The clinical outcomes of mechanical thrombectomy for proximal M1 occlusion involving lenticulostriate perforators: Is it worse than distal M1 occlusion? Retrospective observational study.

ABSTRACT: Although the success rate of recanalization in acute intracranial artery occlusion is high, there is a poor rate of improvement in functional clinical outcome. The purpose of this study was to assess the functional outcome of mechanical thrombectomy for proximal M1 occlusion involving lenticulostriate arteries (LSAs) compared with distal M1 occlusion-sparing the LSAs.A retrospective analysis was conducted in patients with middle cerebral artery (MCA) M1 occlusions who had a successful recanalization subsequent to mechanical thrombectomy. The recanalization results were estimated using the thrombolysis in cerebral infarction grade assessed by digital subtraction angiography. To confirm the ischemic change resulting from the lenticulostriate artery occlusion, we reviewed the neuroimaging findings from magnetic resonance imaging 1 day after mechanical thrombectomy. The functional outcomes were then evaluated using the modified Rankin scale at 90 days.In total, 28 patients with MCA M1 occlusion had successful recanalization outcomes with thrombolysis in cerebral infarction grades IIa, IIb, and III. Among the 28 patients, 17 had proximal M1 occlusions and 11 had distal M1 occlusions. Demographic factors, including initial National Institutes of Health Stroke Scale score, time from symptom to recanalization, and recanalization rate did not differ considerably between patients with proximal and distal M1 occlusions. Regarding infarctions in the basal ganglia, internal capsule, and corona radiata, there were statistically significant differences between the proximal and distal M1 occlusions. However, there were no significant differences in good functional outcome (modified Rankin scale ≤2) observed between the groups at 90 days after mechanical thrombectomy.Although proximal M1 occlusion had more frequent infarctions associated with the LSA territories, these were not related to poor functional outcomes. Both proximal and distal M1 occlusion demonstrated comparably good outcomes.

The prognosis prediction significance of Hounsfield unit value for stroke patients treated by intravenous thrombolysis.

BACKGROUND: Intravenous thrombolysis (IVT) is a rapid and effective treatment in the early stage of ischemic stroke patients and the purpose of this work is to explore the significance of Hounsfield unit (HU) value in Alberta Stroke Program Early CT Score (ASPECTS) for predicting the clinical prognosis of stroke patients with middle cerebral artery occlusion (MCAO) treated by IVT. METHODS: The 84 stroke patients with MCAO treated by IVT were divided into good prognosis group (48 cases) and poor prognosis group (36 cases). HU ratio and HU difference calculated from non-contrast computed tomography between groups were analyzed. RESULTS: The HU ratio of good prognosis group was higher than that in poor prognosis group and the HU difference of good prognosis group was lower than that in poor prognosis group (P < 0.05). The HU ratio and ASPECTS were negatively correlated with the infarct volume, and the HU difference was positively correlated with the infarct volume (P < 0.05). HU difference was an independent risk factor for prognosis of patients with MCAO treated by IVT. The area under the receiver operating characteristic curve of HU ratio and HU difference for prognosis was 0.743 and 0.833 respectively. CONCLUSION: The HU value changes are related to the clinical prognosis of stroke patients with MCAO treated by IVT, HU value may be a prognostic indicator for stroke patients with MCAO treated by IVT.

Association of neonatal inflammatory markers and perinatal stroke subtypes.

