Outcomes of patients with large middle cerebral artery infarct treated with and without intravenous thrombolysis

ABSTRACT Background: Many thrombolytic studies showed that severe stroke was associated with death and having symptomatic intracerebral hemorrhage and inversely related to a favorable outcome. Aims: The purpose of this study is to compare the outcomes of patients with acute large middle cerebral artery (MCA) infarction with and without intravenous recombinant-tissue-plasminogen activator (rtPA) treatment. Methods: Patients with acute, large MCA infarction (National Institute of Health Stroke Scale [NIHSS] >15) who were treated during 2011–2014 were studied. The demographic data and the outcomes were compared between patients with and without intravenous rtPA treatment. Results: Two hundred and forty patients were included. Mean NIHSS score was 20. One hundred and twenty patients were treated with intravenous rtPA treatment. The patients with rtPA treatment had higher rates of favorable outcomes (39% vs. 17%, P < 0.001) and lower mortality rate (16% vs. 51%, P < 0.001). There was no significant difference in the occurrence of symptomatic intracerebral hemorrhage (6% vs. 4%, P = 0.715). Conclusions: The study showed the benefit and safety of intravenous rtPA treatment in patients with acute large MCA infarct.

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Pathophysiology of acute middle cerebral artery infarct by multimodal computed tomography: A pilot study in Thai patients

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.143196 ◽

2015 ◽

Vol 6 (01) ◽

pp. 059-064 ◽

Cited By ~ 1

Author(s):

Pornpatr A. Dharmasaroja ◽

Arvemas Watcharakorn ◽

Utairat Chaumrattanakul

Keyword(s):

Computed Tomography ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Anterior Circulation ◽

Severe Stroke ◽

Middle Cerebral Artery Infarct ◽

Multimodal Ct

ABSTRACTMultimodal computed tomography, including non-contrast computed tomography (CT), computed tomography perfusion (CTP) and computed tomography angiography (CTA), has been increasingly used. Aims: The purpose of this study was to study pathophysiology of acute middle cerebral artery infarct using multimodal CT and to evaluate the safety and feasibility of this method in our center. Materials and Methods: Patients who had moderate to severe stroke (NIHSS score > 10), suspected of anterior circulation infarct and presented within 4 hours after stroke onset were prospectively included. Multimodal CTs, using low-osmolar contrast agents, were performed in all patients. Results: Twenty-two patients were included. Mean NIHSS was 16. All patients received intravenous thrombolysis. Favorable outcome was found in nine patients (41%). CTP was unable to identify ischemic lesions in three patients with small subcortical infarct. Most patients (82%) with large middle cerebral artery infarct still had some salvageable brain (penumbra) which partly recovered in a follow-up imaging. Eleven patients (50%) had major artery occlusion. Two patients had creatinine rising within 72 hours. Conclusions: Multimodal CT does provide information about status of major artery and the volume of salvageable/infarct brain tissue and is safely and easily applicable in our center.

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Abstract WP1: Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent-Retriever, Aspiration, MERCI: Multi-Center Experience

Stroke ◽

10.1161/str.48.suppl_1.wp1 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kunakorn Atchaneeyasakul ◽

Amer M Malik ◽

Dileep R Yavagal ◽

Mehdi Bouslama ◽

Diogo C Haussen ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Tertiary Care ◽

Stent Retriever ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference

Introduction: Recent trials demonstrated that mechanical thrombectomy improve functional outcome in anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) of the middle cerebral artery (MCA) M1 segment. However, such data regarding AIS due to MCA M2 segment ELVO is limited. Analysis of the STAR, SWIFT, and SWIFT-PRIME trials found thrombectomy in MCA M2 occlusion to be feasible in achieving successful reperfusion. The most optimal technique and/or device used for such reperfusion is not clearly defined. We aim to compare the outcome for the contemporary techniques and devices used for thrombectomy of AIS patients due to MCA M2 ELVO. Methods: A retrospective review of AIS patients with MCA M2 ELVO receiving thrombectomy from three tertiary care academic medical centers was conducted. Thrombectomy technique and thrombectomy device utilized were recorded. Outcomes were successful angiographic reperfusion (TICI ≥2b), favorable modified Rankin Scale (mRS≤2) at discharge and at 90 days, and rate of symptomatic intracerebral hemorrhage (sICH). Results: From October 1999 through June 2016, 253 AIS patients underwent thrombectomy for MCA M2 ELVO. Thrombectomy methods utilized were Stent-retriever (n=118), Aspiration only [manual or Penumbra device] (n=83), and MERCI retriever (n=52). Table 1 shows rate of outcomes measured. There was no difference in baseline NIHSS or in stroke onset to groin puncture time. Stent-retriever group showed a significantly higher recanalization rate, lower sICH rate, and favorable 90-day mRS versus Aspiration group or MERCI group, respectively. No significant difference was seen in discharge mRS between the groups. Conclusions: Thrombectomy for AIS patients with MCA M2 ELVO with Stent-retriever appears to be feasible with a significantly higher rate of recanalization, lower sICH rate, and favorable 90-day mRS when compared to Aspiration and MERCI.

