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1.
Medicine (Baltimore) ; 99(36): e22116, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899095

RESUMO

INTRODUCTION: Hemichorea-hemiballismus, which spans a spectrum of involuntary, continuous, nonpatterned movement involving one side of the body, can emerge as the initial manifestation of acute ischemic stroke. However, because of its rarity in the community, the diagnosis and treatment are often delayed. PATIENT CONCERNS: We report a unique case of a 47-year-old female who presented with acute onset hemichorea-hemiballismus. No obvious focal sign apart from involuntary, continuous, nonpatterned movement of her left arm and leg was presented. DIAGNOSIS: Initial diffusion-weighted magnetic resonance imaging (MRI) was negative but significant increase of blood flow velocity in the right middle cerebral artery (MCA) stem was revealed by transcranial doppler sonography. Repeated MRI showed acute infarction in the contralateral globus pallidus. Isolated dissection of the right MCA typified by intimal flap with double lumen was identified by digital subtraction angiography and high-resolution magnetic resonance imaging (HR-MRI). INTERVENTIONS: The patient was initially treated with dual antiplatelet agents but the uncontrollable movement deteriorated during hospitalization. Antithrombotic therapy was then intensified with combination of tirofiban and low-molecular-weight heparin. Other symptomatic treatment included volume expansion with colloidal fluid to improve cerebral perfusion. Her involuntary movement gradually diminished and the patient was discharged with rivaroxaban 15 mg/daily. OUTCOMES: The patient had recovered with significant reduction in her hemichorea-hemiballismus. Three-month follow-up HR-MRI showed complete resolution of the MCA dissection lesions. CONCLUSION: Prompt recognition of acute onset hemichorea-hemiballismus as the manifestation of acute ischemic stroke in appropriate clinical setting may reduce diagnostic delay. Multiple imaging techniques including cerebral digital subtraction angiography and HR-MRI can be applied to diagnosis and further clarify the mechanism of stroke, which facilitate in selection of secondary prevention therapies.


Assuntos
Aneurisma Dissecante/complicações , Aneurisma Dissecante/patologia , Coreia/etiologia , Discinesias/etiologia , Artéria Cerebral Média/patologia , Doença Aguda , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/tratamento farmacológico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Inibidores da Agregação de Plaquetas/uso terapêutico
2.
Medicine (Baltimore) ; 99(31): e21434, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756153

RESUMO

RATIONALE: Intracranial aneurysm with the first manifestation of acute subdural hematoma (aSDH) is rare in the field of neurosurgery. Usually subarachnoid hemorrhage or intracranial hematoma happens after the rupture of an intracranial aneurysm, whereas trauma is the primary cause of aSDH. PATIENT CONCERNS: Here, we present the case of a 71-year-old woman who presented with spontaneous aSDH with progressive headache and vomiting. DIAGNOSIS: Urgent head computed tomography (CT) identified an aSHD, but the patient had no history of trauma. CT angiography (CTA) identified the cause of the aSDH as rupture of an intracranial aneurysm in the left middle cerebral artery. INTERVENTIONS: Emergent craniotomy with hematoma evacuation was performed. OUTCOMES: Due to prompt diagnosis and appropriate intervention, the patient recovered fully with no disability. LESSONS: This unique case demonstrates that aSDH caused by intracranial aneurysm rupture requires timely identification and appropriate action to prevent adverse outcomes. We performed a comprehensive systematic literature review to examine the etiology and pathogenesis of non-traumatic aSDH. Furthermore, digital subtraction angiography should be considered in patients diagnosed with an aSDH with no known cause.


