Outcomes and risk factors of perforating and non-perforating middle cerebral artery infarctions after intravenous thrombolysis

Background and Purpose: Hemosiderin was shown to have a stronger T2 shortening effect than deoxyhemoglobin. Therefore, the extent of “blooming effect” of susceptibility vessel sign (SVS) might represent composition of different iron forms. We aimed to investigate the relationship between extent of overestimation of thrombus burden and middle cerebral artery (MCA) recanalization. Methods: We retrospectively examined clinical and imaging data from consecutive acute ischemic stroke patients with MCA occlusion who underwent MRI before and 24 hours after IV thrombolysis in our hospital. A delayed phase contrast enhanced T1-WI was used to measure the true size of thrombus. We then examined the association of MCA recanalization and extent of overestimation of thrombus burden. Results: We observed the presence of MCA SVS in 44 patients on initial gradient-recalled echo (GRE) scans and MCA recanalization in 21 (47.7%) patients 24 hours after treatment. The extent of overestimation of thrombus width on GRE was an acceptable predictor for MCA recanalization (odds ratio 1.584 per 10%; 95% CI: 1.090 to 2.310; p=0.016), with a receiver-operator characteristic of 0.884 (95% CI: 0.780 to 0.988; p < 0.001). The optimal cut-off point for predicting recanalization was identified at 1.7814, and this yielded a sensitivity of 87.0% and a specificity of 85.7%. Conclusions: Overestimation of thrombus burden on GRE might reflect the content of hemosiderin. A larger overestimation might indicate aged thrombus, which were resistant to thrombolysis.

Download Full-text

Risk Factors for Delayed Neurocognitive Recovery According to Brain Biomarkers and Cerebral Blood Flow Velocity

Medicina ◽

10.3390/medicina56060288 ◽

2020 ◽

Vol 56 (6) ◽

pp. 288

Author(s):

Rasa Bukauskienė ◽

Edmundas Širvinskas ◽

Tadas Lenkutis ◽

Rimantas Benetis ◽

Rasa Steponavičiūtė

Keyword(s):

Risk Factors ◽

Blood Flow ◽

Middle Cerebral Artery ◽

Flow Velocity ◽

Cerebral Artery ◽

Blood Flow Velocity ◽

Cerebral Blood Flow Velocity ◽

Co2 Concentration ◽

Anesthesia Induction ◽

Neurocognitive Evaluation

Background and Objectives: The aim of this study is to identify risk factors for the development of delayed neurocognitive recovery (dNCR). Materials and Methods: 140 patients underwent neurocognitive evaluations (Adenbrooke, MoCa, trial making, and CAM test) and middle cerebral artery (MCA) blood flow velocity (BFV) measurements, one day before cardiac surgery. BFV was re-evaluated after anesthesia induction, before the beginning, middle, end, and after cardiopulmonary bypass (CPB) and postsurgery. To measure glial fibrillary acidic protein (GFAP) and neurofilament heavy chain (Nf-H), blood samples were collected after anesthesia induction, 24 and 48 h after the surgery. Neurocognitive evaluation was repeated 7–10 days after surgery. According to the results, patients were divided into two groups: with dNCR (dNCR group) and without dNCR (non-dNCR group). Results: 101 patients completed participation in this research. GFAP increased in both the non-dNCR group (p < 0.01) and in the dNCR group (p < 0.01), but there was no difference between the groups (after 24 h, p 0.342; after 48 h, p 0.273). Nf-H increased in both groups (p < 0.01), but there was no difference between them (after 24 h, p = 0.240; after 48 h, p = 0.597). MCA BFV was significantly lower in the dNCR group during the bypass (37.13 cm/s SD 7.70 versus 43.40 cm/s SD 9.56; p = 0.001) and after surgery (40.54 cm/s SD 11.21 versus 47.6 cm/s SD 12.01; p = 0.003). Results of neurocognitive tests correlated with CO2 concentration (Pearson’s r 0.40, p < 0.01), hematocrit (r 0.42, p < 0.01), MCA BFV during bypass (r 0.41, p < 0.01), and age (r −0.533, p < 0.01). The probability of developing dNCR increases 1.21 times with every one year of increased age (p < 0.01). The probability of developing dNCR increases 1.07 times with a decrease of BFV within 1 cm/s during bypass (p = 0.02). Conclusion: Risk factors contributing to dNCR among the tested patients were older age and middle cerebral artery blood flow velocity decrease during bypass.

