Different subtypes of collateral vessels in hemorrhagic moyamoya disease with p.R4810K variant.

BACKGROUND: The aim of this study was to investigate the hemorrhgic sites and collateral vessels in hemorrhagic MMD with the p.R4810K variant. METHODS: Hemorrhage sites were classified as either anterior or posterior. Collateral vessels were classified into three subtypes according to origin: lenticulostriate anastomosis, thalamic anastomosis, and choroidal anastomosis. Hemorrhage sites and collateral vessels were compared between patients with wild-type p.R4810K variant (GG) and patients with heterozygous p.R4810K variant (GA) after 1:1 propensity score matching. RESULTS: A total of 130 hemorrhagic MMD patients were included in present study, 21 pairs (42 hemorrhagic hemispheres) were obtained after 1:1 propensity score. In GA group, 16 hemispheres (76.2%) presented anterior hemorrhage, and 5 hemispheres (23.8%) presented with posterior hemorrhage. In GG group, 13 hemispheres (61.9%) presented anterior hemorrhage, and 8 hemispheres (38.1%) presented with posterior hemorrhage. No significant differences were found in hemorrhagic sites between two matched groups (P > 0.05). Of 21 hemispheres in GA group, 10 (47.6%) exhibited lenticulostriate anastomosis, 6 (28.6%) thalamic anastomosis, and 6 (28.6%) choroidal anastomosis. Of 21 hemispheres in GG group, 3 (14.3%) exhibited lenticulostriate anastomosis, 5 (23.8%) thalamic anastomosis, and 9 (42.9%) choroidal anastomosis. There was significant difference in lenticulostriate anastomosis between two matched groups (P = 0.045). After adjustment the age, sex, and PCA involvement, we found that lenticulostriate anastomosis was associated with p.R4810K variant (OR, 5.995; 95% CI, 1.296-27.737; P = 0.022). CONCLUSION: Lenticulostriate anastomosis might be associated with p.R4810K variant. Whereas hemorrhagic sites, thalamic anastomosis, and choroidal anastomosis might not be associted withp.R4810K variant.

Post-thrombolysis rupture of small lenticulostriate aneurysms: A report of 2 consecutive cases.

The 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines stated that the administration of intravenous recombinant tissue-type plasminogen activator (rTPA) for acute ischaemic stroke is probably safe for patients with small (i.e. <10 mm) unruptured intracranial aneurysms. We present 2 cases of small (2 and 5 mm) lenticulostriate artery (LSA) aneurysms which ruptured immediately following rtPA infusion. The ensuing acute intracranial haemorrhages resulted in the death of one patient and severe functional impairment for the other. Given the limited literature available, the natural history of LSA aneurysms is largely unknown. This report suggests that LSA aneurysms, regardless of size, be considered separately from other conventional aneurysms as "high-risk" lesions and a contraindication to thrombolysis.

Recurrent cerebral microbleeds with acute stroke symptoms: A case report.

RATIONALE: Cerebral microbleeds are lesions that appear as round low signal intensity areas with a diameter of 2-5 mm on gradient echo T2-weighted sequence magnetic resonance imaging. Cerebral microblees are hemorrhages found in the brain parenchyma and they are caused by the extravasation of the blood. Although more patients with ischemic stroke are found to have cerebral microbleeds, only a few studies have evaluated other neurologic abnormalities outside of cognitive dysfunction due to cerebral microbleeds. PATIENT CONCERNS: A 73-year-old female patient had only a lacunar infarction with the development of a new microbleed whenever a new neurologic symptom occurred, without the occurrence of acute ischemic stroke. DIAGNOSES: A 73-year-old female patient diagnosed symptomatic cerebral microbleeds. INTERVENTIONS: Brain magnetic resonance imaging was taken within a few hours of the occurrence of a new symptom and we confirmed increased cerebral microbleeds in the ventral-posterolateral area of the thalamus, consistent with the symptoms. OUTCOMES: This case study is meaningful because it proves that repeated occurrences of cerebral microbleeds in a specific area can induce acute ischemic stroke-like symptoms. LESSONS: Cerebral microbleeds have been considered to be asymptomatic lesions thus far. However, recent studies have reported the association of cerebral microbleeds with neurological symptoms including cognitive dysfunction. This study confirmed the presence of newly formed cerebral microbleeds through imaging follow-ups whenever a symptom occurred.

Candida parapsilosis endocarditis in an intravenous drug abuser: an autopsy report.