Assuntos
Angiografia Digital/métodos , Hematoma Subdural Agudo/etiologia , Aneurisma Intracraniano/patologia , Artéria Cerebral Média/diagnóstico por imagem , Ruptura/complicações , Adulto , Idoso , Angiografia Digital/normas , Angiografia por Tomografia Computadorizada/métodos , Craniotomia/métodos , Feminino , Cefaleia/etiologia , Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/patologia , Resultado do Tratamento , Vômito/etiologia
4.
Am J Physiol Cell Physiol ; 319(2): C381-C391, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32491927

RESUMO

Several microRNAs (miRNAs or miRs) regulate cerebral ischemic injury outcomes; however, little is known about the role of miR-539-5p during cerebral ischemic injury or the postischemic state. Cerebral ischemic injury was modeled in vitro by exposing human cortical neurons to oxygen-glucose deprivation (OGD) and in vivo by occluding the middle cerebral artery (MCAO) in a rat model. The effects of miR-539-5p, histone deacetylase 1 (HDAC1), and early growth response 2 (EGR2) on cerebral ischemia were investigated using gain- and loss-of-function experiments. We identified changes in miR-539-5p, HDAC1, EGR2, and phosphorylated c-Jun NH2-terminal kinase (JNK). The interaction among miR-539-5p, HDAC1, and EGR2 was determined by dual luciferase reporter gene assay, chromatin immunoprecipitation, and coimmunoprecipitation. We also investigated the effects on cell viability and apoptosis and changes in inflammatory cytokine expression and spatial memory on MCAO rats. miR-539-5p and EGR2 were poorly expressed, while HDAC1 was highly expressed in OGD-treated HCN-2 cells. miR-539-5p targeted HDAC1, while HDAC1 prevented acetylation of EGR2 resulting in its downregulation and subsequent activation of the JNK pathway. Overexpression of miR-539-5p or EGR2 or silencing HDAC1 improved viability and reduced apoptosis of OGD-treated HCN-2 cells in vitro. Furthermore, overexpression of miR-539-5p improved spatial memory, while decreasing cell apoptosis and inflammation in MCAO rats. Collectively, these data suggest that miR-539-5p targets HDAC1 to upregulate EGR2, thus blocking the JNK signaling pathway, by which cerebral ischemic injury is alleviated.


Assuntos
Isquemia Encefálica/genética , Histona Desacetilase 1/genética , MicroRNAs/genética , Animais , Apoptose/genética , Isquemia Encefálica/patologia , Citocinas/metabolismo , Progressão da Doença , Proteína 2 de Resposta de Crescimento Precoce/genética , Regulação da Expressão Gênica/genética , Glucose/metabolismo , Humanos , Inflamação/genética , Artéria Cerebral Média/lesões , Artéria Cerebral Média/patologia , Neurônios/metabolismo , Neurônios/patologia , Ratos
5.
Comput Biol Med ; 120: 103759, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32421656

RESUMO

BACKGROUND: Computational fluid dynamics(CFD) of intracranial aneurysms requires flow boundary conditions(BCs) as inputs. Patient-specific BCs are usually unavailable and substituted by literature-derived generic BCs. Therefore, we investigated inter-patient BC variations and their influence on middle cerebral artery aneurysmal hemodynamics. METHOD: We retrospectively collected CT angiography and 7-T Phase-Contrast(PC)-MRI data from eight middle-cerebral-artery bifurcation aneurysms to reconstruct the geometry and measure the arterial flowrates, respectively. The coefficient of variation(CoV) was calculated for the inlet flowrate and the pulsatility index(PI). The outflow split estimated by Murray's law was compared with PC-MRI measurements. For each aneurysm, we performed seven simulations: "baseline" using PC-MRI-derived BCs and the other six with changing BCs to explore the influence of BC variations on hemodynamics. RESULTS: From PC-MRI, the inlet flowrate was 1.94 ± 0.71 cm3/s(CoV = 36%) and PI was 0.37 ± 0.13(CoV = 34%). The outflow split estimated by Murray's law deviated by 15.3% compared to PC-MRI. Comparing to "baseline" models, ±36% variations in inlet flowrate caused -61% to +89% changes in time-averaged wall shear stress(WSS), -37% to +32% in normalized WSS(NWSS; by parent-artery), and -42% to +126% in oscillatory shear index(OSI). The ±34% variations in PI caused, -46% to +67% in OSI. Applying ±15% variations in outflow split led to inflow jet deflection and -41% to +52% changes in WSS, -41% to +47% in NWSS, and -44% to +144% in OSI. CONCLUSION: Inflow rate and outflow split have a drastic impact on hemodynamics of intracranial aneurysms. Inlet waveform has a negligible impact on WSS and NWSS but major impact on OSI. CFD-based models need to consider such sensitivity.


