Recent Infarction Research Articles

Small Vessel Disease, a Marker of Brain Health: What the Radiologist Needs to Know.

Small vessel disease, a disorder of cerebral microvessels, is an expanding epidemic and a common cause of stroke and dementia. Despite being almost ubiquitous in brain imaging, the clinicoradiologic association of small vessel disease is weak, and the underlying pathogenesis is poorly understood. The STandards for ReportIng Vascular changes on nEuroimaging (STRIVE) criteria have standardized the nomenclature. These include white matter hyperintensities of presumed vascular origin, recent small subcortical infarcts, lacunes of presumed vascular origin, prominent perivascular spaces, cerebral microbleeds, superficial siderosis, cortical microinfarcts, and brain atrophy. Recently, the rigid categories among cognitive impairment, vascular dementia, stroke, and small vessel disease have become outdated, with a greater emphasis on brain health. Conventional and advanced small vessel disease imaging markers allow a comprehensive assessment of global brain heath. In this review, we discuss the pathophysiology of small vessel disease neuroimaging nomenclature by means of the STRIVE criteria, clinical implications, the role of advanced imaging, and future directions.

The risk factors of old silent brain infarctions in carotid artery stenosis.

This study aims to investigate the risk factors of old ipsilateral silent brain infarctions (iSBIs) in patients with internal carotid artery (ICA) stenosis. Consecutive patients with unilateral ICA stenosis ≥ 50% or occlusion were retrospectively enrolled. Old iSBIs were assessed on magnetic resonance imaging. Baseline characteristics and imaging features were compared between patients with and without iSBIs. Multivariable regression analysis was conducted to identify independent risk factors of iSBIs. We enrolled 274 patients with unilateral ICA stenosis ≥ 50% or occlusion. One hundred thirty-three patients had iSBIs to stenosed ICA (48.54%). One hundred thirty-seven patients had recent brain infarction on either side (50.0%). The patients with iSBIs had a lower level of high-density lipoprotein [OR 0.60, 95% CI (0.36-0.96), P = 0.045], higher prevalence of irregular/ulcer plaque [OR 10.71, 95% CI (4.60-24.95), P < 0.0001], and incompleteness of circle of Willis [OR 0.27, 95% CI (0.16-0.45), P < 0.0001] in all enrolled patients. In the patients without recent infarction on either side, lower level of high-density lipoprotein [OR 0.42, 95% CI (0.27-0.88), P = 0.031], higher prevalence of irregular/ulcer plaque [OR 12.73, 95% CI (4.13-39.22), P < 0.0001] and incompleteness of circle of Willis [OR 0.24, 95% CI (0.11-0.50), P = 0.004] were independently associated with iSBIs. The results were similar in ICA stenosis patients with recent brain infarction on either side. In patients with carotid stenosis, incompleteness of circle of Willis, irregular/ulcer plaque, and lower level of high-density lipoprotein were independently associated with old iSBIs.

Revascularization to the ACA: effectiveness and variation of the STA-RAG-A3 bonnet bypass.

The effectiveness of bypass surgery in patients with atherothrombotic ischemia in the anterior cerebral artery (ACA) domain remains unclear. In this study, three cases with ischemia in the ACA territory underwent revascularization surgery using superficial temporal artery (STA)-radial artery graft (RAG)-A3 (pericallosal artery) bonnet bypass. Herein, we discuss the effectiveness and variations of this approach. Among 182 consecutive patients with atherothrombotic ischemic stroke admitted to the NTT Medical Center, Tokyo, from April 2017 to May 2021, three patients with hemodynamic insufficiency in the extensive ACA territory beyond the recent infarct area were treated using STA-RAG-A3 bonnet bypass. One patient with bilateral severe cerebral blood flow (CBF) deficiency required additional A3-A3 and STA-middle cerebral artery single bypass in conjunction with STA-RAG-A3 bypass. There were no complications associated with the surgical procedure. The patients' hemodynamic study results and neurocognitive performances improved dramatically after surgery. Our results suggest the efficacy of STA-RAG-A3 bypass for atherothrombotic ACA ischemia. However, because the number of cases was too small to generalize our results, more cases and thorough pre- and postoperative hemodynamic studies are necessary to prove the validity of the approach.

Thrombus of the Aorta and SARS-CoV-2 Infection: Cause or Trigger?

