Middle Cerebral Artery Territory Infarction Research Articles

Abstract 116: Reversal of Acute Ocular Ischemic Syndrome Following Rescue Carotid Revascularization: A Case Report

Introduction Ocular ischemic syndrome (OIS) is a rare, vision‐threatening condition resulting from severe carotid artery disease secondary to severe atherosclerosis or arteritis. Common clinical features include acute/subacute to gradual vision loss, ocular pain, amaurosis fugax, photophobia and diplopia. We are presenting a case of acute ocular ischemic syndrome secondary to acute re‐occlusion of the right internal carotid artery (RICA) post Carotid Endarterectomy (CEA), that reversed with carotid revascularization. Methods Case Summary: 59‐year‐old male with history of T2DM, hyperlipidemia, tobacco use presented to an outside hospital with complaints of dizziness, blurry vision, left upper extremity weakness and multiple falls with head trauma. Exam revealed left lower quadrantanopia, mild left arm weakness and left hemineglect. Computed Tomography (CT) Head showed scattered right middle cerebral artery (MCA) territory infarcts. CT Angiography (CTA) revealed ulcerated plaque with a small focus of thrombus intraluminally in the RICA. Subsequently, the patient was initiated on heparin infusion and underwent CEA. On postoperative day (POD) 2, the patient experienced severe stabbing right eye pain with reduced visual acuity and worsening of left arm weakness. Imaging revealed complete occlusion of the right common carotid artery (RCCA). Perfusion imaging did not reveal a core or a penumbra. Given acute loss of vision likely secondary to ocular ischemic syndrome, decision was taken to proceed with rescue stenting. Using a transfemoral approach, an 8‐French balloon guide catheter was advanced into the proximal RCCA. A primary suction thrombectomy was performed under proximal flow arrest. After achieving a complete recanalization in one pass, we started the patient on cangrelor 30 mcg/kg intravenous bolus followed by 4 mcg/kg/min infusion. Post bolus, we placed a tandem closed‐cell carotid stent measuring 8x36mm & 10x37mm. The patient reported immediate relief of ocular pain, vision and weakness following the procedure. He transitioned from cangrelor infusion to ticagrelor 90 mg twice daily and aspirin 81 mg daily. On post‐stenting day 7, the patient experienced acute onset headache, and imaging revealed re‐occlusion of the entire carotid artery sparing only the ophthalmic segment of the RICA which now filled retrograde via anterior communicating artery (AcoA) from the contralateral carotid artery. However, his visual acuity remained unchanged and reported no ocular pain. At one month follow‐up the patient remains symptom‐free. Results Discussion: Incidence of OIS is estimated to be 7.5 cases per million every year. Carotid artery atherosclerosis is the most common etiology. Majority of OIS (∼90%) present with gradual vision loss and approximately 40% present with ocular pain. Gradual vision loss is predominantly related to chronic ocular hypoperfusion and resultant iris neovascularization and glaucoma. In this case, patient suffered acute vision loss secondary to acute ICA occlusion following CEA. Emergent carotid revascularization resulted in restoration of vision and resolution of ocular pain. Conclusion Our main goal is to emphasize the importance of rescue stenting to address symptoms of aOIS. Immediately post‐stenting, there was remarkable improvement in ocular pain and visual acuity. Although, the carotid re‐occluded within seven days post‐stenting, we hypothesize that gradual re‐occlusion while on DAPT provided enough time recruit and preserve collaterals into the right ophthalmic artery via retrograde flow into the ophthalmic segment of RICA from the contralateral carotid artery via the AcoA which was subsequently confirmed on imaging.

Right Middle Cerebral Artery Infarct after Minor Head Trauma in an Infant

Ischemic stroke (IS) in the pediatric population is extremely rare. In this age group, the occurrence of IS often concurs with underlying congenital heart disease, haematological, metabolic or immunological conditions. In contrast, the association between IS and minor head injury in children has been sparse. The authors report a case of a healthy 10 yrs 8 months old male who was found to have a right middle cerebral artery territory infarct. An extensive medical workup was performed, and it was negative for any previously undiagnosed comorbidities. Given the paucity of such cases, the condition and its management are discussed in corroboration with current literature.

