Middle Cerebral Artery Territory Research Articles

Assessing donor-recipient arterial pressure dynamics in STA-MCA bypass for moyamoya disease

BackgroundIn bypass surgery for moyamoya disease (MMD), the superficial temporal artery’s (STA) pressure needs to surpass that of the cortical M4 recipient of the middle cerebral artery (MCA), boosting cerebral blood flow into the MCA and enhancing cerebral circulation. This study investigates the STA-MCA arterial pressure parameters and gradients during bypass surgery, aiming to deepen our understanding of hemodynamic shifts pre- and post-operation.MethodsDSA imaging data were prospectively collected from patients diagnosed with bilateral MMD who underwent STA-MCA bypass surgery between 2022 and 2023 and stratified according to the Suzuki stage. The mean arterial pressure (MAP) of the donor and recipient arteries was directly measured during the STA-MCA bypass procedure, and these data were statistically analyzed and evaluated.ResultsAmong 48 MMD patients, Suzuki grading revealed that 43.8% were in early stages (II and III), while 56.2% were in advanced stages (IV, V, and VI). Predominantly, 77.1% presented with ischemic-type MMD and 22.9% with hemorrhagic type. Pre-bypass assessments showed that 62.5% exhibited antegrade blood flow direction, and 37.5% had retrograde. The mean recipient artery pressure was 35.0 ± 2.3 mmHg, with a mean donor-recipient pressure gradient (δP) of 46.4 ± 2.5 mmHg between donor and recipient arteries. Post-bypass, mean recipient artery pressure increased to 73.3 ± 1.6 mmHg. No significant correlation (r = 0.18, P = 0.21) was noted between δP and Suzuki staging.ConclusionOur study elucidated that cerebral blood pressure significantly decreases beyond the moyamoya network at the distal M4 segment. Furthermore, we observed bidirectional flow in MCA territories and a significant positive pressure gradient between the STA and M4 segments. The lack of correlation between Suzuki stages and M4 pressures indicates that angiographic severity may not reflect hemodynamic conditions before surgery, highlighting the need for customized surgical approaches.

Homolateral Embolic Stroke After Emergency Ligation of the Common Carotid Artery to Stop Heavy Bleeding Caused by Carotid Blowout Syndrome.

Emergency common carotid artery (CCA) ligation for bleeding control during carotid blowout syndrome with consecutive embolic stroke has been reported rarely. The patient is a 70-year-old man, who was suffering from acute profuse bleeding from the left superior thyroid artery into the piriformis sinus, which was not controlled other than by ligation of the left CCA. The cause of the bleeding remained unclear but was suspected to be related to his history of being positive for squamous cell carcinoma of the left hypopharynx with ari and postcricoid infiltration, diagnosed at age 58. Squamous cell carcinoma was treated with local resection, chemotherapy (docetaxel, carboplatin, and cetuximab), and radiotherapy. Neurological examination 4 days after CCA ligation revealed multiple subacute embolic strokes in the territory of the left middle cerebral artery, macroangiopathy of the extra and intracranial cerebral arteries, and hypoplasia of the left vertebral artery. This case demonstrates that carotid blowout syndrome may require CCA ligation when external carotid artery ligation is not possible, and that ligation can be complicated by an asymptomatic embolic stroke.

Characteristics of Atherosclerotic Plaques and Stroke Mechanism in Patients with Border-Zone Infarcts: A High-resolution Magnetic Resonance Imaging Study