Assuntos
Hemodinâmica , Aneurisma Intracraniano/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Velocidade do Fluxo Sanguíneo , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Simulação por Computador , Meios de Contraste , Humanos , Hidrodinâmica , Imageamento Tridimensional , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/fisiopatologia , Angiografia por Ressonância Magnética , Artéria Cerebral Média/patologia , Artéria Cerebral Média/fisiopatologia , Modelos Cardiovasculares , Imagem Multimodal , Fluxo Pulsátil , Estudos Retrospectivos
6.
BMC Neurol ; 20(1): 135, 2020 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-32290834

RESUMO

BACKGROUND: Following acute ischemic stroke (AIS), approximately half of patients do not achieve recanalization after intravenous administration of tissue plasminogen activator (rt-PA). Thrombolysis resistance is a possible reason for recanalization failure. Thrombolysis resistance is likely related to the ultrastructure and composition of the thrombus. However, there is a paucity of published information on the relationship between thrombus ultrastructure and thrombolysis resistance. CASE PRESENTATION: Two patients who underwent mechanical thrombectomy were observed within 4.5 h after stroke onset. One patient failed to respond to rt-PA (defined as thrombolysis resistant), and the other patient did not receive rt-PA treatment (non-rtPA). In each patient, the occluded artery was the internal carotid artery or middle cerebral artery. According to the Trial of ORG 10172 in Acute Stroke Treatment classification, both patients had large atherosclerotic cerebral infarction. By scanning electron microscopy (SEM) and transmission electron microscopy (TEM), we found that the thrombus structure was significantly different between the two patients. CONCLUSION: Grid-like dense fibrin, compressed polyhedral erythrocytes, and large accumulation of neutrophils may be characteristics of thrombolysis resistant thrombi.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/patologia , Feminino , Humanos , Masculino , Artéria Cerebral Média/patologia , Terapia Trombolítica/métodos , Resultado do Tratamento
7.
Medicine (Baltimore) ; 99(16): e19835, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32312005

RESUMO

RATIONALE: Pusher syndrome is a disorder of postural control. It is associated with unilateral lesions on central vestibular system. In the current study, we attempted to identify and investigate neural connectivity of the parieto-insular vestibular cortex in a patient with pusher syndrome, using diffusion tensor imaging. PATIENT CONCERNS: A 60-year-old male patient had left hemiplegia due to an infarction on right premotor cortex, primary motor cortex, corona radiata and temporal and occipital lobe. The patient had severe motor weakness in left upper and lower limb, left side neglect and significant pusher syndrome. DIAGNOSIS: Patient was diagnosed with left hemiplegia due to an infarction in the right middle cerebral artery territory at the neurology department of a university hospital. INTERVENTIONS: One patient and 5 control subjects of similar age participated. Diffusion tensor imaging data were acquired at 4-month and 12-month after the initial injury. OUTCOMES: Fractional anisotropy, mean diffusivity, and tract volume (TV) were measured. TV values in both affected and unaffected hemispheres of the patient were significantly decreased at 4-month compared to those of control subjects. In the unaffected hemisphere of the patient, TV value showed significant increase at 12-month compared to that at 4-month. Although the TV value at 12-month of the affected hemisphere was out of reference range, TV was considerably increased compared to that at 4-month. Mean values for fractional anisotropy or mean diffusivity in 2 hemispheres did not show significant difference compared to those of control subjects regardless of month. LESSONS: Restoration of an injured projection pathway between the vestibular nuclei and parieto-insular vestibular cortex with recovery of pusher syndrome was found in a patient with stroke.