Tuberculosis Related Ischemic Stroke : A Case Report

Tuberculosis (TB) is a widespread infectious disease caused by Mycobacterium Tubercle Bacilli. In 15-20 % cases of active pulmonary TB, infection spreads to extrapulmonary foci, including the nervous system complications. Ischemic stroke related tuberculosis without meningitis is rare. We report a 74-year-old female presented with rapid onset confusion, unconsciousness, and left hemiparesis. She had been recently diagnosed with active TB 3 months ago and treated with combination anti tuberculosis regiment. Her recent acute neurological manifestations began within 24 hours prior to admission in the hospital. The brain CT showed middle cerebral artery territory infarction. The risk factors tracing found no significant abnormality. The only abnormal finding was high CRP. This report describes rare case of a patient with active TB and who presented with acute ischemic stroke.

Neural Injury of the Dopaminergic Pathways in Patients with Middle Cerebral Artery Territory Infarct: A Diffusion Tensor Imaging Study

The mesocortical tract (MCT) and mesolimbic tract (MLT), dopaminergic pathways originating from the ventral tegmental area in the midbrain to the ventral striatum (nucleus accumbens) and prefrontal cortex, play a crucial role in regulating incentive salience. This study aimed to investigate the potential changes in the MCT and MLT pathways following ischemic stroke, such as middle cerebral artery (MCA) infarction. We enrolled thirty-six patients with MCA infarction and forty healthy individuals with no history of psychiatric or neurological disorders. Using diffusion tensor tractography, we examined the injury to the affected and unaffected MCT and MLT pathways in patients with MCA infarction, comparing them to the control group. Our findings revealed a significant difference in the mean values of fractional anisotropy (FA) and tract volume (TV) of the MCT and MLT pathways between the patient and control groups (p < 0.05). Specifically, the mean FA of the MCT and MLT showed a decrease of 7.94% and 6.33%, respectively, in the affected side compared to the control group (p < 0.05). Similarly, the mean TV of the MCT and MLT showed a decrease of 73.22% and 78.79%, respectively, in the affected side compared to the control group (p < 0.05). These changes were significantly different from those of the unaffected MCT, MLT, and control groups (p < 0.05). Our study suggests that MCA infarction can cause significant damage to the affected MCT and MLT pathways, potentially contributing to our understanding of the pathophysiology of post-stroke depression.

Reply to Commentary on "Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction&quot.

See the reply "Pituitary apoplexy in an adolescent male with macroprolactinoma presenting as middle cerebral artery territory infarction" on page 320.

Successful Treatment of a COVID 19-Associated Multisystem Thrombotic Event in a Young Patient in a Neurocritical Care Unit

AbstractThis case report describes a young patient with no comorbidities, who presented with two systemic thrombotic events within 24 hours of admission. She presented with a right middle cerebral artery territory infarct and developed an inferior wall myocardial infarction soon after. The hypotension was refractory to inotropes and required emergency intra-aortic balloon pump insertion. She was evaluated for prothrombotic states and other causes of stroke in young. However, the workup for the same was negative. Coronavirus disease-2019 immunoglobulin G antibody titer and inflammatory markers were found to be extremely elevated, which suggested recent severe infection. This case report throws light on the multidisciplinary management of thrombotic events, most probably secondary to coronavirus infection.

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

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

Early surgical versus endovascular repair of ruptured blood-blister aneurysm of the internal carotid artery: a single-center 20-year experience.