BackgroundRelatively little is known about the plaque characteristics of border-zone infarcts and how they differ between cortical border-zone (CBZ) and internal border-zone (IBZ) infarcts. MethodsWe conducted a prospective observational cohort study of patients of intracranial atherosclerotic disease who underwent high-resolution magnetic resonance imaging (HR-MRI) examination. Individuals with border-zone infarcts in the middle cerebral artery (MCA) territory, detected by diffusion-weighted imaging, were enrolled. Plaque morphological and compositional parameters of both IBZ and CBZ groups were compared. Independent predictors were identified using a binary logistic regression model, and the sensitivity and specificity of the model were assessed using a receiver operating characteristic curve. Kaplan-Meier survival analysis further explored differences in stroke recurrence between BZ patients with mono or dual antiplatelet therapy. ResultsWe reviewed 101 symptomatic patients with border-zone infarcts (BZ) within the MCA territory in the study. Out of the patients meeting the imaging eligibility criteria, we detected 34 cases with isolated IBZ, 23 cases with isolated CBZ, and 6 cases with both IBZ and CBZ infarcts. Those with IBZ infarcts had a higher plaque burden than those without (p<0.001), and those with CBZ infarcts exhibited a complicated plaque less frequently than those without (37.9% vs 67.6%, p=0.018). In those with isolated IBZ or CBZ infarcts, plaque burden was independently associated with isolated IBZ infarcts (odd ratio=1.08; 95% CI, 1.02-1.15; p=0.023). During the median follow-up period of 37 (27, 50) months, 13.8% of patients receiving early dual antiplatelet treatment and 30.4% of those on single antiplatelet therapy experienced stroke recurrence (p=0.182). ConclusionsIntracranial atherosclerotic plaque morphology and composition differ between patients with IBZ and those with CBZ infarcts. Higher plaque burden is more associated with IBZ infarcts.

319 A Case Series of Direct Multi-territory Cerebral Revascularizations Using a Three-Vessel Anastomosis

INTRODUCTION: The ability to perform simultaneous, multi-territory cerebral bypass using a single interposition graft has significant utility for the revascularization of multiple cerebral territories that would otherwise require multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. METHODS: Peri-operative data and outcomes were collected retrospectively for patients undergoing multi-territory cerebral revascularization using a three-vessel anastomosis over a 4-year period (2019-2023). RESULTS: Five patients underwent triple vessel bypass (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery (MCA) aneurysms (one ruptured) were treated multi-territory external carotid artery (ECA)-M2-M2 revascularization using a saphenous vein interposition graft, followed by either proximal ligation or partial/complete aneurysm clip trapping. Two patients with predominately bilateral anterior cerebral artery (ACA) territory moyamoya disease were treated with proximal superficial temporal artery (STA)-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap (RAFF) graft. Bypass patency was 100% and zero patients experienced surgery-related ischemia. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for a post-operative hematoma and RAFF debridement that did not affect bypass patency or neurologic outcome. Median Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores on discharge were 4 (range 3-5) and 2 (range 0-5), respectively. GOS and mRS scores were stable or improved on follow up in 4/5 patients; one patient died from medical complications of their original stroke. CONCLUSIONS: In experienced hands, three-vessel anastomosis can be a viable option for the safe, simultaneous revascularization of multiple ACA and MCA territories.

Ruptured pial-pial collateral aneurysm associated with left internal carotid artery occlusion: nuances of surgical management. Illustrative case.

Carotid occlusion often leads to the formation of a collateral network. On rare occasions, due to hemodynamic influence, aneurysms can occur. Here, the authors describe a 69-year-old male presenting with intracerebral hemorrhage secondary to a ruptured aneurysm within such a network. The patient presented to the emergency department with an altered level of consciousness. Imaging showed a left temporal lobe hemorrhage extending into the ventricle, subdural hematoma, and evidence of contrast extravasation. Digital subtraction angiography revealed an occluded left internal carotid artery with the left middle cerebral artery territory reconstituted by flow through an external carotid artery-internal carotid artery anastomosis. The latter was formed by the superficial temporal artery-superior orbital artery, as well as pial-pial collaterals from the posterior temporal artery. Notably, a 4-mm aneurysm arising from the pial-pial collateral network was identified. Surgical intervention involved a left temporal craniectomy and aneurysm excision, with special attention paid to preserving the anastomotic flow through the superficial temporal artery. This case underscores the importance of recognizing and preserving collateral vascular pathways in cases of carotid occlusion with an associated aneurysm. It emphasizes the necessary balance between managing aneurysm risk and maintaining cerebral perfusion, highlighting the need for careful preoperative planning and intraoperative caution.

