Middle Cerebral Artery Territory Research Articles

Hyperdense middle cerebral artery sign

Not available.

A hospital-based study of post-stroke aphasia: frequency, risk factors, and topographic representation

Background and objectiveThe crude prevalence rate of stroke in Qena, Egypt, is high (922/100,000). For the first time, we estimate the frequency of aphasia following the first-ever ischemic stroke and its relationship to the site of lesion in Arabic-speaking countries.MethodsThe study was conducted on 180 acute or subacute ischemic stroke patients. Aphasia was diagnosed with the short form of the Boston Diagnostic Aphasia Examination after establishment of the cases (at least 10 days of stroke onset). Computed tomography and/or magnetic resonance imaging were performed for topographic localization of stroke, and routine laboratory investigations were done to evaluate the possible stroke risk factors.ResultsThe frequency of post-stroke aphasia was recorded in 20%, and atrial fibrillation (AF) represents a high-risk factor for ischemic stroke with aphasia. The following categories were observed: global aphasia in 50%, motor aphasia in 27.7%, sensory aphasia in 11.1%, nominal aphasia in 2.8%, and conductive aphasia in 8.3%. Global aphasia was mainly associated with complete middle cerebral artery (MCA) territories infarction. Motor aphasia was associated mainly with frontal or frontoparietal operculum lesions as well as basal ganglionic lesions. Sensory aphasia was associated with temporal lobe lesions, inferior parietal lobe, and basal ganglia. Conductive aphasia showed lesions in the deep white matter of the frontal and parietal lobes. Anomic aphasia was associated with inferior parietal lobe lesion.ConclusionOur data are consistent with other reports as regards the frequency and risk factors of post-stroke aphasia. Atrial fibrillation represents a high-risk factor for ischemic strokes with aphasia. Global and motor aphasia are the major subtypes. The lesion locations are predictive of aphasia subtypes.

Movable Thrombi Diagnosed Using Ultrasonography in Non-Significant Carotid Stenosis

Stenosis of an artery of more than 50% is usually regarded as significant stenosis, which may cause ischemic stroke. However, the nature of plaque may be important, even though the stenosis does not reach a significant degree. A 75-year old man with right arm weakness showed multiple scattered small infarct lesions at the left middle cerebral artery territory with mild stenosis of the left carotid artery. No embolic source was detected from cardiac assessments. Carotid duplex sonography showed a mobile plaque at the carotid artery, which was not detected by conventional angiography. Our case report suggests that direct vessel wall imaging can be useful in patients who have ischemic stroke with an embolic pattern without significant arterial stenosis. Key words: Carotid artery ulcerating plaque; Ultrasonography, Doppler, Duplex; Carotid artery thromboses

Clinical-therapeutic and recuperatory features in a patient with pluripatology: ischemic stroke, ischemic heart disease (sechelar myocardial infarction), chronic kidney disease and monstrous gout

Introduction: gout is a chronic inflammatory arthropathy produced by depositing crystals of monosodium uric acid (in joints and tissues) following an anomaly (genetics or acquired) in the purine metabolism (1,2). The manifestations of the disease are: hyperuricemia, recurrent episodes of acute arthritis, the presence of tophi, chronic kidney disease, urinary lithiasis(2). Stroke represents„ the rapid development of localized or global clinical signs of cerebral dysfunction with symptoms exceeding 24 hours, leading to death, without any other cause, except for vascular origin”. (3) Materials and Methods: with the permission of the THEBA Ethics Commission ( no.17464/14.06.2019), we will present the clinical case of a 57-year-old patient admitted to the TEHBA Neuromuscular Recovery Clinic presenting a right hemiplegia and mixed aphasia after an ischemic stroke in the territory of the left middle cerebral artery, on the background of complex polypathology (monstrous gout arthropathy, chronic smoking, arterial hypertension, myocardial infarction with coronary artery stenosis, chronic kidney disease). Results: the patient did in our clinic a neuro-muscular recovery treatment, adapted to his needs,which consisted of kinetotherapy and speech therapy and received appropriate medical treatment. The clinical evolution of the patient was slowly favorable, with improvement in language disorders and motor control of paralyzed limbs. Conclusions: the case of this patient has several particularities. This is a patient with a vicious life style, with a severe arthropathy, with severe cardio-vascular sufferers, hospitalized for recovering neuro-muscular deficits after an ischemic stroke. Despite limited prognosis, the patient has improved ADL and the quality of life after recovery treatment. Key words: stroke, hemiplegia, poly-pathologic, ischemic,