OBJECTIVE: To examine the relationship between neonatal inflammatory cytokines and perinatal stroke using a systems biology approach analyzing serum and blood-spot cytokines from 47 patients. METHODS: This was a population-based, controlled cohort study with prospective and retrospective case ascertainment. Participants were recruited through the Alberta Perinatal Stroke Project. Stroke was classified as neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI). Biosamples were stored blood spots (retrospective) and acute serum (prospective). Controls had comparable gestational and maternal ages. Sixty-five cytokines were measured (Luminex). Hierarchical clustering analysis was performed to create heat maps. The Fisher linear discriminant analysis was used to create projection models to determine discriminatory boundaries between stroke types and controls. RESULTS: A total of 197 participants were analyzed (27 with NAIS, 8 with APPIS, 12 with PVI, 150 controls). Cytokines were quantifiable with quality control measures satisfied (standards testing, decay analysis). Linear discriminant analysis had high accuracy in using cytokine profiles to separate groups. Profiles in participants with PVI and controls were similar. NAIS separation was accurate (sensitivity 77%, specificity 97%). APPIS mapping was also distinguishable from NAIS (sensitivity 86%, specificity 99%). Classification tree analysis generated similar diagnostic accuracy. CONCLUSIONS: Unique inflammatory biomarker signatures are associated with specific perinatal stroke diseases. Findings support an acquired pathophysiology and suggest the possibility that at-risk pregnancies might be identified to develop prevention strategies. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that differences in acute neonatal serum cytokine profiles can discriminate between patients with specific perinatal stroke diseases and controls.

Pathological Yawning in Patients with Acute Middle Cerebral Artery Infarction: Prognostic Significance and Association with the Infarct Location

Background: Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke. Aims: To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location. Study Design: Cross-sectional study. Methods: We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ≥3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short- and long-term outcomes of the patients were evaluated. Results: Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p<0.05). Pathological yawning was related to higher National Institutes of Health Stroke Scale scores. Patients with severe stroke (National Institutes of Health Stroke Scale score ≥10) presented with more pathological yawning than those with mild to moderate strokes (p<0.05). The clinical outcomes and mortality rates showed no significant relationship with the occurrence of pathological yawning. Conclusion: Pathological yawning in middle cerebral artery stroke was associated with stroke severity, presence of cortical involvement, and insular and opercular infarcts. However, no association was found with long-term outcome and mortality.

Rethinking Thrombolysis in Cerebral Infarction 2b: Which Thrombolysis in Cerebral Infarction Scales Best Define Near Complete Recanalization in the Modern Thrombectomy Era?

BACKGROUND AND PURPOSE: Within the thrombolysis in cerebral infarction (TICI) classification, TICI 2b has been historically considered successful recanalization. Recent studies have suggested that TICI 3 and a proposed TICI 2c should be separately reported from TICI 2b, in both the original (>66% reperfusion) and modified (>50% reperfusion) definitions, because of differences in clinical outcomes with greater reperfusion. The purpose of this study was to evaluate differences in early neurological improvement and independence at 90 days using the original TICI, modified TICI, and modified TICI with 2c scales. METHODS: A retrospective review of 129 consecutive patients with middle cerebral artery, M1 segment or intracranial internal carotid artery occlusions. Patient angiograms were graded by 2 experienced readers by percentage recanalization. This was then categorized into original TICI, modified TICI (mTICI), and mTICI with TICI 2c (mTICI 2c) grading scales. Comparison of baseline demographics, early neurological improvement, and independence at 90 days was performed. RESULTS: A significant difference in early neurological improvement was observed between 2b and 3 (P=0.032), as well as between 2b and 2c (P=0.028) under the mTICI 2c grading scale. Similarly, a significant difference in functional independence was observed between 2b and 3 (P=0.037), as well as between 2b and 2c (P=0.047) under the mTICI 2c scale. The difference in early neurological improvement or functional independence between 2b and 3 for the original TICI and mTICI scales was not significant. When combining the 2c and 3 groups under the mTICI 2c scale, there were significant differences between 2b and 2c/3 in regards to both early neurological improvement (P=0.011) and independence (P=0.018). CONCLUSIONS: Using a TICI grading system that includes an additional category beyond TICI 2b allows for refined prediction of early neurological improvement and functional independence.

Pathogenic Heterogeneity of Distal Single Small Subcortical Lenticulostriate Infarctions Based on Lesion Size.

