磁敏感加权成像不对称皮层静脉征与急性缺血性卒中预后的关系研究

目的 探究SWI不对称皮层静脉征（asymmetrical cortical vein sign，ACVS）的相关因素及其对急性缺 血性卒中预后的预测价值。 方法 连续收集2016年11月-2017年11月在河北医科大学第三医院住院的急性大脑中动脉（middle cerebral artery，MCA）供血区梗死的患者125例。所有患者均在发病后7 d内完成头颅MRI检查中的DWI、 SWI及时间飞跃法（time of flight，TOF）MRA序列，并对ACVS、MCA狭窄程度和脑梗死范围进行评价。 采用NIHSS评分评价患者基线神经功能受损情况，采用mRS评分对患者发病3个月时预后进行评估。将 患者分为ACVS组和皮层静脉显影对称组。比较两组人口学信息、临床和影像信息，并通过Logistic回 归分析评估ACVS对卒中预后的预测价值。 结果 在入组的125例患者中，95例（76.0%）SWI表现为显影程度对称的皮层静脉，30例（24.0%） SWI可见ACVS。与皮层静脉显影对称组相比，ACVS组患者MCA重度狭窄或闭塞更为常见（76.7% vs 45.3%，P =0.003），Alberta卒中项目早期CT评分（Albert stroke program early CT score，ASPECTS）较低 （7.5分 vs 8.0分，P =0.018），入院NIHSS评分较高（4.5分 vs 4.0分，P =0.042）；两组患者的3个月不良 预后情况（mRS评分＞1分）差异无统计学意义（63.3% vs 44.2%，P =0.093）。调整干扰因素后，Logistic 回归显示ACVS不是患者3个月预后不良的独立预测因素。 结论 ACVS的存在与卒中患者MCA的狭窄程度、DWI病灶大小及入院时神经功能受损严重程度有关， 但不能独立预测患者的3个月预后。     

Stroke: imaging and differential diagnosis

Structural and vascular imaging helps to differentiate haemorrhagic from acute ischemic stroke (AIS) and rule out non-stroke causes, as well as identify specific subtypes of stroke such as carotid dissection and venous thrombosis. However, it is negative in most AIS patients within 3-6 hrs of onset and thus does not allow efficient patient classification for management purposes. Physiologic neuroimaging with PET, SPECT and combined diffusion- and perfusion-weighted MR gives access to tissue perfusion and cell function/homeostasis. It has near 100% sensitivity in AIS, even in small cortical or brainstem strokes. In middle-cerebral artery (MCA) stroke, physiologic imaging also allows pathophysiological differentiation into four tissue subtypes: i) already irreversibly damaged ("core"); ii) severely hypoperfused ("penumbra"), which represents the main target for therapy; iii) mildly hypoperfused ("oligaemia"), not at risk of infarction unless secondary complications arise; and iv) reperfused/hyperperfused. PET studies have evidenced the penumbra in man, shown its largely cortical topography, documented its anticipated impact on both acute-stage neurological deficit and recovery therefrom, and shown its persistence up to 16 hrs after stroke onset in some patients. However, some patients acutely exhibit extensive irreversible damage, which places them at considerable risk of malignant MCA infarction, and others early spontaneous reperfusion, which is almost invariably associated with rapid and complete recovery. Thrombolytics and/or neuroprotective agents would therefore be expected to benefit, and hence should ideally be reserved to, only those patients in whom a substantial penumbra is documented by physiologic neuroimaging, even perhaps beyond the 3 to 6 hrs rule. In addition, excluding from thrombolytic therapy those patients with substantial necrotic core should avoid many instances of symptomatic haemorrhagic transformations. Finally, patients with extensive core might benefit from early decompressive surgery, and those with early extensive reperfusion from anti-inflammatory agents. Overall, therefore, the pathophysiologic heterogeneity underlying AIS may account for both the complications from thrombolysis and the limited success of clinical trials of neuroprotective agents, despite apparent benefit in the laboratory. Pathophysiological diagnosis as afforded by neuroimaging should now be incorporated in the design of clinical trials as well as in the routine management of stroke.     

