MCA Stenosis Research Articles

A regressed superficial temporal artery–middle cerebral artery bypass cannot accommodate a decrease in cerebral blood flow caused by a re-exacerbation of middle cerebral artery stenosis: illustrative case

BACKGROUND Early superficial temporal artery–middle cerebral artery (STA-MCA) bypass is sometimes considered a salvage therapy for acute MCA territory strokes that fail medical and/or endovascular treatment. OBSERVATIONS A 77-year-old man presented with left hemiparesis for 2 days. Conservative treatment was initiated without acute recanalization. A few hours after hospitalization, his symptoms worsened. An STA-MCA bypass was performed after completing diffusion-weighted imaging (DWI) and perfusion-weighted imaging and observing a DWI-clinical mismatch. After 2 months of rehabilitation, the patient was discharged to home. Magnetic resonance angiography (MRA) at discharge showed that the stenosis in the right MCA had become mild and that the STA-MCA bypass had regressed with increased antegrade blood flow. Two weeks after discharge, the patient experienced worsening left hemiplegia at night and called for emergency medical assistance the following day. Magnetic resonance imaging showed scattered infarcts in the subcortical border zone, and MRA showed progression of the right M1 stenosis, requiring repeat revascularization due to hemodynamic changes caused by the improvement and subsequent re-exacerbation of the MCA stenosis. LESSONS Early STA-MCA bypass for symptomatic and progressive MCA stenosis can be effective; however, symptomatic MCA stenosis can be histologically dynamic. Symptoms can improve or worsen in a short period of time after STA-MCA bypass. https://thejns.org/doi/10.3171/CASE24673

Abstract 238: Detachment of stent retriever device in mechanical thrombectomy for acute ischemic stroke

Introduction/Purpose Mechanical thrombectomy in acute ischemic stroke brings out some undesired events during the procedure. Device related complications is one of the challenging problems. The detachment of trevo stent retriever is a rare situation and can be handled in different ways. Materials/Methods 82 year old male patient was referred to ER with a sudden hemiparesis in the last 70 minutes. He was given apiksaban therapy for atrial fibrillation and known to use regularly. He was diagnosed with left MCA thrombosis which seemed to be the cause of this stroke. As he was under DOAC therapy the only way was to perform EVT. The procedure lasted in 18 minutes and we had a first pass effect. But the final screening showed that the cage of the trevo stent retriever was still in the MCA territory letting the blood flow properly. So instead of removing the remnant stent, we decided to give dual antiplatelet therapy because of the MCA stenosis. The patient covered from this period with mild neurologic defisits but after 2 months he passed away because of rectal bleeding which was suppposed to be the result of a underlying colorectal cancer. Results Stent retriever detachment is not common in the literature. Even trevo stent retriever detachments is much more rare. In this case the vascular curves and the ICAD of the arteries seem to cause this complication even the procedure was smooth. Conclusion It is important to evaluate the device complications properly. Mechanical removement can be applied if possible but it will be good to remember that sometimes medical approach can also stabilise the situation as well.

The Music Within: A Doppler Harmonic Pattern Report in Non-Subarachnoid Hemorrhage Related Cerebral Vasospasm

A 40-year-old male presented an episode of severe thunderclap headache with right hemiparesis. Imaging revealed severe stenosis in the left middle cerebral artery, associated with increased mean velocities detected by Transcranial Doppler Ultrasound (TCD). Notably, a distinctive "tin whistle" sound, known as a doppler harmonic effect, near the highest velocity point was observed during the examination. Extensive workup was performed, including CSF analysis and laboratory investigations, and the diagnosis of Reversible Cerebral Vasoconstriction Syndrome (RCVS) was established. Treatment involving medication and daily monitoring led to a decline in the left MCA's velocity, enabling the patient's discharge with no recurrent headaches or neurological deficits. Notably, a follow-up MRI exhibited the disappearance of the left MCA stenosis. This report discusses the rare occurrence of "musical murmurs" in cerebrovascular diseases, underscoring the potential for early diagnosis using techniques like TCD in emergency settings, particularly in conditions like RCVs.