BACKGROUND: Single small subcortical infarctions (SSSIs) in the lenticulostriate artery territory can be classified as proximal single small subcortical infarction (pSSSI) or distal single small subcortical infarction (dSSSI) lesions depending on the involvement of the lowest part of the basal ganglia. It was reported that pSSSI lesions have more characteristics of large artery atherosclerosis, whereas dSSSI lesions are more characteristic of small vessel disease. Because infarction of small vessels is more likely to be distal and may result in small lesions, we hypothesized that the clinical features of dSSSI lesions might be heterogeneous and classified based on lesion size. METHODS: Lenticulostriate SSSI patients admitted within 72 hours of stroke onset were included from a prospectively registered hospital-based stroke database. We determined the location (lowest slice [LS] involved) and size (total number of slices [TNS] involved) of SSSIs on magnetic resonance imagings. Based on lesion location, SSSIs were divided into pSSSI (LS ≤ 2) and dSSSI (LS > 2); the latter were further subdivided into distal and small SSSI (ds-SSSI, TNS ≤ 2) or distal and large SSSI (dl-SSSI, TNS > 2). The clinical characteristics were compared between different groups. RESULTS: A total of 204 patients were included out of 1158 patients registered in the database. We found that ds-SSSI was most often associated with severe white matter hyperintensities. However, patients with dl-SSSI most often had a higher rate of additional concurrent atherosclerotic disease as coronary heart disease, compared to patients with ds-SSSI. CONCLUSIONS: The pathogenesis of dSSSI may be heterogeneous depending on lesion size.

DWI Lesion Patterns Predict Outcome in Stroke Patients with Thrombolysis.

BACKGROUND: Lesion patterns may predict prognosis after acute ischemic stroke within the middle cerebral artery (MCA) territory; yet it remains unclear whether such imaging prognostic factors are related to patient outcome after intravenous thrombolysis. AIMS: The aim of this study is to investigate the clinical outcome after intravenous thrombolysis in acute MCA ischemic strokes with respect to diffusion-weighted imaging (DWI) lesion patterns. METHODS: Consecutive acute ischemic stroke cases of the MCA territory treated over a 7-year period were retrospectively analyzed. All acute MCA stroke patients underwent a MRI scan before intravenous thrombolytic therapy was included. DWI lesions were divided into 6 patterns (territorial, other cortical, small superficial, internal border zone, small deep, and other deep infarcts). Lesion volumes were measured by dedicated imaging processing software. Favorable outcome was defined as modified Rankin scale (mRS) of 0-2 at 90 days. RESULTS: Among the 172 patients included in our study, 75 (43.6%) were observed to have territorial infarct patterns or other deep infarct patterns. These patients also had higher baseline NIHSS score (p < 0.001), a higher proportion of large cerebral artery occlusions (p < 0.001) and larger infarct volume (p < 0.001). Favorable outcome (mRS 0-2) was achieved in 89 patients (51.7%). After multivariable analysis, groups with specific lesion patterns, including territorial infarct and other deep infarct pattern, were independently associated with favorable outcome (OR 0.40; 95% CI 0.16-0.99; p = 0.047). CONCLUSIONS: Specific lesion patterns predict differential outcome after intravenous thrombolysis therapy in acute MCA stroke patients.

Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging.

BACKGROUND: The association between the location and the mechanism of a stroke lesion remains unclear. A diffusion-weighted imaging study may help resolve this lack of clarity. METHODS AND RESULTS: We studied a consecutive series of 2702 acute ischemic stroke patients whose stroke lesions were confirmed by diffusion-weighted imaging and who underwent a thorough etiological investigation. The vascular territory in which an ischemic lesion was situated was identified using standard anatomic maps of the dominant arterial territories. Stroke subtype was based on the Trial of ORG 10172 in Acute Stroke Treatment, or TOAST, classification. Large-artery atherosclerosis (37.3%) was the most common stroke subtype, and middle cerebral artery (49.6%) was the most frequently involved territory. Large-artery atherosclerosis was the most common subtype for anterior cerebral, middle cerebral, vertebral, and anterior and posterior inferior cerebellar artery territory infarctions. Small vessel occlusion was the leading subtype in basilar and posterior cerebral artery territories. Cardioembolism was the leading cause in superior cerebellar artery territory. Compared with carotid territory stroke, vertebrobasilar territory stroke was more likely to be caused by small vessel occlusion (21.4% versus 30.1%, P<0.001) and less likely to be caused by cardioembolism (23.2% versus 13.8%, P<0.001). Multiple-vascular-territory infarction was frequently caused by cardioembolism (44.2%) in carotid territory and by large-artery atherosclerosis (52.1%) in vertebrobasilar territory. CONCLUSIONS: Information on vascular territory of a stroke lesion may be helpful in timely investigation and accurate diagnosis of stroke etiology.