Objective: Coronavirus disease 19 is a well-established cause of rare arterial thrombosis. Nevertheless, the exact mechanism of arterial thrombosis remains to be elucidated. We herein report the case of a large floating thrombus of the aortic arch, its surgical management and histological analysis.Case: A 65-year-old patient presented to the emergency department with a suspected stroke. He was non-smoker, but presented cardiovascular risk factors, namely hypertension, type 2 diabetes and hyperlipidaemia. A computed tomography of the aorta revealed a large floating thrombus of the aortic arch, at the base of the brachiocephalic trunk, suspected to be the etiology of stroke. Therapeutic anticoagulation was immediately started. The decision was made to perform an open aortic replacement surgery because of the symptomatic thromboembolic event with recent cerebral infarction and the potential harmfulness of the thrombus due to its size. A mobile thrombus was observed at the base of the brachiocephalic trunk by echocardiography. It was attached to a small area of the upper aortic wall and had an irregular surface. Histology revealed a platelet-rich thrombus lying on an aortic atherosclerotic plaque without pronounced inflammation. No plaque ulceration was present but endothelial cell desquamation was observed consistent with plaque erosion.Conclusion: In our case, there was a thrombus lying on an atherosclerotic plaque with intact thick fibrous cap, but associated with a plaque erosion mechanism. The thrombus formation appeared more likely to relate to a very localized endothelial injury.

Vascular dementia neurovisual markers according routine and diffusion-tensor MRI (publications’ review)

The article presents review of the most significant neurovisual biomarkers-predictors of the cognitive disfunction caused by brain vascular pathology. Also given quantitative and qualitative characteristics of this pathology including localization that can be detected using routine and diffusion-tensor MRI. Following biomarkers were noted when using standard MRI protocols: atrophy of gray matter and white matter tracts and basal nuclei; white matter hyperintensities (foci of gliosis and periventricular leukoaraiosis), micro-bleeding (large vessels, white and gray matter deposits of hemosiderin), enlarged perivascular spaces (cystic enlargement of the penetrating arteries, arterioles, veins and venules), recent small subcortical infarcts andpost-ischemic damages in cortex, basal nuclei and white matter tracts. The article outlines diffusion tensor MRI latest developments for cognitive deficits’ risk assessment, such as threshold coefficients (indexes) of the fraction anisotropy, received in neocortex tracts (frontal and temporal lobes; fronto-thalamic pathway).

Giant Prolactinoma Causing Proptosis and Stroke

Background: Although suprasellar and cavernous sinus invasion are common in giant prolactinomas, intra-orbital extension is extremely uncommon [1]. Even less reported are cases of giant prolactinomas causing cerebral ischemia or death.Clinical Case: A 51-year old woman presented to the ED with confusion, right-sided weakness and severe left eye proptosis with loss of vision. Five years prior, she underwent a partial transphenoidal resection for a macroprolactinoma due to acute vision changes with compression of the optic chiasm. Prior to surgery, prolactin level was elevated to 2,106 ng/mL (n 2.4-24.0 ng/mL). Post-operative MRI showed residual 2.7 x 3.1 x 2.6 cm mass. Thereafter she was prescribed cabergoline which she self-discontinued three years later. MRI of the brain at time of presentation demonstrated a 10.1 x 6.4 x 4.3 cm sellar/suprasellar mass extending into the left orbit causing severe proptosis and mass effect on the left frontal lobe, temporal lobe, midbrain, and basilar artery with encasement of the left cavernous internal carotid artery. A recent left striatocapsular infarct due to compression of the left middle cerebral artery was present. Prolactin level was elevated to 16,487 ng/mL. Neurosurgery was consulted and recommended medical management. Free thyroxine level was low and thyroid hormone replacement was started. Although the cosyntropin stimulation test showed an appropriate cortisol level peak of 21.5 mcg/dL, she was given stress dose glucocorticoids. Bromocriptine was initially started and titrated and later changed to cabergoline. Six weeks after discharge, she was readmitted with worsening confusion and seizure activity. On day 2 of admission, she decompensated. New hemorrhage inside the mass with increased vasogenic edema and a midline shift was discovered on a head CT. She underwent emergent craniotomy with surgical debulking of the tumor. Unfortunately, her mental status did not improve post-operatively. She was transitioned to hospice care and died 7 days after surgery. Surgical pathology showed a lactotroph adenoma with markedly elevated Ki67 proliferation index of 20-30%.Conclusion: This case demonstrates an unusually aggressive macroprolactinoma causing severe proptosis, ischemic stroke and death and adds to the very few cases previously reported [2].

