Thrombectomy versus Medical Management for Isolated Anterior Cerebral Artery Stroke: An International Multicenter Registry Study.

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort (P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Topographic Evolution of Anterior Cerebral Artery Infarction and Its Impact on Motor Impairment.

INTRODUCTION: Motor deficit is common following anterior cerebral artery (ACA) stroke. This study aimed to determine the impact on the motor outcome, given the location of descending corticofugal fiber tracts (from the primary motor cortex [M1], dorsal and ventral premotor area [PMdv], and supplementary motor area [SMA]) and the regional variations in collateral support of the ACA territory. METHODS: Patients with ACA vessel occlusion were included. Disruption to corticofugal fibers was inferred by overlap of tracts with a lesion on computed tomography perfusion at the onset and on magnetic resonance imaging (MRI) poststroke. The motor outcome was defined by dichotomized and combined National Institute of Health Stroke Scale (NIHSS) sub-scores for the arm and leg. Multivariate hierarchical partitioning was used to analyze the proportional contribution of the corticofugal fibers to the motor outcome. RESULTS: Forty-seven patients with a median age of 77.5 (interquartile range 68.0-84.5) years were studied. At the stroke onset, 96% of patients showed evidence of motor deficit on the NIHSS, and the proportional contribution of the corticofugal fibers to motor deficit was M1-33%, SMA-33%, and PMdv-33%. By day 7, motor deficit was present in <50% of patients and contribution of M1 fiber tracts to the motor deficit was reduced (M1-10.2%, SMA-61.0%, PMdv-28.8%). We confirmed our findings using publicly available high-resolution templates created from Human Connectome Project data. This also showed a reduction in involvement of M1 fiber tracts on initial perfusion imaging (33%) compared to MRI at a median time of 7 days poststroke (11%). CONCLUSION: Improvements in the motor outcome seen in ACA stroke may be due to the relative sparing of M1 fiber tracts from infarction. This may occur as a consequence of the posterior location of M1 fiber tracts and the evolving topography of ACA stroke due to the compensatory capacity of leptomeningeal anastomoses.

Bihemisphere Ischemia Due to a Unilateral Lesion: A Case Report.

Bihemispheric ischemic strokes secondary to unilateral vessel disease are uncommon. We present the case of a 70-year-old man with multiple acute/subacute bilateral infarcts. The patient was found to have stenosis of the left internal carotid artery secondary to herpes zoster ophthalmicus vasculopathy, with involvement of the left proximal middle and anterior cerebral arteries. Angiographic studies also revealed A1 segment aplasia of the right anterior cerebral artery (ACA), thus indicating dependence on the left-sided circulation for perfusion of the bilateral ACA vascular territory. This case illustrates how A1 segment aplasia, an anatomic variant of the circle of Willis detected by angiographic studies, can contribute to bilateral infarction in the ACA vascular territory.

Effect of Endovascular Therapy on Subsequent Decompressive Hemicraniectomy in Cardioembolic Ischemic Stroke with Proximal Intracranial Occlusion in the Anterior Circulation: Sub-Analysis of the RESCUE-Japan Registry 2.

BACKGROUND: Cardioembolic stroke is associated with a higher rate of functional limitation, which may be related to the larger ischemic lesion size. Endovascular therapy (EVT) for acute stroke caused by large vessel occlusion reduces severe disabilities. OBJECTIVES: We aimed to investigate the relationship between EVT and decompressive hemicraniectomy (DH) in patients with cardioembolic proximal intracranial occlusion in the anterior circulation (CPIOAC) using the data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2. METHODS: Among 2,420 patients in the RESCUE-Japan Registry 2, 555 patients aged 20-80 years with acute cardioembolic occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. The primary outcome was DH. Secondary outcomes were any type of intracranial hemorrhage, symptomatic intracranial hemorrhage indicating neurological worsening of >4 points on the National Institutes of Health Stroke Scale within 72 h after the onset of stroke, and recurrence of stroke or transient ischemic attack (TIA) within 90 days. RESULTS: The median age was 73 years (66-77 years), and 360 patients (65%) were male. DH was performed in 1 of 374 patients in the EVT group and 5 of 181 patients in the no-EVT group (p = 0.032). The incidence of any type of intracranial hemorrhage and symptomatic intracranial hemorrhage within 72 h and recurrence of stroke or TIA within 90 days were similar between both groups. CONCLUSIONS: EVT may reduce DH in patients with CPIOAC without increasing intracranial hemorrhage.