Clinical, imaging features and outcome in internal carotid artery versus middle cerebral artery disease.

BackgroundOnly a very few studies had compared the differences in topographic patterns of cerebral infarcts between middle cerebral artery (MCA) and internal carotid artery (ICA) disease. Besides, the comparison of clinical features and outcomes between MCA and ICA disease had rarely been reported.ObjectivesTo compare the clinical, imaging features and outcome of MCA versus ICA disease.MethodsWe prospectively enrolled 1172 patients with noncardiogenic ischemic stroke in ipsilateral ICA or MCA territory. Clinical, neuroradiologic and outcome of the two groups were compared in this observational cohort study.ResultsThe ICA group more frequently presented with decreased alertness, gaze palsy, aphasia, and neglect than the MCA group at admission, and more often had higher National Institute of Health stroke scale score at admission and discharge. Meanwhile, the ICA group more frequently had multiple acute infarcts, watershed infarcts, territorial infarct, small cortical infarct, and responsible artery stenosis ≥70%. Whereas penetrating artery infarct and parent artery occluding penetrating artery was more often associated with MCA disease. The ICA group more frequently had inhospital complications of pneumonia and deep vein thrombosis, more often had disability at discharge, and had more recurrent ischemic stroke or transient ischemic attack in 1 Year. Multivariable logistic regression identified male (OR, 1.99; 95% CI, 1.30 to 3.05; P = 0.002), history of coronary heart disease (OR, 1.85; 95% CI, 1.03 to 3.32; P = 0.041), multiple acute infarcts (OR, 4.18; 95% CI, 2.07 to 8.45; P<0.0001), and territorial infarct (OR, 2.23; 95% CI, 1.52 to 3.27; P<0.0001) was more often associated with ICA territory disease.ConclusionsThe clinical, radiologic characteristics and outcome are distinctively different between ICA and MCA disease. Compared to MCA disease, ICA disease has more serious clinical and radiologic manifestation, and poorer outcome.

Postoperative change of neuropsychological function after indirect revascularization in childhood moyamoya disease: a correlation with cerebral perfusion study.

The relationships between postoperative functional improvement in various cognitive domains and regional hemodynamic change have not been sufficiently studied in childhood moyamoya disease (MMD). The present study aimed to examine the cognitive benefit of indirect revascularization, the underlying biological mechanism, and factors affecting surgical outcome in childhood MMD. Twenty-three patients with MMD aged under 20years received neuropsychological examinations before and after indirect revascularization surgery, evaluating intellectual function, verbal and visual memory, and executive function. Among them, 13 patients had magnetic resonance perfusion (MRP) studies, in which regional cerebral perfusion was rated. Postoperative improvement was observed in verbal memory performances (p = 0.02-0.03) and in cerebral perfusion at all 26 cerebral hemispheres (p = 0.003-0.005), especially in the middle cerebral artery (MCA) territories (p = 0.001-0.003). Hemodynamic improvement in the left MCA territories was significantly correlated with improvement of both verbal new learning (p = 0.01) and intellectual function (p = 0.004). Postoperative cognitive improvement of immediate recall and verbal intellectual function was associated with female sex (r = - 0.42) and symptom duration (p = - 0.03), respectively. Hemodynamic improvement in the MCA territories was related to longer follow-up intervals (p = 0.02). The findings revealed that the selective postoperative cognitive improvement was associated with increased regional perfusion in the MCA territories, and indicate the importance of early intervention and the potential of indirect revascularization regarding long-term outcome.