Abstract 188: Rescue Left Middle Cerebral Artery Stenting With Xience Skypoint Everolimus‐Eluting Stent: Technical Report

Introduction Drug‐eluting stent (DES) use in symptomatic intracranial atherosclerosis disease (ICAD) has been described in the literature using different guiding and distal access catheters. We describe a case of deployment of a Xience Skypoint everolimus‐eluting stent (EES) (Abbott Vascular, Abbott Park, Illinois) into a symptomatic stenosed left M1 segment using Armadillo catheter (Q'Apel, Fremont, CA) with a successful result. Methods Case report and review of literature Results 67‐year‐old woman with type II diabetes mellitus, hypertension, hyperlipidemia, and recent admission for transient ischemic attack (resolving right hemiparesis and mild dysnomia in the setting of severe left M1 segment stenosis with discharge on Aspirin, Clopidogrel and Atorvastatin), presented with recurrence of symptoms, and MRI brain showing left basal ganglia acute infarction. No tPA was given low NIHSS and resolution of symptoms. Patient’s aphasia and hemiparesis worsened with segmental hypoperfusion which resolved by maintaining high blood pressures with norepinephrine drip. Decision was made to deploy a drug eluting stent into the stenosed M1 segment. Through femoral access, a 7F long destination sheath was inserted to the left common carotid origin. A 7F Armadillo catheter was then inserted into the left internal carotid artery (ICA) terminus. ASAHI Prowater coronary guidewire was inserted over which Xience Skypoint EES deployment was attempted but was unsuccessful given difficulty traversing the ICA ophthalmic segment. Ultimately, Armadillo catheter was advanced over a Phenom catheter (Medtronic) with good access into the distal M1 segment. The Phenom intermediate catheter was then removed, and the 2.25 mm x 12 mm stent was introduced through the Prowater guidewire into the segment and inflated to a pressure of 8 atm, with restoration of blood flow. Postoperatively, SBP was lowered to prevent reperfusion injury. Patient’s exam stabilized with mild dysnomia and right hemiparesis without any elevated blood pressure requirements. At 5‐months follow‐up, patient’s exam was non‐focal with NIHSS 0 and repeat DSA showed no evidence of stent occlusion and patent M1 segment. Conclusion Xience Skypoint EES can be successful in treating symptomatic MCA stenosis refractory to maximal medical therapy with good long term results.

Etiopathology, Clinical and Imaging Characteristics of Border Zone Strokes.

A border zone infarct (BI) is defined as an infarction that is localized to watersheds or border zones in the brain. BI is further classified into cortical border zone infarct (CBZ) and internal border zone infarct (IBZ). This study was conducted to explore the clinical and radiological characteristics of BI. The study was conducted on eligible 400 acute ischemic stroke patients out of which 52 BI patients (diagnosed by the radiologist on DWI MRI images), patients >18 yrs of age were selected and divided into two groups of IBZ and CBZ infarct patients. The degree of intracranial and extracranial stenosis and characteristics on clinical presentation were assessed. The data were collected and analyzed using SPSS version 20.0 software at significance level p-value <0.05. 25% and 75% of CBZ and IBZ patients, respectively, had history of presyncope or syncope before stroke. On vascular evaluation, 3.9% and 51.9% were in MCA and ICA stenosis group, respectively. Evidence of cardio embolism was found in 17.3% of patients. 53.3% of CBZ and 53.8% of IBZ patients were in ICA stenosis group, and 6.7% of CBZ and 7.7% of IBZ patients were in MCA stenosis group, with a statistically insignificant relation (p-value >0.05). Association of BI with events causing hypotension or hypovolemia is well-established in our study, association of BI with large vessel atherosclerosis is common, and its contribution to CBZ and IBZ seems to be equal.

Correlation Analysis of Middle Cerebral Artery Stenosis and Enlarged Perivascular Space in Patients with Moyamoya Disease (S45.007)

<h3>Objective:</h3> To explore the correlation between the MCA stenosis and the CSO-EPVS in patients with MMD and whether brain atrophy plays a mediating role. <h3>Background:</h3> Moyamoya disease (MMD) is a nonatherosclerotic cerebrovascular structural abnormality. Previous studies have found that central semiovale Enlarged enlarged perivascular spaces (CSO-EPVS) are associated with decreased regional cerebral blood flow in MMD patients, but the specific mechanism remains unclear. <h3>Design/Methods:</h3> 177 patients from 2017 to 2022 were consecutively enrolled in this single-center Moyamoya disease cohort. All 354 MCAs were divided into three groups according to the severity of MCA on the MRA: no stenosis, mild or moderate stenosis, and severe stenosis or occlusion. The correlation between cerebral hemisphere volume, MCA stenosis and CSO-EPVS was analyzed, and the confounding factors including age, gender and hypertension were adjusted. <h3>Results:</h3> MCA stenosis was significantly associated with CSO-EPVS (no stenosis vs mild or moderate stenosis: 95%CI [0.954, 4.473], P=0.000; no stenosis vs severe stenosis or occlusion: 95%CI [4.419, 9.586], P=0.000). Cerebral hemisphere volume was correlated with CSO-EPVS (no stenosis vs mild or moderate stenosis: 95%CI [−0.824, 0.414], P=0.047; no stenosis vs severe stenosis or occlusion: 95%CI [−1.051, 4.431], P=0.018), but there was no significant correlation between MCA stenosis and the hemisphere volume (no stenosis vs mild or moderate stenosis: 95%CI [−0.097, 0.123], P=0.434; no stenosis vs. severe stenosis or occlusion: 95%CI [−1.012, 1.210], P=0.403). Mediating variable analysis showed that hemisphere volume had no mediating effect in the correlation between the MCA stenosis and CSO-EPVS (no stenosis vs mild or moderate stenosis: 95%CI [−0.039, 0.329], P=0.910; no stenosis vs severe stenosis or occlusion: 95%CI [−0.118, 0.106], P=0.350). <h3>Conclusions:</h3> Our study shows the association between the MCA stenosis and CSO-EPVS without brain atrophy as a mediator, highlighting the potential correlation between large artery stenosis and small cerebral vessel. <b>Disclosure:</b> Mr. Han has nothing to disclose. Ms. Hong has nothing to disclose. Ding-Ding Zhang has nothing to disclose. Xiaoyuan Fan has nothing to disclose. Ming Yao has nothing to disclose. Jun Ni has nothing to disclose.