A proposed classification for subtypes of arterial ischaemic stroke in children

The aim of this study was to propose a classification system for childhood arterial ischaemic stroke (AIS). Subtypes from the Trial of Org 10172 in Acute Stroke Therapy (TOAST) classification, previously shown to be applicable to children, were retained in the proposed Paediatric Stroke Classification (PSC). Additional important paediatric AIS aetiologies were identified from a literature review. Preliminary validation was performed by three raters who categorized clinical vignettes from 135 patients (66 male; median age 6.3 y, range 0.1 to 16 y). Eight aetiological subtypes were identified and defined, as follows: (1) sickle cell disease; (2) cardioembolic; (3) moyamoya syndrome; (4) cervical arterial dissection; (5) steno-occlusive cerebral arteriopathy; (6) other determined aetiology; (7) multiple probable/possible aetiologies; and (8) undetermined aetiology. There was very good agreement between the raters about categorization of the vignettes. Causes of disagreement were identified and final categories and definitions were modified accordingly. We conclude that the PSC enables the categorization of children with AIS into aetiological subtypes relevant to this age group. This will be useful in multicentre studies of natural history and treatment but will require further independent validation.     

The first three years of the Swiss Neuropaediatric Stroke Registry (SNPSR): a population-based study of incidence, symptoms and risk factors

We report the results of three years of the population-based, prospective Swiss NeuroPaediatric Stroke Registry (SNPSR) of children (up to 16 years) with childhood arterial ischaemic stroke (AIS1), neonatal stroke (AIS2), or symptomatic sinus venous thrombosis (SVT). Data on risk factors (RF), presentation, diagnostic work-up, localisation, and short-term neurological outcome were collected. 80 children (54 males) have been included, 40 AIS1, 23 AIS2, and 17 SVT. The data presented will be concentrated on AIS. The presentation for AIS1 was hemiparesis in 77% and cerebellar symptoms and seizures in 20%, respectively. AIS2 presented in 83% with seizures and in 38% with abnormality of muscle tone. Two or more RF were detected in 54%, one RF in 35%. The most prominent RF for AIS1 were infections (40%), followed by cardiopathies and coagulopathies (25% each). AIS2 were frequently related to birth problems. Neurological outcomes in AIS1 and AIS2 were moderate/severe in 45 % and 32 %, respectively. The outcome correlated significantly with the size of infarction (p = 0.013) and age at stroke (p = 0.027). The overall mortality was 6%. Paediatric stroke is a multiple risk problem, which leads to important long-term sequelae.     

Clinical implications of collateral middle cerebral artery flow in acute ischaemic stroke with internal carotid artery occlusion

Background and purpose: The presence of collateral middle cerebral artery (MCA) flow via the primary collateral pathway is thought to protect against the progression of cerebral ischaemia. However, there have been few reports on early clinical outcomes according to the presence of collateral MCA flow in acute ischaemic stroke (AIS) with internal carotid artery (ICA) occlusion. Therefore, we sought to investigate the early clinical outcomes and lesion patterns according to the presence of collateral MCA flows in AIS with ICA occlusion. Methods: This is a retrospective study of patients with AIS with ICA occlusion consecutively admitted to our stroke center between October 2008 and March 2010. Patients were included if they were admitted within 12 h of symptom onset with AIS and symptomatic ICA occlusion. Collateral MCA flow was defined as the presence of MCA signals from proximal M1 to distal MCA branches ipsilateral to the ICA occlusion by magnetic resonance angiography. Early neurological deterioration (END) was defined as a 4‐point increase in the National Institutes of Health Stroke Scale (NIHSS) score and persistent neurological deterioration for at least 24 h or newly developed neurological symptoms within 7 days. Results: Sixty‐five patients (42 men, 23 women) were finally included. Initial NIHSS scores were significantly lower, and favorable outcomes at 3 months were better in patients with collateral MCA flow than in those without (P < 0.001). Initial lesion patterns were different according to the collateral MCA flow. However, patients with mild AIS might more frequently deteriorate than those with moderate to severe AIS. Conclusions: In our study, collateral MCA flow reduced initial stroke severity and was associated with favorable outcomes at 3 months but did not seem to protect against END in mild AIS patients with ICA occlusion. Therefore, the results of this study suggest that mild AIS patients with ICA occlusion should be carefully managed because their conditions may deteriorate.     

Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection

The aim of the study was to describe the clinical and radiological features of childhood post-varicella cerebral infarction (PVCI). A retrospective review was undertaken of children with arterial ischaemic stroke (AIS) who had experienced varicella zoster virus (VZV) infection within the preceding year. Twenty-four children (15 males, nine females; age range at time of VZV infection 2mo-6y) were identified, with a median of 4 months between VZV and AIS (range 1wk-12mo). All had infarction in the middle cerebral artery (MCA) territory and abnormalities of the M1 segment; arteriopathy affected other arteries in 10 children. After a median of 27 months, six patients had recurrent transient ischaemic attacks (TIA), with new infarcts in two of 22 children on re-imaging. Arterial disease improved in 11 children, was stable in four, and progressed in seven (of whom four had recurrent TIA and two had re-infarction). PVCI affects young, previously healthy children within a few months of VZV infection and is characterized by MCA territory infarction and proximal MCA disease. One quarter of patients have recurrence, usually, but not inevitably, associated with progressive arteriopathy. Treatable co-existing AIS risk factors should always be excluded. A more comprehensive diagnostic evaluation should be considered in children with AIS who do not fit the clinical and radiological profile outlined, even where there is a history of recent VZV infection.     

Bleeding and subsequent anemia: a precipitant for cerebral infarction

BACKGROUND AND OBJECTIVES: The relationship between bleeding and subsequent anemia (BSA) and the occurrence of stroke has not been sufficiently studied. The purpose of the present study was to elucidate the characteristics of stroke associated with BSA. METHODS: We studied 16 consecutive patients with acute stroke associated with anemia (hemoglobin level on admission < or =9.0 g/dl) and compared their stroke subtypes with those of 32 control subjects. RESULTS: The cause of anemia was upper gastrointestinal bleeding in 11 patients (ulcers in 8; carcinomas in 2, and hemorrhagic gastritis in 1), bleeding from a hemorrhoid in 2, uterine cervical bleeding in 1, ecchymosis probably related to medication in 1, and chronic blood drainage in 1. At least 10 patients had a history of recent (<1 week), active bleeding. Clinical and imaging studies showed that all the patients had infarcts and none had intracerebral hemorrhages. Thirteen patients had infarcts in the region of the middle cerebral artery (MCA) (total MCA region in 2; partial, cortical area in 5; subcortical area in 5, and lenticulostriate artery region in 1), 2 had anterior cerebral artery (ACA) region infarction, and 1 had cerebellar infarction. All 11 patients who underwent vascular imaging studies showed significant stenosis and/or occlusion of the internal carotid artery (ICA) (n = 5), the MCA (n = 4), both the ICA and MCA (n = 1), or the ACA (n = 1). Of the different stroke subtypes (large vessel infarction (LVI), small vessel infarction, cardiogenic embolic infarction, intracerebral hemorrhage), LVI was significantly (p<0.05) more frequent in patients with stroke associated with BSA than in the controls, even though the demographics and risk factors were similar in each group. CONCLUSIONS: The close temporal relationship between the bleeding and the onset of stroke, as well as the predominance of the LVI subtype in the BSA-associated group as compared to controls, suggest that BSA may precipitate atherothrombotic cerebral infarction. A hemodynamic alteration, enhanced thrombosis or a combination of these appears to be the pathogenic mechanism.     

A case of cardiogenic cerebral embolism with successful recanalization: apparent diffusion coefficient analysis for prediction of reversible cerebral ischemia]

A 54-year-old woman complaining of left hemiplegia was transferred to our hospital. Computed tomography on admission demonstrated normal. Electrocardiogram showed atrial fibrillation. Cerebral blood flow (CBF) was decreased in both the cortex and the perforator territory of the right middle cerebral artery (MCA), whereas the apparent diffusion coefficient (ADC) in the cortex was normal. Digital subtraction angiography (DSA) revealed an occlusion of the right MCA (M 1 proximal) with collateral flow from the right anterior cerebral artery (ACA) to the territory of the right MCA. After intra-arterial injection of tissue-plasminogen activator (t-PA), DSA showed partial recanalization, and the symptoms of the patient improved considerably. Five days after that, the patient deteriorated again and showed disturbance of consciousness and left hemiplegia. In this episode, both CBF and ADC in the cortex of the right MCA were decreased. DSA revealed an occlusion of the right internal carotid artery (ICA) and collateral flow from the right ACA to the territory of the right MCA disappeared. After intra-arterial injection of t-PA, DSA showed partial recanalization with collateral flow from the right ACA, and the symptoms of the patient improved. DSA 5 weeks after onset showed complete recanalization of both the right MCA and the ICA. The patient was diagnosed as both mitral and aortic stenosis and regurgitation (MSR + ASR) and underwent an operation for both mitral and aortic value replacement. She was discharged with no neurological deficit 4 months after onset. ADC analysis is especially useful for the prediction of reversible ischemic damage and the prevention of hemorrhagic transformation and fatal edema in acute ischemic stroke.     

