Middle Cerebral Artery Territory Research Articles

Occipital artery-anterior cerebral artery bypass with posterior auricular artery-middle cerebral artery bypass for stenosis of the internal carotid artery bifurcation

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, and STA-anterior cerebral artery (ACA) bypass, are options for direct revascularisation of anterior circulation. However, some patients don't have a suitable STA to use as a donor, so an alternative procedure must be performed. A 59-year-old, right-handed man presented with dysphasia and right-sided hemiparesis due to a transient ischaemic attack. Imaging studies revealed severe stenosis of the left internal carotid artery bifurcation. Iodoamphetamine single photon emission computed tomography demonstrated reduced cerebrovascular reserve capacity in the left hemisphere. The patient was started on antiplatelet therapy, but the ischaemic attacks persisted after one month. Thus, revascularisation of the ACA and MCA territories was considered. Digital subtraction angiography revealed prominence in the left occipital artery (OA) and posterior auricular artery (PAA), while the left STA was hypoplastic, terminating at the squamous suture level. Therefore, anastomoses were performed between both the OA and ACA and the PAA and MCA. Revascularisation was successful, and the ischaemic attacks disappeared. OA-ACA bypass, together with PAA-MCA bypass, may be effective for wide cerebral revascularisation when the STA is not available.

Serum Caspase-3 Levels and Early Mortality of Patients with Malignant Middle Cerebral Artery Infarction.

Circulating caspase-3 levels at 24h of ischemic stroke were found to be associated with poorer functional neurological outcome in a previous study. The aim of this study was to determine whether there is an association between serum caspase-3 levels and early mortality in patients with malignant middle cerebral artery infarction (MMCAI). We included patients with MMCAI defined as computer tomography showing ischemic changes in more than 50% of the middle cerebral artery territory and Glasgow Coma Scale ≤ 8. Serum caspase-3 levels at days 1, 4, and 8 of MMCAI were determined. Non-surviving MMCAI (n = 34) showed higher serum caspase-3 levels at days 1 (p < 0.001), 4 (p = 0.001), and 8 (p = 0.01) than surviving patients (n = 34). We found that the area under the curve of serum caspase-3 levels for prediction of mortality at 30days was 88% (95% CI = 78-95%; p < 0.001). Multiple logistic regression showed that serum caspase-3 levels were associated with 30-day mortality (OR = 51.25; 95% CI = 8.30-316.31; p < 0.001). The novel and more important findings of our study were that high serum caspase-3 levels were associated with mortality in MMCAI patients.

Is segmental muscle strength recovery different in patients with dominant versus non-dominant hemispheric ischemic stroke?

Abstract Introduction &amp; objectives: Starting from the well-known functional hemispheric asymmetry and concomitantly, from the clinical findings of practitioners involved in the post-stroke rehabilitation process, the aim of this study was to evaluate whether ischemic stroke in the dominant hemisphere results in more severe initial motor deficit and if its motor recovery is decreased compared to that of the non-dominant hemisphere. Material and method: This was a retrospective study, comprising 39 patients with ischemic stroke in the middle cerebral artery territory, divided into two groups depending on the hemispheric location of the lesion (left/right). They were evaluated for their segmental muscle strength using the Medical Research Council Muscle Strength Grading Scale, both in terms of initial value and evolution between two successive admissions. Results and conclusions: No significant difference was found for motor deficit evaluated on the occasion of the first admission between patients with left-side stroke and those with right-side stroke. Motor recovery was more obvious proximally in the paretic limbs, but without statistical significance. Key words: hemispheric dominance, functional laterality, stroke, motor rehabilitation,

A canine model of mechanical thrombectomy in stroke

PurposeTo develop a preclinical model of stroke with a large vessel occlusion treated with mechanical thrombectomy.Materials and methodsAn ischemic stroke model was created in dogs by the introduction of an...