Acute Ischaemic Stroke With Hyperprolactinemia:A Case Report

Background: Macroincidentalomas were reported in 0.2% of patient underwent imaging (CT scans) for central nervous symptoms (1). In acute ischaemic stroke with hyperprolactinemia, the diagnosis of a double pathology of ischemic stroke and sellar tumour especially prolactinoma need to be considered. Hyperprolactinemia itself may be considered as a risk factor for ischemic stroke due to its thrombogenic effect (3). Clinical Case: A 47-year old man underlying hypertension and diabetes mellitus for 5 years presented with sudden onset of right sided body weakness associated with facial asymmetry and aphasia. No history of fever or trauma. Asymptomatic of hyperprolactinemia previously. On general examinations Glasgow Coma Scale 11/15 Eye 4 Verbal 1 Motor 6, blood pressure was unstable with readings of systolic 244mmHg and diastolic 142mmHg. Neurological examinations showed expressive aphasia, right hemianopia, right facial nerve palsy and absence of gag reflex. Cerebellar signs were negative. Motor function examinations of right upper and lower limbs showed hypertonia, reduce power of 2/5, normal reflexes and up going plantar response. Sensory functions of right upper and lower limbs were reduced. Clinically diagnosed as stroke with hypertensive emergency. CT brain showed multiple hypodensities due to recent infarct and incidental finding of an aggressive sellar mass. MRI brain showed left Middle Cerebral Artery territory infarct and an aggressive sphenoid sinus mass with suprasellar and bilateral cavernous sinus extension possibility of a macroadenoma. Serum prolactin level showed markedly hyperprolactinemia (21146 ng/ml, n 4.04 – 15.2 ng/ml) which level of 500ng/ml or greater is diagnostic of a macroprolactinoma (2). FSH level (0.929 IU/L, n 1.5-12.4 IU/L) and LH level (1.11 IU/L, n 1.7-8.6 IU/L) were low in this patient due to suppression of GnRH secretion from hypothalamus by prolactin. Testosterone level (0.15 nmol/L, n 8.64-29.0 nmol/L) was low secondary to low LH. Serum cortisol, growth hormone and TSH were normal. Platelet count and coagulation profiles were normal. The patient was treated conservatively in ward for acute ischaemic stroke and later was started on dopamine agonist cabergoline for hyperprolactinemia. Conclusion: This is a case report of acute ischaemic stroke with markedly hyperprolactinemia secondary to incidentaloma macroprolactinoma. Reference: (1)Freda PU, Beckers AM, Katznelson L, et al. Pituitary incidentaloma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96 (4): 894-904.(2)Abha Majumdar and Nisha Sharma Mangal. Hyperprolactinemia. J Hum Reprod Sci. 2013 Jul-Sep; 6(3): 168–175.(3)Sankalp Kumar Tripathi, Pallavi Kamble, M.G. Muddeshwar. Serum Prolactin Level in Patients of Ischemic stroke. International Journal of Contemporary Medical Research 2016; 3(12): 3459-3460.

Higher Cerebral Small Vessel Disease Burden in Patients with White Matter Recent Small Subcortical Infarcts

Recent small subcortical infarcts (RSSI) are considered an acute manifestation of cerebral small vessel disease (CSVD). We assessed whether the topography of RSSI was related to CSVD markers on magnetic resonance imaging (MRI). We screened the local registries of two independent stroke centers in Catalonia and selected patients with a symptomatic RSSI on MRI performed during admission. RSSI location was classified into brainstem, supratentorial subcortical structures (SSS), and centrum semiovale (CSO) regions. Clinical variables, including vascular risk factors, were collected. Radiological markers of CSVD on MRI were evaluated individually and by means of the global CSVD burden score. The associations between each RSSI location and CSVD markers were studied in uni- and multivariate logistic regression analysis. Among 475 patients with RSSI, 152 (32%) had an infarct in the brainstem, 227 (48%) in SSS, and 96 (20%) in CSO region. The median CSVD burden score was 2 (IQR, 1-3). After adjusting for confounding factors, a RSSI in CSO was associated with higher periventricular and deep white matter hyperintensity scores [OR 1.64 (95% CI, 1.16-2.33), and OR 1.44 (95% CI, 1.07-1.93), respectively]. Higher CSVD burden score was positively associated with CSO [OR 1.48 (95% CI, 1.22-1.81)] and inversely associated with SSS [0.85 (95% CI, 0.72-0.99)] location after adjusting for relevant confounders. CSO RSSI were related to a higher burden of CSVD, particularly to white matter hyperintensities, compared to other RSSI locations. The pathophysiological significance of such findings should be investigated in the future with advanced neuroimaging techniques.