Crossed Aphasia without Hemiparesis in a Dextral: A Case Report

Introduction:: Aphasia, also known as language impairment, is a condition that affects the ability to express and understand language, as well as the ability to communicate. Crossed Aphasia in Dextral (CAD) is defined as aphasia after a right hemispheric stroke. Usually, aphasia is caused by a left-sided stroke in right-handed individuals. The prevalence of crossed aphasia in right-handed individuals is 0.38% to 3%. CAD is diagnosed when the following factors are present: aphasia, right-handed patient, no family h/o left-handedness, the structural integrity of the left hemisphere, and absence of brain damage in childhood. Another entity, Global Aphasia Without Hemiparesis (GAWH), is a rare stroke syndrome presenting with global aphasia without any weakness and occurs in the lesion of the left-sided peri-sylvian region. Case Report:: A 56-year-old female with a known case of severe mitral stenosis with chronic AF on warfarin and not on regular medications was brought to our hospital as she had not communicated for the past day. On initial examination, the patient was conscious, globally aphasic, with left facial lag and no weakness of limbs. Her initial Computed Tomography (CT) brain scan was normal. She was not thrombolysed as she was out of the window. Brain Magnetic Resonance Imaging (MRI) showed right frontal, temporal, and parietal infarct in middle cerebral artery territory. She was treated conservatively with full-dose anticoagulation and, upon discharge, was started on oral anticoagulants. At the time of discharge, the patient was able to understand a few commands and was having echolalia with non-fluent speech. She was reviewed again at 3 months, and she had a full recovery of her speech. Discussion:: CAD is a rare stroke syndrome with low prevalence. Even though all subtypes of aphasic syndromes are seen in CAD, Broca's aphasia is the common subtype, and men are affected commonly. Most patients also present with apraxia and visuospatial neglect. Our patient had all the criteria for the diagnosis of CAD and also had GAWH and showed rapid recovery. The cause of the disease in this patient was considered to be two different lesions involving language areas due to an embolism in her heart. Conclusion:: This case has been presented for its rarity due to the occurrence of both CAD and GAWH in the same patient in a right-sided infarct.

Brain volume measured by synthetic magnetic resonance imaging in adult moyamoya disease correlates with cerebral blood flow and brain function

Moyamoya disease (MMD) is characterized by progressive arterial occlusion, causing chronic hemodynamic impairment, which can reduce brain volume. A novel quantitative technique, synthetic magnetic resonance imaging (SyMRI), can evaluate brain volume. This study aimed to investigate whether brain volume measured with SyMRI correlated with cerebral blood flow (CBF) and brain function in adult MMD. In this retrospective study, 18 adult patients with MMD were included. CBF was measured using iodine-123-N-isopropyl-p-iodoamphetamine single photon emission computed tomography. Cerebrovascular reactivity (CVR) to acetazolamide challenge was also evaluated. Brain function was measured using the Wechsler Adult Intelligence Scales (WAIS)-III/IV and the WAIS-R tests. Gray matter (GM), white matter, and myelin-correlated volumes were evaluated in six areas. Resting CBF was positively correlated with GM fractions in the right anterior cerebral arterial and right middle cerebral arterial (MCA) territories. CVR was positively correlated with GM fraction in the right posterior cerebral arterial (PCA) territory. Full-Scale Intelligence Quotient and Verbal Comprehension Index scores were marginally positively correlated with GM fractions in the left PCA territory. Processing Speed Index score was marginally positively correlated with GM fraction in the right MCA territory. The SyMRI-measured territorial GM fraction correlated with CBF and brain function in patients with MMD.

Features of Mental Disorders in Right- and Left-Hemisphere Localization of Stroke on the Background of Motor Rehabilitation: Comparative Study

