The anesthetic approach for endovascular recanalization therapy depends on the lesion site in acute ischemic stroke

Abstract Purpose Endovascular therapy (EVT) of large-vessel occlusion in acute ischemic stroke (AIS) may be performed in general anesthesia (GA) or conscious sedation (CS). We intended to determine the contribution of ischemic cerebral lesion sites on the physician’s decision between GA and CS using voxel-based lesion symptom mapping (VLSM). Methods In a prospective local database, we sought patients with documented AIS and EVT. Age, stroke severity, lesion volume, vigilance, and aphasia scores were compared between EVT patients with GA and CS. The ischemic lesions were analyzed on CT or MRI scans and transformed into stereotaxic space. We determined the lesion overlap and assessed whether GA or CS is associated with specific cerebral lesion sites using the voxel-wise Liebermeister test. Results One hundred seventy-nine patients with AIS and EVT were included in the analysis. The VLSM analysis yielded associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas. Stroke severity and lesion volume were significantly higher in the GA group. The prevalence of aphasia and aphasia severity was significantly higher and parameters of vigilance lower in the GA group. Conclusions The VLSM analysis showed associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas including the thalamus that are known to cause neurologic deficits, such as aphasia or compromised vigilance, in AIS-patients with EVT. Our data suggest that higher disability, clinical impairment due to neurological deficits like aphasia, or reduced alertness of affected patients may influence the physician’s decision on using GA in EVT.

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Prestroke statin use enhances collateralization in acute ischemic stroke patients

Restorative Neurology and Neuroscience ◽

10.3233/rnn-201012 ◽

2020 ◽

Vol 38 (4) ◽

pp. 311-321

Author(s):

Jiaying Zhu ◽

Mengmeng Ma ◽

Jinghuan Fang ◽

Jiajia Bao ◽

Shuju Dong ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Statin Therapy ◽

Cerebral Artery ◽

Functional Outcomes ◽

Collateral Circulation ◽

Stroke Severity ◽

Stroke Patients ◽

Statin Use

Background: Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes. Objective: The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients. Methods: We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed. Results: Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195–19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657–5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325–11.289; P = 0.013). Conclusions: Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.

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Susceptibility-diffusion mismatch in middle cerebral artery territory acute ischemic stroke: clinical and imaging implications

Acta Radiologica ◽

10.1177/0284185116675658 ◽

2016 ◽

Vol 58 (7) ◽

pp. 876-882 ◽

Cited By ~ 5

Author(s):

Seyedmehid Payabvash ◽

Shayandokht Taleb ◽

John C Benson ◽

Benjamin Hoffman ◽

Mark C Oswood ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Middle Cerebral Artery Territory

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Characteristics and Outcome in Children With Craniectomy Following Acute Ischemic Stroke in the International Pediatric Stroke Study

Journal of Child Neurology ◽

10.1177/0883073819855534 ◽

2019 ◽

Vol 34 (12) ◽

pp. 765-769 ◽

Cited By ~ 1

Author(s):

Laura L. Lehman ◽

Gabrielle DeVeber ◽

Paola Pergami ◽

Kristin P. Guilliams ◽

Melissa Chung ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Posterior Circulation ◽

Pediatric Stroke ◽

Posterior Decompression ◽

Posterior Circulation Stroke ◽

Stroke Study ◽

International Pediatric

The outcome of children with acute ischemic stroke treated with craniectomy has not been thoroughly examined. In adults, hemicraniectomy after middle cerebral artery territory stroke and posterior decompression after posterior circulation stroke has been shown to improve outcome. Pediatric cases of hemicraniectomy for middle cerebral artery stroke and posterior decompression following posterior circulation stroke suggest relatively good outcome. There are no published data in adults or children with craniectomy after cerebral sinovenous thrombosis. Our aim was to determine the outcome of children with acute ischemic stroke treated with craniectomy in the International Pediatric Stroke Study (IPSS). We included children enrolled who had a craniectomy following stroke presentation. Of 4294 patients in IPSS, 38 children (1%) were found to have craniectomy following an ischemic stroke. Of 38 craniectomy cases, 29 had anterior circulation strokes, 5 had posterior circulation strokes, and 4 had cerebral sinovenous thromboses. The mortality rate was 8%. Overall, children who have craniectomies have significant neurologic deficits. Prospective studies are needed to examine long-term morbidity following craniectomy.