Download Full-text

Hypoperfusion in lenticulostriate arteries territory related to unexplained early neurological deterioration after intravenous thrombolysis

International Journal of Stroke ◽

10.1177/1747493019830595 ◽

2019 ◽

Vol 14 (3) ◽

pp. 306-309 ◽

Cited By ~ 2

Author(s):

Ying Zhou ◽

Wansi Zhong ◽

Anli Wang ◽

Wanyun Huang ◽

Shenqiang Yan ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Neurological Deterioration ◽

Terminal Branch ◽

Stroke Patients ◽

Lenticulostriate Arteries ◽

Early Neurological Deterioration

Background Early neurological deterioration occurs in approximately 10% acute ischemic stroke patients after thrombolysis. Over half of the early neurological deterioration occurred without known causes and is called unexplained early neurological deterioration. Aims We aimed to explore the development of early neurological deterioration at 24 h after thrombolysis, and whether it could be predicted by the presence of baseline hypoperfusion in lenticulostriate arteries territory in acute ischemic stroke patients. Methods We retrospectively reviewed our prospectively collected database of acute ischemic stroke patients in the unilateral middle cerebral artery territory who had baseline perfusion image and received thrombolysis. Unexplained early neurological deterioration was defined as ≥ 2 points increase of National Institutes of Health Stroke Scale (NIHSS) from baseline to 24 h, without known causes. Hypoperfusion lesions in different territories were identified on perfusion maps. Results A total of 306 patients were included in analysis. Patients with pure lenticulostriate arteries hypoperfusion (defined as the presence of hypoperfusion in lenticulostriate artery territory, but not in middle cerebral artery terminal branch territory) were more likely to have unexplained early neurological deterioration than others (27.6% vs. 6.1%; OR, 5.974; p = 0.001), after adjusting for age, baseline NIHSS and onset to treatment time. Conclusions Patients presenting hypoperfusion in pure lenticulostriate arteries territory were easier to experience unexplained early neurological deterioration.

Download Full-text

Malignant middle cerebral artery (MCA) infarction in people over 85 years old – Diagnosis, management and risk factors

Neurologia i Neurochirurgia Polska ◽

10.1016/j.pjnns.2017.12.005 ◽

2018 ◽

Vol 52 (3) ◽

pp. 311-317

Author(s):

Żanna Pastuszak ◽

Zbigniew Czernicki ◽

Waldemar Koszewski ◽

Adam Stępień ◽

Anna Piusińska-Macoch

Keyword(s):

Risk Factors ◽

Middle Cerebral Artery ◽

Cerebral Artery

Download Full-text

Morphology of Susceptibility Vessel Sign Predicts Middle Cerebral Artery Recanalization After Intravenous Thrombolysis

Stroke ◽

10.1161/strokeaha.114.006144 ◽

2014 ◽

Vol 45 (9) ◽

pp. 2795-2797 ◽

Cited By ~ 12

Author(s):

Shenqiang Yan ◽

Haitao Hu ◽

Zhenghao Shi ◽

Xuting Zhang ◽

Sheng Zhang ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Intravenous Thrombolysis

Download Full-text

Urgent Middle Cerebral Artery Embolectomy of Calcified Embolus After Intravenous Thrombolysis: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy404 ◽

2019 ◽

Vol 17 (2) ◽

pp. E54-E55 ◽

Cited By ~ 1

Author(s):

Jiri Fiedler ◽

Svatopluk Ostry ◽

Martin Bombic ◽

Ludek Sterba ◽

Petr Kostal

Keyword(s):

Informed Consent ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Ct Perfusion ◽

Intravenous Thrombolysis ◽

Complete Recovery ◽

Clinical Findings ◽

Left Middle Cerebral Artery ◽

Initial Flow ◽

Ct Perfusion Imaging

Abstract This video shows an urgent microsurgical embolectomy of the inferior division of the left middle cerebral artery in a patient treated by intravenous thrombolysis (IVT). Patient was eligible for endovascular mechanical thrombectomy1; however, the interventional radiologist was not comfortable performing the procedure given prior unsuccessful attempts to remove a calcified cerebral embolus.2 A 75-yr-old female presented with an acute ischemic stroke with isolated aphasia (NIHSS 9). Using the drip-and-ship concept, IVT (0.9 mg/kg rt-PA) was administered in a regional hospital. Fifty-five minutes after a complete recovery following IVT, multiple transient ischemic attacks of aphasia were observed. While the patient was a candidate for mechanical thrombectomy based on CT perfusion imaging, given the unsuccessful reports in the literature and the interventional radiologist's experience, the decision was made to offer microsurgical embolectomy of the calcified cerebral embolus.3 Informed consent for the procedure was obtained directly from the patient. Calcified, crumbly embolus was removed from a 5 mm longitudinal arteriotomy. The arteriotomy was sutured with interrupted 10-0 suture. Initial flow after the embolectomy was 6.5 mL/min. Upon inspection, a distal kink was found in the M2 and after repositioning, flow improved to 35 mL/min. Postoperative CT angiography documented complete recanalization. The clinical findings completely resolved (NIHSS 0) within 12 hr and remained unchanged at 3 mo and 1 yr. Informed consent was obtained from the patient for use of media for educational and publication purposes.

Download Full-text