Abstract WP138: Intracranial Artery Stenosis In Relation To Blood Pressure Components

Introduction: Vascular aging is characterized by structural and functional changes in blood vessels that lead to reduced perfusion pressure to distal organs and high blood pressure (BP). Cerebrovascular aging is strongly associated with high BP, however, systemic BP is constituted by the steady and pulsatile components. We aimed this study to investigate the association of intracranial artery stenosis in relation to the steady and pulsatile components of the systemic BP - such association remains undocumented. Methods: We used cross-sectional data from 292 participants from the Maracaibo Aging Study who underwent ambulatory BP monitoring, magnetic resonance angiography, and MRI between 2011 to 2016. The stenosis of eleven intracranial arteries was measured using magnetic resonance angiography scans and encompassed the right and left sides of the anterior (ACA), middle (MCA), posterior (PCA) cerebral arteries, and internal carotid arteries (ICA), vertebral arteries, and the basilar artery. The steady BP component included the 24-hour mean arterial pressure (MAP) while the pulsatile component included the 24-hour pulse pressure (PP). We performed multivariable logistic regression models to assess the association between intracranial artery stenosis and BP components. Models were accounted for age, sex, head circumference, years of education, body mass index, total and high-density cholesterol ratio, creatinine, diabetes mellitus, and antihypertensive treatments. Results: Mean age was 57.5±11 years, 75% women. After adjustment for confounders, 24-hour pulse pressure was associated (P≤ 0.020) with the stenosis of ICA (Odds ratios [OR], 2.00 per every 5 mmHg of PP; 95% confidence interval [CI], 1.49-2.69), ACA (OR, 1.50; 95% CI, 1.23-1.84), MCA (OR, 1.46; 95%, CI, 1.21-1.77), PCA (OR, 1.55; 95% CI, 1.26-1.91), basilar artery (OR, 1.28; 95% CI, 1.03-1.59) and vertebral arteries (OR, 1.42; 95% CI, 1.14-1.78). The ORs of ICA, ACA, MCA, PCA, basilar artery, and vertebral arteries in relation to high 24-hour MAP levels (P≤ 0.040) ranged from 1.27 (95% CI, 1.00-1.61) to 1.48 (95% CI, 1.15 - 1.91). Conclusion: Elevated levels in the steady and pulsatile components of the systemic BP are associated with intracranial artery stenosis.

CT Perfusion Alterations in Patients with Symptomatic and Asymptomatic Unilateral Middle Cerebral Artery Severe Stenosis or Occlusion.

To investigate the changes in CT perfusion between symptomatic and asymptomatic patients with unilateral middle cerebral artery severe stenosis or occlusion. A total of 64 consecutive patients with unilateral middle cerebral artery severe stenosis or occlusion admitted to the First Affiliated Hospital of Xinxiang Medical College from January 2019 to March 2022 were retrospectively analyzed and divided into the symptomatic group (n = 33), and the asymptomatic group (n = 31). Clinical data of the two groups were collected. Multivariate logistic regression analysis was performed to analyze the factors of symptomatic and asymptomatic MCA stenosis. A t-test was performed to compare the differences in cerebral perfusion parameters between the two groups. Multivariate logistic regression analysis indicated that glycosylated hemoglobin levels and high-density lipoprotein cholesterol levels were associated with the development of asymptomatic MCA severe stenosis or occlusion (odds ratio = 1.591 and 0.04, respectively). There were significant differences in CBV, MTT, and TTP between symptomatic and asymptomatic groups (p < 0.05). The CBF of the affected side in the symptomatic group was lower than that of the unaffected side (p < 0.05), whereas the asymptomatic group in CBF was not. Compared with the asymptomatic group, the CBF, MTT, and TTP of the affected side were significantly different (p < 0.05). In contrast, the cerebral perfusion parameters of the unaffected side were not significantly different (p > 0.05). The use of CT perfusion imaging to analyze the alterations in cerebral perfusion parameters in patients with symptomatic and asymptomatic MCA severe stenosis or occlusion was helpful in clinical diagnosis and selecting treatment strategies and judging the development of the disease.