Candida parapsilosis is a rare cause of endocarditis, which is seen to affect the native valves in patients who are known intravenous drug abusers or following contamination during surgery for prosthetic valves. We discuss a unique constellation of autopsy findings in a 35-year-old chronic opium abuser who presented with left-sided weakness followed by low-grade fever. He was diagnosed to have C. parapsilosis native valve endocarditis with septic emboli involving the myocardial vessels, left middle cerebral artery, spleen, and common iliac artery. In addition, autopsy highlighted a right basal ganglia infarct, focal segmental glomerulonephritis, and talc granulomatosis in the lungs and liver.

Evaluation of Lenticulostriate Arteries Changes by 7 T Magnetic Resonance Angiography in Type 2 Diabetes.

AIM: Progress in neuroimaging techniques allows us to investigate the microvasculature characteristics including lenticulostriate arteries (LSA), which are closely associated with lacunar infarction. Because ischemic stroke is a more critical health problem in East Asian than in other populations, in order to clarify pathological changes underlying cerebral small vessel disease (SVD), we projected an imaging analysis of LSA using high-resolution brain magnetic resonance imaging (MRI) in middle-aged Japanese subjects with type 2 diabetes. METHODS: Twenty-five subjects with type 2 diabetes and 25 non-diabetic control subjects underwent 7 Tesla (7 T) brain MRI. The prevalences of SVD and LSA structural changes were determined in each group. RESULTS: SVD prevalence did not differ significantly between the type 2 diabetes and control groups. The average numbers of stems, as well as numbers of branches, of LSA were significantly smaller in diabetic subjects than non-diabetic control subjects. The signal intensity of LSA was markedly decreased, indicating reduced blood flow in type 2 diabetes. CONCLUSION: In spite of the prevalence of SVD being similar, structural changes and decreased signal intensity of LSA were highly detected in diabetic subjects compared with non-diabetic controls, suggesting that 7 T MRA enables us to determine LSA impairment prior to the development of SVD. Early detection of LSA impairment allows us earlier interventions aimed at the prevention of atherosclerotic events.

Clinical outcome prediction after thrombectomy of proximal middle cerebral artery occlusions by the appearance of lenticulostriate arteries on magnetic resonance angiography: A retrospective analysis.

Post-ischemic vasodynamic changes in infarcted brain parenchyma are common and range from hypo- to hyperperfusion. In the present study, appearance of the lenticulostriate arteries (LSAs) on postinterventional 3T time-of-flight (TOF)-MRA suggestive for altered post-stroke vasodynamics following thrombectomy was investigated. Patients who underwent thrombectomy for a proximal MCA occlusion and for whom postinterventional 3T TOF-MRA (median at day 3) was available, were included in this retrospective analysis (n=98). LSA appearance was categorized into presence (LSA-sign+) or absence (LSA-sign-) of vasodilatation in the ischemic hemisphere. Functional outcome was determined using the modified Rankin scale (mRS). LSA-sign+ was observed in 64/98 patients. Hypertension (adjusted OR: 0.171, 95% CI: 0.046-0.645) and preinterventional IV rtPA (adjusted OR: 0.265, 95% CI: 0.088-0.798) were associated with absence of the LSA-sign+. In multivariate logistic regression, LSA-sign+ was associated with substantial neurologic improvement (adjusted OR: 10.18, 95% CI: 2.69-38.57) and good functional outcome (discharge-mRS ≤ 2, adjusted OR: 7.127, 95% CI: 1.913-26.551 and day 90 mRS ≤ 2, adjusted OR: 3.786, 95% CI: 1.026-13.973) after correcting for relevant confounders. For all clinical endpoints, model fit improved when including the LSA-sign term (p<0.05). Asymmetrical dilatation of LSAs following successful thrombectomy indicates favorable neurologic and mid-term functional outcomes. This may indicate preserved cerebral blood flow regulatory mechanisms.

Lenticulostriate arterial distribution pathology may underlie pediatric anoxic brain injury in drowning.

Drowning is a leading cause of neurological morbidity and mortality in young children. Anoxic brain injury (ABI) can result from nonfatal drowning and typically entails substantial neurological impairment. The neuropathology of drowning-induced pediatric ABI is not well established. Specifically, quantitative characterization of the spatial extent and tissue distribution of anoxic damage in pediatric nonfatal drowning has not previously been reported but could clarify the underlying pathophysiological processes and inform clinical management. To this end, we used voxel-based morphometric (VBM) analyses to quantify the extent and spatial distribution of consistent, between-subject alterations in gray and white matter volume. Whole-brain, high-resolution T1-weighted MRI datasets were acquired in 11 children with chronic ABI and 11 age- and gender-matched neurotypical controls (4-12 years). Group-wise VBM analyses demonstrated predominantly central subcortical pathology in the ABI group in both gray matter (bilateral basal ganglia nuclei) and white matter (bilateral external and posterior internal capsules) (P < 0.001); minimal damage was found outside of these deep subcortical regions. These highly spatially convergent gray and white matter findings reflect the vascular distribution of perforating lenticulostriate arteries, an end-arterial watershed zone, and suggest that vascular distribution may be a more important determinant of tissue loss than oxygen metabolic rate in pediatric ABI. Further, these results inform future directions for diagnostic and therapeutic modalities.

