Reversible Akinetic Mutism after Aneurysmal Subarachnoid Haemorrhage in the Territory of the Anterior Cerebral Artery without Permanent Ischaemic Damage to Anterior Cingulate Gyri

We report on two cases of transient akinetic mutism after massive subarachnoid haemorrhage due to the rupture of an intracranial aneurysm of the anterior cerebral artery (ACA). In the two cases, vasospasm could not be demonstrated by imaging studies throughout the clinical course. Both patients shared common radiological features: a hydrocephalus due to haemorrhagic contamination of the ventricular system and a mass effect of a subpial hematoma on the borders of the corpus callosum. Patients were also investigated using auditory event-related evoked potentials at acute stage. In contrast to previous observations of akinetic mutism, P300 wave could not be recorded. Both patients had good recovery and we hypothesized that this unexpectedly favourable outcome was due to the absence of permanent structural damage to the ACA territory, with only transient dysfunction due to a reversible mass effect on cingulate gyri.

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Unique Presentation of Akinetic Mutism and Coexisting Thyroid Storm Relating to Stroke

Case Reports in Neurological Medicine ◽

10.1155/2014/320565 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4

Author(s):

Mohankumar Kurukumbi ◽

Thao Dang ◽

Najeeb Crossley ◽

Alice Esame ◽

Annapurni Jayam-Trouth

Keyword(s):

Ischemic Stroke ◽

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Case Reports ◽

Anterior Cingulate ◽

Akinetic Mutism ◽

Thyroid Storm ◽

African American Female ◽

Subcortical Structures ◽

Clinical Presentations

Akinetic mutism is described in various clinical presentations but typically is defined as a state wherein the patient appears awake but does not move or speak. It can be divided into two different subtypes; the most common subtypes depend on the lesion location, mesencephalic-diencephalic region, also called apathetic akinetic mutism (somnolent mutism), and those involving the anterior cingulate gyrus and adjacent frontal lobes called hyperpathic akinetic mutism. The pathway of akinetic mutism is believed to originate from circuits that link the frontal and subcortical structures. This case reports a 48-year-old African American female with bilateral anterior cerebral artery stroke and akinetic mutism with coexisting thyroid storm. This patient with bilateral anterior cerebral artery infarcts presented with characteristics that are typical for akinetic mutism such as having intact eye movements but an inability to respond to auditory or visual commands. With the incidence of bilateral anterior cerebral artery (ACA) ischemic stroke being rare and the incidence of akinetic mutism secondary to ischemic stroke even rarer, we suspect that this patient potentially had a unilateral occlusion of anomalous anterior cerebral vasculature.

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Anterior Cerebral Artery (A1 Segment) Aneurysm: Giant Partially Thrombosed A1 Aneurysm with Mass Effect, Treated with a Pipeline Embolization Device, Complete Resolution of the Mass Effect, and Modification of the Shape of the Implant During Long-Term Follow-Up

The Aneurysm Casebook ◽

10.1007/978-3-319-70267-4_150-1 ◽

2019 ◽

pp. 1-10

Author(s):

Rene Viso ◽

Ivan Lylyk ◽

Nicolas Perez ◽

Esteban Scrivano ◽

Pedro Lylyk

Keyword(s):

Cerebral Artery ◽

Complete Resolution ◽

Anterior Cerebral Artery ◽

Mass Effect ◽

Pipeline Embolization Device ◽

Long Term Follow Up

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Microsurgical management of a large ICA bifurcation aneurysm

Neurosurgical FOCUS ◽

10.3171/2015.7.focusvid.14646 ◽

2015 ◽

Vol 39 (videosuppl1) ◽

pp. V18 ◽

Cited By ~ 1

Author(s):

Leonardo Rangel-Castilla ◽

Robert F. Spetzler

Keyword(s):

Optic Nerve ◽

Cerebral Artery ◽

Indocyanine Green Angiography ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Third Ventricle ◽

Mass Effect ◽

Bifurcation Aneurysm ◽

Visual Disturbances ◽

Perforator Arteries

A 70-year-old man with progressive visual disturbances, left superior quadrantanopsia, and right-sided papilledema underwent imaging that demonstrated a right internal carotid artery (ICA) terminus aneurysm with third-ventricle mass effect and ipsilateral optic nerve and chiasm compression. We performed a right modified orbitozygomatic craniotomy, with proximal control and dissection of the aneurysm and small perforator arteries. Temporary ICA and anterior cerebral artery (ACA) clips allowed placement of a large curved permanent clip, reconstructing the ICA bifurcation and maintaining adequate patency of the ACA and middle cerebral artery. Complete aneurysm obliteration was confirmed by intraoperative indocyanine green angiography and postoperative CT angiography.The video can be found here: http://youtu.be/5WEEgmA-g2A.

