Abstract TP34: Is there an Added Value for Vascular Imaging Prior to Administration of Intravenous tPA in Patients with Acute Middle Cerebral Artery Occlusion

Background and objectives: Advanced neurovascular imaging with CT or MR angiography (CTA/MRA) adds information regarding the vascular pathology and prognosis but may delay treatment with intravenous tissue plasminogen activator (tPA) in patients with proximal middle cerebral artery occlusions (pMCAO). Methods: Patients with pMCAO included in our prospective stroke registry were identified. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS) and only patients presenting with NIHSS>10 were included. Patients underwent multi-parametric imaging studies whenever possible. Patients that underwent CTA/MRA were compared to those that only had a non-contrast CT prior to tPA. Disability was measured with the modified Ranking Scale (mRS) and shifts towards favorable outcomes (mRS≤2) were analyzed. Logistic regression was used to determine outcome modifiers. Results: We included 73 patients (median age 73, 52% men) with moderate-severe stroke (median admission NIHSS 14). Forty four patients had a neurovascular imaging study and 29 did not have such a study. There were no differences between the groups in risk factor profile or baseline characteristics including stroke severity and door to needle, door to imaging or imaging to treatment times. At 90 days post stroke there were no statistically significant differences in mortality or favorable outcomes between the groups. On multivariate analysis performance of CTA/MRA had no impact on the chances of obtaining favorable outcome at day 90 after stroke. Conclusions: Advanced neurovascular imaging studies do not delay treatment with tPA but do not impact the outcome of patients with pMCAO treated with tPA and may therefore be unnecessary in the acute stage prior to administration of tPA.

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

Neuroradiology ◽

10.1007/s00234-021-02762-3 ◽

2021 ◽

Author(s):

Kilian Fröhlich ◽

Gabriela Siedler ◽

Svenja Stoll ◽

Kosmas Macha ◽

Thomas M. Kinfe ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Posterior Circulation ◽

Neurological Deficits ◽

Stroke Severity ◽

Lesion Volume ◽

Middle Cerebral Artery Territory ◽

Cerebral Lesion

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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Abstract 11511: Genetic Variation in Retinal Vascular Patterning Predicts Variation in Pial Collateral Extent and Infarct Volume After Middle Cerebral Artery Occlusion

Circulation ◽

10.1161/circ.130.suppl_2.11511 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Pranay Prabhakar ◽

Hua Zhang ◽

De Chen ◽

Stephen Lockett ◽

James E Faber

Keyword(s):

Genetic Variation ◽

Middle Cerebral Artery ◽

Middle Cerebral Artery Occlusion ◽

Cerebral Artery ◽

Genetic Background ◽

Infarct Volume ◽

Indirect Evidence ◽

Artery Occlusion ◽

Stroke Severity ◽

Cerebral Artery Occlusion

Introduction: The presence of a native (pre-existing) collateral circulation in tissues lessens injury in stroke and other occlusive diseases. However, differences in genetic background are accompanied by wide variation in the number and diameter (extent) of native collaterals in mice, resulting in large variation in protection. Indirect evidence suggests a similar wide variation also exists in humans. However, methods of measurement in humans are indirect, invasive and not widely available. Hypothesis: We sought to determine if differences in genetic background in mice result in variation in branch-patterning of the retinal circulation, and if these differences predict differences in collateral extent and, in turn, differences in severity of ischemic stroke. Methods: Patterning metrics were obtained for the retinal arterial trees of 10 mouse strains (n=8 per strain) that differ widely in collateral extent in brain and other tissues. We also obtained pial collateral number and diameter, and infarct volume 24h after permanent middle cerebral artery occlusion. Forward- and reverse-stepwise multivariate regression analysis was conducted and model performance assessed using K-fold cross-validation. Results: Twenty-one metrics varied significantly with genetic strain (p<0.01). Ten metrics (eg, vessel caliber, bifurcation angle, lacunarity, optimality, branch length) strongly predicted collateral number and diameter across 7 regression models. The best models closely predicted (p<0.0001) collateral number (K-fold R 2 =0.83-0.98), diameter (0.73-0.88) and infarct volume (0.85-0.87). Conclusions: Differences in retinal tree patterning are specified by genetic background and closely predict genetic variation in pial collateral extent and, in turn, stroke severity. If these findings can be confirmed in humans, and given that genetic variation in cerebral collaterals extends to other tissues at least in mice, a similar “retinal predictor index” could be developed as a biomarker for collateral extent in brain and other tissues. This could aid prediction of the risk-severity of tissue injury in occlusive disease as well as stratification of patients for treatment options and enrollment in clinical studies.