Multiple Simultaneous Spontaneous Intracerebral Hemorrhages: A Rare Entity.

BACKGROUND: In hospital databases, multiple simultaneous spontaneous intracerebral hemorrhages (ICH-m) account for 0.7-5.6% of all ICHs. Their long-term outcome has never been systematically and prospectively investigated. We aimed at identifying the long-term outcome of patients with ICH-m. METHODS: We prospectively recruited consecutive adults with ICH-m and followed them up for at least 4.5 years. We classified patients into the following 3 groups: (i) definite or probable cerebral amyloid angiopathy (CAA), (ii) deep perforating vasculopathy (DPV) and (iii) unknown causes. RESULTS: Of 562 consecutive patients with ICH, 32 had ICH-m (5.7%): 8 (25%) with probable CAA, 5 (16%) with DPV and 19 (59%) with ICH-m of undetermined cause. At the last visit (cumulative follow-up of 39.5 person-year), 27 patients (84%) had died, and 3 of the 5 survivors were independent. Late-onset seizures, recurrent ICH-m (symptomatic or not) and new brain microbleeds were mainly found in patients with probable CAA. CONCLUSIONS: ICH-m is a rare but extremely severe expression of ICH. Survivors with CAA are more likely to develop late seizures and new hemorrhagic lesions. Because of low survival rates, large multicenter cohort studies are needed for a better understanding of this rare condition.

Lenticulostriate vasculopathy in neonates: Perspective of the radiologist.

Lenticulostriate vasculopathy (LSV) is a diagnosis dependent on neonatal cranial ultrasound (US). The diagnosis of LSV requires the presence of linear or branching echogenicities in the area of the basal ganglia and/or thalamus on gray scale cranial US. Although the diagnosis of LSV is dependent on cranial US, there are no convincing correlates observed on either computerized tomography or magnetic resonance imaging. Moreover, the radiographic criteria for LSV on cranial US remain vague, and intra-observer correlations are generally reported to be poor. The purpose of this review is to examine the issues associated with the use of cranial US and the diagnosis of LSV, including alternative imaging, clinical abnormalities and the significance of LSV on cranial US.

Frameless neuronavigation based only on 3D digital subtraction angiography using surface-based facial registration.

OBJECT: Cerebrovascular lesions can have complicated abnormal anatomy that is not completely characterized by CT or MR angiography. Although 3D rotational angiography provides superior spatial and temporal resolution, catheter angiograms are not easily registered to the patient, limiting the use of these images as a source for neuronavigation. However, 3D digital subtraction angiography (DSA) contains not only vascular anatomy but also facial surface anatomy data. The authors report a novel technique to register 3D DSA images by using only the surface anatomy contained within the data set without having to fuse the DSA image set to other imaging modalities or use fiducial markers. METHODS: A cadaver model was first created to assess the accuracy of neuronavigation based on 3D DSA images registered by facial surface anatomy. A 3D DSA scan was obtained of a formalin-fixed cadaver head, with acquisitions of mask and contrast runs. The right common carotid artery was injected prior to the contrast run with a 45% contrast solution diluted with water-soluble red liquid latex. One week later, the head was registered to a neuronavigation system loaded with the 3D DSA images acquired earlier using facial surface anatomy. A right pterional craniotomy was performed and 10 different vascular landmarks were identified and measured for accuracy using the neuronavigation system. Neuronavigation based only on 3D DSA was then used to guide an open clipping procedure for a patient who presented with a ruptured distal lenticulostriate aneurysm. RESULTS: The accuracy of the measurements for the cadaver model was 0.71 ± 0.25 mm (mean ± SE), which is superior to the 1.8-5 mm reported for neuronavigation. The 3D DSA-based navigation-assisted surgery for the distal lenticulostriate aneurysm aided in localization, resulting in a small craniotomy and minimal brain dissection. CONCLUSIONS: This is the first example of frameless neuronavigation based on 3D catheter angiography registered by only the surface anatomy data contained within the 3D DSA image set. This is an easily applied technique that is beneficial for accurately locating vascular pathological entities and reducing the dissection burden of vascular lesions.

Rupture of lenticulostriate artery aneurysms.