Bilateral Caudate Nucleus Infarctions Following Upper Gastrointestinal Bleeding.

A 75-year-old woman presented with consciousness disturbance accompanied by hematemesis. Brain imaging revealed ischemia in the bilateral caudate nuclei and right cerebral watershed area due to stenosis of the right anterior cerebral artery (ACA) and bilateral internal carotid arteries (ICA), and hypoperfusion in the right caudate nucleus. The patient's only symptom was abulia, which gradually resolved. Further brain scans showed that the ICA stenosis had improved, although the right ACA stenosis persisted. This was a rare case of bilateral caudate nucleus infarctions with a hemodynamic etiology.

Callosal Motor Impersistence: A Novel Disconnection Syndrome.

Motor impersistence, an inability to sustain a certain position or movement, is a motor-intentional disorder, caused more often by right than left hemisphere lesions. Since the right hemisphere is dominant for mediating motor persistence, callosal lesions that disconnect the left hemisphere from the right may induce impersistence of the right upper and lower limbs. After an undiagnosed left callosal infarction, a 65-year-old right-handed man suddenly developed a transient loss of volitional movement of his left leg. Five days after onset, he was admitted to our hospital with signs of callosal disconnection: left-hand agraphia and apraxia, left-hand tactile anomia, failures on cross-replication of hand postures, and intermanual conflict. He had neither weakness nor ataxia of his upper or lower extremities, but when asked to keep his arms or legs extended he could not maintain his right arm and leg in the extended position, suggesting motor impersistence in his dominant limbs. When we examined him 3 months after onset, the motor impersistence had disappeared. In conclusion, motor impersistence of dominant limbs can result from isolated callosal injury that disconnects the left hemisphere from the right hemisphere's frontal-subcortical networks.

A comprehensive analysis of the relationship between ACA velocities and ACA infarction following aneurysmal subarachnoid hemorrhage.

PURPOSE: To evaluate the relationship between anterior cerebral artery (ACA) velocities (and ancillary parameters) and ACA infarction following aneurysmal subarachnoid hemorrhage (aSAH), and to examine the factors that influence velocities. METHODS: Retrospective investigation of 500 consecutive aSAH patients. ACA mean velocities (Vm) were evaluated by daily transcranial ultrasound during the early (days 1-4) and late (days 5-20) periods posthemorrhage. Presence and timing of acute ACA infarctions were identified by serial retrospective review of cerebral computerized tomography (CT) scans. Predictors of ACA velocities were identified and compared to predictors of vasospasm and infarction from the literature. RESULTS: Decreased velocities on the day of infarction were observed in infarct-positive vessels when compared to infarct-negative vessels. ACA velocity increases, ipsilateral/contralateral ACA velocity ratios, and ACA velocity ranges, were inaccurate in anticipating infarction. Decreased ACA index velocities were moderately accurate in anticipating ACA infarction during the early [Vm<60cms/s], late [Vm<70cms/s] and overall [Vm<70cms/s] time periods. Decreased index velocities also independently predicted infarction during all time periods. ACA velocities were most consistently predicted by age, race, hemorrhage quantity on CT, and ACA/ACom (anterior communicating artery) aneurysm location. CONCLUSIONS: ACA velocity increases and ancillary parameters do not relate to the development of infarction, whereas velocity decreases are moderately accurate in anticipating infarction. Predictors of velocity increases generally coincide with those of vasospasm, whereas predictors of velocity decreases coincide more with those of infarction following aSAH.

An extremely rare complication following frontoorbital advancement: infarction of the recurrent artery of Heubner.

