Impact of Asymmetric Middle Cerebral Artery Velocity on Functional Recovery in Patients with Transient Ischemic Attack or Acute Ischemic Stroke

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.

Download Full-text

Sufficient collateral blood supply from accessory middle cerebral artery in a patient with acute ischemic stroke

Interventional Neuroradiology ◽

10.1177/1591019915583230 ◽

2015 ◽

Vol 21 (2) ◽

pp. 215-217 ◽

Cited By ~ 6

Author(s):

Zhen-Sheng Liu ◽

Long-Jiang Zhou ◽

Yong Sun ◽

Xiong-Wei Kuang ◽

Wei Wang ◽

...

Keyword(s):

Ischemic Stroke ◽

Basal Ganglia ◽

Middle Cerebral Artery ◽

Blood Supply ◽

Cerebral Artery ◽

Transient Ischemic Attack ◽

Modified Rankin Scale ◽

Nihss Score ◽

Accessory Middle Cerebral Artery ◽

Ischemic Attack

We reported a case of acute embolic occlusion of the middle cerebral artery with a patent accessory middle cerebral artery. Because of the presence of sufficient collateral blood supply from the accessory middle cerebral artery, the patient only underwent transient ischemic attack and did not need endovascular treatment. There was mild infarction in the basal ganglia and temporal lobe, NIHSS score of the patient at discharge seven days after stroke onset was 0, and modified Rankin scale score at 90 days was 0.

Download Full-text

Abstract WMP44: Differential Middle Cerebral Artery Plaque Characteristics in Patients With Transient Ischemic Attack and Ischemic Stroke: A High-Resolution MR Vessel Wall Imaging Study

Stroke ◽

10.1161/str.51.suppl_1.wmp44 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jiayu Xiao ◽

Matthew Padrick ◽

Qi Yang ◽

Tao Jiang ◽

Shuang Xia ◽

...

Keyword(s):

Risk Factor ◽

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Transient Ischemic Attack ◽

Vessel Wall ◽

Vessel Wall Imaging ◽

Plaque Burden ◽

Ischemic Attack ◽

Wall Imaging

Introduction: Intracranial atherosclerotic disease (ICAD) correlates highly with transient ischemic attack (TIA) and acute ischemic stroke (AIS). Magnetic Resonance (MR) vessel wall imaging (VWI) is an emerging non-invasive imaging modality for directly assessing ICAD lesions. Methods: We retrospectively analyzed MR-VWI from 42 TIA patients and 45 AIS patients with ICAD. All patients fulfilled the following criteria: (1) stenosis >30% of a middle cerebral artery (MCA), (2) symptoms contralateral to stenotic MCA, (3) no coexisting stenosis at other major vessels; (4) lack of compelling evidence to other etiologies of stroke/TIA. Vascular lesions were analyzed with MR-VWI with respect to the stenosis degree, vessel wall irregularity, plaque burden (PB), remodeling index (RI), plaque-wall contrast ratio (CR) and plaque enhancement grade (EG). Results: EG (OR 3.88, 95%CI 1.42-10.57, P=0.006) was a risk factor for AIS while PB (OR 0.65, 95%CI 0.27-1.54, P=0.008) was a risk factor for TIA. In patients with 30-70% degree stenosis, CR (OR 5.38, 95%CI 1.39-20.75, P=0.008) was a risk factor for stroke, while PB (OR 0.4, 95%CI 0.1-1.65, P=0.006) remained a risk factor for TIA. Conclusions: In our study, PB appeared as a risk factor for TIA but not for AIS. This suggests that unstable plaque accounting for AIS may have a wide range of PB. We further found that CR and EG are more associated with AIS than TIA. Lesions with high CR and strong enhancement may be more prone to producing the permanent ischemic injury. Further study is needed to elucidate the role of MR-VWI in differential diagnosis and management of TIA and AIS.

Download Full-text

Sleep for Stroke Management and Recovery Trial (Sleep SMART): Rationale and methods

International Journal of Stroke ◽

10.1177/1747493020903979 ◽

2020 ◽

Vol 15 (8) ◽

pp. 923-929 ◽

Cited By ~ 2

Author(s):

Devin L Brown ◽

Valerie Durkalski ◽

Jeffrey S Durmer ◽

Joseph P Broderick ◽

Darin B Zahuranec ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Ischemic Stroke ◽

Sleep Apnea ◽

Acute Ischemic Stroke ◽

Functional Recovery ◽

Transient Ischemic Attack ◽

Stroke Management ◽

Vascular Events ◽

Obstructive Sleep ◽

Ischemic Attack

Rationale Obstructive sleep apnea is common among patients with acute ischemic stroke and is associated with reduced functional recovery and an increased risk for recurrent vascular events. Aims and/or hypothesis The Sleep for Stroke Management and Recovery Trial (Sleep SMART) aims to determine whether automatically adjusting continuous positive airway pressure (aCPAP) treatment for obstructive sleep apnea improves clinical outcomes after acute ischemic stroke or high-risk transient ischemic attack. Sample size estimate A total of 3062 randomized subjects for the prevention of recurrent serious vascular events, and among these, 1362 stroke survivors for the recovery outcome. Methods and design Sleep SMART is a phase III, multicenter, prospective randomized, open, blinded outcome event assessed controlled trial. Adults with recent acute ischemic stroke/transient ischemic attack and no contraindication to aCPAP are screened for obstructive sleep apnea with a portable sleep apnea test. Subjects with confirmed obstructive sleep apnea but without predominant central sleep apnea proceed to a run-in night of aCPAP. Subjects with use (≥4 h) of aCPAP and without development of significant central apneas are randomized to aCPAP plus usual care or care-as-usual for six months. Telemedicine is used to monitor and facilitate aCPAP adherence remotely. Study outcomes Two separate primary outcomes: (1) the composite of recurrent acute ischemic stroke, acute coronary syndrome, and all-cause mortality (prevention) and (2) the modified Rankin scale scores (recovery) at six- and three-month post-randomization, respectively. Discussion Sleep SMART represents the first large trial to test whether aCPAP for obstructive sleep apnea after stroke/transient ischemic attack reduces recurrent vascular events or death, and improves functional recovery.

Download Full-text

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.

Download Full-text

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.

Download Full-text

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.

Download Full-text

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.

Download Full-text