Early repair of ruptured blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) remains challenging. Although both surgical and endovascular therapies have been established, their relative superiority remains debated. The authors assessed their single-center experience and compared early deconstructive versus reconstructive repair and early reconstructive surgical versus endovascular repair of ruptured BBAs of the ICA. The study included patients who underwent repair of ruptured BBAs of the ICA within 1 week after the ictus during a 20-year period. Multiple variables were recorded, including clinical state, severity of subarachnoid hemorrhage (SAH), characteristics of the BBA, treatment details, complication profile, need for secondary treatment, and clinical outcome. In total, 27 patients underwent early surgical (n = 16) or endovascular (n = 11) repair of BBAs at a median of 24 hours (range 9-120 hours) after the ictus during the period from September 2000 to June 2021 (20.4 years). Primary deconstructive repair (n = 6) without bypass was accompanied by middle cerebral artery (MCA) territory infarction in 5 of 6 (83%) patients and a high mortality rate (4/6 [67%]). Among the 21 patients who underwent early reconstructive repair, surgery was performed in 11 patients (clipping in 6 and clip-wrapping in 5 patients) and endovascular repair in 10 patients (flow diversion in 7 and stent/stent-assisted coiling in 3 patients). No differences were found in complication profiles or clinical outcomes between the surgical and endovascular groups. The mortality rate was low (2/21 [9.5%]), with 1 fatality in each group. From the authors' experience, both surgical and endovascular approaches permitted reconstructive repair of ruptured BBAs of the ICA, with no modality proving superior. Reconstructive treatment is preferable to ICA sacrifice, and if sacrifice is chosen, it should be accompanied with bypass surgery or delayed to the phase when cerebral vasospasm has resumed. The rare occurrence of this disease calls for prospective multicenter studies to improve treatment and delineate which modality is preferable in individual cases.

Thromboembolism from Carotid Web.

HomeRadiologyVol. 306, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyThromboembolism from Carotid WebNoel F. Fanning , Brian J. ManningNoel F. Fanning , Brian J. ManningAuthor AffiliationsFrom the Departments of Neuroradiology (N.F.F.) and Vascular Surgery (B.J.M.), Cork University Hospital, Wilton, Cork, Ireland.Address correspondence to N.F.F. (email: [email protected]).Noel F. Fanning Brian J. ManningPublished Online:Nov 15 2022https://doi.org/10.1148/radiol.221504MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 26-year-old woman presented with 5 hours of acute right neck pain and left arm weakness after exercising. At examination, her National Institutes of Health Stroke Scale score was 3, indicating mild deficits. MRI scans showed a right middle cerebral artery (MCA) infarct (Figure, A), and CT head angiogram showed a right MCA occlusion (not shown in Figure). The patient did not receive thrombolytic therapy due to time from symptom onset. She was transferred to a comprehensive stroke center for further management. Subsequent CT head angiogram showed spontaneous recanalization of the right MCA occlusion (not shown in Figure). CT carotid angiogram revealed shelf-like protrusion from the dorsal aspect of the internal carotid artery just beyond the bifurcation, diagnostic of a carotid web (Figure, B). A carotid endarterectomy (CEA) was performed, showing a firm pale protrusive web from the dorsal internal carotid artery (Figure, C) matching the CT angiogram appearance. Histologic findings showed spindle cells and myxoid degeneration (Figure, D) and no features of atherosclerotic plaque.Images in a 26-year-old woman with acute stroke symptoms. (A) Axial diffusion-weighted MRI scan shows an acute right middle cerebral artery territory infarct. (B) Sagittal CT right carotid angiogram shows a shelf-like protrusion from the dorsal aspect of the internal carotid artery (ICA) just beyond the bifurcation (arrow), diagnostic of a carotid web. (C) Intraoperative photograph shows the opened right ICA with a firm pale protrusive web from the dorsal ICA (arrow) matching the CT angiogram appearance. The asterisks in B and C indicate the external carotid artery for orientation. (D) Hematoxylin and eosin stain of the web show myxoid degeneration (arrow) and no features of atherosclerotic plaque.Download as PowerPointOpen in Image Viewer This patient example illustrates the appearance of carotid webs, an underrecognized cause of stroke. Carotid webs represent an intimal variant of fibromuscular dysplasia. In patients presenting with large vessel occlusions, carotid webs are seen in 1% of cases ipsilateral to the index ischemic stroke. Recurrent stroke occurs in 17% of patients with symptomatic carotid webs within 2 years, despite medical management, compared with 3% recurrence rate without carotid webs (1). Optimal management strategies for carotid webs are yet to be defined. Medical management, carotid endarterectomy, or carotid stenting should be considered as part of a multidisciplinary discussion. The patient has remained well 8 months after CEA, with no residual deficits or recurrent stroke symptoms.Disclosures of conflicts of interest: N.F.F. No relevant relationships. B.J.M. No relevant relationships.