Prevalence of Middle Cerebral Artery Stenosis in Bihar Population (A Trans-cranial Doppler Study)

Background: The prevalence and causes of intra cranial arterial stenosis in adults’ stroke patients is largelyunknown. Hence it has become a great clinical challenge for Neuro-physician, neurosurgeon and radiologist tofind out the aetiologies of intra cranial arterial stenosis.Method: 100 patients of aged between 25 to 60 years were selected for study. Their past history and clinicalmanifestations were noted TCD examination was performed with portable machine (multi-drop (R) + DWL),which is a 2MHz power motion single channel TCD, MCA was approached through temporal windows by use ofstandard protocol. stenosis of arteries were defined by the peak systolic flow velocity more than 140 cm/sec forMCA.Results: The highest clinical manifestation was HTN 75%, followed by DM 58%, obesity 52% and hyper cholestremia48%, smoker 38%, CAD 32% and least was PVD 2%. In odds ratio study HTN was highest 8.5, followed by CADratio was 6 and least ratio was alcoholics 1.6.Conclusion: The present study revealed the aggravating factor like HTN, DM, and CAD. Atherosclerosis causesstenosis of MCA and peak systolic velocity more than 140 mc/sec for MCA. Hence the patients having suchclinical manifestations will be more prone for stenosis of MCA.

Incidence and clinical features of acute multiple small cerebellar infarction

ObjectiveTo investigate the clinical and imaging features and to identify possible etiology of acute multiple small cerebellar infarction (MSCI). MethodsWe retrospectively enrolled 220 patients with acute cerebellar infarction, divided them into MSCI and large cerebellar infarction (LCI) groups, according to the quantity and size of lesions confirmed by MRI analysis. Clinical and imaging features were compared between the two groups to explore the possible etiology and pathogenesis. ResultsAmong 220 patients, 90 patients presented MSCI symptoms. The proportions of extracerebellar lesions (P = 0.001) and bilateral infarction (P = 0.001) in the MSCI group were higher than those in the LCI group. No significant differences were found in terms of age, gender, and common vascular risk factors between the two groups. The proportions of vertigo and headache in the MSCI group were significantly lower than those in the LCI group (P < 0.000 and 0.034, respectively), and limb weakness was significantly higher (P = 0.039) in the MSCI patients. Moreover, the proportions of nystagmus and ataxia in the MSCI group were significantly lower than those in the LCI group (P < 0.043 and 0.003, respectively). The MSCI group had higher proportions of ACA and MCA stenosis, while the proportion of posterior circulation stenosis was similar between the two groups. Infarctions involving the posterior inferior cerebellar (PICA) region and mixed territories were far more frequent than those involving the anterior inferior cerebellar artery (AICA) region and superior cerebellar artery (SCA) territory (P < 0.05). Large-artery atherosclerosis and multiple plus undetermined etiology were the main etiological factors of MSCI. ConclusionIn patients with acute cerebellar infarction, 30% of patients presented with MSCI. MSCI and LCI showed similar vascular risk factors and vascular stenosis in the posterior circulation system. Patients with MSCI should pay more attention to evaluating anterior circulation vessels’ anatomy. Large-artery atherosclerosis was the main pathogenesis of acute MSCI. Assessment of cerebral vessels might be critically required in patients with MSCI complicated atrial fibrillation.

Microsurgical treatment of middle cerebral artery stenosis or occlusion: a single center experience and literature review

BackgroundTo investigate the effect of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in the treatment of MCA stenosis or occlusion.MethodsThe clinical and imaging data of 31 MCA stenosis or occlusion patients with STA-MCA bypass were analyzed retrospectively. The operation was performed by STA-MCA M4 segment bypass via the frontotemporal approach. Modified Rankin Scale (mRS) was used to evaluate the neurological function of patients.ResultsAfter operation, head computed tomography (CT) showed that there was no new infarction or hemorrhage in the operation area. CTA and CTP showed that the bypass vessel was unobstructed in 29 cases and the cerebral perfusion was improved in 31 cases. Among the 31 patients, 7 patients had postoperative complications and 13 patients had improvement of clinical symptoms. The other patients had no complications and the clinical symptoms remained unchanged. The mRs score of 31 patients after operation indicated that the neurological function was significantly improved than pre-operation. Of the 31 patients, 23 cases were followed up. The mRs score showed that the neurological function of these 23 patients was further improved than that at discharge. In addition, DSA (or CTA) and CTP showed that the bypass vessel was unobstructed and the cerebral perfusion was further improved.ConclusionSTA-MCA bypass was an effective method for the treatment of MCA stenosis or occlusion. However, the results should be further verified by large sample, multi-center and long-term follow-up.