Association of Concomitant Intracranial Atherosclerotic Stenosis with Collateral Status in Patients with Emergent Large Vessel Occlusion

Concomitant atherosclerotic stenoses are commonly encountered in emergent large vessel occlusion. This study attempted to prove whether or not the pattern of atherosclerotic stenosis other than symptomatic occlusion is associated with pretreatment collateral status among patients with emergent large vessel occlusion. The study included 115 patients with middle cerebral artery territory infarct within 6 hours of stroke onset who were considered for endovascular revascularization therapy. All patients underwent pretreatment conventional computed tomography angiography using a 128-detector high-definition computed tomography scanner. Based on maximum intensity projection images, ≤50% filling of the occluded territory was considered to indicate poor collaterals, whereas >50% filling was considered to indicate good collaterals. Finding of >50% stenosis on computed tomography angiography was considered significant, and the stenosis patterns were classified into intracranial atherosclerotic stenosis and extracranial atherosclerotic stenosis according to the location of the stenosis. All patients had symptomatic M1 (47.8%), M2 (20.0%), or internal carotid artery (32.2%) occlusion. There were 44 patients with poor collaterals (38.3%) and 71 patients with good collaterals (61.7%). Univariate analysis revealed that poor collateral status was associated with advanced age (≥65 years), hypertension, high National Institutes of Health Stroke Scale score, symptomatic internal carotid artery occlusion, and concomitant atherosclerotic stenosis. Multivariate analysis showed that poor collateral circulation was associated with concomitant intracranial atherosclerotic stenosis and symptomatic internal carotid artery occlusion (vs. a more distal occlusion). Concomitant intracranial atherosclerotic stenosis other than symptomatic occlusion might be a crucial factor associated with pretreatment collateral status among patients with emergent large vessel occlusion.

Evaluation of the Accuracy Equivalence of Head CT Interpretations in Acute Stroke Patients Using a Smartphone, a Laptop, or a Medical Workstation

PurposeTo evaluate and compare the clinical performance of observers interpreting head CT images from patients with symptoms of acute stroke with a medical workstation or a smartphone or laptop reading system. Materials and methodsOur institutional review board approved this retrospective study and waived the requirement for informed consent. We employed a factorial design including 2,256 interpretations (188 patients × 4 neuroradiologists × 3 reading systems). Accuracy equivalence tests, at a threshold of 5% and 10%, were performed for the following variables: detection of imaging contraindications for intravenous recombinant tissue-type plasminogen activator administration (eg, hemorrhagic lesions), ischemic lesions, hyperdense arteries, and acute ischemic lesions. For each clinical variable, the sensitivity, specificity, and receiver operating characteristic (ROC) curves were evaluated. ResultsFor each variable, the shapes of the ROC curves were very similar for all of the reading systems, indicating similar observer performance with different specificities and sensitivities. For all the clinical variables, the areas under the ROC curves were equivalent for all of the reading systems at a 10% threshold and were equivalent at a 5% threshold for hemorrhagic lesions, hyperdense middle cerebral artery, and acute ischemic lesion in the middle cerebral artery territory. There was no more than 30 seconds of difference between the reading time of the mobile devices compared with that for the medical workstation. ConclusionThe results of this pilot study showed equivalent diagnostic accuracy when using smartphone and laptops compared with medical monitors to interpret head CT images of patients with symptoms of acute stroke.

An Unlikely Culprit of Paralysis in Pregnancy [27G

INTRODUCTION: Todd paralysis (TP) is a rare postictal condition characterized by weakness following an epileptic seizure. TP includes both motor and non-motor entities including altered cognition, psychiatric symptoms, automatic behavior, and aphasia. The etiology is unknown. The reported duration of TP varies between half-an-hour to 36 hours. METHODS: A 33-year-old G6P5005 at 37 weeks with past medical history of epilepsy controlled with Levetiracetam, presented with right-sided weakness and elevated blood pressure following a generalized tonic-clonic seizure. Preeclampsia workup was performed and negative. Secondary to post-ictal paralysis Neurology was consulted with the conditional diagnosis of acute stroke. Motor examination showed paralysis on her right side. Cranial Magnetic Resonance Imaging revealed significant diffusion restriction in the territory of the left Middle Cerebral Artery involving the distal branches and watershed segments. After reviewing the clinical manifestations and neuroimaging findings, the diagnosis was established as TP and antiepileptic therapy was initiated. Routine electroencephalography showed slowed left frontal-parietal activity. Patient's weakness gradually improved with recovery to her premorbid status after 48 hours. The cranial Magnetic Resonance Angiography subsequently showed no significant stenosis or occlusion of the intracranial cerebral arteries. CONCLUSION: The nature, duration, and severity of TP are not related to the duration or severity of the seizures nor the presence of lesions or changes on electroencephalogram. Although stroke is the leading differential diagnosis in patients with neurologic deficits; in pregnancy, TP should be included in the differential if convulsive activity is coupled with paralysis. A misdiagnosis of stroke can lead to unnecessary and potential harmful interventions.