Do All ASPECT Score Regions have the Same Predictive Power for Functional Outcomes?

Background and PurposeASPECTS (Alberta Stroke Program Early CT Score) is a 10-point topographic CT scan score that has been shown to be a strong prognostic factor in acute ischemic stroke. We investigated whether all ASPECTS regions have the same prognostic value. MethodsClinical characteristics, ASPECTS, and 3-month modified Rankin Scale (mRS) data were retrospectively collected in 350 patients who were diagnosed with middle cerebral artery (MCA) territory stroke. To describe the 3-month mRS data, an ordered categorical approach was applied using a proportional odds model. Furthermore, external validation was performed using additional data from 30 patients. ResultsAs expected, ASPECTS was an independently important predictor. However, when 10 regions were analyzed separately, the M1, M2, and M3 regions, related to MCA cortex, were not found to predict 3-month mRS scores in the final model. The odds ratios for ischemic change in other regions (except M1, M2, and M3) ranged from 2.6 to 3.8. Moreover, among clinical characteristics, only age was identified as a significant predictor. The sensitivity and specificity of the final model in the external validation were 91% and 88%, respectively. ConclusionsAll ASPECTS regions did not have the same predictive power for functional outcomes, defined as the 3-month mRS. The implementation of a proportional odds model allowed a proper description of the ordered categorical nature of the mRS and the identification of relevant predictors.

Collateral Scores in Acute Ischemic Stroke : Aretrospective study assessing the suitability of collateral scores as standalone predictors of clinical outcome.

Several collateral scores have been published for stroke in the middle cerebral artery territory, each considering different aspects of cerebral collateralization. Currently, there is no gold standard in CT-based collateral assessment. The aim of this retrospective study was to compare five collateral scores and determine whether they are able to predict clinical outcome after thrombectomy as standalone parameters. Inclusion criteria were M1occlusion, premorbid modified Rankin scale (mRS) of0-3, treatment with endovascular thrombectomy and groin puncture within 12 h after stroke onset. The Maas etal., Miteff etal., Tan etal., ASITN/SIR and mCTA collateral scores were retrospectively assessed in multiphase CTA images and correlated with 90-day mRS (90d-mRS) scores. Good outcome was defined as 90d-mRS0-2 or unchanged to premorbid mRS. In total, 108 patients were included of which 39.8% achieved agood outcome. The area under the curve (AUC) values of receiver operating characteristic (ROC) curve analysis for Maas etal., Miteff etal., Tan etal., ASITN/SIR and mCTA scores were 0.60 (0.51-0.70), 0.60 (0.52-0.68), 0.61 (0.51-0.70), 0.59 (0.49-0.70) and 0.61 (0.50-0.71), respectively. The correlation between 90d-mRS and Maas (r = -0.16, P = 0.091), Miteff (r = -0.25, P = 0.009), Tan (r = -0.26, P = 0.007), ASITN/SIR (r = -0.21, P = 0.030) and mCTA (r = -0.22, P = 0.021) scores was poor. Although collaterals are known to correlate with clinical outcome, none of the analyzed collateral scores sufficiently predicted outcome as astandalone parameter.

Neuropsychological impairment in adults with moyamoya angiopathy: preoperative assessment and correlation to MRI and H215O PET.