Comparison of magnetic resonance imaging mismatch criteria to select patients for endovascular stroke therapy.

BACKGROUND AND PURPOSE: The Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study has shown that clinical response to endovascular reperfusion differs between patients with and without perfusion-diffusion (perfusion-weighted imaging-diffusion-weighted imaging, PWI-DWI) mismatch: patients with mismatch have a favorable clinical response to reperfusion, whereas patients without mismatch do not. This study examined whether alternative mismatch criteria can also differentiate patients according to their response to reperfusion. METHODS: Patients from the DEFUSE 2 study were categorized according to vessel occlusion on magnetic resonance angiography (MRA) and DWI lesion volume criteria (MRA-DWI mismatch) and symptom severity and DWI criteria (clinical-DWI mismatch). Favorable clinical response was defined as an improvement of ≥8 points on the National Institutes of Health Stroke Scale (NIHSS) by day 30 or an NIHSS score of ≤1 at day 30. We assessed, for each set of criteria, whether the association between reperfusion and favorable clinical response differed according to mismatch status. RESULTS: A differential response to reperfusion was observed between patients with and without MRA-DWI mismatch defined as an internal carotid artery or M1 occlusion and a DWI lesion<50 mL. Reperfusion was associated with good functional outcome in patients who met these MRA-DWI mismatch criteria (odds ratio [OR], 8.5; 95% confidence interval [CI], 2.3-31.3), whereas no association was observed in patients who did not meet these criteria (OR, 0.5; 95% CI, 0.08-3.1; P for difference between the odds, 0.01). No differential response to reperfusion was observed with other variations of the MRA-DWI or clinical-DWI mismatch criteria. CONCLUSIONS: The MRA-DWI mismatch is a promising alternative to DEFUSE 2's PWI-DWI mismatch for patient selection in endovascular stroke trials.

A new classification system for ischemia using a combination of deep and periventricular white matter hyperintensities.

The Clinical Research Center for Dementia of South Korea (CREDOS) group developed a new classification system for ischemia using a combination of deep and periventricular white matter hyperintensities (WMHs). In this study, we aimed to evaluate the validity of the CREDOS ischemia classification system. A total of 352 patients with cognitive impairments were included. Their WMH scores were rated using the CREDOS WMH visual rating scale. These patients were divided into 3 groups according to the CREDOS ischemia classification system. The volume of WMH was also automatically measured. The number of lacunes and microbleeds (MBs) were counted. The CREDOS ischemia classification system was revised with factor analysis using vascular risk factors and cerebrovascular disease (CVD) markers (WMH volume, lacunes, and MBs). External validation was performed in another group of patients with cognitive impairment using multinomial logistic regression analysis. The CREDOS WMH visual rating scale showed excellent correlation with the automatically measured volume of WMH. The factor analysis showed that the severe group was expanded to D3P1 and D3P2 in the revised CREDOS ischemia classification system. In the validation group, the presence of vascular risk factors and the severity of CVD markers could be distinguished according to the revised CREDOS ischemia classification. We validated a newly developed classification system for ischemia. This simple visual classification system was capable of providing information on vascular risk factors and CVD markers by simply rating WMH on magnetic resonance imaging.