Biallelic Deleterious Germline SH2B3 Variants Cause a Novel Clinical Syndrome of Myeloproliferation and Multi-Organ Autoimmunity

SH2B3 is a negative regulator of cytokine receptor signalling pathways in hematopoietic tissue. Acquired deleterious SH2B3 variants resulting in increased JAK/STAT signalling are observed in myeloproliferative neoplasms (MPN) however the clinical implications and phenotype of deleterious germline variants in SH2B3 are less clear. A single consanguineous kindred has been previously described with homozygous deleterious germline SH2B3 variants presenting with hepatosplenomegaly, autoimmune hepatitis, developmental delay, autoimmune thyroiditis and acute lymphoblastic leukemia (Perez-Garcia, A., et al, Blood, 2013), however a clinically valid gene-disease pair according to formal criteria has not been met to date for SH2B3. We identified two probands from unrelated kindred with germline homozygous deleterious SH2B3 variants. The first patient presented with splenomegaly, thrombocytosis, neutrophilia and a leukoerythroblastic blood film at 3 months old. He developed alopecia areata at 2 years and autoimmune hypothyroidism at 6 years. He was otherwise developmentally normal without any detected liver abnormalities or thrombotic episodes. Whilst his splenomegaly and neutrophil count gradually improved throughout life, his platelet count remained markedly elevated (~1000x109/L at 18 years of age). Targeted NGS identified a homozygous frameshift variant in SH2B3 (NM_005475.3:c.441_468del; p.(Arg148Profs*40)). Both parents were heterozygous carriers of this variant. The second patient was a male born to consanguineous parents and noted shortly after birth to have isolated splenomegaly. He was diagnosed with autoimmune hypothyroidism and Raynaud syndrome at 12 years and was noted to have a persistent thrombocytosis ranging from 550 - 780 x109/L. He developed autoimmune hepatitis and insulin dependent diabetes at 17 years and around the same time he also suffered a right-sided middle cerebral artery territory infarct with a right carotid artery thrombus. Whole genome sequencing detected a homozygous missense variant in SH2B3 (NM_005475.3:c.1204G>A; p.(Val402Met)) in the patient with both parents being heterozygous carriers. In order to understand these variants further we modelled the human p.(Arg148Profs*40) variant from patient 1 in zebrafish. CRISPR-Cas9 gene editing was targeted to the analogous region of zebrafish sh2b3 to create assorted carboxyl-truncating mutations in F0 crispants. On-target gene-editing was verified by Sanger sequencing and NGS. F0 crispants had a significantly increased number of macrophages and CD41-expressing cells (HSCs and thrombocytes), replicating the patient phenotype. Treatment of the sh2b3 crispant fish with the JAK inhibitor ruxolitinib intercepted the myeloproliferative phenotype. The myeloproliferative phenotype was not observed in stable deletion mutants, likely reflecting genetic compensation not present in crispants. Skin-derived fibroblasts from patient 2 who carried the Val402Met homozygous variant, showed increased phosphorylation of JAK2, STAT5 and STAT3 by immunoblotting after stimulation with IL3, GH, GM-CSF and EPO compared to healthy controls. In conclusion, these newly described kindreds showing striking phenotypic similarity to each other as well as the previously described kindred and in conjunction with our functional data provide sufficient evidence for biallelic homozygous deleterious variants in SH2B3 to be considered a valid gene-disease association with a clinical syndrome of bone marrow myeloproliferation and multi-organ autoimmune manifestations. Notably, neither of our patients had evidence of acute lymphoblastic leukemia or overt hematological malignancy and further affected individuals will need to be described in order to fully understand the breadth of the phenotype. Moreover, our data supports ruxolitinib as being a potential therapeutic option for patients with this rare novel immune dysregulatory syndrome.