神经影像辅助下双侧大脑前动脉分布区急性脑梗死发病机制研究-附4例病例报道

目的 借助现代神经影像方法探讨双侧大脑前动脉(anterior cerebral artery,ACA)分布区梗死可能的机制.方法 回顾性分析4例急性双侧ACA分布区脑梗死患者的临床及头MRI、MRA或血管造影等影像学资料.结果 4例患者均有脑血管病危险因素,包括高血压、糖尿病、高脂血症、吸烟等.动脉硬化及血管变异是双...     

Patterns of diffusion‐weighted magnetic resonance imaging associated with etiology improve the accuracy of prognosis after transient ischaemic attack

Objective: Diffusion‐weighted magnetic resonance imaging (DWI) is a sensitive diagnostic tool for detecting acute ischaemic lesions in patients with transient ischaemic attacks (TIAs). The additional predictive value of DWI lesion patterns is not well known. Methods: Two hundred and fifty‐four consecutive patients with TIA underwent DWI within 7 days of symptom onset. The presence and pattern of acute ischaemic lesions were related to clinical features, etiology, and stroke recurrence at seven‐ and 90‐day follow‐up. Results: Diffusion‐weighted images abnormalities were identified in 117 (46.1%) patients. The distribution of DWI lesions was cortical, 31; subcortical, 32; scattered lesions in one arterial territory (SPOT) 42; and in multiple areas, 12. SPOT were significantly associated with motor weakness, large‐artery atherosclerosis (LAA), and the cardioembolic subtype of TIA. Single cortical lesions were also associated with cardioembolism, whereas subcortical acute lesions were associated with recurrent episodes, dysarthria, and motor weakness. During follow‐up, seven patients had a stroke within 7 days (2.8%, 95% CI 2.9–6.4%), and 12 had a stroke within 3 months (4.7%%, 95% CI 2.9–6.4%). In the Cox logistic regression model, the combination of LAA and positive DWI remained as independent predictors of stroke recurrence at 90‐day follow‐up (HR 5.78, 95 CI 1.74–19.21, P = 0.004). Conclusion: According to our results, MRI, including DWI, should be considered a preferred diagnostic test when investigating patients with potential TIAs. The combination of neuroimaging and vascular information could improve prognostic accuracy in patients with TIA.     

Impact of craniotomy area on improvement of cerebral blood flow in combined revascularization surgery for moyamoya disease

ObjectiveTo investigate factors associated with improvements in cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) after combined revascularization surgery for moyamoya disease, with special attention to the size of craniotomy.MethodsWe retrospectively analyzed 35 hemispheres in 27 patients with adult and older pediatric moyamoya disease. CBF and CVR were measured separately in the MCA and ACA territories from acetazolamide-challenged single-photon emission computed tomography before and after 6 months postoperatively, and associations with various factors were analyzed.ResultsPostoperative CBF improved in patients with lower preoperative blood flow in both ACA and MCA territories. Postoperative CVR improved in 32 of 35 patients (91.4%) in the MCA territory and in 30 of 35 patients (85.7%) in the ACA territory, with more prominent improvement in the MCA territory than in the ACA territory (MCA territory 29.7% vs ACA territory 21.1%, p = 0.015). Craniotomy area did not correlate with postoperative CBF and only MCA territory was associated with good (≥30%) CVR improvement (odds ratio 9.33, 95% confidence interval 1.91–45.6, p = 0.003).ConclusionsPostoperative CBF improved in adult and older pediatric cases, reflecting preoperative CBF. Postoperative CVR improved in most cases, although the degree of improvement was more prominent in the MCA territory than in the ACA territory, suggesting a contribution of the temporal muscle. Large craniotomy area was not associated with improved blood flow in the ACA territory and should be applied prudently.     