Many intracranial as well as extracranial complications can be seen following craniosynostosis surgeries. In this article, we would like to share an extremely rare complication of the infarction of the recurrent artery of Heubner, occurred following frontoorbital advancement. In this case, an 18-month-old male patient underwent supraorbital bar and frontal bone remodeling surgery for nonsyndromic metopic suture synostosis. The preoperative neurosurgical evaluation revealed no signs of increased intracranial pressure. On the 3rd postoperative day, the patient developed asymmetric smile and weakness on the left extremities. Computerized tomography showed a hypodense infarction region around the right basal ganglia and internal capsule, concordant with the region supplied by the recurrent artery of Heubner. The patient's symptoms started to regress on the 2nd day of enoxaparine treatment and he was discharged on 12th postoperative day with almost no signs of the event. In this paper, we presented an unlikely complication after frontoorbital advancement. Keeping in mind the long operating time and the proximity of the procedure to the central nervous system, assessment of the neurological function of the patients both before and after the operation and rapid intervention in case of development of neurologic symptoms are of great importance.

The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome.

BACKGROUND: Silent cerebral infarctions (SCIs) can be identified by preoperative computed tomography (CT) scans in patients with severe carotid stenosis being considered for carotid endarterectomy (CEA). It is unknown whether this finding has any effect on perioperative complications or long-term outcome. This study investigates the influence of SCI on early and late complications in asymptomatic patients undergoing CEA. METHODS: All consecutive CEAs undertaken for asymptomatic severe carotid stenosis from 2005 to 2013 were retrospectively evaluated for clinical and anatomic characteristics. SCI was defined as cerebral embolic infarcts in the anterior or middle cerebral artery territory, ipsilateral to the target carotid stenosis, identified on preoperative CT. The end points of the study were to compare the 30-day and long-term stroke and death rate after CEA in patients with and without SCI. All patients were followed yearly through duplex ultrasonography and clinical assessment. Statistical methods used were Cox regression (hazard ratio) and Kaplan-Meier for life-table analysis. RESULTS: A total of 743 CEAs were performed in asymptomatic patients during the study period of which all had CT scans, and 97 (13.1%) demonstrated SCI. All patient stroke and death outcomes at 30 days were 0.5% and 0.7%, respectively. Patients with SCI had a significantly higher 30-day stroke outcome (3.1% vs 0.2%; P = .001; odds ratio, 16.39; 95% confidence interval, 1.33-201.4; P = .02) but not death or stroke/death outcome (0% vs 0.8%; P = .19 and 3.1% vs 0.9%, P = .06, respectively) compared with those without SCI. In addition, at a mean follow-up of 44.3 ± 23.9 months, the patients with SCI had a significantly worse 5-year ipsilateral stroke or any stroke-/death-free survival compared with patients without SCI (86.7% vs 99.0%; P = .001; and 76.9% vs 87.7%; P = .004). SCI was confirmed as an independent predictor of late any stroke/death by Cox regression (hazard ratio, 2.45; 95% confidence interval, 1.29-4.67; P = .006). CONCLUSIONS: Patients who have SCI in the presence of severe carotid stenosis and undergo CEA have significantly worse perioperative stroke and long-term stroke/death outcomes. This data would suggest that asymptomatic patients undergoing CEA who have CT scan evidence of a cerebral infarct have worse prognosis than those with normal CT scans.

Mechanical Thrombectomy of Distal Occlusions in the Anterior Cerebral Artery: Recanalization Rates, Periprocedural Complications, and Clinical Outcome.