Editors' Note: First-Ever Ischemic Stroke and Increased Risk of Incident Heart Disease in Older Adults

Using a propensity-matched cohort of >20,000 patients with acute ischemic stroke and >70,000 matched nonstroke individuals, Dr. Sposato et al. observed a 4-fold higher odds of major cardiac adverse events among patients with recent acute stroke. Importantly, patients were matched based on vascular risk factors, socioeconomic status, hospitalization frequency, and previous medications. The higher incidence of poststroke heart disease may have been related to the index cerebrovascular event, as the authors state. Alternatively, some patients may have experienced a stroke-induced myocardial stunning from excess sympathetic tone, which is supported by existing animal models and observational studies. Dr. Sioka et al. highlighted their own observations (using myocardial perfusion imaging) that subclinical coronary artery disease after stroke may be more common than expected. As noted by Dr. Sposato et al., the cohort reported by Sioka may have been selected for patients at risk of more coronary artery disease, given the stroke mechanisms and vascular profile of the included patients. Whatever the mechanism of myocardial injury, clinicians ought to monitor closely for concomitant cardiac disease among patients with recent cerebral infarction. Using a propensity-matched cohort of >20,000 patients with acute ischemic stroke and >70,000 matched nonstroke individuals, Dr. Sposato et al. observed a 4-fold higher odds of major cardiac adverse events among patients with recent acute stroke. Importantly, patients were matched based on vascular risk factors, socioeconomic status, hospitalization frequency, and previous medications. The higher incidence of poststroke heart disease may have been related to the index cerebrovascular event, as the authors state. Alternatively, some patients may have experienced a stroke-induced myocardial stunning from excess sympathetic tone, which is supported by existing animal models and observational studies. Dr. Sioka et al. highlighted their own observations (using myocardial perfusion imaging) that subclinical coronary artery disease after stroke may be more common than expected. As noted by Dr. Sposato et al., the cohort reported by Sioka may have been selected for patients at risk of more coronary artery disease, given the stroke mechanisms and vascular profile of the included patients. Whatever the mechanism of myocardial injury, clinicians ought to monitor closely for concomitant cardiac disease among patients with recent cerebral infarction.

Analysis of Placenta with SARS-CoV-2 and Fetal Death: Case Report

Introduction: The pandemic of the new coronavirus (SARS-CoV-2) has unfolded at a remarkable speed, presenting unprecedented challenges for society and for health systems. The experience with coronavirus infections during pregnancy is still limited, requiring analysis regarding the impact of SARSCoV-2 on the health of pregnant women and newborns. We aimed to report a case of fetal death of a pregnant woman with COVID-19 and SARS-CoV-2 identified in the placenta with morphological repercussions. Case Report: Primigravida, 39 years old, gestation initially twinned, evolved non-evolution of the second embryo, verified in ultrasound evaluation in the first trimester of pregnancy. In the course of 35 weeks, she reported watery diarrhea, without blood or mucus, with progressive worsening, about 10 to 12 episodes in 24 hours, associated with diffuse colicky abdominal pain. She denies having other symptoms. 48 hours after the onset of diarrhea, the pain worsened, radiating bilaterally into the lumbar region, in addition to prostration and asthenia, seeking emergency care at a maternity hospital. Physical examination revealed active labor (9 cm dilation), rupture of ovular membranes and lack of fetal vitality by cardiac auscultation and evaluation of fetal movement. A cesarean section was performed, in which fetal death was confirmed. Soon after the procedure, still in the delivery room, a naso-oropharyngeal swab was collected from the patient, and SARS-CoV-2 was detected through RT-PCR technique. Conclusion: The maternal surface of the placenta had an area of previous infarction and an area of recent infarction, peripheral, making up about 20% of the organ and the placental cuts showed white bundles. The fetal membranes had thickened and yellowish areas. Histopathological examination of the placenta showed diffuse villitis, characterized by lymphoplasmacytic infiltrate, in addition to intervillositis with areas of intense intervillous fibrin deposition. Swab collection was performed from the placental cut surface for detection of SARS-CoV-2 by RT-PCR, which was positive. The naso-oropharyngeal swab of the fetus was negative