Dual-Energy Computed Tomography for Evaluating Acute Brain Infarction of Middle Cerebral Artery Territories: Optimization of Voltage Settings in Virtual Monoenergetic Imaging.

To evaluate the optimal virtual monochromatic energy in dual-energy computed tomography for differentiating between infarcted areas and normal brain parenchyma. We enrolled 29 patients with middle cerebral artery acute brain infarction of who underwent examination by dual-energy computed tomography. We calculated the contrast-to-noise ratio (CNR) between white or gray matter and the infarcted area (CNR(W-I) and CNR(G-I), respectively) and normalized CNRs. From the normalized CNRs, we assessed which monochromatic energy gave the best balance between the infarcted area and normal brain parenchyma. The 70-keV images were used for comparison. The 99-keV images demonstrated the best balance between the infarction and normal brain parenchyma. In quantitative analysis, the 99-keV images were not inferior to the 70-keV images. (CNR(G-I), 1.92 ± 0.80 vs 2.00 ± 0.70, respectively [P = 0.16]; CNR(W-I), 0.52 ± 0.72 vs 0.40 ± 0.64, P < 0.01, respectively). Monochromatic 99-keV energy images may be optimal for evaluating middle cerebral artery acute brain infarction.

Impact of cerebral large-artery disease and blood flow in the posterior cerebral artery territory on cognitive function

ObjectivesThe purpose of this study was to elucidate the association of cerebral large artery disease (CLAD) with cerebral blood flow (CBF) in the posterior cerebral artery (PCA) territory and cognitive performance. MethodWe prospectively registered patients with CLAD who had internal carotid or middle cerebral artery (MCA) with the degree of stenosis ≥50%. Automated brain segmentation was used to quantify CBF in the thalamus, hippocampus, and PCA and MCA territories. We measured cognitive function of patients using the Wechsler Memory Scale Revised (WMS-R), the Mini-Mental State Examination (MMSE), and the Montreal Cognitive Assessment. Patients were divided into 3 groups according to CBF of the cortical and subcortical PCA territory. ResultsThere were 60 patients included in this study. The degree of stenosis was significantly correlated with CBF in the PCA territory (Γ = 0.35, P = .006) and hippocampus (Γ = 0.34, P = .008). Verbal memory, general memory, and reproduction on WMS-R and MMSE were significantly reduced areas with low CBF in the PCA territory compared with areas with middle and high CBF. ConclusionsCBF of the PCA territory was significantly inversely correlated with the degree of stenosis in CLAD patients. Low CBF of the PCA territory was significantly associated with reduced cognitive and memory functions.

Vestibular symptoms in acute hemispheric strokes.

A prospective study focused on whether vestibular symptoms are seen in acute hemispheric strokes, and if so, the frequency and lateralization of causative lesions on MRI. Among 668 patients with hemispheric infarction, we prospectively included those with chief complaints of acute vestibular symptoms, such as vertigo/dizziness, nausea/vomiting and gait instability, in the "VS" group. We also retrospectively reviewed MRI of all stroke patients, and included cases with the findings of parieto-insular vestibular cortex (PIVC) or temporo-periSylvian vestibular cortex (TPSVC) lesion by diffusion-weighted MRI, in the "PIVC" group. Eight patients were found to belong to the VS group, and six other patients to the PIVC group. In the VS group, six patients had the responsible lesion on the right hemisphere, in the middle cerebral artery (MCA) territory except one case and two on the left MCA territory, particularly in the insula, retro-insular region, superior/middle temporal gyrus, angular gyrus, supra-marginal gyrus, putamen and hippocampus/para-hippocampal gyrus. In contrast, none of the six other patients of the PIVC group had vestibular symptoms. One of them had a lesion in the right hemisphere and five in the left hemisphere. Four lesions were located in the insular area and two within the temporal lobe. In conclusion, cerebral hemispheric infarction limited to the PIVC or TPSVC does not necessarily cause vertigo. However, unilateral hemispheric infarctions, restricted to the areas belonging to the vestibular cortical network may cause vestibular symptoms. The lesions responsible for vestibular symptoms are located more often in the right hemisphere.