INTRODUCTION. In post-stroke patients have a high incidence of cognitive and emotional pathology, it is very important to take into account the particular features of mental state in order to achieve significant results of rehabilitation. The data on brain asymmetry indicate a certain lateralization of some mental functions (speech, emotional and cognitive functions).&#x0D; AIM. To study cognitive, emotional disorders and quality of life in patients with ischemic stroke depending on the localization of the lesion in the right or left cerebral hemisphere and their dynamics on the background of motor rehabilitation.&#x0D; MATERIALS AND METHODS. 39 patients with localization of an ischemic focus in the middle cerebral artery territory (group 1 (n = 19) — right hemisphere, and group 2 (n = 20) — left hemisphere) in the recovery period after an ischemic stroke, underwent an inpatient course of motor rehabilitation. Conditions of the patients were assessed at the beginning and at the end of hospitalization using the 6-point muscular strength scale, the modified Ashfort scale, a TUG test, the FIM and Berg balance scales, MMSE, MoCA, the Schulte Table methods, he Beck Depression Inventory, the State-Trait Anxiety Inventory (Spielberger-Khanin) and the Quality of Life at stroke.&#x0D; RESULTS. Attention disorders were found in patients of groups 1 and 2 in 84.6 and 75 %, respectively. Emotional disorders were diagnosed in almost half of post-stroke patients, anxiety disorders prevailed over depressive ones. In group 2 patients scoring ≤ 23 points on the MMSE were found 5 times more frequently. In group 1 depression was 4 times more frequent. However, the obtained intergroup differences were not statistically significant. At the end of the rehabilitation, both groups demonstrated a significant decrease in the level of trait anxiety, and in group 1 an increase in the attentional stability.&#x0D; DISCUSSION. The observed prevalence of more severe cognitive impairments in the LMCA group and emotional impairments in the RMCA group are consistent with the data on brain asymmetry.&#x0D; CONCLUSION. Motor rehabilitation has a positive effect on the emotional state of patients after a stroke, and insignificantly on their cognitive functions, which, along with a high incidence of cognitive impairments, necessitates consideration of the transition from motor to cognitive-motor rehabilitation in order to improve the effectiveness of the treatment.

Cortisol as a cerebral cortex neurons apoptosis regulator in acute phase of ischemic stroke (clinical and pathological study)

In response to ischemic stroke (IS) a natural activation of the stress-realizing system occurs. The features of this activation influence the outcome of the acute period and the prognosis of recovery and can be adjusted. At the same time, the role of the stress-realizing system in the pathogenesis of IS is still unexplored.Objective: to investigate the effect of peripheral blood cortisol concentration on the regulation of apoptosis of neurons of the cerebral cortex in the acute phase of IS.Material and methods. A prospective clinical and pathological study was performed. It included 9 patients with IS in the left middle cerebral artery territory who were admitted to hospital and died in the hyperacute phase of IS and had no infectious complications, allergic reactions or oncological diseases and who did not undergo thrombolysis. The cerebral cortex was examined. Neuron-specific enolase (NSE), protein 53 (p53), caspase 3, caspase 8, Fas receptor (CD95), and Fas apoptotic inhibitory molecule 2 (FAIM2) were determined on the slices using an indirect immunoperoxidase immunohistochemical staining method. A total of 567 microscopic fields were analysed for the group of patients with IS and 63 fields for the control group (three people). Before death, the blood concentrations of sFas, sFasL, cortisol, adrenocorticotropic hormone, adrenaline and norepinephrine were determined by enzyme immunoassay (the control group consisted of 28 people).Results. Significant correlation was found between the proportion of casp3-positive neurons and the concentration of cortisol in peripheral blood in zones 2 (r=0.263; p&lt;0.01) and 3 (r=0.383; p&lt;0.01). In the 2nd zone, significant negative correlation was found with the concentrations of sFas (r=-0.177; p&lt;0.05) and sFasL (r=-0.164; p&lt;0.05); in the 3rd zone, significant positive correlation was found with the ratio of the concentrations of sFasL and sFas (r=0.240; p&lt;0.01). The proportion of Fas-positive neurons in the cerebral cortex correlated significantly with the concentration of the soluble form of this molecule (for the 1st zone – r=0.222, for the 2nd zone – r=0.438, for the 3rd zone – r=0.289; p&lt;0.01) and the ratio of the concentrations of sFasL and sFas (respectively: r=0.231, r=0.266 and r=0.281; p&lt;0.01) in the peripheral blood.Conclusion. Peripheral blood cortisol concentration is a factor that determines the regulation of apoptosis of neurons in the cerebral cortex in the acute phase of IS.