Imaging Features of Symptomatic MCA Stenosis in Patients of Different Ages: A Vessel Wall MR Imaging Study.

The prevalence of intracranial artery stenosis is high in Asian people. This study aimed to investigate whether there are differences in the imaging features of symptomatic MCA stenosis in patients of different ages using vessel wall MR imaging. We retrospectively reviewed the data of consecutive patients with unilateral MCA stenosis based on a prospectively established vessel wall MR imaging data base between January 2017 and December 2018. According to age, the patients were divided into the young group (18-45 years of age) and the middle-aged and elderly group (older than 45 years of age). Overall, 131 patients with unilateral MCA stenosis were included (45.8% in the young group and 54.2% in the middle-aged and elderly group). Middle-aged and elderly patients had a higher prevalence of hypertension (P = .01) and diabetes (P = .05). The lesion length (P < .0001), proportion of circular involvement (P = .006), and proportion of circular enhancement (P = .03) were higher in the young group than in the middle-aged and elderly group. The analysis of the atherosclerotic subgroup showed that compared with middle-aged and elderly patients, young patients had longer lesions (P = .002). The atherosclerotic-versus-nonatherosclerotic subgroup analysis showed that the maximal wall thickness in the patients with atherosclerosis was larger than that of patients without it (P = .002). Compared with the middle-aged and elderly group, young patients with MCA stenosis tended to have longer lesions and more circular wall involvement and circular enhancement, which may indicate the differences in underlying vascular pathophysiologic and developmental mechanisms in symptomatic MCA stenosis.

Transcranial Color-Coded Duplex as A Predictor of Early Outcome in Acute Ischemic Stroke

The improvement of transcranial shading coded duplex sonography (TCCS) has restored the desire for protected, continuous bedside mind imaging past adolescence. This exploration gives a review of the job transcranial shading coded duplex (TCCD) as an indicator of early result in intense ischemic stroke. In this relative cross-sectional examination, we looked to research the capacity of TCCD to recognize early clinical result in patients with intense ischemic stroke. 50 CVIS patients were enlisted for this examination. Extracranial carotid course duplex and TCCD was done at day 1. Appraisal of seriousness of stroke was done dependent on NIHSS at introduction. Evaluation of result at 3 months after beginning was done dependent on Barthel record score (BI). Center cerebral course (MCA) stenosis and unevenness were essentially connected with helpless result. Stenosis was higher in dead cases. Be that as it may, typical MCA status was altogether connected with great result. Patients with consolidated MCA+ intracranial carotid supply route (ICA) stenosis had essentially higher NIHSS at introduction, fundamentally lower BI than isolated intracranial MCA stenosis. The presence of intracranial MCA stenosis or lopsidedness is an autonomous indicator of helpless result for stroked patients.

Cerebral revascularization by EC-IC bypass in ischemic conditions of different etiologies

Background: Even after the failure of EC-IC bypass trial, EC- IC bypass can help many patients in preventing future stroke. Here we present a case series of patients with cerebral ischemia from different etiological modes who underwent EC-IC bypass with positive end results. Methods: Patients in these cases series with TIA/stroke/recurrent stroke were evaluated clinically for the history of TIA or recurrent/hemodynamic TIA (in rest or during work) or progressive hemiparesis/aphasia/visual disturbances or sudden hemiplegia/hemiparesis/aphasia with subsequent significant (days to a week) recovery. MRI of the brain was done in ischemic protocol in all cases. To see the arterial pathology dynamic CTA was also done in all cases except one case. DSA was done in 03 cases. When clinical features, cerebral ischemia on MRI and arterial stenosis/occlusion on angiogram were concordant with each other, only then cerebral revascularization was done. After bypass, all patients were followed up regularly. All recorded data were reviewed retrospectively. Results: Total no. of cases were 08. The most common presentation was hemiparesis. Etiologies were infective thrombosis of ICA, orbital cellulitis, thrombosed giant ICA aneurysm, single &amp; multiple vessel occlusion and MCA stenosis. High flow EC-IC bypass was done in one case. STA- MCA bypass was done in rest of the cases. All patient were ambulant with static neuro-status without new stroke till last follow up. All bypasses were patent and functioning till last follow up (clinical, Doppler/Imaging). Conclusion: In carefully selected cases cerebral revascularization in ischemic conditions can result positive outcome.

