Patterns of Visual Task-based Functional MRI Activation in Chronic Posterior Cerebral Artery Stroke Patients.

PURPOSE: Stroke is a principal cause of disability worldwide. In motor stroke, the tools for stratification and prognostication are plentiful. Conversely, in stroke causing mainly visual and cognitive problems, there is still no gold standard modality to use. The purpose of this study was to explore the fMRI recruitment pattern in chronic posterior cerebral artery (PCA) stroke patients and to investigate fMRI as a biomarker of disability in these patients. METHODS: The study included 10 chronic PCA stroke patients and another 10 age-matched volunteer controls. The clinical presentation, cognitive state, and performance in visual perceptual skills battery (TVPS-3) were determined for both patients and control groups. Task-based fMRI scans were acquired while performing a passive visual task. Individual and group analyses of the fMRI scans as well as correlation analysis with the clinical and behavioral data were done. RESULTS: At the level of behavioral assessment there was non-selective global impairment in all visual skills subtests. On visual task-based fMRI, patients recruited more brain areas than controls. These activations were present in the ipsilesional side distributed in the ipsilesional cerebellum, dorsolateral prefrontal cortex mainly Brodmann area (BA) 9, superior parietal lobule (somatosensory associative cortex, BA 7), superior temporal gyrus (BA 22), supramarginal gyrus (BA 40), and contralesional associative visual cortex (BA 19). Spearman's rank correlation was computed to assess the relationship between the TVPS scores and the numbers of fMRI neuronal clusters in each patient above the main control activations, there was a negative correlation between the two variables, r(10) = -0.85, p ≤ 0.001. CONCLUSION: In chronic PCA stroke patients with residual visual impairments, the brain attempts to recruit more neighboring and distant functional areas for executing the impaired visual skill. This intense recruitment pattern in poorly recovering patients appears to be a sign of failed compensation. Consequently, fMRI has the potential for clinically relevant prognostic assessment in patients surviving PCA stroke; however, as this study included no longitudinal data, this potential should be further investigated in longitudinal imaging studies, with a larger cohort, and multiple time points.

Accuracy of Visual Fields in Localizing MRI Lesions in Posterior Cerebral Artery Infarction.

BACKGROUND: The representation of the visual field in visual cortex was established over a century ago by correlating perimetric defects with the estimated location of war wounds. The availability of high-definition MRI offers the possibility of more precise correlation. METHODS: Homonymous hemianopias disclosed on automated visual fields (HVFs) were drawn from an electronic medical record search from 2009 to 2020 at the Michigan Medicine, a tertiary care academic medical center. The patterns of the visual field defects (VFDs) were interpreted by a consensus of 2 authors. The VFDs were correlated with the location of MRI lesions in 92 patients with posterior cerebral artery (PCA) domain ischemic strokes, as determined by the neuroradiologist author, who was masked as to the VFDs. RESULTS: Among the 77 VFDs confined to 1 hemifield, 74 (96%) correctly predicted the side of the visual cortex lesion. In 3 cases, the MRI lesion in the opposite cerebral hemisphere was not foretold. Among the 15 VFDs present in both hemifields, 5 (33.3%) overestimated the MRI lesions, which were evident in only 1 hemisphere. Among the 30 VFDs confined to 1 quadrant, 29 (97%) correctly predicted the lesioned visual cortex quadrant. However, 14 VFDs failed to predict MRI lesions present in both superior and inferior visual cortex quadrants on the same side. Those unpredicted lesions mostly had subtle or indistinct signal abnormalities or were confined to anterior visual cortex, an area that is inaccessible with the HVF test protocol used in this study. CONCLUSION: In this study of PCA ischemic stroke, VFDs limited to 1 hemifield were accurate in locating the side and quadrant of the MRI visual cortex lesions. However, the quadrantic VFDs sometimes failed to predict that the lesions involved both the superior and inferior quadrants on the same side, largely because those lesions had subtle imaging features that defied accurate radiologic assessment or were out of the reach of the visual field test protocol.

Mechanisms of Stroke in Patients with Fetal Posterior Cerebral Artery.