Abstract TP40: Identification of Domain-Specific Cognitive Phenotypes of Post Stroke Vascular Contributions to Cognitive Impairment and Dementia

Introduction: Vascular contributions to cognitive impairment and dementia (VCID) are variably expressed following stroke. The purpose of this investigation is to identify the domain-specific cognitive phenotypes of VCID in the acute and sub-acute post-stroke interval measured using the Mark VCID battery. Methods: Mark VCID neurocognitive test battery was administered to 33 patients with incident ischemic stroke in the left (n=15), right (n=17), and bilateral (n=1) hemispheres including the anterior and middle cerebral artery territory, and 39 age and sex matched healthy controls (HC). Participants ranged in age from 42 to 88 years (Patient M=65.64 yrs, Control M=64.97 yrs). Patient group consisted of 17 males and 22 females, and the control group had 20 males and 13 females. Mean post stroke interval was 8 weeks (Range: 2.5 to 19 weeks). The test battery assessed: language (naming, fluency), perception (facial recognition, spatial orientation), psychomotor speed (digit symbol substitution), memory (word list, story recall), and attention (trails, number span). Normative test scores were converted to z-scores for assessment of between group differences using independent t-tests. Results: Patients with stroke performed significantly worse (p&lt;0.05) than HCs on measures of language (semantic and phonemic fluency), perception (facial recognition and spatial orientation), and psychomotor speed (symbol digit modalities test) (Figure 1). There were no significant group differences in the scores of memory (Hopkins Verbal Learning, Craft Story) and attention tracking (Oral Trails A, Number Span). Conclusion: Cognitive abnormalities in these acute stoke patients represent impairments in diverse dominant (language) and non-dominant (perceptual/spatial) hemisphere cortical and subcortical (psychomotor speed) abilities. At the group level, the findings suggest a phenotype of VCID in patients with acute middle and anterior cerebral artery ischemic stroke.

Abstract TP129: Automated Vessel Density Maps on CT Angiography Identify M2 Occlusions

Introduction: Patients with occlusions of the M2 branch of the middle cerebral artery are frequently considered for endovascular thrombectomy. Most AI software programs focus on identification of large vessel occlusions and frequently miss M2 inclusions. An automated software program with good sensitivity for detecting more distal occlusions could help rapidly identify patients for reperfusion therapies. Methods: Consecutive patients with a final diagnosis of occlusion of an M2 branch of the middle cerebral artery were identified from the Johns Hopkins Stroke database. All occlusions were verified by a neuroradiologist (VY). The baseline CTA from these patients was evaluated with the Rapid CTA vessel density software. This software identifies a reduction in vessel density within the middle cerebral artery territory and classifies the vessel density reduction as as: 20-25%, 26-40%,41-55% or &gt;55%. A reduction of greater than 20% or greater was consider positive as a potential indicator of M2 occlusion. Adding a sample of about 50 pts with no evidence of vessel occlusion would be desirable to be able to report specificity. Results: Forty-four of 62 patients (71%) with M2 occlusions had a reduction in vessel density of at least 20% on automated CTA. Among the positive cases, 20 percent had a 20-25% reduction, 20% had 26-40%, 30% had 41-55% and 30% had a &gt;55% reduction. Conclusion: The Rapid CTA hyperdensity program identified 71% of M2 occlusions with most patients having more than a 25% reduction in vessel density. Automated software has the potential to quickly identify patients with M2 branch inclusions.

Abstract TP199: Prominent Laterality of the Posterior Cerebral Artery on MR Angiography Before Mechanical Thrombectomy in Patients With the Middle Cerebral Artery Occlusion Predicts Long-Term Functional Outcome

Background and Purpose: Well-developed collateral flow is reported to be associated with a reduction of infarct volume, successful reperfusion, and better functional outcome in acute ischemic stroke (AIS). Relatively increased visualization of posterior cerebral artery (PCA) ipsilateral to the ischemic lesion on MR angiography (MRA), a sign of prominent PCA laterality (PCAL), represents the development of collateral flow from PCA to middle cerebral artery (MCA) territory. However, the prognostic value of PCAL on functional outcome in AIS patients having MCA occlusion and undergoing mechanical thrombectomy, is not well known. Methods: We retrospectively reviewed initial MRA scans of pre-morbidly independent patients treated with mechanical thrombectomy for M1-segment occlusion from September 2017 to May 2022. PCAL was defined as better visualization of ipsilateral PCA, compared to contralateral PCA, by one or more segments on MRA. We divided patients into two groups, those presenting PCAL and not, and compared the background characteristics, in-hospital management, and functional outcome between the two groups. Factors associated with favorable outcome (mRS score 0-2) at 3 months after onset were assessed using multivariate logistic regression analysis. Results: In total, 172 patients (76 female [44%], median age 77 [IQR 74.5-78.0] years, median NIHSS score 16 [15-18]) were included. Of these, 86 patients (50%) presented PCAL on initial MRA. There is no significant difference between the two groups in age, sex, major vascular risk factors, NIHSS on admission, DWI-ASPECTS, onset-to-recanalization time (OTR), and preclinical modified Rankin scale. Multivariate logistic regression analysis showed an adjusted odds ratio of 2.11 for a favorable outcome in patients with PCAL (95% CI: 0.986 to 4.53, P=0.054). When focused on the cases with OTR &gt;6 hours (n=53), PCAL was independently associated with favorable outcome (OR 5.77, 95% CI: 1.28 to 26.0, P=0.022). Conclusion: PCAL on initial MRA in patients with M1-segment occlusion predicts favorable long-term functional outcome after mechanical thrombectomy, especially in the case taking longer time from onset to recanalization.