Patients with moyamoya angiopathy (MMA) are known to have an increased risk of impaired executive function (dysexecutive cognitive syndrome (DCS)). Numbers of moyamoya patients with DCS vary strongly in the literature; evidence of a correlation to affected vascular territories is low. This study aims to identify cognitive impairment in adult moyamoya patients and to correlate findings with imaging results. In addition, the predictive value of individual tests for the identification of DCS was analyzed. Neuropsychological test data of 41 adult moyamoya patients was analyzed for a possible correlation with territorial hypoperfusion on H215O PET with acetazolamide (ACZ) challenge (cerebrovascular reserve-CVR) and infarction patterns observed in MRI. Each vascular territory was analyzed separately and correlated to neuropsychological test results and to the presence of DCS. In total, 41.5% of patients presented with DCS. Significant association of DCS and affection of the right middle cerebral artery (MCA) territory was seen for insufficient CVR in PET (p = 0.030) and for patients with infarctions seen in MRI (p = 0.014). Analysis of individual neuropsychological test results confirmed the main association with the right MCA territory, as well as some association with the right anterior cerebral artery (ACA) territory. Analysis of a subgroup of patients with chronic disease on MRI (presence of large post-infarction gliosis and brain atrophy in affected territories) revealed a significantly higher risk for DCS (85% affected) than non-chronic patients (21% affected) (p < 0.001). Analysis of neuropsychological test data in this moyamoya cohort reveals DCS in 41.5% of all patients. Correlation between DCS and an impairment of CVR seen in PET and/or infarctions seen in MRI was significant for the right MCA territory. Patients with chronic disease had a significantly higher risk for DCS than non-chronic patients (p < 0.001).

A case report of multiple cerebral abscess formation complicating serogroup B Neisseria meningitidis meningitis

BackgroundInvasive meningococcal disease (IMD) presenting with meningitis causes significant mortality and morbidity. Suppurative complications of serogroup B meningococcal sepsis are rare and necessitate urgent multidisciplinary management to mitigate long-term morbidity or mortality.Case presentationWe present a rare case of invasive meningococcal disease in a 28-month old boy complicated by multiple abscess formation within a pre-existing antenatal left middle cerebral artery territory infarct. Past history was also notable for cerebral palsy with right hemiplegia, global developmental delay and West syndrome (infantile spasms). Two craniotomies were performed to achieve source control and prolonged antimicrobial therapy was necessary. The patient was successfully discharged following extensive multidisciplinary rehabilitation.ConclusionsLongstanding areas of encephalomalacia in the left MCA distribution may have facilitated the development of multiple meningococcal serogroup B abscess cavities in the posterior left frontal, left parietal and left temporal lobes following an initial period of cerebritis and meningitis. A combination of chronic cerebral hypoperfusion and some degree of pre-existing necrosis in these areas, may also have facilitated growth of Neisseria meningitidis, leading ultimately to extensive cerebral abscess formation following haematogenous seeding during meningococcemia. In this case report we review similar cases of cerebral abscess or subdural empyema complicating serogroup B meningococcal meningitis.

Cerebral blood flow imbalance is associated with motor outcome after pediatric arterial ischemic stroke.

Cerebral hemodynamics after arterial ischemic stroke (AIS) in children are largely unknown. This study aims to explore long-term cerebral perfusion balance of vital tissue and its relation to motor outcome after childhood AIS. Patients diagnosed with childhood AIS (≤16 years at diagnosis, time since stroke ≥2 years) and typically developing peers were examined. Hemiparesis was classified according to the Pediatric Stroke Outcome Measure. Manual ability was assessed using the ABILHAND-Kids questionnaire. Cerebral blood flow was measured by arterial spin labeling and analyzed in the following brain regions: the hemispheres, the territory of the anterior cerebral artery (ACA), the middle cerebral artery (MCA), and in subregions of the MCA territory (MCA anterior, middle, posterior). To assess cerebral perfusion balance, laterality indices were calculated using cerebral blood flow in the ipsi- and contralesional hemisphere. Laterality indices were compared between stroke patients with and without hemiparesis, and peers. Twenty participants diagnosed with AIS were included (12 boys, 8 girls; mean age 14.46±4.96 years; time since stroke 8.08±3.62 years); 9 (45%) were diagnosed with hemiparesis. Additionally, 47 typically developing peers (21 boys, 26 girls; mean age 14.24±5.42 years) were studied. Laterality indices were higher in stroke patients and oriented to the contralesional hemisphere in all brain regions except the ACA territory and MCA posterior subregion. This was significantly different from peers, who showed balanced laterality indices. There was a significant correlation between laterality indices and manual ability, except in the ACA territory. AIS is associated with long-term alterations of cerebral blood flow in vital tissue, even in patients without hemiparesis. The degree of imbalance of cerebral perfusion in children after AIS is associated with manual ability.