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Treatment of Middle Cerebral Artery Occlusion and Internal Carotid Artery Dissection with Combined Mechanical Thrombectomy and Stenting of the Internal Carotid Artery

The Neuroradiology Journal ◽

10.1177/197140091302600114 ◽

2013 ◽

Vol 26 (1) ◽

pp. 84-88 ◽

Cited By ~ 2

Author(s):

A. Wetter ◽

Mi-Rim Shin ◽

D. Meila ◽

F. Brassel ◽

M. Schlunz-Hendann

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Artery Dissection ◽

Severe Stroke ◽

The Right

We describe a case of combined mechanical thrombectomy of the right middle cerebral artery and stent angioplasty of the right internal carotid artery in a severe stroke caused by arterio-arterial embolism due to a traumatic dissection of the internal carotid artery. The patient was admitted with an NIHSS score of 19 and was discharged from hospital with a score of 2. Three months later neurological examination disclosed no pathological findings. The case demonstrates the crucial role of interventional procedures in the treatment of severe stroke where intravenous thrombolysis has little prospect of success.

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Aggressive intervention to treat a young woman with intracranial hemorrhage following unsuccessful intravenous thrombolysis for left middle cerebral artery occlusion

Journal of Neurosurgery ◽

10.3171/2011.3.jns101514 ◽

2011 ◽

Vol 115 (2) ◽

pp. 359-363 ◽

Cited By ~ 2

Author(s):

Kyle M. Fargen ◽

Brian L. Hoh ◽

Gregory L. Fautheree ◽

Walter R. Morgan ◽

Gregory J. Velat ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Young Patients ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Left Middle Cerebral Artery ◽

Stroke Patients ◽

Contrast Extravasation ◽

Left Middle

Stroke patients whose condition does not improve after intravenous administration of tissue plasminogen activator (tPA) may be candidates for endovascular intervention. Patients with new intracerebral hemorrhage noted during such interventions pose a difficult challenge to neurointerventionists and are often sequestered as treatment failures and deemed inappropriate for intraarterial recanalization efforts. The authors present a case in which aggressive intervention was performed despite evidence of contrast extravasation on preintervention angiography. This 37-year-old woman presented with an occlusion of the M1 segment of the left middle cerebral artery and a National Institutes of Health Stroke Scale score of 24. She received intravenous tPA without improvement. Angiography revealed M1 thrombus as well as active contrast extravasation without arterial displacement. Thromboaspiration was performed in light of her known hemorrhage with excellent recanalization. Immediate postprocedure imaging demonstrated a large insular hematoma and emergent craniectomy and hematoma evacuation were performed. At 4 months' follow-up, the patient was living at home, was ambulating, and had excellent comprehension with mild expressive aphasia. There is little peer-reviewed data in the literature to aid in the decision-making process when contrast extravasation is recognized at the time of preinterevention angiography. Continuation of mechanical endovascular stroke intervention, in light of active contrast extravasation, may be warranted in young patients with major deficits and absence of arterial displacement or delayed global filling. Further thrombolytics are not advised. In select stroke patients, continuation of a planned attempt at mechanical recanalization without the further use of thrombolytics may be warranted in light of known intracerebral hemorrhage.

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Intravenous thrombolysis with recombinant tissue plasminogen activator in a thirteen-year-old girl with cerebral infarction secondary to spontaneous intracranial arterial dissection with middle cerebral artery occlusions: a case report

Nosotchu ◽

10.3995/jstroke.10306 ◽

2015 ◽

Vol 37 (5) ◽

pp. 322-326

Author(s):

Daisuke Yamamoto ◽

Tsuyoshi Uchiyama ◽

Hirotsugu Takashima ◽

Takashi Sugiyama ◽

Keishiro Sato ◽

...