Stroke in young secondary to infective endocarditis complicating hypertrophic cardiomyopathy – A case report

Hypertrophic cardiomyopathy is an autosomal dominant disease of cardiac sarcomere with the varied clinical presentation. The common manifestations are heart failure (dyspnea), palpitations, chest pain, stroke and even sudden death. Majority of patients are not recognized because of being asymptomatic. Stroke is one of the complications of hypertrophic cardiomyopathy and usually occurs in the setting of atrial fibrillation, advanced age and congestive cardiac failure. Although infective endocarditis is known, but relatively uncommon, complication of hypertrophic cardiomyopathy, it is not reported from Nepal. We report here a case of 42-year male patient with hypertrophic cardiomyopathy in normal sinus rhythm with infective endocarditis who developed malignant cardioembolic stroke involving left middle cerebral artery territory.

Association Between Duration of Dysphagia Recovery and Lesion Location on Magnetic Resonance Imaging in Patients With Middle Cerebral Artery Infarction.

ObjectiveTo investigate association between lesion location on magnetic resonance imaging (MRI) performed after an infarction and the duration of dysphagia in middle cerebral artery (MCA) infarction.MethodsA videofluoroscopic swallowing study was performed for 59 patients with dysphagia who were diagnosed as cerebral infarction of the MCA territory confirmed by brain MRI. Lesions were divided into 11 regions of interest: primary somatosensory cortex, primary motor cortex, supplementary motor cortex, anterior cingulate cortex, orbitofrontal cortex, parieto-occipital cortex, insular cortex, posterior limb of the internal capsule (PLIC), thalamus, basal ganglia (caudate nucleus), and basal ganglia (putamen). Recovery time was defined as the period from the first day of L-tube feeding to the day that rice porridge with thickening agent was prescribed. Recovery time and brain lesion patterns were compared and analyzed.ResultsThe mean recovery time of all patients was 26.71±16.39 days. The mean recovery time was 36.65±15.83 days in patients with PLIC lesions and 32.6±17.27 days in patients with caudate nucleus lesions. Only these two groups showed longer recovery time than the average recovery time for all patients. One-way analysis of variance for recovery time showed significant differences between patients with and without lesions in PLIC and caudate (p<0.001).ConclusionInjury to both PLIC and caudate nucleus is associated with longer recovery time from dysphagia.

Optimization of post-label delay in single-phase arterial spin labeling (ASL) using multi-phase ASL in four-dimensional magnetic resonance angiography.

To optimize the post-label delay in single-phase arterial spin labeling (SP-ASL) using multi-phase ASL in 4-dimensional magnetic resonance angiography (4D-MRA). Ten healthy volunteers (six men, four women; age range, 24-37 years; mean, 29.1) were enrolled. 4D-MRA and SP-ASL were performed on a 3T magnetic resonance imaging (MRI) scanner. Signal intensities in four cerebral arterial territories (anterior cerebral artery, middle cerebral artery, posterior cerebral artery, and whole area) were measured using both 4D-MRA and SP-ASL, and peak time of maximum intensity through each technique was recorded. Regression analysis was used to determine the correlation between the peak times using 4D-MRA and those using SP-ASL, and the regression function obtained was used to estimate the peak time for SP-ASL (optimum post-label delay) from that obtained for 4D-MRA. The peak time in anterior cerebral artery territory for SP-ASL was expressed as 1.19 + 0.30 × (peak time of 4D-MRA) s, ( p = 0.017, r2 = 0.14). The peak time in middle cerebral artery territory for SP-ASL was 0.96 + 0.58 × (peak time of 4D-MRA) s, ( p < 0.001, r2 = 0.32). The peak time in posterior cerebral artery territory for SP-ASL was expressed as 0.92 + 0.58 × (peak time of 4D-MRA) s, ( p < 0.001, r2 = 0.33). The peak time in whole brain for SP-ASL was expressed as 1.04 + 0.46 × (peak time of 4D-MRA) s, ( p < 0.001, r2 = 0.25). The peak time values at 4D-MRA showed potential for use in predicting the optimum post-label delay of SP-ASL.

