Symptomatic Middle Cerebral Artery Occlusion Research Articles

Clinical study on endovascular recanalization of non-acute symptomatic middle cerebral artery occlusion.

Endovascular recanalization in patients with non-acute symptomatic middle cerebral artery occlusion remains clinically challenging. Here, we aimed to evaluate the feasibility and safety of endovascular recanalization for non-acute symptomatic middle cerebral artery occlusion and propose a new patient classification. Between January 2019 and December 2021, 88 patients with non-acute symptomatic middle cerebral artery occlusion underwent prospective endovascular recanalization at our hospital. All patients were divided into three groups according to occlusion length, occlusion duration, occlusion nature, calcification of the occlusion site, and occlusion angulation. The indicators of each group were analyzed, including general baseline data, imaging data, surgical conditions, and follow-up results. Of the 88 patients, 73 were successfully recanalized and 15 were abandoned because the instruments either could not reach the distal true lumen of the occlusion or broke through the blood vessels. The overall technical success rate was 83.0% (73/88), and perioperative complications occurred in 15 patients. Preoperatively, all patients were divided into three risk groups: low, medium, and high. From the low- to high-risk groups, the recanalization rate gradually decreased (100.0, 91.7, and 16.7%, respectively, P = 0.020), the perioperative complication rate gradually increased (0, 13.9, and 83.3%, respectively, P < 0.001), the proportion of the modified Rankin scale scores >2 at 90 days increased (0, 11.7, and 50.0%, P < 0.001), and the restenosis/reocclusion rates in the 73 cases of successful recanalization increased (0, 16.1, and 100%, P = 0.012) during follow-up. Endovascular recanalization may be feasible and safe in well-selected patients with non-acute symptomatic middle cerebral artery occlusion, especially in the low- and medium-risk groups.

Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study

BackgroundDespite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue...

Clinical analysis of low flow bypass in the treatment of chronic symptomatic middle cerebral artery occlusion

Clinical analysis of low flow bypass in the treatment of chronic symptomatic middle cerebral artery occlusion

Distal versus Proximal Middle Cerebral Artery Occlusion: Different Mechanisms

Background: Clinical and radiological characteristics of middle cerebral artery (MCA) infarction may differ according to the location of occlusion. Objectives: We investigated the difference between proximal and distal symptomatic MCA occlusion (MCAO) in patients with ischemic stroke. The factors associated with the imaging characteristics were also analyzed. Methods: Patients with ischemic stroke due to MCAO were consecutively enrolled. The location of MCAO was determined by the ratio of the length of the ipsilesional MCA to that of the contralateral MCA and dichotomized to proximal and distal MCAO. Clinical and radiological characteristics were compared between patients with proximal and distal MCAO. Factors associated with the basal ganglia (BG) involvement, hemorrhagic transformation (HT), and neurological change during admission were investigated. Results: Among 181 included patients, MCAO location showed a bimodal peak (at the proximal [n = 99] and distal MCA [n = 82]). Proximal MCAO was more frequently associated with hyperlipidemia and large artery atherosclerosis, whereas distal MCAO was more frequently associated with hypertension, atrial fibrillation, and cardioembolic stroke. BG involvement was similar between the 2 groups (48 vs. 39%; p = 0.21), whereas HT was more frequent in distal MCAO (10 vs. 23%; p = 0.02). Among patients with proximal MCAO, hyperintense vessel sign was less frequently observed in those with a BG involvement than those without (38 vs. 60%; p = 0.03). Among those without BG involvement, the presence of HT was very low and similar between patients with proximal and distal MCAOs (1.9 vs. 2.0%). However, in patients with BG involvement, HT was more frequently observed in those with distal MCAO than in those with proximal MCAO (54.8 vs. 15.7%; p < 0.001). The presence of hyperintense vessel sign (OR 0.172, 95% CI 0.051–0.586; p = 0.005) and distal MCAO (OR 0.200, 95% CI 0.059–0.683; p = 0.011) was independently associated with improvement during admission. Conclusion: Proximal MCAO is more frequently associated with atherosclerosis, whereas distal MCAO is more frequently associated with cardioembolism. In proximal MCAO, the status of collateral flow presented by hyperintense vessel sign may affect the involvement of BG. In distal MCAO, distal migration of the embolus, which first impacted at the proximal MCA causing BG ischemia, may explain the high rate of HT by reperfusion injury. Hyperintense vessel sign and distal MCAO were independently associated with neurological improvement during admission.

Multiple intracranial arterial stenosis influences the long-term prognosis of symptomatic middle cerebral artery occlusion.