Impact of the pandemic and concomitant COVID-19 on the management and outcomes of middle cerebral artery strokes: a nationwide registry-based study

ObjectivesTo investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions.DesignRegistry-based study.SettingWe used the National Inpatient...

Abstract TMP11: Cerebral Visual Impairment in Pediatric Stroke Patients Assessed by Virtual Reality Testing

Introduction: Pediatric stroke is one of the leading causes of disability in children, many of whom incur brain injury affecting critical visual anatomical networks. Dedicated ophthalmologic examinations that detect cerebral visual impairment (CVI) - the leading cause of congenital visual impairment in developed countries - are not standard of care and can delay diagnosis and interventions. There is limited CVI data in pediatric stroke patients, and in this work we present data defining visual processing deficits in pediatric stroke patients. Hypothesis: We hypothesize that pediatric stroke patients will (1) demonstrate greater visual-spatial processing impairments than controls and (2) demonstrate increasing performance impairment as a function of increasing visual task demands. Methods: Using a virtual reality (VR) based visual search task system, we characterized significant deficits in higher-order visual processing of pediatric stroke patients (n = 17) as compared to healthy controls (n = 13). Stroke patients suffered from a perinatal (n = 8) or pediatric (n = 9) stroke - confirmed with brain MRI - affecting various vascular territories of the anterior and posterior circulations. The task required searching for on-screen targets with increasing visual complexity. Metrics such as reaction time, gaze error, shifted ellipse area, success rate, and pursuit saccade ratio were analyzed using unpaired group-level t-tests and considered significant if p &lt; 0.05. Results: Stroke patients took longer to identify the target (p = 0.001), were less accurate in finding it (p = 0.007), and exhibited greater impairment in performance with an increasing number of distractors compared to healthy children. Groups had comparable task compliance, as indexed by an off-screen count metric. Conclusion: This original work demonstrates that pediatric stroke patients, particularly those with strokes affecting the middle cerebral artery and posterior circulation vascular territories, exhibit impaired higher-order visual processing. This highlights the urgent need for standardized clinical testing to provide quantitative performance measures of cortical visual processing. This will allow timely detection and implementation of interventional therapies.

Region-specific interobserver agreement of the Alberta Stroke Program Early Computed Tomography Score: A meta-analysis.

The Alberta Stroke Program Early CT Score (ASPECTS) is a widely used scoring system for evaluating ischemic stroke to determine therapeutic strategy. However, there is variation in the interobserver agreement of ASPECTS. This systematic review and meta-analysis aimed to investigate the interobserver agreement of total and regional ASPECTS. A comprehensive search was conducted in the Web of Sciences, PubMed, and Scopus databases to identify relevant studies. Inclusion criteria were studies of noncontrast CT performed within 24hours of ischemic stroke in the middle cerebral artery territory. A total of 20 studies, with 3482 patients, reporting interobserver agreement of total and regional ASPECTS were included in the meta-analysis. The interobserver agreement for total ASPECTS in studies using Kappa coefficient (κ) analysis was substantial (κ=.67, 95% confidence interval [CI]: .57-.78). In studies using intraclass correlation coefficient (ICC) analysis, agreement was excellent (ICC=.84, 95% CI: .77-.90). Interobserver agreement was higher in studies in which the observer was unblinded to clinical scenario in both groups (κ=.74, 95% CI: .59-.89, and ICC=.82, 95% CI: .79-.85). Per-region analysis showed that the caudate nucleus had the highest agreement (κ=.68, 95% CI: .60-.76, and ICC=.84, 95% CI: .74-.93), while M2 and internal capsule in Kappa studies (κ=.45, 95% CI: .34-.55 and κ=.47, 95% CI: .28-.66), and M4 and internal capsule in ICC studies (ICC=.54, 95% CI: .43-.64 and ICC=.55, 95% CI: .18-.91) had the lowest agreement. This meta-analysis demonstrates substantial to excellent interobserver agreement for total ASPECTS, which supports using this method for stroke treatment. However, findings emphasize the need to consider interobserver agreement in specific regions of ASPECTS for treatment decisions.

