Outcome after acute ischemic stroke is linked to sex-specific lesion patterns.

Acute ischemic stroke affects men and women differently. In particular, women are often reported to experience higher acute stroke severity than men. We derived a low-dimensional representation of anatomical stroke lesions and designed a Bayesian hierarchical modeling framework tailored to estimate possible sex differences in lesion patterns linked to acute stroke severity (National Institute of Health Stroke Scale). This framework was developed in 555 patients (38% female). Findings were validated in an independent cohort (n = 503, 41% female). Here, we show brain lesions in regions subserving motor and language functions help explain stroke severity in both men and women, however more widespread lesion patterns are relevant in female patients. Higher stroke severity in women, but not men, is associated with left hemisphere lesions in the vicinity of the posterior circulation. Our results suggest there are sex-specific functional cerebral asymmetries that may be important for future investigations of sex-stratified approaches to management of acute ischemic stroke.

Deep Brain Stimulation and Thalamotomy for the Treatment of Dystonia Acquired by Moyamoya Disease with Stroke.

Background: Moyamoya disease (MMD) is a type of chronic cerebrovascular disease. Currently, revascularization surgery including direct/indirect procedure is recommended for symptomatic patients. However, some patients still respond poorly to the treatment or develop secondary symptoms. Case report: We report the first case of an MMD patient treated with deep brain stimulation (DBS) and thalamotomy. Symptoms of dystonia due to hemorrhage in the thalamus responded poorly to revascularization surgery, but were considerably alleviated by stereotactic neurosurgery. Discussion: Our case report provides a potential strategy for management of refractory symptomatic MMD patients with dystonia and also supports the combined efficacy of DBS with thalamotomies. Highlights: Approximately 30% of patients with Moyamoya disease (MMD) presenting movement symptoms do not respond well to revascularization surgery. We reported an MMD patient treated with deep brain stimulation (DBS) and thalamotomy with significant dystonia and dystonic tremor symptom amelioration. It indicates that DBS or stereotactic lesioning might be a potential treatment for the refractory movement symptoms of MMD.

Mechanical Revascularization in the Era of the Field Assessment Stroke Triage for Emergency Destination (FAST-ED): A Retrospective Cohort Assessment in a Community Stroke Practice.

BACKGROUND: Endovascular mechanical revascularization has become the mainstay acute stroke management secondary to emergent large vessel occlusions. In patients who can benefit from mechanical revascularization, the ability to intervene in a timely manner directly correlates with improved outcomes. The field assessment for stroke triage (FAST-ED) prehospital triage tool, is one of many stroke severity scales designed to decrease time to diagnosis in the field and optimize patient triage to comprehensive stroke centers. It is however unclear what impact if any, this tool has on time to activation of hospital stroke intervention teams. We set out to assess the impact of the implementation of the FAST-ED triage tool on the activation of the stroke intervention team in a community stroke treatment practice. METHODS: We retrospectively reviewed institutional records for consecutive admissions with reported stroke alerts between March 2017 and September 2018, and selected patients who presented via Emergency Medical Services (EMS). The association between FAST-ED scores and impact on time to revascularization as well as the association between FAST-ED scores and the presence of emergent large vessel occlusion were analyzed. RESULTS: There was a statistically significant improvement in interventional team activation times in favor of the FAST-ED cohort, (P < .05). CONCLUSIONS: FAST-ED implementation demonstrates a statistically significant improvement on stroke team activation times for patients who are candidates for mechanical revascularization. Larger cohort analysis is needed to fully evaluate the magnitude of this effect.

STA-MCA Bypass Under Local Anesthesia.

BACKGROUND AND AIMS: The superficial temporal artery to middle cerebral artery (STA-MCA) bypass procedure has continually evolved and new strategies have been advocated to reduce anesthetic or surgical mortality and morbidity. Further simplifying and decreasing the invasiveness of STA-MCA bypass by performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: We performed STA-MCA bypass using local anesthesia using a sedative in 45 patients with hemodynamically compromised cerebrovascular occlusive disease as well as multiple comorbidities in the period between February 2010 and April 2016. The technique is based on preoperative identification of the point at which the donor and recipient vessels are in closest proximity. The preoperative use of computed tomography angiography allowed us to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp block local anesthesia with an unsecured airway. RESULTS: Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway/ventilation complications occurred and no patient was converted to general anesthesia. The patients subjectively tolerated this technique well with a high rate of satisfaction. Postoperative magnetic resonance angiography confirmed patent bypass in 44 of 45 patients (patency rate of 97.8%). There were two postoperative hyper-perfusion syndromes and one cerebral ischemia with transient neurological symptoms (postoperative complication rate of 6.3%). No recurrence of ipsilateral cerebral ischemia was observed during the follow-up periods. There was one contralateral cardiogenic cerebral embolism during the follow-up period. The overall stroke rate was calculated as 1%/patient/year. CONCLUSIONS: Our initial experience confirms the feasibility of performing STA-MCA bypass under local anesthesia without endotracheal general anesthesia.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

[Improvement of visual functions after successful microsurgical exclusion of a giant aneurysm of the right internal carotid artery using revascularization techniques]. / Uluchshenie zritel'nykh funktsii posle uspeshnogo mikrokhirurgicheskogo vykliucheniia gigantskoi anevrizmy pravoi vnutrennei sonnoi arterii s primeneniem revaskuliariziruiushchikh metodik.