BackgroundLarge intracranial occlusive vascular disease is a major contributor to the incidence of stroke worldwide, especially when it involves the middle cerebral artery (MCA). The data on the prognosis of symptomatic atherosclerotic MCA occlusions (MCAO) with concomitant intracranial arterial disease (MCAO-AIS) are limited. MCAO-AIS may reflect the extent of the atherosclerotic intracranial disease, we hypotheses that coexisting intracranial arterial disease influenced the prognosis of MCAO.MethodsPatients having survived at least one month after the initial ischemic stroke who suffered from atherosclerotic occlusion of the MCA were enrolled. According to their concomitant atherosclerotic intracranial arterial disease, the patients were assigned to one of two groups: the MCAO or the MCAO-AIS. All of the patients’ cerebrovascular risk factors were recorded. Recurrent ischemic stroke and death were the end-point events during the follow-up.ResultsA total of 232 patients (mean age 57.68 ± 9.50 years; 69% male) were analyzed. The mean follow-up time was 17.65 months. The end-point events occurred in 35 (15.09%) patients, resulting in an annual rate of 10.26%. The presence of MCAO- AIS was an independent risk factor associated with the patient’s prognosis in the cohort (OR = 3.426, 95% CI 1.261 to 9.308; p = 0.016), as well as gender and diabetes mellitus. The MCAO-AIS were more likely to experience ipsilateral ischemic strokes, but the difference was not statistically significant.ConclusionConcomitant intracranial arterial disease may influence the prognosis of patients with atherosclerotic MCAO. The result warrants further research in larger sample population.

Intra-Arterial Signal on Arterial Spin Labeling Perfusion MRI to Identify the Presence of Acute Middle Cerebral Artery Occlusion

Background: The susceptibility vessel sign on gradient echo-type-T2*-weighted imaging is a well-known marker of arterial occlusion. Stagnant flow in front of the middle cerebral artery (MCA) occlusion sites may contribute to the intra-arterial, high-intensity signal on arterial spin labeling magnetic resonance imaging (MRI), making it another potential marker of MCA occlusion. We compared the intra-arterial, high-intensity signal and susceptibility vessel sign in patients with symptomatic MCA occlusion and patients without major vessel occlusion. Methods: We identified transient ischemic attack or ischemic stroke patients with (1) 3-T MRI performed within 24 h after clinical onset including arterial spin labeling, T2*-weighted imaging, and magnetic resonance angiography (MRA) and (2) either having MCA occlusion (n = 34 patients) or without major vessel occlusion (n = 24 patients). The intra-arterial, high-intensity signal was defined as an enlarged circular or linear bright hyperintensity within the artery. The susceptibility vessel sign was defined as an enlarged spot of hypointensity within the MCA, in which the diameter of the hypointense signal within the vessel exceeded the contralateral vessel diameter. The presence or absence of the intra-arterial, high-intensity signal and susceptibility vessel sign were assessed, along with their inter-rater agreement and consistency with the presence of MCA occlusion on MRA. Results: The intra-arterial, high-intensity signal was detectable in 30 patients (52%), and susceptibility vessel sign was observed in 17 patients (29%). The sensitivity of the intra-arterial high-intensity signal was significantly higher than that of the susceptibility vessel sign (88% vs. 50%; p < 0.05). The accuracy of the intra-arterial high-intensity signal was also higher than that of the susceptibility vessel sign (93% vs. 71%; p < 0.05). The intra-arterial high-intensity signal was situated in the proximal regions of the susceptibility vessel sign on T2*WI within the MCA. Neither the intra-arterial high-intensity signal nor the susceptibility vessel sign was observed in patients without major vessel occlusion. Inter-rater agreement was good for intra-arterial high-intensity signal detection (κ = 0.73) and moderate for susceptibility vessel sign detection (κ = 0.47). The presence or absence of the intra-arterial high-intensity signal was highly consistent with that of MCA occlusion on MRA (κ = 0.74). Conclusions: The intra-arterial high-intensity signal on arterial spin labeling appears to be useful to identify the presence of acute MCA occlusion and may be associated with stagnant flow in front of occlusion sites. The intra-arterial high-intensity signal may also be used to identify the occlusion site.

Luminal thrombosis in middle cerebral artery occlusions: a high-resolution MRI study.