Intellectual function and memory in children with moyamoya disease: relationship between Wechsler Intelligence Scale and Benton Visual Retention Test scores and regional cerebral blood flow.

Intellectual function declines in about 30% of children with moyamoya disease (MMD). Memory function underpins higher order brain function, but the relationship between intellectual function and memory in pediatric MMD patients has not been well studied. This study aimed to investigate correlations between scores on the Wechsler Intelligence Scale for Children (WISC) and the Benton Visual Retention Test (BVRT), a visual memory test that can be administered to children, in children with MMD. Relationships between intellectual function or memory and regional cerebral blood flow (rCBF) have also not been well clarified in pediatric MMD patients. The authors also investigated associations between WISC or BVRT scores and rCBF in various brain regions. WISC and BVRT scores and rCBF were assessed in 17 children with ischemic-onset MMD before revascularization. Single-photon emission CT with 123I-iodoamphetamine was used to measure rCBF. Relationships between WISC and BVRT scores were evaluated using Spearman's correlation coefficient and multivariate linear regression analysis. Cutoff values were identified for BVRT scores. Sensitivity and specificity were calculated to predict full-scale intelligence quotient (FSIQ) > 85 or ≤ 85. Associations between rCBF and WISC or BVRT scores were evaluated using linear regression analysis. BVRT scores were significantly correlated with FSIQ and scores on the Working Memory Index (WMI), Processing Speed Index, and Verbal Comprehension Index (VCI)/Verbal Intelligence Quotient (VIQ) of WISC. Multivariate linear regression revealed that number correct score and number of errors score of BVRT were associated with FSIQ. As cutoff values, a number correct score of 5 and a number of errors score of 8 offered the most reliable predictors of FSIQ > 85 and ≤ 85, respectively. FSIQ correlated positively with rCBF in the right and left hemispheres, right and left ganglia, right and left thalamus, right and left cerebellum, right middle cerebral artery (MCA) territory, pons, and vermis. WMI score was positively associated with rCBF in the right hemisphere, right anterior cerebral artery territory, right MCA territory, right basal ganglia, right and left thalamus, right and left cerebellum, pons, and vermis. BVRT score correlated well with WISC index scores, suggesting that BVRT may be helpful in screening for intellectual impairments in children with MMD. In the MCA territory, basal ganglia, thalamus, cerebellum, pons, and vermis, rCBF associated well with WISC index scores, suggesting that reduced rCBF in relevant brain regions may influence intellectual function.

Study of Cerebral Hemispheric Lateralization in Stroke and the Arterial Territories Involved in High-risk Patients