An observational and cross-sectional study on prevalence of cognitive impairment and short-term changes in cognitive function after ischemic stroke in a tertiary care hospital

Background: Stroke is a leading cause physical and cognitive disability. Aims and Objectives: The aims of this study were to investigate the prevalence and pattern of cognitive impairment (CI) after first-ever ischemic stroke. Materials and Methods: Sixty subjects with first-ever ischemic strokes, confirmed by magnetic resonance imaging (MRI), were selected. Their clinic-diagnostic and comorbidity data were collected. Mini mental state examination (MMSE) was done after 3–7 days on each patient. MRI was used to ascertain the side, vascular territory, extent, and neural tissues (cortical/subcortical) involved. CIs were categorized as normal, mild, and moderate-to-severe according to MMSE scores ≥ 24, 18–23, and 0–17, respectively. Data were summarized as mean±standard deviation (SD) for numerical variables and counts and percentages for categorical variables. Results: (1) Elderly (61–70 years), male and higher educated patients were more prevalent, hypertension (HTN) was the most common comorbidity. (2) Subcortical, middle cerebral artery (MCA), and anterior cerebral artery (ACA) lesions and non-dominant side involvement were common. (3) 80% patients had CI (65% mild and 15% moderate-to-severe). (4) CI was the most common in patients aged 71–80 years, of lower educational status and having both diabetes and HTN. MCA territory strokes and non-dominant side involvement resulted in more moderate/severe CI. (5) Registration followed by recall was least affected whereas language and praxis were more affected domains. Conclusion: Post-stroke cognitive decline is more common in elderly population and patients with lower education. CI is more in people with HTN and DM and in people with MCA territory infarct. Language and praxis were the most affected domain of all.

Examining the Role of Magnetic Resonance Imaging (MRI) in Cerebral Ischemic Stroke: A Cross-Sectional Study

Objective: The aim of this study is to examine the role of Magnetic Resonance Imaging (MRI) when detecting cerebral ischemic stroke. Study design: A cross-sectional study Place and Duration: This study was conducted at Sandeman Provincial Hospital/ Bolan medical complex hospital Quetta, Quetta from March 2021 to March 2022 Methodology: Age and gender distribution of infarcts was done to find out the territory and location of the blood vessels involved. Overall, 52 individuals were involved in this research. Every patient was clinically suspected to have a cerebral ischemic stroke during the time span of our research. HDXT software with 1.5 Tesla 16 channel GE was used to perform the MRI scans. FLAIR axial, T1WI axial, T2WI axial and coronal, ADC maps, and gradient echo axial were the sequences used. SWI was optional. Results: The age group which was above 60 years included more percentage of males than females. It was seen that in the age group above 60 years, infarction was the most common and hypertension was the most common risk factor. Hemiplegia (Weakness) was seen to be the most common clinical presentation. It was seen that middle cerebral artery (MCA) territory infarcts had a slight rise on the right side. On the diffusion-weighted imaging (DWI), restricted diffusion was seen from subacute as well as acute infarcts along with a low apparent diffusion coefficient (ADC)valves. T2 FLAIR was normal in acute infarcts, but changes were reflected by DWI. Practical implication : Expanding the rationale for acute stroke thrombolysis may be more rationally accomplished by comprehending the clinical implications of numerous valuable MRI findings and thoroughly incorporating those factors into treatment decision-making. Conclusion: No radiation hazard is seen in MRI and it is non-invasive. The multiplanar imaging ability and grey-white resolution of the MRI perceive the subtle lesions. Infarcts are detected early due to the sensitivity of MRI to altered water content. Keywords: magnetic resonance imaging, stroke, cerebral infarcts,

Prediction of the gait function using the nigrostriatal and corticoreticulospinal tracts of the affected hemisphere in a cerebral infarct: A diffusion tensor imaging study.