Abstract WP174: A Large-Scale Perfusion Imaging Atlas of Subacute Ischemia in MCA Atherosclerotic Stenosis

Background: Impaired perfusion may be an important determinant of outcomes in intracranial atherosclerotic disease (ICAD). CT and MRI perfusion imaging patterns of stenosis due to MCA ICAD have not been studied in detail. We characterized CT and MRI perfusion imaging measures of subacute ischemia subjects with MCA stenosis to create a novel atlas and define specific blood flow parameters. Methods: A retrospective, 5-year, analysis of consecutive ICAD patients evaluated with CT or MRI perfusion imaging for recent TIA or stroke (0-7 days) due to sub-occlusive (50-99%) MCA stenosis was conducted. CT/MRI volumes of core and hypoperfusion (&gt;5 ml) were extracted with RAPID (iSchemaView, Inc.) and analyzed with respect to clinical variables. Descriptive statistics were used to quantify and map patterns of impaired perfusion. Results: 194 (median age 71, range 30-102 years; 53% women) patients with subacute ischemia were evaluated with MRI (n=161) or CT (n=33) perfusion imaging. Median initial NIHSS was 5 and median inpatient length of stay (LOS) was 4 (1-42) days. Hypoperfusion with Tmax&gt;4s delay volumes (median 66.5 ml, mean 107.5 ml) were noted in 162 (84%) patients, Tmax&gt;6s delay volumes (median 11.0 ml, mean 41.5 ml) in 118 (61%), Tmax&gt;8s delay volumes (median 0 ml, mean 23.4 ml) in 81 (42%) and Tmax&gt;10s delay volumes (median 0 ml, mean 16.9 ml) in 61 (31%). Hypoperfusion intensity ratios (Tmax&gt;10s/Tmax&gt;6s) were median 0.08 and mean 0.24. Ischemic core volumes on MRI (ADC&lt;620) were mean 10.3±33.2 ml and mean 5.6±16.1 ml on CT (rCBF&lt;30%). Mismatch volumes were mean 32.0±79.8 ml and mismatch ratios mean 4.8±9.9 ml. The extent of Tmax&gt;6s hypoperfusion was unrelated to initial NIHSS (r=0.17, p=NS) or LOS (r=0.11, p=NS). Conclusions: Hypoperfusion is common in recently symptomatic ICAD patients with MCA stenosis. Tmax delay volumes and hypoperfusion intensity ratios are distinct from acute MCA occlusion. Mapping and understanding these specific patterns of perfusion will be instrumental in planning future ICAD trials.

Reversible middle cerebral artery stenosis and stroke symptoms after correcting severe iron deficiency anemia

Little has been known about the relationship between iron deficiency anemia (IDA) and acute ischemic stroke. We present a case of patient with acute ischemic infarction with bilateral MCA stenosis complicated by severe IDA, which resolved rapidly after correcting IDA. A 67-year-old woman was referred to emergency department with right hemiparesis on wake-up. On examination she had MRC grade 3 weakness of the right upper and lower extremities with a NIH Stroke Scale score (NIHSS) of 4. DWI showed multifocal diffusion restriction foci involving Lt. temporal, both parietal and occipital lobes. MRA revealed segmental severe stenosis at both proximal MCA. Her haemoglobin level of 1.9 g/dL, which rose to 4.0 g/dL after RBC transfusion. In 2 hours, her neurologic symptoms improved to NIHSS 1. Gastrofiberscopy, colonoscopy, and CT scan of the chest and abdomen revealed no signs of malignancy or acute internal bleeding. The results of hematological and biochemical studies were compatible with the diagnosis of IDA. Follow-up MRA on 5th days showed remarkably improved bilateral MCA stenosis compared with baseline MRA. Results of the baseline and follow-up TCD also suggested improved MCA stenosis. She was discharged with a haemoglobin level of 7.8 g/dL and without significant neurologic deficit. We report an acute ischemic stroke patient with bilateral MCA stenosis and severe IDA. Stroke severity and the degree MCA stenosis improved promptly by correcting anemia with RBC transfusion. Severe anemia may be a trigger factor for aggravating stenosis of intracranial arteries and stroke symptoms.