The authors report on 3 rare cases of ruptured lenticulostriate artery (LSA) aneurysms that were heralded by deep cerebral hematomas. The hematomas were unilateral in 2 cases and bilateral in 1; in the bilateral case, only a single LSA aneurysm could be identified on the right side of the brain. Because of their small size (≤ 2 mm), fusiform aspect, and deep location within the brain, all of the aneurysms were treated conservatively. There was no hemorrhage recurrence, and follow-up angiography demonstrated spontaneous thrombosis in 2 of the 3 cases. The clinical course was favorable in 2 of the 3 patients. The course in the patient with the bilateral hematoma was marked by an ischemic event after the initial episode, resulting in an aggravation of deficits. The cause of this second event was uncertain. Because our knowledge about the natural history of LSA aneurysms is incomplete, there is no consensus concerning a therapeutic strategy. The authors' experience in 3 reported cases leads them to think that a conservative approach involving close angiographic monitoring may be proposed as first-line treatment. If the monitored aneurysm then persists or grows in size, its occlusion should be considered. Nonetheless, other studies are needed to further strengthen the legitimacy of this strategy.

Impact of albuminuria on early neurological deterioration and lesion volume expansion in lenticulostriate small infarcts.

BACKGROUND AND PURPOSE: Albuminuria, a marker of chronic kidney disease, is associated with an increased risk of incident stroke and unfavorable long-term outcomes. However, the association of albuminuria with short-term outcomes and change in infarct volume in patients with acute small subcortical infarction remains unknown. METHODS: We retrospectively reviewed 85 consecutive patients with acute small subcortical infarcts in the lenticulostriate artery territory who were admitted to our stroke center within 24 hours of symptom onset and underwent serial diffusion-weighted imaging (DWI). Albuminuria was determined based on the urinary albumin-to-creatinine ratio obtained from a first morning spot urine after admission. Infarct volume was measured on axial sections of the initial and follow-up DWI. Early neurological deterioration (END) was defined as an increase of ≥2 points in the National Institutes of Health Stroke Scale score during the first 5 days after admission. RESULTS: Albuminuria (UACR ≥30 mg/g creatinine) was observed in 14 of 18 patients with END (77.8%) and in 25 of 67 patients without END (37.3%), P=0.002. Multivariate logistic regression analysis revealed that albuminuria was associated with END after adjustment for age, low estimated glomerular filtration rate (<60 mL/min per 1.73 m2), and infarct volume on initial DWI (odds ratio, 6.64; 95% confidence interval, 1.62-27.21; P=0.009). In addition, albuminuria was an independent predictor of increase in infarct volume using multivariate linear regression analysis (ß coefficient=0.217; P=0.038). CONCLUSIONS: Our findings suggest that albuminuria is associated with END and infarct volume expansion in patients with small subcortical infarcts in the lenticulostriate artery territory.

Real-time imaging of mouse lenticulostriate artery following brain ischemia.

Detection of microvascular changes in experimental stroke models is limited by current technologies. Using state-of-the-art synchrotron radiation (SR), we explored the feasibility of detecting the normal morphological variations of lenticulostriate arteries (LSAs) and the changes to LSAs following middle cerebral artery occlusion (MCAO). Cerebral microvessels of ICR mice were imaged with synchrotron radiation microangiography using nonionic iodine and barium sulfate as contrast agents. Using SR we reproducibly observed the detailed cerebral microvasculature of LSAs arising from the origin of middle cerebral artery (MCA) with a resolution of approximately 5 micrometers, at least a 20-fold greater resolution compared to CT or MRI imaging. Notably, SR microangiography was able to reveal ischemia/reperfusion induced leakage in the lenticulostriate artery territory. To our knowledge this is the first time that the three-dimensional morphology of LSAs and real time visualization of LSA hemorrhage have been characterized in live mice. This work demonstrates that SR microangiography can provide a unique tool for furthering experimental stroke research to examine the efficacy of neuroprotective therapies on parameters such as angiogenesis and vascular integrity.

Trans-striatocapsular contralateral interhemispheric resection of anterior inferior basal ganglia cavernous malformation.

OBJECTIVE: To describe a technique to approach the anterior inferior basal ganglia. CASE DESCRIPTION: A 29-year-old man presented with several episodes of facial droop and a cavernous malformation anterior, inferior, and lateral to the head of the caudate nucleus. Several possible surgical approaches were considered, including a transsylvian approach and a contralateral interhemispheric approach. Ultimately, the patient underwent a contralateral interhemispheric trans-striatocapsular approach to the lesion and was discharged without neurologic deficit within 72 hours. CONCLUSION: The approach described here is a novel alternative to transsylvian or supracarotid approaches to the anterior inferior basal ganglia and in this patient provided a well-tolerated surgical corridor that allowed complete resection of his cavernoma. We discuss several advantages and disadvantages of the various approaches to the anterior inferior basal ganglia.