We describe a clinical case of successful treatment of a female patient with a giant paraclinoid aneurysm of the right ICA. The aneurysm had a pseudotumoral course and manifested as pronounced progressive visual impairments. The patient underwent microsurgery including trapping/clipping of the right ICA aneurysm after creation of an EICMA and a high-flow anastomosis between the ECA and the M2 segment of the MCA. The surgery enabled decompression of the optic nerves, avoiding their injury. Postoperatively, the patient underwent transcutaneous electrical stimulation of the optic nerves. The case feature was that the patient developed gradual restoration of the blind eye vision.

Flow diversion versus traditional endovascular coiling therapy: design of the prospective LARGE aneurysm randomized trial.

BACKGROUND AND PURPOSE: The goal of aneurysm treatment is occlusion of an aneurysm without morbidity or mortality. Using well-established, traditional endovascular techniques, this is generally achievable with a high level of safety and efficacy. These techniques involve either constructive treatment of the aneurysm (coils with or without an intravascular stent) or deconstruction (coil occlusion) of the aneurysm and the parent artery. While established as safe and efficacious, the constructive treatment of large and giant aneurysms with coils has typically been associated with relatively lower rates of complete occlusion and higher rates of recurrence. Parent artery deconstruction, though immediately efficacious in achieving complete and durable occlusion, does require occlusion of a major intracranial blood vessel and is associated with risk of stroke. MATERIALS AND METHODS: Flow diversion represents a new technology that can be used to constructively treat large and giant aneurysms. Once excluded successfully, the vessel reconstruction and aneurysm occlusion appears durable. The ability to definitively reconstruct cerebral blood vessels is an attractive approach to these large and giant complex aneurysms and allows the treatment of some aneurysms which were previously not amenable to other therapies. By comparison, conventional coiling techniques have traditionally been used for endovascular treatment of large aneurysms. Large and giant aneurysms that are amenable to either flow diversion or traditional endovascular treatment will be randomized to either therapy with FDA (or appropriate regulatory body) approved devices. RESULTS: The trial is currently enrolling and results of the data are pending the completion of enrollment and follow-up. CONCLUSIONS: This paper details the trial design of the LARGE trial, a blinded, prospective randomized trial of large anterior circulation aneurysms amenable to either traditional endovascular treatments using coils or reconstruction with flow diverters.

Advances and innovations in revascularization of extracranial vertebral artery.

Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients.

Arterial spin-labeling magnetic resonance imaging after revascularization of moyamoya disease.

Arterial spin labeling (ASL) magnetic resonance imaging (MRI) is a technique for depicting cerebral perfusion without contrast medium. The purpose of this study was to determine whether ASL can be used to detect hyperperfusion after revascularization for moyamoya disease as effectively as N-isopropyl-[123I]ß-iodoamphetamine ((123)I-IMP) single-photon emission computed tomography (SPECT). Fifteen consecutive patients with moyamoya disease were included in the study. All patients underwent surgical revascularization. Postoperatively, regional cerebral blood flow (rCBF) was measured by flow-sensitive alternating inversion recovery (FAIR) ASL and (123)I-IMP SPECT during the acute stage, and rCBF of the operative side was compared with the other side. The asymmetry ratio (AR) was then calculated from the rCBF as measured using each modality. The postoperative AR of ASL was moderately correlated with that of (123)I-IMP SPECT (y = 0.180x + 0.819; R = 0.80; P = .0003). In this series, 2 patients (13.3%) suffered symptomatic hyperperfusion after revascularization and accordingly exhibited increased AR of ASL. Our data indicate that early increases in rCBF in patients with hyperperfusion could be detected using FAIR ASL supplemental to (123)I-IMP SPECT after revascularization. Our data indicate that FAIR ASL is a convenient method for evaluating hyperperfusion that can be performed repeatedly without the use of contrast medium or radioisotopes.

Superficial temporal artery-middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia.

OBJECT: Superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients. METHODS: The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway. RESULTS: Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation. CONCLUSIONS: This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.

Subcutaneous hematoma associated with manual cervical massage during carotid artery stenting. A case report.