Analysis of Placenta with SARS-CoV-2 and Fetal Death: Case Report

Introduction: The pandemic of the new coronavirus (SARS-CoV-2) has unfolded at a remarkable speed, presenting unprecedented challenges for society and for health systems. The experience with coronavirus infections during pregnancy is still limited, requiring analysis regarding the impact of SARSCoV-2 on the health of pregnant women and newborns. We aimed to report a case of fetal death of a pregnant woman with COVID-19 and SARS-CoV-2 identified in the placenta with morphological repercussions. Case Report: Primigravida, 39 years old, gestation initially twinned, evolved non-evolution of the second embryo, verified in ultrasound evaluation in the first trimester of pregnancy. In the course of 35 weeks, she reported watery diarrhea, without blood or mucus, with progressive worsening, about 10 to 12 episodes in 24 hours, associated with diffuse colicky abdominal pain. She denies having other symptoms. 48 hours after the onset of diarrhea, the pain worsened, radiating bilaterally into the lumbar region, in addition to prostration and asthenia, seeking emergency care at a maternity hospital. Physical examination revealed active labor (9 cm dilation), rupture of ovular membranes and lack of fetal vitality by cardiac auscultation and evaluation of fetal movement. A cesarean section was performed, in which fetal death was confirmed. Soon after the procedure, still in the delivery room, a naso-oropharyngeal swab was collected from the patient, and SARS-CoV-2 was detected through RT-PCR technique. Conclusion: The maternal surface of the placenta had an area of previous infarction and an area of recent infarction, peripheral, making up about 20% of the organ and the placental cuts showed white bundles. The fetal membranes had thickened and yellowish areas. Histopathological examination of the placenta showed diffuse villitis, characterized by lymphoplasmacytic infiltrate, in addition to intervillositis with areas of intense intervillous fibrin deposition. Swab collection was performed from the placental cut surface for detection of SARS-CoV-2 by RT-PCR, which was positive. The naso-oropharyngeal swab

Lacunar Stroke Lesion Extent and Location and White Matter Hyperintensities Evolution 1 Year Post-lacunar Stroke.

Lacunar strokes are a common type of ischemic stroke. They are associated with long-term disability, but the factors affecting the dynamic of the infarcted lesion and the brain imaging features associated with them, reflective of small vessel disease (SVD) severity, are still largely unknown. We investigated whether the distribution, volume and 1-year evolution of white matter hyperintensities (WMH), one of these SVD features, relate to the extent and location of these infarcts, accounting for vascular risk factors. We used imaging and clinical data from all patients [n = 118, mean age 64.9 (SD 11.75) years old] who presented to a regional hospital with a lacunar stroke syndrome within the years 2010 and 2013 and consented to participate in a study of stroke mechanisms. All patients had a brain MRI scan at presentation, and 88 had another scan 12 months after. Acute lesions (i.e., recent small subcortical infarcts, RSSI) were identified in 79 patients and lacunes in 77. Number of lacunes was associated with baseline WMH volume (B = 0.370, SE = 0.0939, P = 0.000174). RSSI volume was not associated with baseline WMH volume (B = 3.250, SE = 2.117, P = 0.129), but predicted WMH volume change (B = 2.944, SE = 0.913, P = 0.00184). RSSI location was associated with the spatial distribution of WMH and the pattern of 1-year WMH evolution. Patients with the RSSI in the centrum semiovale (n = 33) had significantly higher baseline volumes of WMH, recent and old infarcts, than patients with the RSSI located elsewhere [median 33.69, IQR (14.37 50.87) ml, 0.001 ≤ P ≤ 0.044]. But patients with the RSSI in the internal/external capsule/lentiform nucleus experienced higher increase of WMH volume after a year [n = 21, median (IQR) from 18 (11.70 31.54) ml to 27.41 (15.84 40.45) ml]. Voxel-wise analyses of WMH distribution in patients grouped per RSSI location revealed group differences increased in the presence of vascular risk factors, especially hypertension and recent or current smoking habit. In our sample of patients presenting to the clinic with lacunar strokes, lacunar strokes extent influenced WMH volume fate; and RSSI location and WMH spatial distribution and dynamics were intertwined, with differential patterns emerging in the presence of vascular risk factors. These results, if confirmed in wider samples, open potential avenues in stroke rehabilitation to be explored further.