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Study protocol for SFX-01 after subarachnoid haemorrhage (SAS): a multicentre randomised double-blinded, placebo controlled trial

BMJ Open ◽

10.1136/bmjopen-2018-028514 ◽

2020 ◽

Vol 10 (3) ◽

pp. e028514 ◽

Cited By ~ 1

Author(s):

Ardalan H Zolnourian ◽

Stephen Franklin ◽

Ian Galea ◽

Diederik Oliver Bulters

Keyword(s):

Subarachnoid Haemorrhage ◽

Middle Cerebral Artery ◽

Flow Velocity ◽

Cerebral Artery ◽

Short Form ◽

Controlled Trial ◽

High Morbidity ◽

Aneurysmal Subarachnoid Haemorrhage ◽

Double Blind ◽

South Central

IntroductionSubarachnoid haemorrhage (SAH) from a ruptured cerebral aneurysm carries high morbidity and mortality. Despite huge advances in techniques to secure the aneurysm, there has been little progress in the treatment of the deleterious effects of the haemorrhage.Sulforaphane is an Nrf2 inducer with anti-oxidant and anti-inflammatory properties. It has been shown to improve clinical outcome in experimental models of SAH, but is unstable. SFX-01 (Evgen Pharma) is a novel composition comprised of synthetic sulforaphane stabilised within an α-cyclodextrin complex. On ingestion, the complex releases sulforaphane making SFX-01 an ideal vehicle for delivery of sulforaphane.Methods and analysisThe objective of the study is to assess the safety, pharmacokinetics and efficacy of SFX-01. This is a prospective, multicentre, randomised, double-blind placebo-controlled trial in patients aged 18–80 years with aneurysmal subarachnoid haemorrhage in the previous 48 hours. 90 patients will be randomised to receive SFX-01 (300 mg) or placebo two times per day for up to 28 days.Safety will be assessed using blood tests and adverse event reporting.Pharmacokinetics will be assessed based on paired blood and cerebrospinal fluid (CSF) sulforaphane levels on day 7. A subgroup will have hourly samples taken during 6 hours post-dosing on days 1 and 7. Pharmacodynamics will be assessed by haptoglobin and malondialdehyde levels, and maximum flow velocity of middle cerebral artery will be measured by transcranial Doppler ultrasound.Clinical outcomes will be assessed at days 28, 90 and 180 with modified Rankin Scale, Glasgow Outcome Score, SAH Outcome Tool, Short Form-36, Brain Injury Community Rehabilitation Outcome Scales and Check List for Cognitive and Emotional consequences following stroke. MRI at 6 months including quantitative susceptibility mapping and volumetric T1 will measure iron deposition and cortical volume.Safety, CSF sulforaphane concentration and middle cerebral artery flow velocity will be primary outcomes and all others secondary.Ethics and disseminationEthical approval was obtained from South Central Hampshire A committee. Outcomes of the trial will be submitted for publication in a peer-reviewed journal.Trial registration numberNCT02614742.

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Anterior Cerebral Artery Stroke: Role of Collateral Systems on Infarct Topography

Stroke ◽

10.1161/strokeaha.120.032867 ◽

2021 ◽

Author(s):

Tharani Thirugnanachandran ◽

Richard Beare ◽

Melissa Mitchell ◽

Chloe Wong ◽

Jason Vuong ◽

...