Oxfordshire Community Stroke Project classification but not NIHSS predicts symptomatic intracerebral hemorrhage following thrombolysis.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a simple tool to categorize clinical stroke syndromes. We compared the outcomes of stroke patients after intravenous thrombolysis stratified by the baseline National Institutes of Health Stroke Scale (NIHSS) score or by the OCSP classification. METHODS: We assessed the safety of thrombolysis in consecutive stroke patients who received intravenous thrombolysis within 3h after onset. The patients were grouped by the NIHSS score into mild to moderate stroke (≤ 20) and severe stroke (>20), and also by the OCSP classification as having total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation infarcts (POCI), or lacunar infarcts (LACI). Symptomatic intracerebral hemorrhage (SICH) was used as the primary outcome. RESULTS: Of the 145 patients included in the study, 45 had a baseline NIHSS score>20. Their stroke syndromes were as follows: 78 with TACI, 29 with PACI, 16 with POCI, and 22 with LACI. The proportion of SICH was comparable between patients with high or low NIHSS score (11.1% vs. 9.0%, P=0.690). The chance of SICH was highest in patients with TACI (15.4%), followed by LACI (4.5%), PACI (3.4%), and POCI (0%). After adjustment for age, baseline glucose, and use of antiplatelet agents before admission, SICH was significantly increased in patients with TACI relative to those with non-TACI (odds ratio 5.92; 95% confidence interval 1.24-28.33, P=0.026). CONCLUSIONS: The OCSP clinical classification may help clinicians evaluate the risk of SICH following intravenous thrombolysis.

Consistent focal cerebral ischemia without posterior cerebral artery occlusion and its real-time monitoring in an intraluminal suture model in mice.

OBJECT: In the intraluminal suture model of middle cerebral artery occlusion (MCAO) in the mouse, disturbance of blood flow from the internal carotid artery to the posterior cerebral artery (PCA) may affect the size of the infarction. In this study, PCA involvement in the model was investigated and modified for consistent MCAO without involving the PCA territory. METHODS: Thirty-seven C57Bl/6 mice were randomly divided into 4 groups according to the length of coating over the tip of the suture (1, 2, 3, or 4 mm) and subjected to transient MCAO for 2 hours. Real-time topographical cerebral blood flow was monitored over both hemispheres by laser speckle flowmetry. After 24 hours of reperfusion, the infarct territories and volumes were evaluated. RESULTS: The 1- and 2-mm coating groups showed all lesions in the MCA territory. In the 3- and 4-mm coating groups, 62.5% and 75% of mice, respectively, showed lesions in both the MCA and the PCA territories and other lesions in the MCA territory. Mice in the 1- and 2-mm coating groups had significantly smaller infarct volumes than the 3- and 4-mm groups. Laser speckle flowmetry was useful to distinguish whether the PCA territory would undergo infarction. CONCLUSIONS: Small changes in the coating length of the intraluminal suture may be critical, and 1-2 mm of coating appeared to be optimal to produce consistent MCAO without involving the PCA territory. Laser speckle flowmetry could predict the territory of infarction and improve the consistency of the infarct size.

Scalp acupuncture effects of stroke studied with magnetic resonance imaging: different actions in the two stroke model rats.

BACKGROUND: Scalp acupuncture (SA) therapy on strokes has been empirically established and widely used in clinics in China. The evidence from clinical studies suggests that SA produces significant benefits for some patients with stroke. METHODS: The effect of scalp acupuncture was studied using MRI for two different stroke models: spontaneously hypertensive stroke-prone (SHR-SP) rats and rats with transiently induced focal cerebral ischaemia by middle cerebral artery occlusion for 2 h (MCAO rats). RESULTS: Stroke onset in SHR-SP rats was characterised by a development of vasogenic oedema without any appearance of cytotoxic oedema. Scalp acupuncture reduced rapidly neurological dysfunction in SHR-SP rats and reduced the volume of the vasogenic oedema during the same period. In contrast, in MCAO rats, focal cerebral ischaemia caused an immediate development of cytotoxic oedema without any appearance of vasogenic oedema. Vasogenic oedema developed after reperfusion. Scalp acupuncture had no significant effects on the cytotoxic oedema, vasogenic oedema or neurological dysfunction of the MCAO rats within the time span examined. CONCLUSION: Scalp acupuncture had a rapid and strong effect on neurological dysfunction only in the hypertensive stroke-model by reducing the vasogenic oedema. Our results suggest that, if there are similar underlying mechanisms in human strokes, scalp acupuncture may be more beneficial for patients with strokes of hypertension-caused vasogenic origin than ischaemic origin.