Assuntos
Imagem de Tensor de Difusão/métodos , Hemiplegia/diagnóstico , Sistema Nervoso/diagnóstico por imagem , Equilíbrio Postural/fisiologia , Anisotropia , Infarto Encefálico , Córtex Cerebral/fisiopatologia , Imagem de Difusão por Ressonância Magnética/métodos , Feminino , Hemiplegia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Córtex Motor/diagnóstico por imagem , Córtex Motor/patologia , Sistema Nervoso/fisiopatologia , Lobo Occipital/diagnóstico por imagem , Lobo Occipital/patologia , Lobo Parietal/fisiopatologia , Córtex Somatossensorial/fisiopatologia , Substância Branca/diagnóstico por imagem , Substância Branca/patologia
8.
AJNR Am J Neuroradiol ; 41(3): 535-541, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32115418

RESUMO

BACKGROUND AND PURPOSE: Conventional angiography is the criterion standard for measuring intracranial arterial stenosis. We evaluated signal intensity ratios from TOF-MRA as a measure of intracranial stenosis and infarct risk in pediatric stroke. MATERIALS AND METHODS: A retrospective study was undertaken in children with intracranial arterial stenosis, who had TOF-MRA and conventional angiography performed within 6 months. Arterial diameters were measured for percentage stenosis. ROI analysis on TOF-MRA measured signal intensity in pre- and poststenotic segments, with post-/pre-signal intensity ratios calculated. The Pearson correlation was used to compare percentage stenosis on MRA with conventional angiography and signal intensity ratios with percentage stenosis; the point-biserial correlation was used for infarcts compared with percentage stenosis and signal intensity ratios. Sensitivity, specificity, and positive and negative predictive values were calculated for determining severe (≥70%) stenosis from MRA and signal intensity ratios against the criterion standard conventional angiography. P < .05 was considered statistically significant. RESULTS: Seventy stenotic segments were found in 48 studies in 41 children (median age, 11.0 years; range, 5 months to 17.0 years; male/female ratio, 22:19): 20/41 (48.8%) bilateral, 11/41 (26.8%) right, and 10/41 (24.4%) left, with the most common site being the proximal middle cerebral artery (22/70, 31%). Moyamoya disease accounted for 27/41 (65.9%). Signal intensity ratios and conventional angiography stenosis showed a moderate negative correlation (R = -0.54, P < .001). Receiver operating characteristic statistics showed an area under the curve of 0.86 for using post-/pre-signal intensity ratios to determine severe (≥70%) carotid stenosis, yielding a threshold of 1.00. Sensitivity, specificity, and positive and negative predictive values for severe stenosis were the following-MRA: 42.8%, 58.8%, 30.0%, and 71.4%; signal intensity ratio >1.00: 97.1%, 77.8%, 71.7%, and 97.4%; combination: 75.5%, 100%, 100%, and 76.8%, respectively. Signal intensity ratios decreased with increasing grade of stenosis (none/mild-moderate/severe/complete, P < .001) and were less when associated with infarcts (0.81 ± 0.52 for arteries associated with downstream infarcts versus 1.31 ± 0.55 for arteries without associated infarcts, P < .001). CONCLUSIONS: Signal intensity ratios from TOF-MRA can serve as a noninvasive measure of intracranial arterial stenosis and allow identification of high-risk lesions in pediatric stroke.