Concomitant AngioVac thrombectomy and patent foramen ovale closure in a patient with a large right atrial thrombus and recent paradoxical embolic stroke

A 59-year-old male with a history of gallbladder adenocarcinoma receiving chemotherapy and on therapeutic anticoagulation for portal vein thrombosis presented to the emergency department via ambulance after being found unresponsive and in cardiac arrest. Initial workup upon return of spontaneous circulation revealed a large right atrial mass, patent foramen ovale (PFO), and bilateral acute cortical infarctions. This constellation of findings were concerning for PFO-related paradoxical embolic strokes. Given the risk of recurrent paradoxical embolic events and the absolute contraindication to thrombolysis due to recent cerebral infarction, the decision was made to proceed with percutaneous vacuum-assisted thrombectomy using the AngioVac device. To prevent intraoperative thrombus propagation, PFO-closure was performed immediately prior to thrombectomy. Aspiration thrombectomy and PFO-closure were successful with complete thrombus removal and no intraoperative thrombus propagation. This case presents a minimally invasive and rapid treatment for a complex problem. An efficient and effective interdisciplinary team-based approach allowed the patient to resume cancer treatment relatively unabated.

Post-stroke Cognition at 1 and 3 Years Is Influenced by the Location of White Matter Hyperintensities in Patients With Lacunar Stroke.

Lacunar strokes are a common type of ischemic stroke. They are known to have long-term cognitive deficits, but the influencing factors are still largely unknown. We investigated if the location of the index lacunar stroke or regional WMH and their change at 1 year could predict the cognitive performance at 1 and 3 years post-stroke in lacunar stroke patients. We used lacunar lesion location and WMH-segmented data from 118 patients, mean age 64.9 who had a brain MRI scan soon after presenting with symptoms, of which 88 had a repeated scan 12 months later. Premorbid intelligence (National Adult Reading Test) and current intelligence [Addenbrooke's Cognitive Exam-Revised (ACE-R)] were measured at 1, 12, and 36 months after the stroke. ANCOVA analyses adjusting for baseline cognition/premorbid intelligence, vascular risk factors, age, sex and total baseline WMH volume found that the recent small subcortical infarcts (RSSI) in the internal/external capsule/lentiform nucleus and centrum semiovale did not predict cognitive scores at 12 and 36 months. However, RSSI location moderated voxel-based associations of WMH change from baseline to 1 year with cognitive scores at 1 and 3 years. WMH increase in the external capsule, intersection between the anterior limb of the internal and external capsules, and optical radiation, was associated with worsening of ACE-R scores 1 and 3 years post-stroke after accounting for the location of the index infarct, age and baseline cognition.

Abstract P374: Dolichoectacic Features of Basilar Artery Serve an Imaging Surrogate of Branch Artery Disease in Patients With Pontine Infarcts