Multiple Burr-Hole Surgery for the Treatment of Moyamoya Disease and Quasi-Moyamoya Disease in Children: Preliminary Surgical and Imaging Results

Moyamoya disease (MMD) is characterized by a progressive spontaneous occlusion of distal internal carotid arteries and its main branches. It is necessary to promptly diagnose and treat this condition, especially in children, because of the high risk of stroke and consequent severe disability. In this study, we examine the role of multiple burr-hole surgery (MBHS) in the treatment of pediatric patients with MMD and quasi-MMD and the role of perfusion magnetic resonance imaging (MRI) in the surgical indication and during follow-up. We reviewed preoperative, early postoperative, and late postoperative MRI perfusion and digital subtraction angiography images together with clinical and surgical outcomes in 10 children with MMD treated by MBHS. Fourteen MBHS procedures (6 unilateral, 2 bilateral, and 2 single-setting bilateral) were performed in 10 children. Clinical and radiologic follow-up for all patients ranges from 16 months to 7 years. No ischemic events (transient ischemic attacks or stroke) occurred during the follow-up period. Postoperative digital subtraction angiography showed good revascularization around the burr-hole sites in all patients. The functional efficacy of the surgery was confirmed by dynamic susceptibility contrast perfusion MRI studies in 8 patients. Our data underline the good rate of success of MBHS in pediatric MMD and quasi-MMD. This technique results in good collateral revascularization, improved cerebral perfusion and excellent short and long-term symptoms control, with low perioperative risk. Postoperative changes of perfusion parameters and ivy sign MRI finding seem to show a positive correlation and mainly occur in posterior middle cerebral artery territory.

Blood Flow Lateralization and Collateral Compensatory Mechanisms in Patients With Carotid Artery Stenosis.

Background and Purpose—Four-dimensional phase-contrast magnetic resonance imaging enables quantification of blood flow rate (BFR; mL/min) in multiple cerebral arteries simultaneously, making it a promising technique for hemodynamic investigation in patients with stroke. The aim of this study was to quantify the hemodynamic disturbance and the compensatory pattern of collateral flow in patients with symptomatic carotid stenosis.Methods—Thirty-eight patients (mean, 72 years; 27 men) with symptomatic carotid stenosis (≥50%) or occlusion were investigated using 4-dimensional phase-contrast magnetic resonance imaging. For each patient, BFR was measured in 19 arteries/locations. The ipsilateral side to the symptomatic carotid stenosis was compared with the contralateral side.Results—Internal carotid artery BFR was lower on the ipsilateral side (134±87 versus 261±95 mL/min; P<0.001). BFR in anterior cerebral artery (A1 segment) was lower on ipsilateral side (35±58 versus 119±72 mL/min; P<0.001). Anterior cerebral artery territory bilaterally was primarily supplied by contralateral internal carotid artery. The ipsilateral internal carotid artery mainly supplied the ipsilateral middle cerebral artery (MCA) territory. MCA was also supplied by a reversed BFR found in the ophthalmic and the posterior communicating artery routes on the ipsilateral side (−5±28 versus 10±28 mL/min, P=0.001, and −2±12 versus 6±6 mL/min, P=0.03, respectively). Despite these compensations, BFR in MCA was lower on the ipsilateral side, and this laterality was more pronounced in patients with severe carotid stenosis (≥70%). Although comparing ipsilateral MCA BFR between stenosis groups (<70% and ≥70%), there was no difference (P=0.95).Conclusions—With a novel approach using 4-dimensional phase-contrast magnetic resonance imaging, we could simultaneously quantify and rank the importance of collateral routes in patients with carotid stenosis. An important observation was that contralateral internal carotid artery mainly secured the bilateral anterior cerebral artery territory. Because of the collateral recruitment, compromised BFR in MCA is not necessarily related to the degree of carotid stenosis. These findings highlight the importance of simultaneous investigation of the hemodynamics of the entire cerebral arterial tree.