Assuntos
Estenose das Carótidas/diagnóstico por imagem , Angiografia por Ressonância Magnética/métodos , Acidente Vascular Cerebral/etiologia , Adolescente , Algoritmos , Estenose das Carótidas/complicações , Estenose das Carótidas/patologia , Criança , Feminino , Humanos , Lactente , Masculino , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Acidente Vascular Cerebral/patologia
9.
Medicine (Baltimore) ; 99(12): e19574, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32195967

RESUMO

RATIONALE: Fat embolism syndrome (FES) is characterized by the classical triad of cerebral, respiratory, and cutaneous manifestations. In contrast, cerebral fat embolism (CFE), corresponding to incomplete pure type FES, is much rarer and usually follows trauma. CFE typically shows a "starfield" pattern on diffusion-weighted magnetic resonance imaging due to the involvement of multiple small arteries. We report 2 unusual cases of CFE that showed a nontraumatic etiology and the involvement of a single dominant cerebral artery. PATIENT CONCERNS: Case 1 was a 33-year-old woman without a history of trauma who visited the emergency room due to hemiparesis and hemisensory deficits. She was a heavy smoker and had used oral contraceptives for several years. Most importantly, she had 2 experiences of autologous fat grafting 2 months previously. Magnetic resonance angiography (MRA) revealed acute occlusion of the right middle cerebral artery. Case 2 was an 80-year-old man suddenly presented with dizziness, ataxia, and left-sided sensorimotor dysfunction. He had a history of hypertension, untreated atrial fibrillation, and chronic alcoholism. MRA demonstrated the occlusion of the distal basilar artery. DIAGNOSIS: Case 1: Microscopic findings demonstrated variable sized fat vacuoles intermixed with moderate amounts of thrombi. Case 2: Histologically, mature adipocytes were intermingled with fibrin, blood cells, and a fragment of entrapped soft tissue resembling the vessel wall. INTERVENTION: Case 1 and 2 underwent aspirational thrombectomy guided by transfemoral cerebral angiography. OUTCOME: Case 1 recovered well but Case 2 still suffers from gait ataxia. LESSONS: CFE can rarely occur in various nontraumatic conditions, with or without evident etiology. Furthermore, it may not show characteristic clinicopathological manifestations. Therefore, careful follow up of those who have undergone procedures that are likely to trigger FES or who have hemodynamic or hypercoagulable risk factors is needed.


Assuntos
Embolia Gordurosa/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Paresia/diagnóstico , Adulto , Idoso de 80 Anos ou mais , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/patologia , Angiografia Cerebral/métodos , Transtornos Cerebrovasculares/etiologia , Embolia Gordurosa/patologia , Embolia Gordurosa/cirurgia , Feminino , Humanos , Embolia Intracraniana/patologia , Embolia Intracraniana/cirurgia , Angiografia por Ressonância Magnética , Masculino , Artéria Cerebral Média/patologia , Paresia/etiologia , Trombectomia/instrumentação , Trombectomia/métodos , Resultado do Tratamento
10.
Acta Neurochir (Wien) ; 162(4): 911-915, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32020299

RESUMO

BACKGROUND: Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully. METHODS: We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels. CONCLUSION: In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.


Assuntos
Aneurisma Roto/cirurgia , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Trombose/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/patologia , Artéria Cerebral Média/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/instrumentação , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Instrumentos Cirúrgicos
11.
World Neurosurg ; 137: e138-e143, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32004740