[Mouse stroke models and strains-related differences in susceptibility to cerebral ischemia].

Mouse stroke models provide experiment basis for study of the mechanisms of cell death and neural repair, and the neuroprotective effect of new drugs. There are at least three models of middle cerebral artery occlusion (MCAO) routinely used in experimental study. These models vary widely in their application in study of cell death or neural repair, and simulation of human diseases. This review article is focused on the characteristics of three mouse MCAO models and the strains-related differences in susceptibility to cerebral ischemia.

Lesion volume increase is related to neurologic progression in patients with subcortical infarction.

It remains unknown whether subacute lesion volume increase is related to neurologic progression (NP) and clinical outcome (CO) in patients with single subcortical infarct (SSI) in the middle cerebral artery (MCA) territory. We studied 77 patients who underwent diffusion-weighted MRI (DWI) within 48 h after stroke onset, which revealed unilateral SSI in the MCA territory, and follow-up DWI and MR angiography within 7 days of onset. Neurologic progression was defined as the increase of the National Institutes of Health Stroke Scale (NIHSS) score by > or = 2 during the first week. Clinical outcome was dichotomized as good (< or = 2) and poor (> or = 3) according to the modified Rankin Scale at 1 month after the onset. Lesion volume increase was defined when the infarct volume in the follow-up MRI exceeds the initial one by either > or = 30% or 50%. Fourteen patients (18.2%) had NP, and 17 (22.1%) had poor CO. Increase in lesion volume, found in 42 patients (54.5%) when defined by 50% increase and in 51 (66.2%) by 30%, was significantly associated with NP (50%, p=0.010; 30%, p=0.027) and poor CO (50%, p=0.040; 30%, 0.111). Multivariate logistic analyses revealed that lesion volume increase was independently related to NP (odd ratio, 8.48; 95% CI, 1.55-46.46) and that NP was the important predictor for poor CO (odd ratio, 39.69; 95% CI, 3.44-458.68). We conclude that subacute lesion volume growth is closely related to the NP and that the NP predicts subsequent poor CO.

[Two cases of cardioembolic stroke with stepwise progression].

We reported two patients of cardioembolic stroke with stepwise progression. Magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) showed narrowing of the middle cerebral artery (MCA) in both patients at the acute phase of onset. Case 1 was classified as "undetermined" based on the TOAST classification although his electrocardiogram revealed atrial fibrillation. Case 2 was classified as "large artery atherosclerosis" with no evidence of cardioembolic source at the acute phase of onset. Follow-up MRA was performed at seventeen days after the onset in case 1 and ten days after the onset in case 2 respectively, which showed complete recanalization of the MCA in each case. The presence of cardioembolic source was also detected in both patients at that time, resulting in the final diagnosis of cardioembolic stroke. Cardioembolic stroke may occasionally present in a stepwise manner suggesting a thrombotic process. When MRA shows stenosis or occlusion of the arteries supplying the cortical areas at the acute phase of onset, it is advisable to examine recanalization of these arteries by follow-up MRA with simultaneous efforts to find out the possible embolic source.

Can we discriminate stroke mechanisms by analyzing the infarct patterns in the striatocapsular region?