We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting.A 73-year-old man with left cervical carotid artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintained in the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became entrapped by the stent, it did not reach the distal side of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed spontaneously.Cervical subcutaneous hematoma can occur in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet therapy and anticoagulation therapy.

Effects of bepridil versus E-4031 on transmural ventricular repolarization and inducibility of ventricular tachyarrhythmias in the dog.

BACKGROUND: Bepridil (a multiple channel blocker) may markedly prolong the QT interval and induce polymorphic ventricular tachyarrhythmias (VTA). We compared the transmural ventricular repolarization characteristics and inducibility of polymorphic VTA after administration of bepridil versus the pure I(Kr) blocker, E-4031, each administered to five open-chest dogs. METHODS: We used plunge needle electrode to record transmural left ventricular (LV) repolarization and activation-recovery interval (ARI) to estimate local repolarization. The correlation between paced cycle length and ARI was separately examined in the LV endocardium, mid-myocardium (Mid), and epicardium. Attempts to induce VTA were made during bradycardia and sympathetic stimulation. RESULTS: Bepridil and E-4031 prolonged QT interval and ARI in all LV layers, though the magnitude of prolongation was greatest in Mid, increasing the transmural ARI dispersion, particularly during bradycardia. Compared with E-4031, bepridil caused mild, reverse use-dependent changes in ventricular repolarization, and less ARI dispersion than E-4031 during slow ventricular pacing. Both drugs increased ARI(max) and cycle length at 50% of ARI(max), though the changes were smaller after bepridil than after E-4031 administration. Bradycardia after the administration of each drug induced no VTA; however, sympathetic stimulation induced sustained polymorphic VTA in two of five dogs treated with E-4031 versus no dog treated with bepridil. CONCLUSIONS: Unlike the pure I(kr) blocker, E-4031, bepridil exhibited weak properties of reverse use-dependency and protected against sympathetic stimulation-induced VTA. It may be an effective supplemental treatment for recipients of implantable cardioverter defibrillator.

Dissection of the posterior inferior cerebellar artery in a young adult with cerebellar infarct.

The posterior inferior cerebellar artery (PICA) is frequently involved in dissection of the vertebral artery (VA); however, isolated PICA dissection has rarely been reported. A 37-year-old man experienced acute and progressive drowsiness, vertigo, occipital headache, vomiting, and ataxia. There was no precedent trauma or chiropractic manipulation. Neurologically, he had dysmetria of the left extremities. His NIHSS score was 3. Brain magnetic resonance imaging showed an acute cerebellar infarct in the left PICA territory. Magnetic resonance angiography showed a faint signal adjacent to the junction of the left VA and PICA, suggesting a vascular shadow. Catheter angiography showed focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA that was highly suggestive of dissection with pseudoaneurysm formation. He was treated with clopidogrel and was free of neurological symptoms 3 months after the stroke event. Isolated PICA dissection may be considered in patients with PICA territory infarct or subarachnoid hemorrhage. Treatment depends on the manifestations; ruptured dissecting aneurysms are often treated with surgery or embolization, and infarcts are usually treated with antithrombotic agents.

Gene expression in cerebral ischemia: a new approach for neuroprotection.

Cerebral ischemia is one of the strongest stimuli for gene induction in the brain. Hundreds of genes have been found to be induced by brain ischemia. Many genes are involved in neurodestructive functions such as excitotoxicity, inflammatory response and neuronal apoptosis. However, cerebral ischemia is also a powerful reformatting and reprogramming stimulus for the brain through neuroprotective gene expression. Several genes may participate in both cellular responses. Thus, isolation of candidate genes for neuroprotection strategies and interpretation of expression changes have been proven difficult. Nevertheless, many studies are being carried out to improve the knowledge of the gene activation and protein expression following ischemic stroke, as well as in the development of new therapies that modify biochemical, molecular and genetic changes underlying cerebral ischemia. Owing to the complexity of the process involving numerous critical genes expressed differentially in time, space and concentration, ongoing therapeutic efforts should be based on multiple interventions at different levels. By modification of the acute gene expression induced by ischemia or the apoptotic gene program, gene therapy is a promising treatment but is still in a very experimental phase. Some hurdles will have to be overcome before these therapies can be introduced into human clinical stroke trials.

Absence epilepsy associated with moyamoya disease. Case report.

The authors present the case of a 6-year-old girl with typical absence epilepsy induced by hyperventilation associated with moyamoya disease (MMD). A diffuse 3-Hz spike-and-wave complex induced by hyperventilation was apparent on an electroencephalogram, and her seizures were intractable to medication. Significant ischemia in the bilateral frontal lobes was present. The epilepsy disappeared after superficial temporal artery-middle cerebral artery anastomosis with encephalomyosynangiosis on both sides. In the treatment of children with intractable absence epilepsy, the possibility of underlying MMD and indications that revascularization surgery may be needed should be taken into consideration.

Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients.

OBJECTIVE: Microsurgical clipping of basilar artery aneurysms carries a risk of neurological compromise resulting from midbrain or thalamic ischemia. Somatosensory evoked potential (SSEP) monitoring and electroencephalography are the standard techniques for assessing the level of cerebroprotective anesthesia and monitoring ischemia during temporary occlusion or after permanent clipping. Transcranial motor evoked potential (TcMEP) monitoring was added to determine whether this modality improved intraoperative monitoring. METHODS: Combined SSEP/electroencephalographic/TcMEP monitoring was used for 30 consecutive patients with basilar artery apex aneurysms in the past 1.5 years. Voltage thresholds were recorded before, during, and after aneurysm treatment for the last 10 patients. RESULTS: All 30 patients underwent an orbitozygomatic craniotomy for clipping (28 patients), wrapping (1 patient), or superficial temporal artery-superior cerebellar artery bypass (1 patient). Electrophysiological changes occurred for 10 patients (33%), elicited by temporary clipping (6 patients), permanent clipping (3 patients), or retraction (1 patient). Isolated SSEP changes were observed for one patient, isolated TcMEP changes for five patients, and changes in both TcMEPs and SSEPs for four patients. Among patients with simultaneous changes, TcMEP abnormalities were more robust and occurred earlier than SSEP abnormalities. Impaired motor conduction was detected first with an increase in the voltage threshold (from 206 +/- 22 to 410 +/- 49 V, P < 0.05, n = 3) and then with loss of TcMEP responses. SSEP and TcMEP signals returned to baseline values for all patients after corrective measures were taken. CONCLUSION: TcMEP monitoring can be safely and easily added to traditional neurophysiological monitoring during basilar artery aneurysm surgery. These results suggest that TcMEPs may be more sensitive than SSEPs to basilar artery and perforating artery ischemia. This additional intraoperative information might minimize the incidence of ischemic complications attributable to prolonged temporary occlusion or inadvertent perforator occlusion.

[Spontaneous extra-cranial vertebral artery dissection accompanied with multiple cerebral infarctions due to re-canalization].

In this paper we report a case of vertebral artery occlusion caused by spontaneous extra-cranial vertebral artery dissection accompanied with cerebellar and thalamic infarctions due to recanalization. Furthermore, after a nine-week time lapse we performed PTA/stenting. A 62-year-old man with vertigo, dysarthria and nuchal pain without injury was admitted to our hospital. Emergent cerebral angiography revealed an occlusion of the right vertebral artery and the right PICA. The patient's symptoms gradually improved owing to local-fibrinolysis with urokinase for the right PICA via the left vertebral artery. Follow-up angiography (2 weeks later) showed re-canalization and dissection of the right vertebral artery. Treatment for spontaneous extra-cranial vertebral artery dissection is chosen, depending on whether there is co-lateral circulation or not. We obtained a good result using PTA/Stenting in this case of spontaneous extra-cranial vertebral artery dissection within nine weeks after onset.

Papel de la anastomosis extra-intracraneal y de la terapia endovascular intervencionista en el tratamiento de aneurismas complejos cerebrales / The role of the extra-intracraneal anastomosis and interventionist endovascular therapy in the treatment of complex cerebral aneurysms

La revascularización cerebral es una herramienta muy útil en el caso de aneurismas gigantes o complejos que no pueden ser abordados directamente por diversos motivos. A su vez, la terapia endovascular intervencionista, técnica emergente con muy buenos resultados en aneurismas cerebrales en los últimos cinco años, constituye una nueva ruta complementaria a la cirugía revascularizadora en el tratamiento de estos aneurismas de difícil resolución. En el presente trabajo se destaca el beneficio de la realización de revascularización cerebral, seguida, en un corto espacio de tiempo, de terapia endovascular intervencionista. Ésta hará posible la oclusión del vaso proximal al aneurisma o excluirá a la malformación vascular de la circulación cerebral. Se resaltan las ventajas de dicha terapia frente a la cirugía directa, se discute la forma de seleccionar a los pacientes y se enumeran las técnicas de revascularización más actuales (AU)

Electromagnetic therapeutic angiogenesis: the next step.

Therapeutic angiogenesis, in the form of growth factor protein administration or gene therapy, is a new method of treatment for patients with severe coronary and peripheral artery disease not amenable to conventional methods of revascularization. Furthermore, a new experimental strategy increases endogenous angiogenesis in ischemic tissue to induce local 'angiogens' by means of electromagnetic stimulation. Further studies examining the molecular basis and clinical efficacy of electromagnetic angiogenesis are necessary.