RESUMO

BACKGROUND: Mirror intracranial aneurysms with different rupture status is a useful model to investigate features associated with aneurysm rupture. Morphological and hemodynamic analyses of ruptured middle cerebral artery (MCA) mirror aneurysms are rarely reported. The purpose of this study was to determine the morphological or hemodynamic characteristics associated with ruptured MCA mirror aneurysms. METHODS: We performed a retrospective analysis of consecutive 317 patients with MCA aneurysms. Ruptured MCA mirror aneurysms (1 ruptured and mirror unruptured aneurysm) were included. In the matched pairs of ruptured and unruptured mirror aneurysms, 13 morphological parameters were measured using 3-dimensional computed tomography angiography and 6 hemodynamic parameters were evaluated using high-resolution computational fluid dynamic simulations. The association of morphological and hemodynamic characteristics with the rupture of MCA mirror aneurysms was determined. RESULTS: A total of 20 (6.31%) patients with 40 MCA mirror aneurysms were included in this study. There were significant differences in morphological and hemodynamic parameters between the ruptured and unruptured mirror aneurysms. Irregular aneurysms were 3 times more common in the ruptured aneurysms than in the unruptured aneurysms. A larger aneurysm (P = 0.025), a higher aneurysm (P = 0.020), a larger size ratio (P = 0.009), a higher bottleneck ratio (P = 0.033), an irregular aneurysm (P = 0.022), a higher maximum intra-aneurysmal wall shear stress (WSS; P = 0.020), and a lower normalized average WSS (P = 0.008) were associated with MCA mirror aneurysm rupture. CONCLUSIONS: Larger aneurysms, a larger size ratio, irregular aneurysms, a lower spatial average WSS, and a higher maximum WSS may contribute to evaluating the risk of rupture of MCA aneurysms independent of patient characteristics.


Assuntos
Aneurisma Roto/complicações , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/patologia , Artéria Cerebral Média/patologia , Aneurisma Roto/patologia , Angiografia Digital/métodos , Angiografia Cerebral/métodos , Feminino , Hemodinâmica/fisiologia , Humanos , Hidrodinâmica , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Estudos Retrospectivos , Estresse Mecânico
12.
J Neurointerv Surg ; 12(8): 768-773, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32107286

RESUMO

Our perspective on anatomy frequently depends on how this anatomy is utilized in clinical practice, and by which methods knowledge is acquired. The thrombectomy revolution, of which the middle cerebral artery (MCA) is the most common target, is an example of a clinical paradigm shift with a unique perspective on cerebrovascular anatomy. This article reviews important features of MCA anatomy in the context of thrombectomy. Recognizing that variation, frequently explained by evolutionary concepts, is the rule when it comes to branching pattern, vessel morphology, territory, or collateral potential is key to successful thrombectomy strategy.


Assuntos
Artéria Cerebral Média/patologia , Sistema Nervoso/irrigação sanguínea , Sistema Nervoso/patologia , Trombectomia , Humanos , Artéria Cerebral Média/cirurgia
13.
J Neurol Surg A Cent Eur Neurosurg ; 81(2): 185-187, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31935781

RESUMO

BACKGROUND: A pial arteriovenous fistula (PAVF) is a rare neurovascular pathology consisting of a direct connection between one or more arterial feeders and a single venous channel. A PAVF was previously considered a subtype of an arteriovenous malformation (AVM). In the current literature these are distinguished as two independent entities with different clinical, physiopathologic, and structural characteristics. We report a case of a surgically treated 37-year-old woman with an extremely rare combination of an unruptured PAVF and AVM. PATIENT: The AVM was mainly supplied by feeders of the middle cerebral artery and drained into the sigmoid sinus via an abnormally dilated and tortuous vein. Following its resection, intraoperative digital subtraction angiography (DSA) in the hybrid operating room revealed the presence of a PAVF that had not been noted during the preoperative planning. Hence the PAVF was completely disconnected as confirmed by DSA again. CONCLUSION: This is the second reported case of an AVM-associated PAVF. Without the intraoperative DSA in the hybrid operating room, this unusual complex cerebrovascular entity would likely have been missed.


Assuntos
Fístula Arteriovenosa/complicações , Veias Cerebrais , Malformações Arteriovenosas Intracranianas/complicações , Adulto , Angiografia Digital , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/cirurgia , Angiografia Cerebral , Veias Cerebrais/diagnóstico por imagem , Veias Cerebrais/patologia , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/cirurgia , Imagem por Ressonância Magnética , Artéria Cerebral Média/patologia , Artéria Cerebral Média/cirurgia , Procedimentos Neurocirúrgicos , Planejamento de Assistência ao Paciente , Tomografia Computadorizada por Raios X , Resultado do Tratamento
14.
Acta Neurol Scand ; 141(3): 193-201, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31598961