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Prevalence, Comorbid Associations and Prognostic Value of the Hyperdense Middle Cerebral Artery Sign

ISRN Stroke ◽

10.1155/2013/954825 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Patrick Aouad ◽

Andrew Hughes ◽

Nishant Valecha ◽

Yash Gawarikar ◽

Kate Ahmad ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Interobserver Variability ◽

Kappa Statistic ◽

Stroke Severity ◽

Ischemic Attack ◽

Sensitivity Specificity ◽

Hyperdense Middle Cerebral Artery

Background. The significance of the Hyperdense Middle Cerebral Artery Sign (HMCAS) is uncertain. Aims. This prospective study investigated the sensitivity, specificity, prevalence, prognosis, interobserver variability, and associated clinical features of HMCAS in acute ischemic stroke. Methods. Initial CT scans of 117 patients with acute ischemic stroke or transient ischemic attack (TIA) and 65 age-matched controls were reported independently by two neuroradiologists blinded to diagnosis. Details of initial stroke severity and comorbidities were collected, and outcome on the modified Rankin scale (mRS) was assessed at 3–6 months. Results. HMCAS was seen in 15% of all ischemic strokes and 25% of all middle cerebral artery (MCA) strokes; specificity was 100%. HMCAS was associated with more severe initial deficit and atrial fibrillation. Only 21% of patients with a first-ever MCA stroke and HMCAS had a good outcome (mRS≤2) compared to 55% of those without the sign (P<0.001). Interobserver agreement was only 0.747 (Kappa statistic). Conclusion. The prevalence, specificity, sensitivity, and clinical associations of HMCAS were similar to previous reports. This study confirmed prospectively that HMCAS was associated with a poorer outcome at 3 to 6 months and demonstrated interobserver variability in detection of the sign.

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An Observational Study Investigating the Need for Decompressive Hemicraniectomy after Thrombectomy in Acute Ischemic Stroke of the Middle Cerebral Artery Territory

Cureus ◽

10.7759/cureus.9665 ◽

2020 ◽

Author(s):

Arsalaan Salehani ◽

Borna E Tabibian ◽

D M Self ◽

Bonita Agee ◽

Gustavo Chagoya ◽

...

Keyword(s):

Ischemic Stroke ◽

Observational Study ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Middle Cerebral Artery Territory ◽

Decompressive Hemicraniectomy

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Abstract WMP120: Pre-stroke Statin Enhancement of Collateralization in Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wmp120 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mengmeng Ma ◽

Jiaying Zhu ◽

Li He

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Cerebral Artery ◽

Collateral Circulation ◽

Stroke Onset ◽

Stroke Severity ◽

Stroke Patients ◽

Statin Use

Background: Recent studies suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcome in case of stroke onset. It was speculated that pre-stroke statin may enhance collateral circulation and result in favorable functional outcome. This study aimed to investigate the association of pre-stroke statin use with leptomeningeal collaterals in acute ischemic stroke patients. Methods: We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 hours from May 2011 to April 2017. CTA imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; admission NIHSS was used to measure stroke severity; modified Rankin scale (mRS) at 90 day was used to measure outcome. Univariate and multivariate analyses were performed. Results: 239 patients met inclusion criteria. 54 patients use statin before stroke onset. Pre-stroke statin use was independently associated with good collateral circulations (rLMCS>10) (OR, 4.786; 95% CI, 1.195 - 19.171; P = 0.027). Pre-stroke statin use was not independently associated with lower stroke severity (NIHSS≤14) (OR, 1.955; 95%CI, 0.657- 5.816; P = 0.228), but pre-stroke statin use was independently associated with good outcome (mRS≤2) (OR, 3.868; 95%CI, 1.325 - 11.289; P = 0.013). Conclusion: Pre-stroke statin use seems enhance collateralization and improve clinical outcomes in patients with acute stroke. However, clinical controlled studies should be used to verify this claim.