High signals within occluded vessels on T1-weighted fat-suppressed images (HST1) are highly suggestive of luminal thrombosis. We sought to investigate the feasibility of in vivo identification of luminal thrombosis in middle cerebral artery (MCA) occlusions using high-resolution magnetic resonance imaging (HR-MRI). We retrospectively reviewed the HR-MRI data of 25 patients with unilateral symptomatic MCA occlusion. HST1 were defined as an area of high signal within the cross-section of occluded MCA, the intensity of which was >150% of the signal of adjacent muscles. The prevalence of HST1 and their relationship to infarct sizes and infarct patterns were analyzed. The average time from stroke onset to HR-MRI examination was 9±6 days. There were 18 (72%) occluded vessels with HST1 on HR-MRI. HST1 were observed in 5/7 patients with a large territory infarct (≥1/3 MCA distribution) and 13/18 patients without (P=0.37). In the patients with non-large territory infarcts, the presence of HST1 was similar in those with and without border zone infarcts (9/13 vs. 4/5, P=0.42). It's feasible to in vivo identify luminal thrombosis in occluded MCA. HR-MRI is a potentially powerful tool for investigating the mechanisms of stroke due to MCA occlusions.

Prognostic effect of posterior cerebral artery laterality on middle cerebral artery occlusion

To explore the prognostic value of posterior cerebral artery (PCA) laterality in patients with symptomatic middle cerebral artery (MCA) occlusion on standard medical therapy. Forty consecutive patients with first onset isolated atherosclerotic occlusion in M1 segment of MCA received medication from June 2009 to March 2013. All patients underwent magnetic resonance angiography (MRA) for assessment of PCA laterality. Clinical data and modified Rankin Scale (mRS) at 3 months were compared between PCA positive and negative patients. Retrospective analysis was performed on their clinical and imaging data. Among them, 20 patients (50%) showed PCA laterality on MRA and 32 patients (80%) completed a 3-month follow-up. No significant difference existed between PCA laterality positive and negative groups in a favorable outcome of mRS = 0-1 at 3 months (P = 0.433). The presence of PCA laterality showed no prognostic effect on patients with symptomatic MCA occlusion on standard medical therapy.

Combined thrombolysis with abciximab and rtPA in patients with middle cerebral artery occlusion

In patients with acute middle cerebral artery (MCA) occlusion, recanalization rates with intravenous (IV) recombinant tissue plasminogen activator (rtPA) are limited. Aim- We evaluated the feasibility and safety of combined IV thrombolysis with abciximab and reduced dose rtPA in a 3- to 6-h time window. We prospectively (March 2002 to February 2005) studied patients with symptomatic MCA occlusion on computed tomography (CT) angiography and absence of major early ischemic changes (EIC) on non-contrast CT (NCCT) within 3-6 h from symptom onset. Patients were treated with IV abciximab and half-standard dose rtPA. Outcome parameters were symptomatic intracerebral hemorrhage (sICH), early clinical improvement and functional independence at discharge (modified Rankin Scale score < or = 2). Of 13 patients, mean age was 62 +/- 11 years, onset-to-treatment time 4.8 +/- 0.9 h and median baseline National Institutes of Health Stroke Scale score 11 (interquartile range 6.5-13.5). sICH occurred in one patient (8%). We observed early clinical improvement in four patients (31%). Six patients (46%) were functionally independent at discharge. In patients with acute symptomatic MCA occlusion and absence of major EIC on NCCT, combined IV thrombolysis with abciximab and half-standard dose rtPA was feasible and seemed to be safe if applied within 3-6 h from symptom onset.

Endoscopic saphenous vein graft harvest for extracranial-intracranial bypass procedures

Background The introduction of endoscopic harvest of saphenous vein grafts (SVGs) for coronary artery bypass procedures over the past few years has reduced the morbidity and enhanced patient satisfaction associated with this procedure. This report introduces the use of the endoscopic SVG harvest for extracranial-intracranial (EC-IC) bypass procedures. Methods Endoscopic SVG harvest has been performed in more than 4000 patients at Duke University Medical Center from 1998 to 2003. We have performed 4 such procedures for EC-IC bypass, including 3 for the treatment of large or giant cerebral aneurysms and 1 for symptomatic middle cerebral artery occlusion. A 2-cm transverse incision is made to harvest 25- to 30-cm segment of SVG using a VasoView graft harvest system (Guidant Cardiac and Vascular Surgery, Menlo Park, CA). Skin closure was performed using a 4-0 Vicryl subcuticular stitch. Results Endoscopic SVG harvest was possible in each of the 4 patients. No graft leaks were visualized microscopically with infusion pressure testing of the graft before graft anastomosis, and no postoperative graft harvest complications (infection, hematoma, dehiscence, etc) were encountered in either the immediate or long-term follow-up (mean, 14 months). Conclusions The use of endoscopic SVG harvest presents an attractive alternative to open SVG harvest for EC-IC bypass procedures. A high-quality long graft may be harvested with apparent decreased morbidity via this minimally invasive technique.