RESUMO

Hyperdense middle cerebral artery sign (HMCAS) on admitting to neuroimaging is reported to have prognostic value for poor outcomes after thrombolysis, while evidence from studies comprising a sufficiently large sample size is limited. To detect prognostic predictors after thrombolysis could help improve therapeutic clinical strategies for acute ischemic stroke. We included prospective and retrospective studies of stroke patients that were treated with intravenous thrombolysis, in which functional outcomes (ie, a modified Rankin scale [mRS]) and systematic intracranial hemorrhage (sICH) were assessed in relation to HMCAS during pretreatment head CT. Random-effects models were used to calculate pooled risk ratios (RR) of poor outcomes and sICH for HMCAS patients as compared to patients without HMCAS. Eleven studies permitted identification of 11 818 patients. The risk of poor outcome at 3 months in the HMCAS-positive group was 1.56-fold the negative group (RR, 1.56; 95% CI 1.50-1.62; P < .001). The sICH risk when comparing both groups was found to be non-significant. Sensitivity analysis regarding studies performing thrombolysis within 3 hours also exhibited significant differences in their functional outcomes (RR, 1.56, 95% CI 1.49-1.62; P < .001) in patients with HMCAS as compared to non-HMCAS patients, although this was true for sICH risk. The presence of HMCAS on pretreatment CT predicts a poor outcome at 3 months after intravenous thrombolysis, while its relationship with the incidence of sICH was found to have no statistic value. Our study implies that more aggressive treatment should be considered for HMCAS patients.


Assuntos
Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/patologia , Terapia Trombolítica , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Prognóstico , Acidente Vascular Cerebral/diagnóstico por imagem , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X/métodos
15.
Stroke ; 51(2): 659-662, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31856694

RESUMO

Background and Purpose- This study aims to investigate the association between the characteristics of atherosclerotic plaques of middle cerebral artery and recurrent ischemic stroke using magnetic resonance vessel wall imaging. Methods- One hundred and five patients with ischemic stroke attributed to middle cerebral artery plaque underwent high-resolution black-blood magnetic resonance vessel wall imaging. They were divided into group 1, with the first episode of acute stroke (imaging within 4 weeks of stroke, n=44); group 2, with recurrent acute stroke (n=29); and group 3, with chronic stroke (imaging after 3 months of stroke, n=32). Plaque characteristics including plaque area, plaque burden, contrast-enhancement ratio, eccentricity, and degree of stenosis were measured and compared across 3 groups. Association between plaque characteristics and recurrent strokes was investigated by multivariate analysis. Results- Plaque burden was significantly greater in recurrent stroke group than the other 2 groups (median: group 2, 82.7%, versus group 1, 76.3%, and group 3, 73.4%; P=0.001). Patients with acute stroke had higher enhancement ratio than patients with chronic stroke (median: group 1, 1.59, and group 2, 1.90, versus group 3, 1.33; P=0.014). Comparing to first-onset acute stroke patients, recurrent stroke patients were older, more likely with female sex and hypertension, and had higher plaque burden. After adjustment of clinical factors, plaque burden was the only independent imaging feature associated with recurrent stroke (odds ratio, 2.26, per 10% increase [95% CI, 1.03-4.96]; P=0.042). Conclusions- Higher plaque burden of middle cerebral artery identified on magnetic resonance vessel wall imaging is independently associated with recurrent ischemic stroke.