Background: The arterial pathology underlying recent small subcortical infarctions (historically known as lacunar stroke) is heterogenous and includes lipohyalinosis, branch artery atherosclerosis or embolism. Although the use of high-resolution imaging studies directed to vessel wall might be helpful in teasing out these different pathologies, more readily available imaging surrogates such as size or spatial characteristics of the ischemic lesion are used for this purpose in clinical practice. Herein, we determined the distribution of dolichoectacic features of basilar artery in patients presenting with pontine penetrator artery stroke with different underlying occlusive pathologies. Methods: The dolichoectacic features of basilar artery were retrospectively evaluated according to Smoker’s criteria (diameter: &gt;4.5 mm, laterality: more lateral to the lateral margin of clivus or dorsum sellae, and height of bifurcation: at least at the level of third ventricular floor) on CT angiography in ischemic stroke patients with a single penetrator artery occlusion in the pons. Patients with basilar artery pathologies such stenosis, dissection, or apparent dolichoectasia were excluded. Ischemic lesions extending to the surface of pontine base on DWI were judged to be secondary to branch artery occlusion, rather than lipohyalinosis. Results: Out of 122 patients, 68 (56%) had at least one feature suggestive of basilar artery dolichoectasia. Patients with lateral deviation of basilar artery were more likely to harbor infarcts extending to pontine surface (69% vs. 50%); no such relationship was identified for other imaging markers of dolichoectasia. After adjustment for age, gender and vascular risk factors, lateral deviation of the basilar artery remained significantly associated with an infarct pattern suggestive of branch artery occlusion (OR=2.8, 95%CI 1.1-7.3; p=0.031). There was also a tendency for ischemic lesions to be located on the ipsilateral side of the lateral deviation (63%; p=0.081). Conclusion: Our findings highlight that lateral displacement of basilar artery, an imaging feature of basilar dolichoectasia, can be used as an additional surrogate marker of branch artery pathology in patients with pontine penetrator artery infarction.

Lenticulostriate artery combined with neuroimaging markers of cerebral small vessel disease differentiate the pathogenesis of recent subcortical infarction

Recent subcortical infarction (RSI) in the lenticulostriate artery (LSA) territory with a non-stenotic middle cerebral artery is a heterogeneous entity. We aimed to investigate the role of LSA combined with neuroimaging markers of cerebral small vessel disease (CSVD) in differentiating the pathogenic subtypes of RSI by whole-brain vessel-wall magnetic resonance imaging (WB-VWI). Fifty-two RSI patients without relevant middle cerebral artery (MCA) stenosis on magnetic resonance angiography were prospectively enrolled. RSI was dichotomized as branch atheromatous disease (BAD; a culprit plaque located adjacent to the LSA origin) (n = 34) and CSVD-related lacunar infarction (CSVD-related LI; without plaque or plaque located distal to the LSA origin) (n = 18). Logistic regression analysis showed lacunes (odds ratio [OR] 9.68, 95% confidence interval [CI] 1.71–54.72; P = 0.010) and smaller number of LSA branches (OR 0.59, 95% CI 0.36–0.96; P = 0.034) were associated with of BAD, whereas severe deep white matter hyperintensities (DWMH) (OR 0.11, 95% CI 0.02–0.71; P = 0.021) was associated with CSVD-related LI. In conclusion, the LSA branches combined with lacunes and severe DWMH may delineate subtypes of SSI. The WB-VWI technique could be a credible tool for delineating the heterogeneous entity of SSI in the LSA territory.

Magnetic resonance imaging manifestations of cerebral small vessel disease: automated quantification and clinical application.

The common cerebral small vessel disease (CSVD) neuroimaging features visible on conventional structural magnetic resonance imaging include recent small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, microbleeds, and brain atrophy. The CSVD neuroimaging features have shared and distinct clinical consequences, and the automatic quantification methods for these features are increasingly used in research and clinical settings. This review article explores the recent progress in CSVD neuroimaging feature quantification and provides an overview of the clinical consequences of these CSVD features as well as the possibilities of using these features as endpoints in clinical trials. The added value of CSVD neuroimaging quantification is also discussed for researches focused on the mechanism of CSVD and the prognosis in subjects with CSVD.

Acute Arterial Ischemic Stroke in a Treated Child with Hunter's Syndrome: A Case Report and Review of the Literature