OBJECTIVES: The fetal-type posterior cerebral artery (FTP) is a normal variation of the posterior cerebral artery (PCA), occurring in 3-36% of general population. The effects of the FTP in stroke mechanisms remain debatable. We aimed to investigate the differences in stroke mechanisms and lesion locations between patients with and without FTP. METHODS: A total of 394 patients with PCA territory stroke were divided into those with PCA ischemic stroke associated with ipsilateral FTP and those without. The baseline characteristics, vascular risk factors, infarct pattern, stroke location, stroke etiology, and the diameter of P1 in patients without FTP or posterior communicating artery (PcoA) in patients with FTP were investigated. RESULTS: Among the 394 patients, 52 (13.2%) PCA stroke patients with ipsilateral FTP were enrolled. Patients with FTP, in comparison with those without, had a higher frequency of deep infarct pattern (69.2% vs. 47.1%, P=0.012), small vessel occlusion (51.9% vs. 28.9%, P=0.009), ventrolateral thalamic involvement (65.4% vs. 49.1%, P=0.042), and a lower frequency of cardiac embolism (9.6% vs. 24.0%, P=0.009). The diameter of P1 in patients without FTP was larger than that of PcoA in patients with FTP (2.1 ± 0.3 mm vs. 1.6 ± 0.2 mm, P <0.001). CONCLUSIONS: The stroke mechanisms, infarct pattern, and the location of the stroke were different between patients with and without FTP. PCA stroke patients with FTP more often had small vessel occlusion and ventrolateral thalamic involvement. These results are probably associated with difference in the hemodynamic status according to the presence of FTP.

A clinical study of 288 patients with anterior cerebral artery infarction.

OBJECTIVE: Acute ischemic stroke in the territory of anterior cerebral artery (ACA) is uncommon. Therefore, large population studies evaluating ACA infarction are scarce. We sought to evaluate epidemiological and etiological characteristics of ACA infarction compared to other territorial infarctions. METHODS: We analyzed a prospectively collected stroke registry of all acute ischemic stroke patients for 19 years at two tertiary hospitals. We included patients with acute ischemic stroke caused by large vessel stenosis or occlusion including ACA, middle cerebral artery (MCA), posterior cerebral artery (PCA), and vertebrobasilar artery (VBA). RESULTS: A total of 4171 patients were enrolled. Patients with ACA infarction (N = 288) were significantly older with more females than those with MCA, PCA, or VBA infarction. There were more patients with history of prior ischemic stroke in the ACA infarction group than in other groups. The etiology of the ACA infarction was similar to those of the MCA, PCA and also the total population (66.7-71.8% of LAA and 17.9-20.9% of CE). When patients had prior ischemic stroke history, ACA infarction was more likely to be caused by LAA than MCA or PCA infarction (OR = 6.2, 95% CI 2.0-19.2, p = 0.002 and OR = 4.0, 95% CI 1.1-14.6, p = 0.038, respectively). CONCLUSIONS: Patients with ACA infarction had significantly more prior ischemic stroke than those with MCA, PCA, or VBA infarction. The etiology of ACA infarction in patients with prior ischemic stroke showed significantly more LAA than that of MCA or PCA infarction.

Lesion topography of posterior cerebral artery infarcts.

This study analyzed the topography of acute ischemic stroke in the posterior cerebral artery (PCA) territory. We studied 84 patients with unilateral ischemic PCA stroke. Patients were classified according to lesion levels as cortico-subcortical (superficial), combined (cortical and mesodiencephalic) or isolated thalamic. To receive a lesion map, data from acute MR and CT imaging were normalized and labelled automatically by mapping to stereotaxic anatomical atlases. Cortical lesions accounted for 41.7%, combined for 36.9%, and isolated thalamic lesions for 21.4%. The maximum overlay of ischemia and, thus, highest occurrence of PCA ischemic stroke was found in the ventral and medial occipito-temporal cortex and adjacent white matter association tracts. Dorsal and peripheral segments of the occipito-temporo-parietal region were only rarely lesioned. This configuration was similar in both hemispheres. Consistent with this lesion pattern, visual field defects (VFD) were the most frequent signs, followed by sensorimotor signs, dizziness and sopor, cognitive and oculomotor deficits, and ataxia. The three vascular subgroups differed not only by their anatomical lesion profile and lesion load, but also by their clinical manifestation; although patients with combined and thalamic lesions were sigificantly younger, they were more disabled than participants with cortical lesions. VFD were only found in cortical and combined, and oculomotor deficits only in mesodiencephalic lesions. White matter lesions were common in the cortico-subcortical and the combined group. Basal occipito-temporal and calcarine regions, and neighbouring white matter tracts have the highest risk of ischemia in acute PCA stroke.

Splenial Restricted Diffusion as MRI Correlate of Diaschisis in a Blind Infant With Unilateral Posterior Cerebral Artery Stroke.