Prognosis predictability of the nigrostriatal tract (NST) and corticoreticulospinal tract (CRT) of affected hemisphere at early stage for gait function at chronic stage were investigated using diffusion tensor tractography (DTT) in patients with a cerebral infarction.Thirty consecutive patients with middle cerebral artery (MCA) territory infarction were recruited. Functional ambulation category (FAC) was used to evaluate the gait function at chronic stage. Fractional anisotropy (FA) and tract volume (TV) of ipsilesional NST and ipsilesional CRT were determined to be DTT parameters at early stage.FAC score at chronic stage showed strong positive correlations with TVs of ipsilesional NST and ipsilesional CRT at early stage (ipsilesional NST R = 0.786; ipsilesional CRT R = 0.821; P < .05). According to regression model, FAC score at chronic stage was positively related to TVs of ipsilesional NST and ipsilesional CRT at early stage (Adjusted R2 = 0.700, F = 34.905, P < .05). FAC score at chronic stage was associated more positively with TV of ipsilesional CRT (β = 0.532) than that of ipsilesional NST (β = 0.362).Ipsilesional NST and ipsilesional CRT at early stage had prognosis predictability for gait function at chronic stage in patients with an MCA infarction. Moreover, ipsilesional CRT had stronger predictability than ipsilesional NST.

Blood flow and perfusion lateralization in border zone infarct using 4D flow and arterial spin labeling.

Hemodynamics may play an important role in border zone infarct (BZI), but macroscopic and microscopic hemodynamics of BZI still remain unclear. This study aims to investigate arterial flow and tissue perfusion differences between BZI and non-BZI in patients with unilateral middle cerebral artery (MCA) territory infarcts. Subacute ischemic stroke patients with unilateral infarcts at MCA territory were included. Imaging protocols included 4D flow, ASL (arterial spin labeling), and routine clinical brain MRI scan. A total of 56 patients (56.1 ± 11.9years, 39 male) were included and divided as BZI (n = 26) and non-BZI (n = 30). BZI was further subdivided as cortical BZI (CBZI, n = 9), internal BZI (IBZI, n = 11), and mixed BZI (n = 6). Average blood flow (Flowavg), regional average cerebral blood flow (CBFavg) were compared between infarct and contralateral sides to test hemodynamic lateralization. Flow-index and CBF-index (infarct sides/contralateral sides) were compared between groups and subgroups. Flowavg and CBFavg showed significant lateralization in both BZI and non-BZI as well as CBZI and IBZI. Flow-index (0.51 ± 0.37 vs. 0.87 ± 0.36, p < 0.01) and CBF-index (0.70 ± 0.21 vs. 0.90 ± 0.19, p < 0.01) were significantly different between BZI and non-BZI but were not significantly different between CBZI and IBZI. In summary, hemodynamic lateralization can occur in subacute stroke patients with BZI and non-BZI and the one that occurs in BZI tends to be more severe in view of arterial flow and tissue perfusion.

Cognitive Profile of Large-Vessel Vascular Dementia-An Observational Study from a Tertiary Care Center in Kolkata.