Neurovascular territory involved in different etiological subtypes of ischemic stroke in the Perugia Stroke Registry

We studied the correlation between the potential causes of stroke (TOAST etiological groups) and the involvement of different vascular territories seen on computed tomography (CT) scans in patients with ischemic stroke. Information from consecutive patients with a first-ever stroke have been prospectively coded and entered into a computerized data bank (Perugia Stroke Registry). A population of 1,719 patients were evaluated: 1,284 patients (74.7%) had ischemic stroke. Large artery disease was the main cause of entire middle cerebral artery (MCA) territory infarcts (40.9%), superficial MCA territory infarcts (35.7%), and watershed infarcts (68.2%). The highest presence of emboligenic heart disease was found in the entire MCA territory infarcts (28.8%) or superficial (29.4%) supratentorial infarcts and in cerebellar infarcts (36.8%). Small artery disease was the most common presumed cause of deep MCA infarcts (75.0%) and posterior cerebral artery (PCA) territory infarcts (52.1%). In conclusion: stroke location could depend on its etiology. Lacunar infarcts are the most prevalent (36.7%), being mostly localized in the deep MCA territory; large artery disease includes more than two-thirds of watershed infarcts; the most prevalent territories involved in cardioembolic stroke are the entire MCA and posterior fossa.     

Middle cerebral artery occlusive disease: The New England medical center stroke registry.

To analyze the clinical features, vascular lesions, and infarct distribution in Asian and white patients with middle cerebral artery (MCA) territory ischemia, we studied age, sex, race, risk factors, angiographic, and neuroimaging findings among patients in the New England Medical Center Stroke Registry. We included patients with well-defined intrinsic occlusive lesions of the MCAs and patients with embolic MCA territory infarcts. Among 695 patients in the stroke registry, 89 (12.8%) qualified. They had 28 MCA intrinsic stenoses, 17 MCA embolic occlusions (cardiogenic or unknown origin), and 44 carotid artery (CA) stenoses or occlusions. MCA intrinsic disease patients were more often Asians and women, and more often had hypertension. Asians were older than whites. Coronary artery disease (27%), peripheral vascular disease (20.5%), and smoking (39%) were more common in CA disease patients. The most common site of MCA intrinsic stenosis (78%) and embolic occlusion (59%) was the mainstem MCA. Infarcts in patients with MCA intrinsic disease mostly involved the striatocapsular area (61%). Infarcts in patients with MCA embolic occlusion (75%) and CA disease (43%) most often involved the parietal lobe. In our hospital, most patients with MCA intrinsic disease are Asians and women and have hypertension and striatocapsular infarctions. Asian patients are usually older than white patients. The most common site of vascular lesions is the mainstem MCA.     

Social competence following pediatric stroke: Contributions of brain insult and family environment

Limited information is available regarding predictors of psychosocial difficulties in children following stroke. This study aimed to (i) compare social competence of children with arterial ischemic stroke (AIS) to those with chronic illness and healthy controls and (ii) investigate the contribution of stroke pathology, neurological outcome and environment. Thirty-six children with AIS > 12 months prior to recruitment were compared with children with chronic illness (asthma) (n = 15) and healthy controls (n = 43). Children underwent intellectual assessment, and children and parents completed questionnaires to assess social competence. Children with AIS underwent MRI scan and neurological evaluation. Child AIS was associated with poorer social adjustment and participation, and children with AIS were rated as having more social problems than controls. Lesion volume was not associated with social outcome, but subcortical stroke was linked to reduced social participation and younger stroke onset predicted better social interaction and higher self-esteem. Family function was the sole predictor of social adjustment. Findings highlight the risk of social impairment following pediatric stroke, with both stroke and environmental factors influencing children's social competence in the chronic stages of recovery. They indicate the potential for intervention targeting support at the family level.     