MOYAMOYA DISEASE: RARE CAUSE OF STROKE

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Moyamoya disease is a rare chronic cerebrovasculopathy of unknown etiology characterized by progressive stenosis of the internal carotid artery and it is main proximal branches. This stenosis leads to growth of small collateral circulation which look like “Puffs of Smoke” known as Moyamoya in Japanese (1). Moyamoya disease was first described in Japan by Takeuchi and Shimizu in 1957(2). CASE PRESENTATION: Our patient is a 41-year-old Caucasian female who presented to our emergency department with new onset of left sided facial droop, left arm weakness, and inability to speak. The patient has a history of Seizure disorder and Moyamoya disease with chronic right MCA stenosis who is currently on Aspirin and Plavix. At time of arrival, vital signs were noted to be stable except blood pressure being elevated. Brain CTA was done which showed chronic narrowing of the right MCA and also what appeared to be an acute embolic event in the right ACA which was felt to be the cause of her symptoms. Review of other labs showed no significant abnormalities. The patient underwent a Cerebral Angiogram but a mechanical thrombectomy was unsuccessful due to report small caliber of the Right A1 segment. Brain MRI was done and confirms acute infarction in the Right posterior frontal cortex along the margin of the primary motor cortex, which is the watershed of the two collateral circulations supplying the Right hemisphere. We treated the patient mainly symptomatic by prevent hypoperfusion by keeping systolic blood pressure around 170S mmHg, continuing aspirin, and switched Plavix to Ticagrelor. DISCUSSION: Moyamoya disease has been recognized as a cause of ischemic and hemorrhagic strokes. It usually exhibits recurrent transient ischemic attacks (TIA) or infarction in the territory of the ICA. AS in our case patient presented with hemi-paresis and expressive aphasia. Even though MRI angiography is used to confirm the diagnosis and to see the anatomy of the vessels involved, CT angiography can also be used to see intracranial stenosis suggesting Moyamoya (3). The process of blockage, once it begins, tends to continue despite any known medical management unless treated with surgery. Since surgery is the only viable option, revascularization procedures are gaining importance as a primary treatment for Moyamoya. A good option for adult symptomatic patients is superficial temporal artery-middle cerebral artery bypass or middle meningeal artery to middle cerebral artery bypass (3). The estimated rate of symptomatic progression is only 2.6% after surgery according to a meta-analysis involving 1156 patients (4). CONCLUSIONS: This case highlights the importance of understanding Moyamoya disease and its prognosis. Moyamoya is a very progressive disease and should have been recognized as a cause of ischemic and hemorrhagic strokes. Surgical revascularization should be considered to prevent complications, mainly stroke. Reference #1: Janda PH, Bellew JG, Veerappan V. Moyamoya disease: case report and literature review. J Am Osteopath Assoc. 2009;109(10):547–53. Reference #2: Takeuchi K. Hypoplasia of bilateral internal carotid arteries. Brain nerve. 1957;9:37–43. Reference #3: Gudepu RK, Qureshi MA, Qureshi IA, Rao L. Case Report: A case report of Moyamoya disease in a 36 year old African American woman. F1000Research. 2014;3. DISCLOSURES: No relevant relationships by MAHMOUD ABOUZID, source=Web Response No relevant relationships by Waiel Abusnina, source=Web Response No relevant relationships by Yonas Raru, source=Web Response No relevant relationships by Fuad Zeid, source=Admin input

Application of FLAIR Vascular Hyperintensity-DWI Mismatch in Ischemic Stroke Depending on Semi-Quantitative DWI-Alberta Stroke Program Early CT Score.

Objective: Diffusion-weighted imaging (DWI)-Alberta Stroke Program Early CT Score (ASPECTS) is a simple, widely used method to estimate the size of the infarct. Our aim is to determine whether there is a relationship between DWI-ASPECTS and fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH)-DWI mismatch and to better quantify FVH-DWI mismatch to assess the prognosis of cerebral infarction.Materials and Methods: A retrospective analysis of 109 patients with MCA stenosis or occlusion with cerebral infarction was performed by dividing this cohort into FVH-DWI match group and FVH-DWI mismatch group based on FVH and DWI results. The clinical and imaging data of these two groups of patients were reviewed and analyzed to identify associations between FVH-DWI mismatch and prognosis of patients for preservation of neurological function. Correlation between DWI-ASPECTS and FVH-DWI mismatch was also performed.Results: FVH-DWI mismatch was present in 66/109 (60.55%) patients, and FVH-DWI match was present in 43/109 (39.45%). Patients with FVH-DWI mismatch had higher DWI-ASPECTS (7.0 vs. 4.0, P < 0.001) and lower mRS at 3 months (3.0 vs. 4.0, P < 0.001) than patients without FVH-DWI mismatch. Multiple regression analysis suggested that DWI-ASPECTS (OR = 4.7, 95% CI = 2.5–9.2, P < 0.001) remained significantly associated with FVH-DWI mismatch. Two threshold points for DWI-ASPECTS of 3 and 8 can be used to distinguish whether there is a mismatch in FVH-DWI by smooth curve fitting.Conclusions: The DWI-ASPECTS score was an independent predictor of FVH-DWI mismatch. At DWI-ASPECTS ≤ 3, the FVH-DWI mismatch offers no prognostic value; whereas, at DWI-ASPECTS ≥ 8, the FVH-DWI mismatch had the highest prognostic value. DWI-ASPECTS can roughly determine whether there is a FVH-DWI mismatch in order to select optimal clinical treatment and accurately assess prognosis.