Arterial spin-labeling cerebral perfusion changes after revascularization surgery in pediatric moyamoya disease and syndrome.

Moyamoya disease is a dynamic cerebrovascular condition that often requires vascular surveillance. Arterial spin labeling (ASL) is an MR perfusion method that is increasingly used for stroke and other various neurovascular pathologies. Unlike perfusion-weighted MRI, ASL uses endogenous water molecules for signal and therefore obviates gadolinium use; and provides direct, not relative, quantitative cerebral blood flow (CBF) measures. Presently, the potential role of ASL for evaluating postoperative pediatric moyamoya patients is relatively unexplored. This study investigated the role for ASL in evaluating cerebral hemodynamic changes in children who underwent revascularization surgery. This retrospective study examined 15 consecutive pediatric patients with moyamoya disease (n = 7) or moyamoya syndrome (n = 8) presenting between 2010 and 2014 who underwent revascularization and in whom 3T ASL was performed pre- and postoperatively. Postoperative MRI at least 3 months after revascularization procedure was used for analysis. Quantitative CBF in various vascular territories was interrogated: anterior, middle, and posterior cerebral arteries, and basal ganglia supplied by the lenticulostriate collaterals, resulting in evaluation of 20 brain regions. After revascularization, CBF in the high middle cerebral artery territory significantly increased (p = 0.0059), accompanied by a decrease in CBF to the ipsilateral lenticulostriate-supplied basal ganglia (p = 0.0053). No perfusion changes occurred in the remaining cerebral vascular territories after surgery. ASL-based quantitative CBF showed improved cerebral perfusion to the middle cerebral artery territory after revascularization in children with both moyamoya syndrome and disease. Reduced perfusion to the basal ganglia might reflect pruning of the lenticulostriate collaterals, potentially from effects of revascularization. ASL can quantitatively evaluate hemodynamic changes in children with moyamoya after revascularization, and it may be a useful adjunct to routine clinical MRI surveillance.

The Effect of Intravenous Magnesium Sulfate in Improvement of Acute Ischemic Stroke Induced Disability: A Randomized Double Blinded Clinical Trial

Background: Stroke is the third main cause of death and chronic disabilities in adults, which requires finding neuroprotective drugs to reduce its mortality and morbidity. Objectives: To determine the efficacy of magnesium sulfate as an adjunctive neuroprotective agent in patients with stroke. Materials &amp; Methods: This randomized double-blind clinical trial recruited 120 patients with acute ischemic stroke in the middle cerebral artery territory presenting to Ahvaz Golestan Hospital from 2015 to 2016. The patients were randomly assigned into two groups. The first group received 4 grams bolus intravenous magnesium sulfate and then 16 grams/24 hours for 5 consecutive days. The second group received normal saline as placebo. Functional disability was assessed on admission and at the end of the first and third months after stroke by modified National Institutes of Health Stroke Scale (mNIHSS) and modified Rankin Scale Score (mRSS). Qualitative variables were compared using chi-square test in SPSS V. 16. Results: The results showed that difference of the mean mNIHSS, before (P=0.596) and one (P=0.512) and three (P=0.664) months after the treatment was not statistically significant between magnesium and placebo groups. Also it was true for mRSS before (P=0.669) and three month (P= 0.878) after the treatment. Conclusion: IV magnesium sulfate probably did not have significant positive effects on the outcome of patients with acute middle cerebral artery infarction. Studies on larger populations are recommended to show its possible effects.

Neurodevelopmental outcome in hypoplastic left heart syndrome after hybrid procedure