Efficacy of Neuroprotective Drugs in Acute Ischemic Stroke: Is It Helpful?

Background Out of several neuroprotective drugs (NPDs) studied in animals and humans, four NPDs (citicoline, edaravone, cerebrolysin, and minocycline) have been found to have beneficial effects in acute ischemic stroke (AIS). Objective The purpose is to evaluate the efficacy of citicoline, edaravone, minocycline, and cerebrolysin compared with placebo in patients with middle cerebral artery (MCA) territory AIS. Materials and Methods This was a prospective, single center, single-blinded, and hospital-based study. One hundred patients with MCA territory AIS with 20 patients in each group including control group were included. Barthel index (BI), National Institute of Health Stroke Scale (NIHSS) score, and modified Rankin Scale score were recorded at admission, at day 11 and after 90 days. Results The mean NIHSS score was significantly lesser at day 11 and after 90 days in citicoline, edaravone, and cerebrolysin group in comparison with placebo. Similarly, the mean BI score was significantly higher at day 11 and after 90 days in citicoline, edaravone, and cerebrolysin group in comparison with placebo. In minocycline group, there was no significant change in the NIHSS score and BI score at day 11 and after 90 days. Conclusion There was significant improvement in the functional outcome of patients with AIS involving MCA territory at 90 days receiving citicoline, edaravone, and cerebrolysin. However, minocycline did not offer the same efficacy as compared with other neuroprotective agents.

“A storm in the middle” evolution of a lateral medullary syndrome to a bilateral medial medullary infarct: A case report

Introduction Posterior circulation infarction accounts for about 20–25% of all ischemic strokes in the general adult population. Medial medullary infarction (MMI) is reported to be less than 1% of vertebrobasilar artery strokes, with only 18% of such cases occurring bilaterally to involve both medial side of the medulla. Objective To present a rare case of Wallenberg syndrome evolving to a bilateral medial medullary infarct. Case: A 55-year old, hypertensive, male complaining of sudden onset vertiginous dizziness and non-projectile vomiting with initial manifestation of right pseudoptosis, sensory deficit on the right side of the face, unequal palatal elevation, weak gag reflex with no sensorimotor deficit. However, progression of symptoms was noted during hospitalization. Patient became quadriplegic with inability to protrude tongue and impaired deep sensations. MRI and CTA were done. Results Cranial MRI result revealed acute bilateral medial medullary infarcts corresponding to the pyramidal tracts, along the vascular territories of the medullary perforating branches of the vertebral arteries. Angiographic results revealed “short segment narrowing at the M1-M2 junction of the right middle cerebral artery territory (R MCA) and in the territories of right vertebral artery (R VA)”. Conclusion Bilateral medial medullary infarction is a rare stroke which has a poor clinical outcome. Though it occurs due to an atheromatous occlusion of a distal Vertebral Artery, it can also be preceded or occurred simultaneously with Wallenberg Syndrome. Diagnosis of such combination warrants vigilance, thorough neurologic examination and a high suspicion together with the aid of MRI to arrive with the accurate neurologic diagnosis.

Sympathomimetic drug (xylometazoline) abuse and acute ischemic stroke.