BACKGROUND AND PURPOSE: Patients with acute ischemic stroke in the anterior circulation are at risk for either primary or, following mechanical thrombectomy, secondary occlusion of the anterior cerebral artery. Because previous studies had only a limited informative value, we report our data concerning the frequency and location of distal anterior cerebral artery occlusions, recanalization rates, periprocedural complications, and clinical outcome. MATERIALS AND METHODS: We performed a retrospective analysis of prospectively collected data of patients with acute ischemic stroke undergoing mechanical thrombectomy in the anterior circulation between June 2010 and April 2015. RESULTS: Of 368 patients included in this analysis, we identified 30 (8.1%) with either primary (n = 17, 4.6%) or secondary (n = 13, 3.5%) embolic occlusion of the distal anterior cerebral artery. The recanalization rate after placement of a stent retriever was 88%. Periprocedural complications were rare and included vasospasms (n = 3, 10%) and dissection (n = 1, 3.3%). However, 16 (53.5%) patients sustained an (at least partial) infarction of the anterior cerebral artery territory. Ninety days after the ictus, clinical outcome according to the modified Rankin Scale score was the following: 0-2, n = 11 (36.6%); 3-4, n = 9 (30%); 5-6, n = 10 (33.3%). CONCLUSIONS: Occlusions of the distal anterior cerebral artery affect approximately 8% of patients with acute ischemic stroke in the anterior circulation receiving mechanical thrombectomy. Despite a high recanalization rate and a low complication rate, subsequent (partial) infarction in the anterior cerebral artery territory occurs in approximately half of patients. Fortunately, clinical outcome appears not to be predominately unfavorable.

Prediction of lower limb motor outcomes based on transcranial magnetic stimulation findings in patients with an infarct of the anterior cerebral artery.

The aim was to investigate the relationship between transcranial magnetic stimulation (TMS) at the early stage of stroke and 6-month motor outcome for patients with anterior cerebral artery territory infarct. Patients were classified into TMS(+) and TMS(-) groups. At the 6-month evaluation, lower limb motor function for the TMS(+) group was significantly better than those for the TMS(-) group. Thus, early TMS evaluation is useful for predicting recovery of lower limb motor function in patients experiencing this type of stroke.

Reappraisal of Microsurgical Revascularization for Anterior Circulation Ischemia in Patients with Progressive Stroke.

BACKGROUND: Intravenous thrombolysis using tissue plasminogen activator and endovascular treatment for acute ischemic stroke is becoming an established standard therapy. However, there is no consensus in the treatment of patients who are suffering from progressive neurologic symptoms in the later stages. The purpose of this study was to evaluate the safety and efficacy of microsurgical revascularization in such patients with progressive stroke. METHODS: We retrospectively reviewed the clinical and radiological records of 14 consecutive patients with progressive stroke who underwent emergency open surgery for anterior circulation occlusion within 7 days after onset. Surgical candidates were carefully selected on the basis of symptom severity, diffusion-weighted imaging, and perfusion study. Superficial temporal artery to middle cerebral artery bypass was applied for atherosclerotic occlusion, and microsurgical embolectomy was applied for embolic occlusion. RESULTS: Superficial temporal artery to middle cerebral artery bypass was performed in 12 patients, microsurgical embolectomy in 1, and the combination of these modalities in 1. As a result, complete revascularization was achieved in all patients. The National Institutes of Health Stroke Scale scores significantly improved after surgery (at third postoperative day, P < 0.05; at 14th postoperative day, P < 0.01). A favorable outcome (modified Rankin Scale 0-2) was achieved in 12 of the 14 (85.7%) patients. Minor intracerebral hemorrhage occurred in 1 patient and hyperperfusion syndrome occurred in 1 patients; however, the patients subsequently recovered without additional treatment. CONCLUSIONS: Microsurgical revascularization is a feasible treatment option for patients with progressive stroke due to anterior circulation major vessel occlusion.

Etiology and Risk Factors of Posterior Circulation Infarction Compared with Anterior Circulation Infarction.

BACKGROUND: Many clinicians regard posterior circulation infarction (PCI) as different from anterior circulation infarction (ACI), leading them to apply different treatments. Few studies have validated this practice by directly comparing the etiology and risk factors of PCI and ACI. METHODS: We compared the etiology and risk factors of 2245 consecutive patients with a diagnosis of PCI or ACI confirmed by magnetic resonance imaging in the Chengdu Stroke Registry. Stroke etiology in each patient was classified according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. RESULTS: Our sample included 482 patients (21.5%) with PCI and 1763 (78.5%) with ACI. The most frequent etiology for both infarction types was small-artery occlusion, occurring in 37.6% of patients with PCI and 37.1% of those with ACI. Cardioembolism caused infarction in a significantly smaller proportion of patients with PCI (5.4%) than in patients with ACI (13.3%; odds ratio [OR] = .373; 95% confidence interval [CI], .245-.566). Frequencies of other stroke etiologies were similar between the 2 patient groups. Analysis of risk factor frequencies in the 2 groups showed hypertension to be the most common, occurring in 47.9% of patients in either group. Multivariable analysis identified 2 factors as conferring greater risk of PCI than ACI: male gender (OR = 1.392; 95% CI, 1.085-1.786) and diabetes mellitus (OR = 1.667; 95% CI, 1.275-2.180). The same analysis identified 2 factors as conferring greater risk of ACI: atrial fibrillation (OR = .530; 95% CI, .295-.951) and heart valve disease (OR = .433; 95% CI, .203-.922). Frequencies of other possible risk factors were similar between the 2 groups. CONCLUSIONS: These findings suggest that PCI and ACI are more similar than different in their etiology and risk factors and that the 2 types of infarction should be treated based more on etiology and risk factors than on their posterior or anterior localization.