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Accuracy of thin-slice model-based iterative reconstruction designed for brain CT to diagnose acute ischemic stroke in the middle cerebral artery territory: a multicenter study

Neuroradiology ◽

10.1007/s00234-021-02745-4 ◽

2021 ◽

Author(s):

Hidenori Mitani ◽

Fuminari Tatsugami ◽

Toru Higaki ◽

Yoko Kaichi ◽

Yuko Nakamura ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Multicenter Study ◽

Iterative Reconstruction ◽

Middle Cerebral Artery Territory ◽

Brain Ct ◽

Thin Slice ◽

Model Based

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Study of Short Latency Somatosensory and Brain Stem Auditory Evoked Potentials Patients with Acute Ischemic Stroke Involving Middle Cerebral Artery Territory

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0041-1727558 ◽

2021 ◽

Author(s):

Abhishek Miryala ◽

Mahendra Javali ◽

Anish Mehta ◽

Pradeep R. ◽

Purushottam Acharya ◽

...

Keyword(s):

Ischemic Stroke ◽

Evoked Potentials ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Brain Stem ◽

Functional Outcome ◽

Cerebral Artery ◽

Negative Correlation ◽

Auditory Evoked Potentials ◽

Positive Correlation

Abstract Background The precise timings of evoked potentials in evaluating the functional outcome of stroke have remained indistinct. Few studies in the Indian context have studied the outcome of early prognosis of stroke utilizing evoked potentials. Objective The aim of this study was to determine somatosensory evoked potentials (SSEPs) and brain stem auditory evoked potentials (BAEPs), their timing and abnormalities in acute ischemic stroke involving the middle cerebral artery (MCA) territory and to correlate SSEP and BAEP with the functional outcome (National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS) and Barthel’s index) at 3 months. Methods MCA territory involved acute ischemic stroke patients (n = 30) presenting consecutively to the hospital within 3 days of symptoms onset were included. Details about clinical symptoms, neurological examination, treatment, NIHSS score, mRS scores were collected at the time of admission. All patients underwent imaging of the brain and were subjected to SSEP and BAEP on two occasions, first at 1 to 3 days and second at 4 to 7 days from the onset of stroke. At 3 months of follow-up, NIHSS, mRS, and Barthel’s index were recorded. Results P37 and N20 amplitude had a strong negative correlation (at 1–3 and 4–7 days) with NIHSS at admission, NIHSS at 3 months, mRS at admission, and mRS at 3 months and a significant positive correlation with Barthel’s index (p < 0.0001). BAEP wave V had a negative correlation (at 1–3 and 4–7 days) with NIHSS at admission, NIHSS at 3 months, mRS at admission, and mRS at 3 months and a positive correlation with Barthel’s index (p < 0.0001). Conclusion SSEP abnormalities recorded on days 4 to 7 from onset of stroke are more significant than those recorded within 1 to 3 days of onset of stroke; hence, the timing of 4 to 7 days after stroke onset can be considered as better for predicting functional outcome.

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Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

Cerebrovascular Diseases ◽

10.1159/000512106 ◽

2021 ◽

pp. 1-12

Author(s):

Jang Hun Kim ◽

Wonki Yoon ◽

Chi Kyung Kim ◽

Haewon Roh ◽

Hee Jin Bae ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Bypass Surgery ◽

Superficial Temporal Artery ◽

Pooled Analysis ◽

Published Data ◽

Efficacy And Safety ◽

Nihss Score

Background: Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. Aims: We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. Methods: Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. Results: In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. Conclusions: Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

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