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Impaired cerebral autoregulation and neurovascular coupling in middle cerebral artery stroke: Influence of severity?

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x18794835 ◽

2018 ◽

Vol 39 (11) ◽

pp. 2277-2285 ◽

Cited By ~ 13

Author(s):

Angela SM Salinet ◽

Nathália CC Silva ◽

Juliana Caldas ◽

Daniel S de Azevedo ◽

Marcelo de-Lima-Oliveira ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Functional Outcome ◽

Cerebral Artery ◽

Cerebral Autoregulation ◽

Cerebral Blood Flow Velocity ◽

Neurovascular Coupling ◽

Stroke Severity ◽

Healthy Controls ◽

Stroke Patients ◽

Severe Stroke

We aimed to assess cerebral autoregulation (CA) and neurovascular coupling (NVC) in stroke patients of differing severity comparing responses to healthy controls and explore the association between CA and NVC with functional outcome. Patients admitted with middle cerebral artery (MCA) stroke and healthy controls were recruited. Stroke severity was defined by the National Institutes of Health Stroke Scale (NIHSS) scores: ≤4 mild, 5–15 moderate and ≥16 severe. Transcranial Doppler ultrasound and Finometer recorded MCA cerebral blood flow velocity (CBFv) and blood pressure, respectively, over 5 min baseline and 1 min passive movement of the elbow to calculate the autoregulation index (ARI) and CBFv amplitude responses to movement. All participants were followed up for three months. A total of 87 participants enrolled in the study, including 15 mild, 27 moderate and 13 severe stroke patients, and 32 control subjects. ARI was lower in the affected hemisphere (AH) of moderate and severe stroke groups. Decreased NVC was seen bilaterally in all stroke groups. CA and NVC correlated with stroke severity and functional outcome. CBFv regulation is significantly impaired in acute stroke, and further compromised with increasing stroke severity. Preserved CA and NVC in the acute period were associated with improved three-month functional outcome.

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Early middle cerebral artery stenosis following stent-assisted thrombectomy

Interventional Neuroradiology ◽

10.1177/1591019915581947 ◽

2015 ◽

Vol 21 (3) ◽

pp. 337-340 ◽

Cited By ~ 3

Author(s):

Süha Akpınar ◽

Güliz Yılmaz

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Direct Contact ◽

Vessel Wall ◽

Arterial Occlusion ◽

Treatment Method ◽

Vascular Changes ◽

Imaging Studies ◽

Middle Cerebral Artery Stenosis

Stent-assisted thrombectomy (SAT) is an extensively used endovascular treatment method for stroke in which the thrombectomy stents come into direct contact with the vascular intimal surface and entrap the thrombus causing the arterial occlusion. Although there are a few studies that demonstrate that the vessel wall changes in the arteries where stroke intervention is performed, we observed progressive stenosis in early follow-up imaging studies in a case. We present a middle cerebral artery (MCA) stroke patient who had four repetitive stent passes during SAT and developed distal MCA stenosis 2 months after SAT at the control magnetic resonance angiography (MRA). Inclusion of early follow-up MRA studies would be helpful in defining the silent vascular changes in patients who have undergone repetitive SAT.

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Intravenous tissue plasminogen activator before endovascular treatment increases symptomatic intracranial hemorrhage in patients with occlusion of the middle cerebral artery second division: subanalysis of the RESCUE-Japan Registry

Neuroradiology ◽

10.1007/s00234-015-1608-3 ◽

2015 ◽

Vol 58 (2) ◽

pp. 147-153 ◽

Cited By ~ 4

Author(s):

Toshinori Takagi ◽

◽

Shinichi Yoshimura ◽

Kazutaka Uchida ◽

Yukiko Enomoto ◽

...