Study on the relationship between post-circulatory lesions and cerebral infarction in children with ischemic moyamoya disease

Objective To explore the relationship between post-circulatory lesions and cerebral infarction in children with ischemic moyamoya disease (MMD). Methods A total of 44 children with ischemic MMD who were admitted to Department of Neurosurgery, Tianjin Medical University General Hospital from January 2010 to December 2018 were retrospectively enrolled into this study. All of them were divided into cerebral infarction group (15 cases) and non-cerebral infarction group (29 cases) according to whether they had cerebral infarction or not. Three cases were treated with encephalo-myosynangiosis (EMS), 5 cases with superficial temporal artery-middle cerebral artery anastomosis bypass (STA-MCA bypass) and 36 cases with EMS+ STA-MCA. All children were followed up by outpatient visits or telephone and were asked about the improvement of clinical symptoms and whether there were any cerebral infarction events. The outcome was assessed by the modified Rankin scale score (mRS). The clinical efficacy was compared between the 2 groups of children. The clinical factors affecting the children with cerebral infarction were further analyzed by single factor and multiple factor logistic regression. Results All 44 patients underwent successful operation. Postoperative complications occurred in 12 cases (27.3%, 12/44). There was no statistically significant difference in the incidence of complications between 2 groups [40.0% (6/15) vs. 28.7% (6/29), P=0.615]. The follow-up duration of 44 cases was 7.2±1.5 months (6-12 months). During the follow-up period, none of the children had cerebral infarction. Among the 44 cases, 35 (79.5%) had good outcomes and 9 (20.5%) had poor outcomes. There was no statistically significant difference in the favorable prognosis rate between the 2 groups [66.7% (10/15) vs. 86.3% (25/29), P=0.130]. Single factor analysis showed that MCA stenosis, PCA (posterior cerebral artery) stenosis and transient ischemic attack before operation were the influencing factors of cerebral infarction in children (all P < 0.05). Further multiple factor analysis showed that PCA stenosis was an independent risk factor for cerebral infarction in children (OR=5.465, 95% CI: 1.224-24.400, P=0.026). Conclusion In children with ischemic MMD, PCA stenosis is an independent risk factors for cerebral infarction, and whether there is cerebral infarction has no significant effect on the prognosis of those children. Key words: Moyamoya disease; Child; Factor analysis, statistical; Post-circulatory lesions; Cerebral infarction

The Association between FLAIR Vascular Hyperintensity and Stroke Outcome Varies with Time from Onset

FLAIR vascular hyperintensity has been recognized as a marker of collaterals in ischemic stroke, but the impact on outcome is still controversial. We hypothesized that the association between FLAIR vascular hyperintensity and outcome varies with time. We included 459 consecutive patients with middle cerebral artery stroke and divided them into 3 groups by symptom-to-MR imaging time (group 1, ≤7 days; group 2, 8-14 days; group 3, ≥15 days). The FLAIR vascular hyperintensity score, ranging from 0 to 3 points, was based on territory distributions of different MCA segments. The associations between FLAIR vascular hyperintensity and outcome with time were analyzed qualitatively and quantitatively. No patients underwent MR imaging within 6 hours of onset. The proportion of FLAIR vascular hyperintensity (+) and severe stenosis or occlusion of MCA was not significantly dependent on time. In groups 1 and 2, FLAIR vascular hyperintensity (+) was significantly associated with larger lesions, the prevalence of flow injury, and unfavorable outcome (mRS ≥ 2). There were no such associations in group 3. Multiple logistic regressions demonstrated that FLAIR vascular hyperintensity (+) was an independent risk factor for unfavorable outcome in group 2. Infarction volume tended to increase with the increase of the distal FLAIR vascular hyperintensity score in groups 1 and 2, while declining in group 3. FLAIR vascular hyperintensity is associated with unfavorable outcome within 6 hours to 14 days of onset, while the wider distribution of distal FLAIR vascular hyperintensity may be favorable beyond 14 days of onset in MCA infarction. Symptom-to-MR imaging time should be considered when assessing the prognostic value of FLAIR vascular hyperintensity.