Introduction Vascular dementia is the second leading cause of dementia worldwide. Its heterogenous presentation along with potential for reversibility at earlier stages makes it unique among all dementias. Objectives We aimed to study the cognitive dysfunction in large-vessel vascular dementia. Second, we tried to study the cognitive dysfunction in large-vessel vascular dementia as per the arterial territory involvement. Additionally, we also tried to study the contribution of hemispheric involvement to the dementia severity as evidenced by clinical dementia rating (CDR) scale. Materials and Methods We recruited 28 patients of large-vessel vascular dementia and categorized them on the basis of the arterial territories and hemisphere involved. The groups were later studied for the type of cognitive and behavioral dysfunctions as well as the dementia severity. Results Among 28 patients of large-vessel vascular dementia, attention (100%), executive function (100%), and behavior (100%) were more impaired in anterior cerebral artery territory infarcts ( p < 0.05). Language (53.8%) and memory (53.8%) were more impaired in middle cerebral artery territory infarcts, while visuoperceptual (33.3%) domains were more impaired in posterior cerebral artery territory infarcts ( p > 0.05). The mean CDR was lower in patients of right-sided lesions (1.292) than in those with left-sided (1.750) or bilateral lesions (2.000). Conclusion Different arterial territory lesions have different patterns of cognitive impairment in large-vessel vascular dementia. The dementia severity is less in right-sided lesions when compared with left-sided or bilateral lesions.

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.

Risk of Incident Epilepsy After a Middle Cerebral Artery Territory Infarction.

BackgroundAmong poststroke morbidities, poststroke epilepsy (PSE) has been identified as a significant clinical issue. Although middle cerebral artery (MCA) infarct is the most common type of stroke among all vascular territories, very few studies specifically focused on the risk factors leading to PSE in patients with MCA infarct.MethodsA population study in Taiwan has been conducted, linking the National Health Insurance Research Database and Hospital Stroke Registry, from 2001 to 2015 and 2006 to 2010, respectively. Patients were divided into MCA and non-MCA groups, and the diagnosis of incident epilepsy between the groups has been compared. The multivariable Cox proportional hazard model was used to identify the risk factors for developing PSE. The distribution of time to PSE was estimated using the Kaplan–Meier method.ResultsIn total, 1,838 patients were recruited, with 774 and 1,064 in the MCA and non-MCA groups, respectively. PSE incidence in the MCA group was 15.5% vs. 6.2% in the non-MCA group, with a hazard ratio of (95% CI) 2.06 (1.33–3.19). Factors significantly associated with PSE included atrial fibrillation, depression, National Institutes of Health Stroke Scale (NIHSS) scores of ≥ 16, and alert on arrival. For patients with MCA infarct, higher NIHSS and Glasgow coma scale scores, the presence of visual field defects and weakness, urination control impairment, and complications during hospitalization were associated with a higher risk for PSE development.ConclusionsThis study established the conditions leading to a higher risk of PSE and identified the important clinical risk factors in patients experiencing MCA infarct. Efforts to manage these risk factors may be important in preventing PSE in patients with MCA infarct.

Redefining the upper age limit of decompressive craniectomy surgery for malignant middle cerebral artery infarct

Background: Decompressive craniectomy is an effective treatment for malignant middle cerebral artery (MCA) territory infarct. But the age limit for surgery is not well defined. The time window of the surgery is considered less than 96 hours.Methods: This retrospective study of 60 patients of MCA territory infarct who underwent decompressive craniectomy surgery is selected in this study and using modified Rankin score.Results: In this study 36 patients were less than 60 years and were above 60 years. 38 patients were right sided and 22 were left sided MCA infarct. Out of 60 patients, 22 patients were operated within 48 hours of onset of symptoms and 38 were operated between 48 to 96 hours. 49% patients operated within 48 hours had modified Rankin score (mRS) 0–3 at 3 months follow up while only 37% patients operated after 48 hours had mRS 0–3 at 3 months follow up.Conclusions: Decompressive craniectomy in malignant MCA infarction can reduce the case fatality rate but the favorable outcome is questionable. Hence the surgical decision should depend on social and patient factors.

High-Resolution Intracranial Vessel Wall MRI Findings Among Different Middle Cerebral Artery Territory Infarction Types.