Keyword(s):

Case Report ◽

Cerebral Infarction ◽

Middle Cerebral Artery ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Arterial Dissection ◽

Tissue Plasminogen

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Brain Lesions as a Predictor of Therapeutic Outcomes of Hand Function in Infants With Unilateral Cerebral Palsy

Journal of Child Neurology ◽

10.1177/0883073818801632 ◽

2018 ◽

Vol 33 (14) ◽

pp. 918-924

Author(s):

Rena Chamudot ◽

Shula Parush ◽

Amihai Rigbi ◽

Varda Gross-Tsur

Keyword(s):

Cerebral Palsy ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Upper Limb ◽

Hand Function ◽

Brain Lesion ◽

Brain Lesions ◽

Significant Difference ◽

Unilateral Cerebral Palsy ◽

Middle Cerebral Artery Infarct

Aim: The present study aimed to investigate whether the response variability of infants to modified constraint-induced movement therapy and bimanual therapy are associated with different types of brain lesions. Method: Infants with unilateral cerebral palsy (N = 22) ages 8-15 months (mean = 10.95, standard deviation = 2.15 months) were grouped according to having either a periventricular brain lesion or a middle cerebral artery infarct lesion. Improvement in hand function was analyzed based on the mini–Assistive Hand Assessment results. Results: Infants with periventricular brain lesion displayed greater positive response to upper limb treatment compared to those with middle cerebral artery infarct ( P = .02). A significant difference in improvement according to type of treatment was found in the middle cerebral artery infarct group but not in the periventricular brain lesion. Conclusion: The present study showed an association between the type of brain lesion and the efficacy of upper limb treatment in infants. Infants with periventricular brain lesions displayed greater positive responses than those with middle cerebral artery infarct.

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Prolonged/delayed cerebral hyperperfusion in adult patients with moyamoya disease with RNF213 gene polymorphism c.14576G>A (rs112735431) after superficial temporal artery–middle cerebral artery anastomosis

Journal of Neurosurgery ◽

10.3171/2020.6.jns201037 ◽

2020 ◽

pp. 1-8

Author(s):

Ryosuke Tashiro ◽

Miki Fujimura ◽

Masahito Katsuki ◽

Taketo Nishizawa ◽

Yasutake Tomata ◽

...

Keyword(s):

Genetic Analysis ◽

Gene Polymorphism ◽

Intracerebral Hemorrhage ◽

Middle Cerebral Artery ◽

Moyamoya Disease ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Adult Patients ◽

Cerebral Hyperperfusion

OBJECTIVESuperficial temporal artery–middle cerebral artery (STA-MCA) anastomosis is the standard surgical management for moyamoya disease (MMD), whereas cerebral hyperperfusion (CHP) is one of the potential complications of this procedure that can result in delayed intracerebral hemorrhage and/or neurological deterioration. Recent advances in perioperative management in the early postoperative period have significantly reduced the risk of CHP syndrome, but delayed intracerebral hemorrhage and prolonged/delayed CHP are still major clinical issues. The clinical implication of RNF213 gene polymorphism c.14576G>A (rs112735431), a susceptibility variant for MMD, includes early disease onset and a more severe form of MMD, but its significance in perioperative pathology is unknown. Thus, the authors investigated the role of RNF213 polymorphism in perioperative hemodynamics after STA-MCA anastomosis for MMD.METHODSAmong 96 consecutive adult patients with MMD comprising 105 hemispheres who underwent serial quantitative cerebral blood flow (CBF) analysis by N-isopropyl-p-[123I]iodoamphetamine SPECT after STA-MCA anastomosis, 66 patients consented to genetic analysis of RNF213. Patients were routinely maintained under strict blood pressure control during and after surgery. The local CBF values were quantified at the vascular territory supplied by the bypass on postoperative days (PODs) 1 and 7. The authors defined the radiological CHP phenomenon as a local CBF increase of more than 150% compared with the preoperative values, and then they investigated the correlation between RNF213 polymorphism and the development of CHP.RESULTSCHP at POD 1 was observed in 23 hemispheres (23/73 hemispheres [31.5%]), and its incidence was not statistically different between groups (15/41 [36.6%] in RNF213-mutant group vs 8/32 [25.0%] in RNF213–wild type (WT) group; p = 0.321). CHP on POD 7, which is a relatively late period of the CHP phenomenon in MMD, was evident in 9 patients (9/73 hemispheres [12.3%]) after STA-MCA anastomosis. This prolonged/delayed CHP was exclusively observed in the RNF213-mutant group (9/41 [22.0%] in the RNF213-mutant group vs 0/32 [0.0%] in the RNF213-WT group; p = 0.004). Multivariate analysis revealed that RNF213 polymorphism was significantly associated with CBF increase on POD 7 (OR 5.47, 95% CI 1.06–28.35; p = 0.043).CONCLUSIONSProlonged/delayed CHP after revascularization surgery was exclusively found in the RNF213-mutant group. Although the exact mechanism underlying the contribution of RNF213 polymorphism to the prolonged/delayed CBF increase in patients with MMD is unclear, the current study suggests that genetic analysis of RNF213 is useful for predicting the perioperative pathology of patients with MMD.

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