Keyword(s):

Endovascular Treatment ◽

Middle Cerebral Artery ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Intracranial Hemorrhage ◽

Cerebral Artery ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Symptomatic Intracranial Hemorrhage

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Impact of blood rheology on wall shear stress in a model of the middle cerebral artery

Interface Focus ◽

10.1098/rsfs.2012.0094 ◽

2013 ◽

Vol 3 (2) ◽

pp. 20120094 ◽

Cited By ~ 26

Author(s):

Miguel O. Bernabeu ◽

Rupert W. Nash ◽

Derek Groen ◽

Hywel B. Carver ◽

James Hetherington ◽

...

Keyword(s):

Shear Stress ◽

Wall Shear Stress ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Decomposition Analysis ◽

Blood Rheology ◽

Vascular Pathology ◽

Newtonian Model ◽

Wall Shear ◽

The Impact

Perturbations to the homeostatic distribution of mechanical forces exerted by blood on the endothelial layer have been correlated with vascular pathologies, including intracranial aneurysms and atherosclerosis. Recent computational work suggests that, in order to correctly characterize such forces, the shear-thinning properties of blood must be taken into account. To the best of our knowledge, these findings have never been compared against experimentally observed pathological thresholds. In this work, we apply the three-band diagram (TBD) analysis due to Gizzi et al. (Gizzi et al. 2011 Three-band decomposition analysis of wall shear stress in pulsatile flows. Phys. Rev. E 83 , 031902. ( doi:10.1103/PhysRevE.83.031902 )) to assess the impact of the choice of blood rheology model on a computational model of the right middle cerebral artery. Our results show that, in the model under study, the differences between the wall shear stress predicted by a Newtonian model and the well-known Carreau–Yasuda generalized Newtonian model are only significant if the vascular pathology under study is associated with a pathological threshold in the range 0.94–1.56 Pa, where the results of the TBD analysis of the rheology models considered differs. Otherwise, we observe no significant differences.

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Patterns of Vascular Pathology in Acute, First-Ever Cerebral Infarction

Scottish Medical Journal ◽

10.1177/003693309303800203 ◽

1993 ◽

Vol 38 (2) ◽

pp. 41-44 ◽

Cited By ~ 10

Author(s):

A.R. Naylor ◽

P.A.G. Sandercock ◽

R.J. Sellar ◽

C.P. Warlow

Keyword(s):

Cerebral Infarction ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Indirect Evidence ◽

Acute Cerebral Infarction ◽

Vascular Pathology ◽

Clinical Classification ◽

Anterior Circulation ◽

Major Vessel ◽

Preliminary Study

This was a preliminary study to see whether patterns of vascular pathology correlated with a simple clinical classification of acute cerebral infarction. Thirty-two patients with acute, first-ever hemispheric cerebral infarction were prospectively studied clinically together with an extra- and transcranial Doppler ultrasound. All 14 patients with the triad of ipsilateral motor/sensory deficit, homonymous hemianopia and higher cortical dysfunction (Total Anterior Circulation Infarction,[TACI]) had occlusion of the symptomatic middle cerebral artery and/or internal carotid artery, or a severe middle cerebral artery stenosis. Three patients with lacunar infarction had no evidence of major vessel occlusion. Eleven of thirteen patients with Partial Anterior Circulation, Infarction (PACI) I(i.e. only one or two clinical features of the TACI triad) had patent symptomatic major vessels, with indirect evidence to suggest distal branch occlusion(s) of the middle cerebral artery in six. The remaining two PACI patients had major vessel occlusions. Two patients were not clinically classifiable, but both had significant vascular pathology on ultrasound. The findings of this preliminary study therefore suggest that a simple clinical classification was generally capable of predicting patterns of vascular pathology inpatients with acute cerebral infarction, which could have implications for the selection of patients for clinical trials of thrombolytic therapy.

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