Xylometazoline is a nasal decongestant which stimulates the alpha adrenergic receptors in arterioles of nasal mucosa and produces vasoconstriction. It has a potential to cause stroke due to its sympathomimetic activity. A 54 year male, with history of chronic xylometazoline use presented with acute onset tingling and numbness in left upper limb and lower limb, giddiness in form of imbalance while walking and swaying towards the left side, vertigo and dysphagia, dysarthria, dysphonia. On examination he had absence of pain sensation on left side of the face, decreased power on left upper limb and lower limb with left sided cerebellar signs and truncal ataxia, nystagmus and Horner’ syndrome. MRI brain suggestive of acute left lateral medullary infarct with left vertebral artery stenosis. Hemogram, liver, renal function, 2D ECHO, ECG and Neck vessel angiography were all normal. On revisiting the history, he had a habit of using xylometazoline nasal spray daily for three-four times since last 5-6years which he started to use after he was prescribed it once for an upper respiratory tract infection. So possibility of Xylometazoline associated cerebral vasoconstriction leading to stroke was considered. Dual antiplatelets and statins were prescribed and he was advised to stop xylometazoline. A review of literature shows 5 cases of ischemic stroke reported in association with xylometazoline use out of which 2 were in the posterior circulation territory and 3 were in the middle cerebral artery territory. Xylometazoline abuse can lead to stroke and its over-the-counter availability should be curtailed.

SUDDEN DYSPHASIA IN A YOUNG MAN WHO COUGHED.

A healthy 19-year-old man with no risk factors presented with focal neurological symptoms (dysphasia and right hemiparesis) in the setting of an acute febrile illness and severe cough. Initial CTs showed pan-sinusitis and pulmonary infiltrates. The cerebrospinal fluid was normal. Human coronavirus OC43 was identified in nasal swabs. Repeat CTA/MRA revealed multiple infarcts in the territory of the left middle cerebral artery (MCA) and proximal intra-luminal left internal carotid artery filling defects due to thrombi were demonstrated. No thrombophilia was found and there are no reports of sinusitis-associated carotid thrombosis in the literature. Recent infection, in particular respiratory infection is a confirmed risk factor of ischemic stroke (IS) in adults and intriguingly, also in young patients. Myriad mechanisms have been demonstrated or postulated in the very young and our report suggests adding carotid thrombi. Previously described cough-induced carotid dissection could not be demonstrated, but similarly, cough-induced intimal injury of the carotid artery remains the most likely culprit, precipitating local thrombus formation and embolization.

SUDDEN DYSPHASIA IN A YOUNG MAN WHO COUGHED

A healthy 19-year-old man with no risk factors presented with focal neurological symptoms (dysphasia and right hemiparesis) in the setting of an acute febrile illness and severe cough. Initial CTs showed pan-sinusitis and pulmonary infiltrates. The cerebrospinal fluid was normal. Human coronavirus OC43 was identified in nasal swabs. Repeat CTA/MRA revealed multiple infarcts in the territory of the left middle cerebral artery (MCA) and proximal intra-luminal left internal carotid artery filling defects due to thrombi were demonstrated. No thrombophilia was found and there are no reports of sinusitis-associated carotid thrombosis in the literature. Recent infection, in particular respiratory infection is a confirmed risk factor of ischemic stroke (IS) in adults and intriguingly, also in young patients. Myriad mechanisms have been demonstrated or postulated in the very young and our report suggests adding carotid thrombi. Previously described cough-induced carotid dissection could not be demonstrated, but similarly, cough-induced intimal injury of the carotid artery remains the most likely culprit, precipitating local thrombus formation and embolization.