ABSTRACT: A 3-month-old male infant appeared on multiple clinical examinations to have acutely developed bilateral retrogeniculate blindness. Electroencephalography showed focal status epilepticus confined to the left posterior cerebral hemisphere. MRI demonstrated restricted diffusion in the domain of the left posterior cerebral artery consistent with acute stroke. Notably, the restricted diffusion extended across the midline in the splenium of the corpus callosum. This splenial sign may be the imaging correlate of cerebral diaschisis, a well-described phenomenon in which patients with new brain lesions develop acutely impaired neurologic function in related but nonlesioned brain regions. Diaschisis has been posited as the explanation for the temporary bilateral blindness in adult patients suffering from unilateral occipital infarctions.

Clinical Course of Acute Ischemic Stroke Due to Medium Vessel Occlusion With and Without Intravenous Alteplase Treatment.

BACKGROUND AND PURPOSE: Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. METHODS: Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. RESULTS: Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5-12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase (P=0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23-4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88-3.25]). CONCLUSIONS: One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in <50% of patients despite intravenous alteplase treatment.

Detection and Quantification of Symptomatic Atherosclerotic Plaques With High-Resolution Imaging in Cryptogenic Stroke.

BACKGROUND AND PURPOSE: High-resolution vessel wall imaging (HR-VWI) is a powerful tool in diagnosing intracranial vasculopathies not detected on routine imaging. We hypothesized that 7T HR-VWI may detect the presence of atherosclerotic plaques in patients with intracranial atherosclerosis disease initially misdiagnosed as cryptogenic strokes. METHODS: Patients diagnosed as cryptogenic stroke but suspected of having an intracranial arteriopathy by routine imaging were prospectively imaged with HR-VWI. If intracranial atherosclerotic plaques were identified, they were classified as culprit or nonculprit based on the likelihood of causing the index stroke. Plaque characteristics, such as contrast enhancement, degree of stenosis, and morphology, were analyzed. Contrast enhancement was determined objectively after normalization with the pituitary stalk. A cutoff value for plaque-to-pituitary stalk contrast enhancement ratio (CR) was determined for optimal prediction of the presence of a culprit plaque. A revised stroke cause was adjudicated based on clinical and HR-VWI findings. RESULTS: A total of 344 cryptogenic strokes were analyzed, and 38 eligible patients were imaged with 7T HR-VWI. Intracranial atherosclerosis disease was adjudicated as the final stroke cause in 25 patients. A total of 153 intracranial plaques in 374 arterial segments were identified. Culprit plaques (n=36) had higher CR and had concentric morphology when compared with nonculprit plaques (P≤0.001). CR ≥53 had 78% sensitivity for detecting culprit plaques and a 90% negative predictive value. CR ≥53 (P=0.008), stenosis ≥50% (P<0.001), and concentric morphology (P=0.030) were independent predictors of culprit plaques. CONCLUSIONS: 7T HR-VWI allows identification of underlying intracranial atherosclerosis disease in a subset of stroke patients with suspected underlying vasculopathy but otherwise classified as cryptogenic. Plaque analysis in this population demonstrated that culprit plaques had more contrast enhancement (CR ≥53), caused a higher degree of stenosis, and had a concentric morphology.

Response to Speech and Language Therapy According to Artery Involvement and Lesion Location in Post-stroke Aphasia.

PURPOSE: Aphasia is one of the most common complications after stroke and occurs in 21-38% of the patients during acute period. The present study aimed to investigate the response to speech and language therapy according to artery involvement and lesion location in patients with post-stroke aphasia. METHOD: The medical records of 107 patients with post-stroke aphasia (mean age, 58.8 ± 14.8 years) who were admitted to a single rehabilitation center for usual care after stroke were reviewed. Location of the ischemic lesion and involved artery was determined assessing the brain MRI of the patients. All the patients received 24 sessions speech and language therapy (3 days a week) as a part of 8-week rehabilitation program. Evaluation of the aphasia was performed with Gülhane Aphasia Test-2 (GAT-2) at baseline and at the end of the rehabilitation program. RESULTS: Baseline GAT-2 scores was significantly worse in patients with middle cerebral artery (MCA) involvement compared to patients with other artery involvements (p = 0.007). While the GAT-2 scores of patients with MCA involvement were improved significantly after speech and language therapy (p < 0.001), the changes in those with anterior cerebral artery (ACA) and posterior cerebral artery (PCA) involvements were not significant (p > 0.05). CONCLUSIONS: The present findings suggested that speech functions might be more affected in ischemic lesion of MCA and response to SLT might be better in patients with MCA involvement.

Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients.

BACKGROUND AND PURPOSE: Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19. METHODS: We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019. RESULTS: Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (P=0.18 and P=0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Successful recanalization rate was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, P=0.025). CONCLUSIONS: Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.

Bilateral posterior cerebral artery territory infarction in a SARS-Cov-2 infected patient: discussion about an unusual case.

In time of SARS-Cov2 pandemic, neurologists need to be vigilant for cerebrovascular complications of Covid-19. We present a case of bilateral occipito-temporal infarction revealed by a sudden cortical blindness with haemorrhagic transformation after intravenous thrombolysis in a diabetic patient infected by Covid-19. Differential diagnoses are discussed in front of this unusual presentation and evolution.

A Juvenile Case of Bow Hunter's Syndrome Caused by Atlantoaxial Dislocation with Vertebral Artery Dissecting Aneurysm.

BACKGROUND: Bow hunter's syndrome (BHS) is caused by posterior circulation insufficiency that results from the occlusion or compression of the vertebral artery (VA) during neck rotation. Owing to its rarity, there is no guideline to support the decision of selecting a conservative or a surgical approach. Management of BHS is dependent on each patient. CASE DESCRIPTION: A 13-year-old girl presented with transient visual disturbance, hypoesthesia, and paralysis of the left side of the body. Magnetic resonance imaging revealed an acute cerebral infarction in the right thalamus, and magnetic resonance angiography demonstrated occlusion of the right posterior cerebral artery and dilation of V3 of the left VA. Digital subtraction angiography revealed a left VA dissecting aneurysm at V3 and left VA occlusion at the level of C1-C2 during neck rotation to the right. A dynamic x-ray suggested atlantoaxial joint instability, and three-dimensional computed tomography revealed aplasia of C1 lamina and atlantoaxial rotatory dislocation. BHS with left VA dissecting aneurysm caused by atlantoaxial rotatory dislocation was diagnosed. We performed C1-C2 posterior fusion by the Goel-Harms technique. Stroke did not recur, and computed tomography angiography obtained 8 months postoperatively demonstrated a decrease in the dissecting aneurysm. CONCLUSIONS: To our knowledge, this is the first case of BHS with VA dissecting aneurysm and aplasia of C1 lamina. Based on this case, we suggest that C1-C2 posterior fusion is effective for BHS with VA dissecting aneurysm.

Investigation of risk factors, topographic location and stroke mechanisms of unilateral isolated and posterior cerebral ARTERY thalamic infarcts.

BACKGROUND AND PURPOSE: In this study, we aimed to examine the risk factors, topographic features and stroke mechanisms of acute ischemic unilateral infarcts of thalamus. METHODS: Patient with isolated thalamic infarct and those with posterior cerebral artery (PCA) infarction who were admitted to our hospital between January 2014 and January 2017 with acute unilateral thalamic infarction (TI) were included in this study (isolated thalamic infarction/ isolated TI; thalamic and posterior cerebral artery infarction/PCA+TI). Demographic characteristics and vascular risk factors of the patients were determined. Thalamic infarct areas were recorded topographically as anterior, posteromedial, ventrolateral, posterolateral, more than one area, and variant areas. Stroke mechanism was determined according to the criteria of "Trial of Org 10172 in Acute Stroke Treatment" (TOAST). Patients with isolated TI and PCA TI were compared according to risk factors, stroke mechanism and infarct topography. RESULTS: Forty-three patients with a mean age of 63.3 ± 14.5 years were included in the study. Twenty-eight patients (60.1%) were found to have isolated TI and the remaining 15 patients (34.9%) had PCA+TI. 32.1% of patients with isolated TI had sensory symptoms on presentation, and 60% of patients with PCA-TI had sensorimotor symptoms. The mean age, the mean score on National Institutes of Health Stroke Scale (NIHSS) and the mean frequency of atrial fibrillation were higher in PCA+TI patients than in isolated-TI patients (p: 0.04, p: 0.004, p: 0.02 respectively). 32.6% of the patients had ventrolateral, 30.2% had posteromedial involvement. Ventrolateral topography was seen in 46.7% of the PCA+TI patients, while posteromedial topography was seen in 39.3% of the isolated-TI patients. 53.6% of the isolated-TI had small vessel disease etiology, while 40% of the PCA+TI had cardioembolic etiology, and the other 40% had large artery atherosclerosis. CONCLUSION: Our study showed that the most ommon stroke mechanism in patients with thalamic infarction is the small vessel disease. Isolated TI and PCA+TI patients differ in terms of etiologic mechanism and infarct topography. Variant territorial involvement and multiple area involvements can be quite common in thalamic infarcts.