Ischemic cortical neuronal damage and cognitive impairments in atherosclerotic occlusive disease of the major cerebral artery: a PET study

In atherosclerotic internal carotid artery (ICA) or middle cerebral artery (MCA) disease, selective neuronal damage can be detected as a decrease in central benzodiazepine receptors (BZRs) in an apparently normal cerebral cortex. To investigate the association between cortical BZRs decreases and executive dysfunctions, we measured BZRs using positron emission tomography (PET) and (11)C-flumazenil in 60 non-disabled patients with unilateral atherosclerotic ICA or MCA disease and no cortical infarction. Using 3-dimensional stereotactic surface projections, we calculated the BZR index, a measure of abnormally decreased BZRs in the cerebral cortex within the anterior cerebral artery (ACA) or MCA territory, and found that it to be correlated with the patient's score on the Wisconsin Card Sorting Test (WCST). Based on the WCST results, 39 patients were considered abnormal (low categories achieved) for their age. The BZR index of the ACA territory in the hemisphere affected by arterial disease was significantly higher in abnormal patients than in normal patients. The BZR index of the MCA territory differed significantly between the 2 groups when patients with left arterial disease (n = 28) were analyzed separately. The BZR indices of the anterior cingulate gyrus and the middle frontal gyrus carrelated significantly and positively with the total number of WCST errors. In atherosclerotic ICA or MCA disease, selective neuronal damage that is manifested as a decrease in BZRs in the non-infarcted cerebral cortex is associated with executive dysfunction. PET imaging of BZRs is useful as an objective measure of cognitive impairments in atherosclerotic occlusive disease of the major cerebral artery.     

The validity of a simple clinical classification of acute ischaemic stroke

The aim of the study reported here was to test the validity of a simple clinical classification of acute ischaemic stroke (Oxfordshire Community Stroke Project, OCSP) in predicting the site and size of cerebral infarction on computed tomography (CT). Consecutive patients admitted to hospital with acute ischaemic stroke were prospectively identified and classified into one of four clinical syndromes according to the OCSP classification, blind to the result of CT. The CT brain scans were classified blind to the clinical features into those demonstrating: small, medium or large cortical infarcts; small or large subcortical infarcts in the anterior circulation territory; and posterior cerebral circulation territory infarcts. A total of 108 patients were included. A recent infarct was seen. on the CT scan in 91 patients (84%), and the clinical classification correctly predicted the site and size of the cerebral infarct in 80 of these (88%; 95% confidence interval 77–92%). The positive predictive value was best for large cortical infarcts (0.94) and worst for small subcortical infarcts (0.63). The OCSP clinical classification is a reasonably valid way of predicting the site and size of cerebral infarction on CT and can, therefore, be used very early after stroke onset before the infarct appears on the scan.     

Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes

BACKGROUND: Different topographic patterns in patients who experience an acute ischemic stroke may be related to specific stroke causes. OBJECTIVE: To determine if lesion patterns on early diffusion-weighted imaging (DWI) are associated with stroke subtypes determined by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification. DESIGN: Cross-sectional study. SETTING: General community hospital.Patients We studied 172 consecutive ischemic stroke patients with a symptomatic lesion on DWI performed within 24 hours of stroke onset. MAIN OUTCOME MEASURES: Lesion patterns on DWI were classified into single lesions (corticosubcortical, cortical, subcortical > or =15 mm, or subcortical <15 mm), scattered lesions in one vascular territory (small scattered lesions or confluent with additional lesions), and multiple lesions in multiple vascular territories (in the unilateral anterior circulation, in the posterior circulation, in bilateral anterior circulations, or in anterior and posterior circulations). RESULTS: We found an overall significant relationship between DWI lesion patterns and TOAST stroke subtypes (P<.001). Corticosubcortical single lesions (P =.01), multiple lesions in anterior and posterior circulations (P =.03), and multiple lesions in multiple cerebral circulations (P =.008) were associated with cardioembolism. Multiple lesions in the unilateral anterior circulation (P =.04) and small scattered lesions in one vascular territory (P =.06) were related to large-artery atherosclerosis. Nearly half (11/23) of the patients with a single subcortical lesion that was 15 mm or larger were classified as having cryptogenic strokes (P =.001), although 9 of these patients had a classic lacunar syndrome without cortical hypoperfusion. CONCLUSIONS: Early DWI lesion patterns are associated with specific stroke causes. Conventional 15-mm criteria for lacunes, however, may underestimate the diagnosis of small-vessel occlusion with DWI.     