Keyword(s):

Cerebral Artery ◽

Computer Model ◽

Anterior Cerebral Artery ◽

Artery Occlusion ◽

Anterior Cingulate ◽

Anterior Communicating Artery ◽

Cingulate Gyrus ◽

Vessel Occlusion ◽

Cerebral Artery Occlusion

Background and Purpose: The circle of Willis (CoW) and leptomeningeal anastomoses play an important role in transforming infarct topography following middle cerebral artery occlusion. Their role in infarct topography following anterior cerebral artery occlusion is not well understood. The aim of this study was to evaluate the role of the CoW and leptomeningeal anastomoses in modifying regional variation in infarct topography following occlusion of the anterior cerebral artery and its branches. Methods: Perfusion and magnetic resonance imaging of patients with anterior cerebral artery stroke and evidence of vessel occlusion were segmented and manually registered to standard brain template for voxel-wise comparison. Next, a computer model of the cerebral arteries was formulated as network of nodes connected by cylindrical pipes. The experiments included occlusion of successive branches of the anterior cerebral artery while the configurations of the CoW were varied. Results: Forty-seven patients with a median age of 77.5 years (interquartile range, 68.0–84.5 years) were studied. The regions with the highest probabilities of infarction were the superior frontal gyrus (probability =0.26) and anterior cingulate gyrus (probability =0.24). The regions around the posterior cingulate gyrus (probability =0.08), paracentral lobule (probability =0.05), precuneus and superior parietal lobule (probability =0.03) had a low probability of infarction. Following occlusions distal to the anterior communicating artery, the computer model demonstrated an increase in flow (>30%) in neighboring cortical arteries with leptomeningeal anastomoses. Conclusions: Traditionally the CoW has been regarded as the primary collateral system. However, our computer model shows that the CoW is only helpful in redirecting flow following proximal vessel occlusions (pre-anterior communicating artery). More important are leptomeningeal anastomoses, which play an essential role in distal vessel occlusions, influencing motor outcome by modifying the posterolateral extent of infarct topography.

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Akinetic mutism cases due to bilateral anterior cerebral artery infarct

European Journal of Therapeutics ◽

10.5152/eurjther.2017.06071 ◽

2017 ◽

Vol 23 (2) ◽

pp. 83-86

Author(s):

Gulsum Comruk ◽

Fatih Demir ◽

Aylin Akcali

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Akinetic Mutism

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Correlation of the middle cerebral artery flow velocity with the clinical course and CT-visualized subarachnoid blood in patients after aneurysmal subarachnoid haemorrhage

Timing of Aneurysm Surgery ◽

10.1515/9783110858853-056 ◽

1985 ◽

pp. 429-436

Keyword(s):

Subarachnoid Haemorrhage ◽

Middle Cerebral Artery ◽

Flow Velocity ◽

Cerebral Artery ◽

Clinical Course ◽

Aneurysmal Subarachnoid Haemorrhage ◽

Subarachnoid Blood ◽

Artery Flow

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Placing intracerebral probes to optimise detection of delayed cerebral ischemia and allow for the prediction of patient outcome in aneurysmal subarachnoid haemorrhage

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x16675880 ◽

2016 ◽

Vol 37 (8) ◽

pp. 2820-2832 ◽

Cited By ~ 6

Author(s):

Yannick Tholance ◽

Gleicy K Barcelos ◽

Armand Perret-Liaudet ◽

Edris Omar ◽

Romain Carrillon ◽

...

Keyword(s):

Patient Outcome ◽

Cerebral Ischemia ◽

Subarachnoid Haemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Delayed Cerebral Ischemia ◽

Detection Sensitivity ◽

Cerebral Microdialysis ◽

Anterior Communicating Artery ◽

Aneurysmal Subarachnoid Haemorrhage

Cerebral microdialysis could be useful to detect delayed cerebral ischemia in aneurysmal subarachnoid haemorrhage patients. The optimal location of the probes, however, remains controversial. Here, we determined the vascular territories with the highest infarct risk in relation to aneurysm location to define probe implantation guidelines. These guidelines were retrospectively validated by studying the likelihood of probe to fall in a secondary infarct area, and by analysing their influence to predict patient outcome. The vascular territories with highest risk of infarction were the anterior cerebral arteries for anterior communicating artery aneurysms and the ipsilateral middle cerebral artery for internal carotid artery, posterior communicating artery and middle cerebral artery aneurysms. When cerebral microdialysis probes had been implanted in these territories, 79% were located within an infarcted area versus 54% when they were implanted in other territories. Delayed cerebral ischemia was detected only when the probe was located within a brain area later affected by secondary infarction, which could justify the use of implantation guidelines. Moreover, individual patient outcomes could be predicted when probes were placed in the brain territories as suggested by this study. Thus, a precise probe placement algorithm can improve delayed cerebral ischemia detection sensitivity and allow for a better prediction concerning patient outcome.

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