroke and received tissue plasminogen activator (tPA) and had a mechanical thrombectomy (MT). She had a dramatic response without any hemorrhagic complications. She is a 68-year-old Caucasian woman with the past medical history of TS since childhood who presented to the hospital with symptoms of left middle cerebral artery (MCA) syndrome (right-sided weakness, sensory loss, right facial droop, aphasia, hemianopia, and dysarthria). National Institute of Health Stroke Scale (NIHSS) score was 19. Head computed tomography (CT) was negative for any acute abnormality except cortical tubers, subependymal ventricular calcification. CT angiography of the head and neck showed proximal occlusion of the left internal carotid artery. After ruling out all exclusion criteria, the patient received tPA and had an MT with complete reperfusion (thrombolysis in cerebral infarction (TICI) 3). Brain magnetic resonance imaging (MRI) showed an acute stroke in the multivessel territories (bilateral parietal cortices, the left lentiform nucleus, medial left temporal lobe, left thalamus, and right occipital lobe) suggestive of an embolic phenomenon and did not show any hemorrhagic complication. TS patients are at increased risk of intracerebral hemorrhage either in the setting of vascular malformation or due to hemorrhage into the subependymal giant cell astrocytoma. The best explanation for the latter could be secondary to elevated venous pressure from increased intracranial pressure. Fortunately, our TS patient who presented with acute ischemic stroke was within the window and received tPA and MT. The patient not only did not have any hemorrhagic side effects afterward but also had a significant improvement in her neurologic symptoms. To our best knowledge, this is the only case report of tPA administration in a TS patient. Moreover, we need more case reports to evaluate the safety of tPA in these patients. J Neurol Res. 2020;10(4):140-143 doi: https://doi.org/10.14740/jnr595

Management of a wake-up stroke

Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from...

The Management of Acute Ischemic Strokes and the Prevalence of Large Vessel Occlusion in Left Ventricular Assist Device

Background: Ischemic and hemorrhagic strokes are frequent complications among those with left ventricular assist device (LVAD). Scarce data exist regarding the prevalence of acute large vessel occlusion (LVO) and treatment of acute ischemic stroke (AIS) in this setting. Methods: We reviewed prospectively collected data of LVAD patient registry from a single, tertiary center from October 2004 to November 2016. Among those with AIS complications, patients were divided into early stroke (during implantation hospitalization) and late stroke (post-discharge) groups, and neuroimaging was reviewed and data on acute stroke therapy were collected. Results: Of 477 persons with LVAD, 49 (10.3%) AIS occurred. The majority (29/49, 59%) of AIS occurred in-hospital. Thirty-two (65%) persons had international normalized ratios less than 1.7 at the time of AIS, but none qualified to receive acute intravenous thrombolysis. Of 25 (51%) persons who underwent CT angiography (CTA), 33% (16/49) had acute LVOs. Thirty-one percent (5/16) of persons with acute LVOs underwent intra-arterial endovascular therapy. All of 5 cases presented with middle cerebral artery syndrome with a median pre-procedural National Institutes of Health Stroke Scale of 13 (interquartile range 10–18). Successful recanalization was achieved in all 5 cases. Conclusions: In-hospital strokes and acute LVOs are common in LVAD-associated AIS. Prompt evaluation with CTA and endovascular therapy should be pursued for these critically ill patients.

Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers

Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.