Use of 3-Dimensional, Black-Blood, Contrast-Enhanced, T1-Weighted Magnetic Resonance Imaging to Identify Vascular Occlusion in the Posterior Circulation After Acute Ischemic Stroke.

BACKGROUND: Three-dimensional, black-blood, contrast-enhanced, T1-weighted magnetic resonance imaging (3D-BB-ceT1-MRI) could play a role in detection of thrombi and symptomatic intracranial atherosclerotic stenosis. We investigated the role of 3D-BB-ceT1-MRI in patients with acute ischemic stroke in the posterior circulation, and compared our findings with those from susceptibility-weighted imaging (SWI). MATERIALS AND METHODS: We retrospectively reviewed 3D-BB-ceT1-MRI for patients between January 2017 and August 2018 with acute ischemic symptoms in the posterior circulation. During this period, 199 patients with acute infarction in the posterior circulation were enrolled. Time-of-flight-magnetic resonance angiography or cerebral angiography was used as the reference standard. RESULTS: Of these 199 patients, 47 had vessel occlusion associated with acute infarction. The sensitivity of 3D-BB-ceT1-MRI for detection of vessel occlusion was significantly higher than that of SWI (95.7% versus 53.2%, P < .001). Twenty-one lesions with strong enhancement on 3D-BB-ceT1-MRI showed a negative susceptibility vessel sign (SVS) on SWI. CONCLUSIONS: 3D-BB-ceT1-MRI showed strong enhancement (due to contrast stagnation) in the intra-arterial thrombi of patients with acute infarction in the posterior circulation. 3D-BB-ceT1-MRI had higher sensitivity than that of an SVS on SWI for detection of intra-arterial thrombi.

Supratentorial Cerebral Arterial Territories for Computed Tomograms: A Mapping Study in 1160 Large Artery Infarcts.

We recently generated a high-resolution supratentorial vascular topographic atlas using diffusion-weighed MRI in a population of large artery infarcts. These MRI-based topographic maps are not easily applicable to CT scans, because the standard-reference-lines for axial image orientation (i.e., anterior-posterior commissure line versus orbito-meatal line, respectively) are 'not parallel' to each other. Moreover, current, widely-used CT-based vascular topographic diagrams omit demarcation of the inter-territorial border-zones. Thus, we aimed to generate a CT-specific high-resolution atlas, showing the supratentorial cerebrovascular territories and the inter-territorial border-zones in a statistically rigorous way. The diffusion-weighted MRI lesion atlas is based on 1160 patients (67.0 ± 13.3 years old, 53.7% men) with acute (<1-week) cerebral infarction due to significant (>50%) stenosis or occlusion of a single large cerebral artery: anterior, middle, or posterior cerebral artery. We developed a software package enabling the transformation of our MR-based atlas into a re-oriented CT space corresponding to the axial slice orientations used in clinical practice. Infarct volumes are individually mapped to the three vascular territories on the CT template-set, generating brain maps showing the voxelwise frequency of infarct by the affected parent vessel. We then mapped the three vascular territories collectively, generating a dataset of Certainty-Index (CI) maps to reflect the likelihood of a voxel being a member of a specific vascular territory. Border-zones could be defined by using either relative infarct frequencies or CI differences. The topographic vascular territory atlas, revised for CT, will allow for easier and more accurate delineation of arterial territories and borders on CT images.

Ischemic Stroke Associated With Calcitonin Gene-Related Peptide Inhibitor Therapy for Migraine: A Case Report.

Calcitonin gene-related peptide (CGRP) is involved in nociception and neurogenic inflammation in migraine, but also serves as a potent vasodilator acting on intracranial arteries. This latter effect raises concern about the possibility of drugs inhibiting CGRP precipitating cerebral ischemia. We describe a 41-year-old woman with migraine without aura who developed a right thalamic infarction following a first dose of erenumab, a CGRP-receptor blocker. Stroke onset occurred during a typical migraine. Imaging demonsrated right posterior cerebral artery near-occlusion initially with normalization of the vessel at follow-up imaging 2 months later, suggesting vasospasm as a possible mechanism. Extensive evaluation revealed no other specific cause of stroke or vascular risk factors aside from long-term use of oral contraceptive pills. CGRP inhibitors might be associated with ischemic stroke due to blockade of normal cerebral vasodilatory regulatory function.