Coexistent ipsilateral venous sinus thrombosis and arterial stroke in iron deficiency anemia

Concomitant ipsilateral cerebral venous sinus thrombosis and arterial infarction are exceedingly rare clinical entity. We suggest that iron deficiency anemia caused the simultaneous affection of the two arterial beds. We report a 34-year-old right-handed male who presented with headache, vomiting, left hemiplegia and drowsiness. On arrival to ER, he had hypotension and sinus bradycardia necessitating inotropic support. He was drowsy and had signs of right middle cerebral artery involvement confirmed by unenhanced CT brain showing acute right temporo-parietal ischemic infarction. The investigations revealed anemia (Hb 8.8 g/dL, MCV 57.7fL), hypoferritinemia (<5 ng/mL) and hypochromic microcytic anemia suggesting iron deficiency anemia. Other investigations including inflammatory markers, bacterial cultures, anticoagulation profile, lipids, glycemic indices, Hb Electrophoresis, autoimmune markers including antiphospholipid syndrome, cryoglobulins, thrombophilia screen, viral markers for hepatitis B and C as well as HIV were negative. The echocardiogram and a pan CT abdomen and chest were unremarkable. A repeat CT brain on the same day revealed right middle cerebral artery territory infarction with hyperdense right transverse and sigmoid sinuses. CT cerebral angio- and venogram showed dural sinus thrombosis involving the right transverse and sigmoid sinuses, jugular bulb and proximal jugular vein along with linear filling defect at the origin of the right internal carotid artery. Later, he underwent decompressive hemicraniectomy. He received blood transfusions, iron supplementations and therapeutic anticoagulation. Inotropic support was weaned off gradually. Neurologically, residual hemiplegia prevailed.

Acute Phase Neuronal Activity for the Prognosis of Stroke Recovery.

Strokes causing similar lesions and clinical states can be followed by diverse regains of neurological functions, indicating that the clinical recovery can depend on individual modulating factors. A promising line to disclose these factors, to finally open new therapeutic strategies, is to search for individual indices of recovery prognosis. Here, we pursued on strengthening the value of acute phase electrophysiological biomarkers for poststroke functional recovery in a wide group of patients. We enrolled 120 patients affected by a monohemispheric stroke within the middle cerebral artery territory (70 left and 50 right damages) and collected the NIH stroke scale (NIHSS) score in the acute phase (T0, median 4 days) and chronic follow-up (T1, median 6 months). At T0, we executed electrophysiological noninvasive assessment (19-channel electroencephalography (EEG) or 28 channels per side magnetoencephalography (MEG)) of brain activity at rest by means of band powers in the contra- and ipsilesional hemispheres (CLH, ILH) or the homologous area symmetry (HArS). Low-band (2-6 Hz) HArS entered the regression model for predicting the stabilized clinical state (p < 0.001), with bilateral impairment correlated with a poor outcome. Present data strengthen the fact that low-band impairment of homologous ipsi- and contralesional hemispheric regions in the acute stroke indicate a negative prognosis of clinical recovery.

DNA and RNA oxidative damage are associated to mortality in patients with cerebral infarction.

Secondary injury due to oxidation may occur during ischemic stroke, possibly leading to oxidative damage to deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). Higher blood concentrations of 8-hydroxy-2'-deoxyguanosine (8-OHdG) (through the oxidation of guanosine from DNA) have been found in ischemic stroke patients than in healthy subjects, and in patients with versus without post-ischemic stroke depression. The present study was carried out to explore the possible association between serum DNA and RNA oxidative damage and mortality in patients with cerebral infarction. A prospective, multicenter observational study was carried out in the Intensive Care Units of 6 Spanish hospitals. We included patients with severe malignant middle cerebral artery infarction (MMCAI) defined as ischemic changes evidenced by computed tomography in more than 50% of the middle cerebral artery territory and a Glasgow Coma Score (GCS)<9. Serum concentrations of the three oxidized guanine species (OGS) (8-hydroxyguanine from DNA or RNA, 8-hydroxyguanosine from RNA, and 8-OHdG from DNA) on the day of MMCAI diagnosis were determined. The study endpoint was 30-day mortality. We found higher serum OGS levels (p<0.001) in non-surviving (n=34) than in surviving patients (n=34). Logistic regression analyses showed serum OGS levels to be associated to 30-day mortality controlling for lactic acid, GCS and platelet count (OR=1.568; 95%CI=1.131-2.174; p=0.01). The novel observation in this study is the association between global serum OGS concentration and mortality in ischemic stroke patients.