Visualization of lenticulostriate arteries by flow-sensitive black-blood MR angiography on a 1.5 T MRI system: a comparative study between subjects with and without stroke.

BACKGROUND AND PURPOSE: The branches of the LSA are the main causative arteries for lacunar infarction, though the vascular changes are largely unknown. Herein, we examined the correlation of LSA imaging findings in patients with lacunar infarction compared with controls by using FSBB-MRA. MATERIALS AND METHODS: Fifteen patients (9 men, 6 women; mean age, 73 years) with infarction at the basal ganglia and/or its vicinity were prospectively enrolled, and 12 aged-matched control subjects (6 men, 6 women; mean age, 68 years) were examined by using FSBB-MRA on a 1.5T MR imaging system. Total number and length of visualized LSA branches were compared by a 2-tailed 2-sample t test. Stepwise multiple regression analyses were performed, including hypertension, hyperlipidemia, smoking history, and diabetes mellitus after evaluation of their colinearity. P<.05 after correction for multiple comparisons was considered significant. RESULTS: Patients with stroke had significantly fewer LSA branches (average, 6.3; 95% CI, 5.4-7.1) than controls (8.7; 95% CI, 7.8-9.5) (P=.0003). The total LSA lengths were 117 mm (95% CI, 96-138 mm) for patients with stroke and 162 mm (95% CI, 133-91 mm) for control subjects (P=.01). In stepwise multiple regression analysis, only the LSA branch numbers were significantly related to infarction (P=.0003), while only hypertension was significantly related to total LSA length (P=.0085). CONCLUSIONS: Using FSBB-MRA to visualize LSA branches, we found a significant reduction in the numbers of LSA branches in patients with stroke, and hypertension was inversely related to total LSA length. FSBB is a promising method to investigate the LSA by using 1.5T MR imaging.

Microsurgical clipping of an unruptured lenticulostriate aneurysm.

Aneurysms of the lenticulostriate artery have been associated with hypertension, vasculopathy, tumors, and arteriovenous malformations. Although several cases of microsurgical treatment of ruptured lenticulostriate artery aneurysms have been reported, to our knowledge there is no published case of microsurgical treatment of an unruptured lenticulostriate artery aneurysm. We report a 66-year-old woman with a history of moyamoya disease, previously treated with a right-sided middle cerebral artery-to-superficial temporal artery bypass who presented with an unruptured aneurysm of a lenticulostriate artery. We report successful microsurgical treatment of this rare lesion and discuss the rationale for our treatment strategy.

Traumatic subarachnoid hemorrhage, basal ganglia hematoma and ischemic stroke caused by a torn lenticulostriate artery.

Subarachnoid hemorrhage (SAH), basal ganglia hematoma (BGH) and ischemic stroke are common diseases with diverging therapies. The simultaneous occurrence of these diseases is rare and complicates the therapy. We report the case of a 30-year-old man with a ruptured lenticulostriate artery after traumatic brain injury that caused the combination of SAH, BGH and ischemic stroke and subsequent cerebral vasospasm. This rupture mimicked the pathophysiology and imaging appearance of aneurysmal SAH. The site of rupture was not secured by any treatment; however, hyperdynamic therapy and percutaneous transluminal angioplasty were feasible in this setting to prevent additional delayed neurological deficit.

Association of incompleteness of the anterior part of the circle of Willis with the occurrence of lacunes in the basal ganglia.

BACKGROUND AND PURPOSE: This study investigated whether incompleteness of the anterior part of the circle of Willis affects the occurrence of lacunes in the basal ganglia. METHODS: One thousand and seventy-seven healthy individuals examined by magnetic resonance (MR) imaging and MR angiography were divided into eight subgroups according to our new classification. RESULTS: Logistic regression analysis demonstrated that healthy individuals with incompleteness of the anterior circle of Willis had significantly higher frequency of lacunes [odds ratio (OR): 2.121, 95% confidence interval (CI): 1.477-3.108; or OR: 2.46, 95% CI: 1.377-4.384 in cases without or with fetal type posterior communicating artery, respectively] and higher numbers of lacunes (P < 0.001 or P < 0.001 in cases without or with fetal type posterior communicating artery, respectively) compared to patients with complete circle of Willis. CONCLUSIONS: Incompleteness of the anterior part of the circle of Willis significantly affected the occurrence of lacunes.