AbstractEnzyme replacement therapy (ERT) has limited therapeutic effects on neurologic, skeletal, and cardiovascular pathophysiology. We report an acute right-sided flaccid hemiparesis in an 11-year-old boy with the severe neuronopathic phenotype of Hunter's syndrome who was receiving weekly idursulfase ERT. Due to his psychomotor regression and epilepsy, his presentation to the hospital was delayed. Computed tomography scan of brain showed no acute changes or hemorrhage. Stroke code was not called as patient was already outside of the time window for tissue plasminogen activator (tPA) therapy. Brain magnetic resonance imaging (MRI) showed diffuse cortical and deep atrophy consistent with his baseline neurological status and restricted diffusion in the territory of the left-middle cerebral artery (MCA) consistent with recent infarction. T1-weighted MRI revealed low signal intensity of the left insular cortex, as well as volume loss, consistent with previous undiagnosed stroke in the same vascular territory. In addition, MR angiogram (MRA) demonstrated left terminal M1 segment MCA occlusion. Echocardiogram showed aortic root dilation and moderate aortic valve insufficiency. Patient was also noted to have bacteremia related to port infection. ERT is limited by blood–brain barrier and the underlying glycosaminoglycans (GAGs) extracellular tissue accumulation which produces a proinflammatory state. GAG and bacterial lipopolysaccharide (LPS) are known to activate toll-like receptor 4 (TLR-4). GAGs released in the extracellular space of intracranial vessels induce inflammation by activating the TLR-4 pathway which is exacerbated by bacterial LPS contributing to focal arteritis. Our case suggests the importance of GAGs in the activation of the TLR-4 pathway as a cause of stroke in Hunter's syndrome.

Macula Structure and Microvascular Changes in Recent Small Subcortical Infarct Patients

Purpose: This study aimed to assess the macula structure and capillaries in the macula and optic nerve head in recent small subcortical infarct (RSSI) patients.Methods: This observational cross-sectional study included 40 RSSI patients and 46 healthy controls. Optical coherence tomography angiography was used to image the capillaries in the macula and optic nerve head. An inbuilt algorithm was used to measure the densities in the microvasculature of the macula [superficial retinal capillary plexus (SRCP) and deep retinal capillary plexus (DRCP)] and optic nerve head [radial peripapillary capillary (RPC)] and thickness around the optic nerve head, peripapillary retinal nerve fiber layer (pRNFL).Results: Densities in RPC (P < 0.001), SRCP (P = 0.001), and DRCP (P = 0.003) were reduced in RSSI patients when compared with healthy controls. The pRNFL thickness was thinner (P < 0.001) in RSSI patients than healthy controls. In the RSSI group, the SRCP density significantly correlated with the DRCP density (rho = 0.381, P = 0.042). The pRNFL thickness displayed a significant relationship with the RPC density (rho = 0.482, P = 0.003) in the RSSI group.Conclusions: RSSI patients showed interrupted capillary plexuses leading to its significant impairment and neurodegeneration. Our report provides insight into the macula capillary microcirculation changes in RSSI.

Analysis of Placenta with SARS-CoV-2 and Fetal Death: Case Report

Introduction: The pandemic of the new coronavirus (SARS-CoV-2) has unfolded at a remarkable speed, presenting unprecedented challenges for society and for health systems. The experience with coronavirus infections during pregnancy is still limited, requiring analysis regarding the impact of SARSCoV-2 on the health of pregnant women and newborns. We aimed to report a case of fetal death of a pregnant woman with COVID-19 and SARS-CoV-2 identified in the placenta with morphological repercussions. Case Report: Primigravida, 39 years old, gestation initially twinned, evolved non-evolution of the second embryo, verified in ultrasound evaluation in the first trimester of pregnancy. In the course of 35 weeks, she reported watery diarrhea, without blood or mucus, with progressive worsening, about 10 to 12 episodes in 24 hours, associated with diffuse colicky abdominal pain. She denies having other symptoms. 48 hours after the onset of diarrhea, the pain worsened, radiating bilaterally into the lumbar region, in addition to prostration and asthenia, seeking emergency care at a maternity hospital. Physical examination revealed active labor (9 cm dilation), rupture of ovular membranes and lack of fetal vitality by cardiac auscultation and evaluation of fetal movement. A cesarean section was performed, in which fetal death was confirmed. Soon after the procedure, still in the delivery room, a naso-oropharyngeal swab was collected from the patient, and SARS-CoV-2 was detected through RT-PCR technique. Conclusion: The maternal surface of the placenta had an area of previous infarction and an area of recent infarction, peripheral, making up about 20% of the organ and the placental cuts showed white bundles. The fetal membranes had thickened and yellowish areas. Histopathological examination of the placenta showed diffuse villitis, characterized by lymphoplasmacytic infiltrate, in addition to intervillositis with areas of intense intervillous fibrin deposition. Swab collection was performed from the placental cut surface for detection of SARS-CoV-2 by RT-PCR, which was positive. The naso-oropharyngeal swab of the fetus was negative