ObjectiveIntracranial atherosclerotic stroke occurs through various mechanisms, mainly by artery-to-artery embolism (AA) or branch occlusive disease (BOD). This study evaluated the spatial relationship between middle cerebral artery (MCA) plaques and perforating arteries among different MCA territory infarction types using vessel wall magnetic resonance imaging (VW-MRI).Materials and MethodsWe retrospectively enrolled patients with acute MCA infarction who underwent VW-MRI. Thirty-four patients were divided into three groups according to infarction pattern: 1) BOD, 2) both BOD and AA (BOD-AA), and 3) AA. To determine the factors related to BOD, the BOD and BOD-AA groups were combined into one group (with striatocapsular infarction [BOD+]) and compared with the AA group. To determine the factors related to AA, the BOD-AA and AA groups were combined into another group (with cortical infarction [AA+]) and compared with the BOD group. Plaque morphology and the spatial relationship between the perforating artery orifice and plaque were evaluated both quantitatively and qualitatively.ResultsThe plaque margin in the BOD+ group was closer to the perforating artery orifice than that in the AA group (p = 0.011), with less enhancing plaque (p = 0.030). In the BOD group, plaques were mainly located on the dorsal (41.2%) and superior (41.2%) sides where the perforating arteries mainly arose. No patient in the AA group had overlapping plaques with perforating arteries at the cross-section where the perforator arose. Perforating arteries associated with culprit plaques were most frequently located in the middle two-thirds of the M1 segment (41.4%). The AA+ group had more stenosis (%) than the BOD group (39.73 ± 24.52 vs. 14.42 ± 20.96; p = 0.003).ConclusionThe spatial relationship between the perforating artery orifice and plaque varied among different types of MCA territory infarctions. In patients with BOD, the plaque margin was closer and blocked the perforating artery orifice, and stenosis degree and enhancement were less than those in patients with AA.

Early Prediction of Malignant Edema After Successful Recanalization in Patients with Acute Ischemic Stroke.

Postinterventional cerebral hyperdensities are common on non-contrast-enhanced computed tomography (CT) after endovascular thrombectomy in patients with acute ischemic stroke, which may reflect blood-brain barrier damage. The disruption of the blood-brain barrier may lead to malignant brain edema. The relationship between the extent of postinterventional cerebral hyperdensities and malignant brain edema is unclear. Patients with middle cerebral artery territory infarction and successful recanalization were consecutively enrolled. Postinterventional non-contrast-enhanced CT was performed to evaluate postinterventional cerebral hyperdensities within 24h after endovascular thrombectomy. On the basis of the areas of the Alberta Stroke Program Early CT Score, we devised the Hyperdensity on CT Score to evaluate the extent of postinterventional cerebral hyperdensities. The primary outcome was malignant brain edema, defined as the development of clinical signs of herniation (including a decrease in consciousness and/or anisocoria), accompanied by imaging evidence of brain swelling. The component of postinterventional cerebral hyperdensities was divided into contrast staining and hemorrhage on the basis of persistency. Three hundred sixty patients were included (50.6% male, mean age 67.9years), of whom 247 (68.6%) developed postinterventional cerebral hyperdensities and 66 (18.3%) developed malignant brain edema. After adjustment for confounders, including the component of postinterventional cerebral hyperdensities, the extent of postinterventional cerebral hyperdensities assessed by the Hyperdensity on CT Score was significantly associated with malignant brain edema (odds ratio 1.46, 95% confidence interval 1.20-1.77, p < 0.001). A Hyperdensity on CT Score greater than 3 had a sensitivity of 0.73 and a specificity of 0.87 for predicting malignant brain edema. The extent of postinterventional cerebral hyperdensities on postinterventional non-contrast-enhanced CT was associated with malignant brain edema. The Hyperdensity on CT Score could be used to predict malignant brain edema regardless of the component of postinterventional cerebral hyperdensities.