Isolated middle cerebral artery disease: clinical and neuroradiological features depending on the pathogenesis

BACKGROUND: Isolated atherosclerotic middle cerebral artery (MCA) disease is often difficult to differentiate from cardioembolic disease if intracranial atherosclerosis coexists with cardiac disease. OBJECTIVES: To evaluate whether clinical and neuroradiological features of isolated MCA disease differ according to the underlying aetiology. METHODS: Isolated MCA disease was defined as a unilateral angiographically occlusive lesion of the MCA on the symptomatic side without lesions of other intracranial or extracranial vessels. Patients with isolated MCA disease were divided into atherosclerotic and potentially cardioembolic, and the clinical, laboratory, and neuroradiological data analysed. RESULTS: Among the 850 consecutive patients with acute ischaemic stroke or transient ischaemic attack, 107 (12.6%) met the criteria for isolated MCA disease (76 with atherosclerotic disease and 31 with a potential source of cardiac embolism). Total anterior circulation infarcts were more common and baseline NIHSS score was higher in potentially embolic occlusions than in atherosclerotic disease (each p<0.001). While cortical infarcts and territorial infarcts were more common in the potential embolism group (p = 0.028 and p<0.001, respectively), subcortical border zone infarcts were more common in the atherosclerotic group (p<0.001). Multiple regression analysis showed that border zone infarcts and mild stroke were independently associated with atherosclerotic MCA disease, while territorial and cortical infarcts were associated with potential cardiac embolic disease. CONCLUSIONS: Clinical and neuroradiological characteristics can differentiate isolated atherosclerotic MCA disease from MCA disease associated with potential sources of cardiac embolism, and may reflect the differences in underlying pathogenesis.     

Mechanical Thrombectomy in Stroke from Infective Endocarditis: Case Report and Review

ObjectiveTo characterize outcomes after mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) from infective endocarditis.MethodsCase report and review of published cases.ResultsWe report the case of a 59-year-old woman with fungal endocarditis who developed AIS from a proximal middle cerebral artery (MCA) embolus. She underwent MT, with good outcome. An additional 25 similar cases were identified from 14 publications. Among the 26 cases analyzed (mean [SD] age, 55 [18.7] years, 42% women), the MCA was the most common site of arterial occlusion. Four patients received intravenous tissue plasminogen activator treatment before MT. The median admission NIH Stroke Scale score (NIHSSS) was 15.5 [interquartile range 9.75-19.25] and the median post-procedure NIHSSS was 2 [interquartile range .75-6]. No patient developed symptomatic intracerebral hemorrhage.ConclusionsMT appears to be a safe and effective therapeutic option in infective endocarditis-related AIS with proximal-artery occlusion.     

Topography of cerebral infarction associated with carotid artery dissection

Because the pathogenesis of cerebral ischaemia in internal carotid artery dissection (ICAD) is controversial we studied the topography of cerebral infarction that results from ICAD according to pathophysiology of embolic and haemodynamic stroke. Sixty-four patients with 67 ICADs diagnosed by angiography, Doppler duplex sonography and magnetic resonance imaging (MRI) were studied prospectively during the past decade. According to current pathophysiological concepts, cortical territorial infarcts and large subcortical lenticulostriate infarcts revealed by CT or MRI were classified as embolic, while smaller infarcts in the subcortical junctional zone and infarcts in the cortical borderzone between the middle (MCA) and anterior cerebral artery were interpreted as haemodynamic infarcts. Of the 67 dissections 37 (55%) were associated with brain infarcts, of which territorial MCA infarcts of variable size accounted for 60%. These were combined with infarcts of the anterior and posterior cerebral artery in 5%; 8% of the patients had complete MCA infarction. Large lenticulostriate infarcts were present in 11%. Haemodynamic infarcts involved the subcortical junctional zone in 16% but never the anterior cortical borderzone. Although different abnormal Doppler findings indicated haemodynamically significant carotid obstruction in all symptomatic ICADs, only the characteristic high-resistance Doppler signal was significantly associated with the occurrence of brain infarction (in 66%,P < 0.01). The angiographic features of ICAD did not correlate with the incidence or with the topography of cerebral infarction. Patterns of infarction in ICAD indicate a predominantly embolic causation probably due to thrombus formation in the dissected carotid artery in the presence of severe haemodynamic obstruction, as demonstrated by Dopppler sonography.Presented in part at the 3rd European Stroke Conference, Stockholm, May 1994