Introduction: According to WHO, Stroke is the 2nd leading cause of death and disability after Ischemic heart disease. Prevalence rate of stroke in India varies from 44.45 to 150 per lakh population. Studies have reported a higher frequency of stroke of the left hemisphere. The artery reported to be the most affected is Left Middle Cerebral artery(MCA) followed by Right Middle Cerebral artery. The aim of this study is to determine the side of cerebral hemisphere most affected by stroke and the arterial territories involved in high-risk patients aged above 35 years presenting to the tertiary healthcare centre, as well as to study the sex predilection of stroke. Materials and Methods: A cross-sectional prospective study of 50 high risk stroke patients with Diabetes Mellitus(DM) and /or Hypertension(HTN) presenting to General medicine OPD of a tertiary healthcare centre were investigated with CT/MRI for the side of the cerebral hemisphere affected and the arterial territories involved. The data was tabulated over the course of three months and statistical analysis was carried out. Results: The left cerebral hemisphere was affected in 50%, right in 40% and bilateral involvement was found in 10% patients. Slight predilection of stroke towards the left was seen, however it was not found to be statistically significant (P-value= 0.249). MCA territory was involved in 66% of the patients, Posterior Cerebral Artery(PCA) territory in 8%, Vertebrobasilar Artery(VB) territory in 8%, Anterior Cerebral Artery(ACA) territory in 6% and MCA+ACA in 4%, MCA+VB in 2% and MCA-PCA watershed in 6% patients. Conclusions: We found a slight predilection of stroke towards the left, which was however, not found to be statistically significant. We also found that Middle Cerebral Artery(MCA) territory is the most commonly involved in stroke.

Klüver–Bucy Syndrome Secondary to A Dominant Middle Cerebral Artery Ischemic Stroke: A Case Report and Review of The Literature

Abstract Klüver–Bucy syndrome (KBS) is a neuropsychiatric disorder secondary to temporal lobe damage. This can be associated with various causes. This syndrome is rarely caused by stroke. We describe the case of a KBS, admitted to the neurology department of the military hospital of Agadir, in September 2022 secondary to ischemic stroke in middle cerebral artery territory. The patient presented most of the clinical features of KBS. These neurobehavioral manifestations improved after the start of treatment.

Paracentral acute middle maculopathy as the first sign of internal carotid artery dissection

Purpose: It is proposed to present a clinical case of a patient with a paracentral acute middle maculopathy (PAMM) as the first sign of presentation of severe internal carotid artery (ICA) dissection.Methods: An initial basic ophthalmologic examination of the patient was performed, followed by an optical coherence tomography (OCT) and an OCT‐angiography (OCT‐A) of each eye. Finally, the patient was evaluated by a neurologist, performing a cerebral and supra‐aortic trunks (SAT) computed tomography (CT) angiography.Results: We present a 54‐year‐old patient who came to the emergency room complaining of central blurred vision in his left eye (OS) during 24 h. On ophthalmological examination, it is remarkable a visual acuity (VA) of counting fingers at 1 m in OS. Eye fundus (EF) of OS showed small oval whitish macular lesions. Macular OCT of OS revealed hyperreflective bands in the internal nuclear layer (INL) and OCT‐A showed areas with low flow at deep capillary plexus (DCP) and macular vascular density (MVD) parameters decreased compared to the right eye (OD). During the examination, the patient began to feel a slight loss of strength in his right hemibody with dizziness, so he was explored by a neurologist and a cerebral and SAT CT angiography was performed, which reported severe left ICA dissection with an area of hypoperfusion in the territory of the left middle cerebral artery, but without intracranial vascular occlusion. Since there was no image of occlusion and given the mild neurological symptoms, endovascular treatment was rejected and anticoagulation with enoxaparin was established. Two months later, VA of OS improved to 1, with no significant lesions in the EF. The OCT of OS showed a slight thinning of the INL and the OCT‐A revealed a greater flow in the DCP with better MVD values.Conclusions: This entity should be considered in patients with visual disturbances. PAMM may be the first sign of ICA pathology.

НАРУЖНОЕ ВЕНТРИКУЛЯРНОЕ ДРЕНИРОВАНИЕ ПРИ ЗЛОКАЧЕСТВЕННОМ ИШЕМИЧЕСКОМ ИНСУЛЬТЕ (КЛИНИЧЕСКИЙ СЛУЧАЙ)

Malignant ischemic stroke (MIS) in the territory of the middle cerebral artery (MCA) is the most severe form of supratentorial ischemia. Its conservative therapy is accompanied by a high mortality rate, which may reach 80%. A more effective method of treatment is decompressive hemicraniectomy (DH). However, its implementation is limited by strict indications and several contraindications. In connection with the above, an urgent task is to find an effective method of treating this category of patients. The paper presents a clinical case of successful external ventricular drainage (EVD) in a patient with ischemia affecting the total left MCA territory. Keywords: External ventricular drainage, malignant ischemic stroke, middle cerebral artery, cerebral edema, clinical case.