Little is known about the mid-term outcome and brain development in patients following the hybrid approach for hypoplastic left heart syndrome (HLHS). This study investigates neurodevelopmental outcome, quality of life (QoL) and brain MRI findings in HLHS preschoolers treated with the hybrid approach. Twenty HLHS patients (60% males) have been examined after neonatal hybrid Stage I and comprehensive stage II operation at the Pediatric Heart Center Giessen, Germany, between 2012 and 2016. Patients were evaluated with the Bayley Scales of Infant and Toddler Development III (Bayley-III), neurological examination, the Preschool Children Quality of Life Questionnaire (TAPQOL) at age 26.5±3.6 months, and again at 39.7±3.9 months with the Pediatric Cardiac Quality of Life Inventory (PCQLI). Furthermore, brain volumetric measurements and conventional brain MRI findings (27.3±4.5 months) were analyzed and compared with six healthy controls (29.2±11.1 months, P=0.53). Children with verified genetic comorbidities were excluded. Mean cognitive, language, and motor composite scores on the Bayley-III were not different from healthy norms (100±15), and were 101±9.3 (P=0.48), 100±13 (P=0.93), and 98±11.7 (P=0.45), respectively. Status post stroke was the most common brain MRI abnormality, and was found in 3/19 (16%) patients, most common affecting the middle cerebral artery territory. In comparison to controls, total white matter volumes were reduced (P=0.014), and cerebrospinal fluid (CSF) volumes were increased (P=0.042) in patients. Overall health-related QoL in 2 to 3 years aged children HLHS was good, but inferior scores in the motor subscale were noted compared to healthy norms (P=0.007). However, at 3 to 4 years, parents reported comparable QoL for their children in the PCQLI to children with biventricular heart lesion. HLHS patients followed by hybrid approach without major complications show a favorable neurodevelopment at 2-3 years of age. Despite extensive health-related burden, the vast majority of Fontan preschoolers with HLHS showed a good health-related QoL. Nevertheless, comprehensive care and establishing routine follow-up examinations are important to recognize long-term challenges and further improve neurodevelopmental outcome of this high-risk patient population.

Tau and TDP-43 accumulation of the basal nucleus of Meynert in individuals with cerebral lobar infarcts or hemorrhage

A previous study reported that a massive cerebral infarct in the territory of the middle cerebral artery (MCA) may be associated with development of neurofibrillary tangles (NFTs) in the ipsilateral basal nucleus of Meynert (BNM). We analyzed 19 cases of an MCA territory infarct and 12 with a putaminal hemorrhage (mean age 82.5 years; female/male ratio 8/23; mean time from stroke onset to autopsy 4182 days). In both groups, 74–100% had a significantly higher rate of phosphorylated tau immunoreactive or Gallyas Braak silver stain-positive neurons on the BNM-affected side than on the BNM-unaffected side. These NFTs were immunoreactive for anti-RD3 and anti-RD4 antibodies, and a triple-band pattern was observed by immunoblot analysis with anti-tau antibody. Most NFTs might be formed within the 5–10 years after stroke onset. There were significantly more TAR DNA-binding protein 43 (TDP43) immunoreactive structures on the BNM-affected side than on the BNM-unaffected side. We showed that many NFTs with TDP43-immunoreactive structures were observed in the ipsilateral BNM associated with a massive cerebral infarct in the MCA territory or a putaminal hemorrhage.

Evaluation of Diffusional Kurtosis Imaging in Sub-acute Ischemic Stroke: Comparison with Rehabilitation Treatment Effect

Stroke is a serious worldwide medical condition that causes neurological function disability. Diffusional kurtosis imaging, which measures the non-Gaussianity of water diffusion, has been demonstrated to be a sensitive biomarker in many neuro-pathologies. This study explores the relationship between neural function recovery and transformation of the ischemic lesion and/or corticospinal tract during the sub-acute phase after stroke by using diffusional kurtosis imaging. We performed a prospective study of function recovery and K metrics of 43 patients with sub-acute ischemic stroke in the middle cerebral artery territory. The effect of rehabilitation treatment was evaluated using both the Fugl-Meyer motor function score and modified Barthel index score at post-treatment compared with admission, and patients were allocated to two groups: good and poor rehabilitation effect (GRE and PRE). Metrics of diffusional kurtosis imaging within ischemic lesion and along the corticospinal tract were acquired, respectively. All three relative axial diffusional kurtoses (rKas) along the corticospinal tract in the GRE group (n = 21) were significantly larger than those of the PRE group (n = 22), including rKa in the posterior limb of internal capsule, rKa in the cerebral peduncle, and rKa in the basal part of the pons (p = 0.014, 0.005, and 0.021, respectively). This multi-parametric magnetic resonance imaging study showed that diffusional kurtosis imaging has the potential to complement existing stroke imaging techniques and revealed its own advantages in elucidating the possible biophysical mechanism of functional restoration underlying ischemic stroke.