47. Claudication, Cerebral infarct and Cyclophosphamide

IntroductionWe present a severe and rare case of GCA involving the right middle cerebral artery (MCA) resulting in an ischaemic stroke. Our patient presented in 2017, before tocilizumab was approved as a treatment option in refractory GCA. Intravenous cyclophosphamide was used as a glucocorticoid-sparing agent in this patient with good response. This case contributes to our current limited evidence base in the treatment and prognosis of intracranial GCA.Case descriptionThe patient was 75 years old when referred by his GP with a four-month history of left temporal headache, jaw claudication and weight loss in August 2017. He had type 2 diabetes and hypertension. He also had a stroke in 2015 and was subsequently found to have paroxysmal atrial fibrillation so was commenced on rivaroxaban. His bloods showed ESR of 66 and CRP 18. ESR had been persistently raised for two months. Ophthalmology assessment revealed bilateral cataracts only. A clinical diagnosis of GCA was made and he was commenced on prednisolone 60mg daily. A biopsy of his left temporal artery was performed six days later and the histology showed transmural inflammation with multinucleated giant cells. His headache and jaw claudication improved with prednisolone but he was still experiencing localised temporal artery tenderness. In the last week of September 2017, he presented to the Emergency Department with a two-day history of incoordination and left arm weakness. MRI of his head showed small foci of infarcts in the right MCA territory. He had suffered an ischaemic stroke likely secondary to GCA despite being treated with high dose oral glucocorticoid. He was given three pulses of intravenous methylprednisolone followed by intravenous cyclophosphamide.Subsequent CT angiogram (CTA) confirmed the involvement of intracranial arteries – circumferential thickening of the right internal carotid artery with near complete occlusion of right cavernous and intracranial segments. There was also mural thickening involving the left vertebral artery. He went on to have five more cycles of cyclophosphamide and responded well to treatment. Oral methotrexate 15mg weekly was added in two weeks after the last course of cyclophosphamide. During his last clinic visit, he was taking prednisolone 2mg daily and the plan was to taper the dose down to zero over eight weeks.DiscussionThough uncommon, GCA can affect vertebrobasilar arteries causing strokes. The involvement of intracranial arteries, on the other hand, is thought to be extremely uncommon in GCA due to their increased wall thickness. There is only a limited number of intracranial GCA cases reported in the medical literature. A review of nearly 500 patients with a diagnosis of central nervous system vasculitis at the Mayo Clinic identified only two patients with convincing evidence of intracranial GCA.Our patient’s MRI and CTA were reviewed in the neuroradiology multidisciplinary meeting and the consensus was that there was a near complete occlusion of the right MCA due to a vasculitic process. Importantly, his GCA went into remission and he has not had any relapses thus far (21 months since his initial presentation). He has also improved from the stroke point of view. We have been able to reduce his prednisolone dose to a minimal level.The use of oral or intravenous cyclophosphamide in the treatment of refractory GCA have been reported. It was found to be effective in inducing a sustained remission in a majority of patients in a series of 35 patients in Germany. However, significant adverse events were reported in one third of the patients.Our patient tolerated intravenous cyclophosphamide therapy well. He was given fluconazole and co-trimoxazole as prophylactics. He did not report any major infections or adverse events during the four-month period when he was on cyclophosphamide.Key learning pointsThis case represents a severe variant of GCA. Our patient was only referred to secondary care after being unwell for several months. It illustrates the importance of promptly initiating investigations and treatment when GCA is suspected. This case demonstrates the importance of following up with patients closely as well as working closely with the multispecialty team in managing patients with GCA. Conflicts of interestThe authors have declared no conflicts of interest.