Research article: clinical characteristics of isolated anterior cerebral artery territory infarction due to arterial dissection.

BACKGROUND: Isolated brain infarction in the anterior cerebral artery (ACA) territory is rare, and its etiology has not yet been fully elucidated. Thus, we aimed to determine the etiologic and clinical characteristics of patients with isolated ACA territory infarction due to arterial dissection. METHODS: Of 2315 patients with acute cerebral infarction admitted to our hospital between April 2007 and September 2013, 34 patients (1.5%; 28 men, 6 women; mean age, 65 ± 15 years) suffered isolated ACA territory infarction. We performed cranial magnetic resonance (MR) imaging and MR angiography for all the patients. Whenever possible, we also performed 3-dimensional computed tomography angiography, digital subtraction angiography, and MR cisternography to diagnose the stroke subtype. RESULTS: The stroke subtypes of the 34 patients with isolated ACA territory infarction were atherothrombotic infarction, cardioembolic infarction, arterial dissection, and unclassified in 11 patients (32%), 11 patients (32%), 11 patients (32%), and 1 patient (3%), respectively. The mean ages at onset were 48 ± 9 and 72 ± 11 years in the dissection and nondissection groups, respectively (P < .001). Headaches were present at onset in 4 patients (36%) and 1 patient (4%) with and without dissection, respectively (P = .026). Blood pressure at onset was significantly higher among patients with dissection (systolic, 179 ± 34 mm Hg; diastolic, 102 ± 17 mm Hg) than among patients without dissection (systolic, 155 ± 30 mm Hg; diastolic, 86 ± 21 mm Hg; P < .05), and d-dimer values were significantly lower among patients with dissection (P = .034). Favorable clinical outcome (modified Rankin Scale score, 0-2) at discharge was achieved in 9 patients (82%) and 10 patients (43%) with and without dissection, respectively (P = .035). CONCLUSIONS: Patients with isolated ACA territory infarction demonstrated a relatively high frequency of dissection (32%). Patients with dissection were younger, had a higher frequency of headaches, and demonstrated more favorable prognoses than patients without dissection.

Severe cerebral vasospasm after traumatic brain injury.

Severe traumatic brain injury is associated with both acute and delayed neuro- logical injury. Cerebral vasospasm is commonly associated with delayed neurological decline in aneurysmal subarachnoid hemorrhage patients. However, the role played by vasospasm in traumatic brain injury is less clear. Vasospasm occurs earlier, for a shorter duration, and often without significant neurological consequence among traumatic brain injury patients. Detection and management strategies for vasospasm in aneurysmal subarachnoid hemorrhage are not easily transferrable to traumatic brain injury patients. We present a patient with a severe traumatic brain injury who had dramatic improvement following emergent decompressive hemicraniectomy. Two weeks after initial presentation he suffered a precipitous decline despite intensive surveillance. This case illustrates the distinct challenges of diagnosing cerebral vasospasm in the setting of severe traumatic brain injury.

[Recurring arterial reocclusion following endovascular recanalisation in a patient with protein S deficiency]. / Reoclusion arterial recurrente tras recanalizacion endovascular en un paciente con deficit de proteina S.

TITLE: Reoclusion arterial recurrente tras recanalizacion endovascular en un paciente con deficit de proteina S.