BACKGROUND AND AIMS: The aims of our study were to elucidate the differences in the distribution of acute middle cerebral artery (MCA) infarctions involving the striatocapsular region and to compare those following embolic striatocapsular infarctions with those originating from MCA disease (MCAD). METHODS: We prospectively enrolled patients with acute large infarcts located in the lenticulostriate artery territory. Brain coronal diffusion-weighted imaging (DWI) and magnetic resonance angiography were carried out in all patients. The types of infarct distribution were divided into 3 categories: (1) dominant in the distal territory (DD), (2) distributed equally between the distal and proximal territories (DE) and (3) dominant in the proximal territory. Stroke mechanisms were classified into stroke from proximal embolism, MCAD and stroke of undetermined etiology. RESULTS: A total of 71 patients were recruited. Proximal embolic sources were significantly more prevalent in patients with a DE lesion, but symptomatic MCA stenoses were more common in patients with a DD lesion than in those with a DE lesion. CONCLUSION: These results suggest that the dominant area of striatocapsular infarctions on coronal DWI can be an important clue for stroke etiology.

[Topography of ischemic strokes in Abidjan (Côte d'Ivoire): a computed tomographic approach]. / Approche tomodensitométrique des accidents vasculaires cérébraux ischémiques à Abidjan (Côte d'Ivoire).

OBJECTIVE: The authors used computed tomography (CT) to assess and categorize the topography of ischemic strokes (IS) among blacks living in Abidjan, the commercial and administrative center of Côte d'Ivoire, in West Africa. METHODS: This retrospective study analyzed CT data of patients admitted to the Sainte Anne Marie Polyclinic (the principal private hospital in the country) and to the neurology department of the university hospital center in Cocody, from January 1, 2000, to December 31, 2001. The study included patients who met World Health Organisation criteria for stroke and had CT performed during the hospitalization for this stroke. We examined CT data to find early and late signs of IS, analyze lesion diameter (15 mm cutoff used to distinguish infarcts from lacuna), and determine their topography (cerebral arterial territory and localization, that is, brain lobes, basal ganglia and posterior cerebral fossa). RESULTS: We included 260 subjects (58% males) with a median age of 45 years (range: 20-80 years). CT findings were abnormal for 224 patients with infarcts (72.7%), lacuna (27.3%), or both (8%). As reported elsewhere, the anterior arterial territory was most often affected (83.9%) with a middle cerebral artery lesion in 79.4% of patients. Posterior territory (16.1%) lesions and lacuna were probably underestimated because CT exploration is reported to be less useful for this area than for the carotid area. On the other hand, CT diagnoses infarcts more easily than it does lacuna. CT was normal for 36 patients although performed no more than 3 days after IS. These patients did not undergo CT angiography, which might have shown cerebral artery occlusion. CONCLUSION: Our study included IS of all types and typography. Stroke registries in Africa would provide useful data for better assessment of prevalence for specific topographic and etiologic types of stroke.

Combined carotid and transcranial ultrasound findings compared with clinical classification and stroke severity in acute ischemic stroke.

BACKGROUND: The aim of this study was to assess the association between cerebral hemodynamics and the clinical picture as defined by the Oxfordshire Community Stroke Project (OCSP) classification, as well as the clinical severity as defined by the National Institute of Health Stroke Scale (NIHSS) within the first 6 h of an acute middle cerebral artery (MCA) stroke onset. METHODS: 70 unselected patients were grouped according to the OCSP classification and NIHSS. All patients immediately had extracranial and transcranial Doppler (TCD) ultrasound examinations. RESULTS: In the study population as a whole, there was a significant association between intracranial vascular pathology and the OCSP classification (p<0.001) as well as the NIHSS score (p<0.001). In patients with severe stroke, however, TCD demonstrated the hypothesized proximal MCA(1) occlusion in only 34% of patients with an OCSP-defined total anterior circulation syndrome and in 42% of patients with an NIHSS score of >or=15. In moderate stroke, the OCSP classification was misleading in almost half of the patients with a partial anterior circulation syndrome, i.e. a hypothesized distal MCA(2) occlusion suitable for thrombolysis. CONCLUSIONS: Neither the OCSP classification nor the NIHSS grading provided reliable information about the site or presence of intracranial arterial occlusion in acute stroke within the first 6 h after stroke onset in the individual patient. The results of this study strongly suggest that selection of acute ischemic stroke patients for thrombolysis should also include an assessment of cerebral hemodynamics.