Assuntos
Arteriosclerose Intracraniana/patologia , Angiografia por Ressonância Magnética , Artéria Cerebral Média/patologia , Placa Aterosclerótica/patologia , Acidente Vascular Cerebral/patologia , Isquemia Encefálica/complicações , Isquemia Encefálica/patologia , Infarto Cerebral/complicações , Infarto Cerebral/patologia , Feminino , Humanos , Angiografia por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/complicações
16.
PLoS One ; 14(12): e0225906, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31805111

RESUMO

BACKGROUND: Only a very few studies had compared the differences in topographic patterns of cerebral infarcts between middle cerebral artery (MCA) and internal carotid artery (ICA) disease. Besides, the comparison of clinical features and outcomes between MCA and ICA disease had rarely been reported. OBJECTIVES: To compare the clinical, imaging features and outcome of MCA versus ICA disease. METHODS: We prospectively enrolled 1172 patients with noncardiogenic ischemic stroke in ipsilateral ICA or MCA territory. Clinical, neuroradiologic and outcome of the two groups were compared in this observational cohort study. RESULTS: The ICA group more frequently presented with decreased alertness, gaze palsy, aphasia, and neglect than the MCA group at admission, and more often had higher National Institute of Health stroke scale score at admission and discharge. Meanwhile, the ICA group more frequently had multiple acute infarcts, watershed infarcts, territorial infarct, small cortical infarct, and responsible artery stenosis ≥70%. Whereas penetrating artery infarct and parent artery occluding penetrating artery was more often associated with MCA disease. The ICA group more frequently had inhospital complications of pneumonia and deep vein thrombosis, more often had disability at discharge, and had more recurrent ischemic stroke or transient ischemic attack in 1 Year. Multivariable logistic regression identified male (OR, 1.99; 95% CI, 1.30 to 3.05; P = 0.002), history of coronary heart disease (OR, 1.85; 95% CI, 1.03 to 3.32; P = 0.041), multiple acute infarcts (OR, 4.18; 95% CI, 2.07 to 8.45; P<0.0001), and territorial infarct (OR, 2.23; 95% CI, 1.52 to 3.27; P<0.0001) was more often associated with ICA territory disease. CONCLUSIONS: The clinical, radiologic characteristics and outcome are distinctively different between ICA and MCA disease. Compared to MCA disease, ICA disease has more serious clinical and radiologic manifestation, and poorer outcome.


Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/patologia , Doenças Arteriais Cerebrais/diagnóstico , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Idoso , Idoso de 80 Anos ou mais , Doenças Arteriais Cerebrais/mortalidade , Diagnóstico Diferencial , Diagnóstico por Imagem/métodos , Feminino , Seguimentos , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Fatores de Risco , Avaliação de Sintomas
18.
AJNR Am J Neuroradiol ; 40(11): 1886-1892, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31624115

RESUMO

BACKGROUND AND PURPOSE: Vessel wall imaging can identify intracranial atherosclerotic plaque and give clues about its components. We aimed to investigate whether the plaque hyperintensity in the middle cerebral artery on T2-weighted vessel wall imaging is associated with ischemic stroke. MATERIALS AND METHODS: We retrospectively reviewed our institutional vessel wall MR imaging data base. Patients with an acute ischemic stroke within 7-day onset in the MCA territory were enrolled. Patients with stroke and stenotic MCA plaque (stenosis degree, ≥50%) were included for analysis. Ipsilateral MCA plaque was defined as symptomatic, and contralateral plaque, as asymptomatic. Plaque was manually delineated on T2-weighted vessel wall imaging. The plaque signal was normalized to the ipsilateral muscle signal. The thresholds and volume of normalized plaque signal were investigated using logistic regression and receiver operating characteristic analysis to determine the association between normalized plaque signal and stroke. RESULTS: One hundred eight stenotic MCAs were analyzed (from 88 patients, 66 men; mean age, 58 ± 15 years), including 72 symptomatic and 36 asymptomatic MCA plaques. Symptomatic MCA plaque showed larger plaque hyperintensity volume compared with asymptomatic MCA plaque. The logistic regression model incorporating stenosis degree, remodeling ratio, and normalized plaque signal 1.3-1.4 (OR, 6.25; 95% CI, 1.90-20.57) had a higher area under curve in differentiating symptomatic/asymptomatic MCA plaque, compared with a model with only stenosis degree and remodeling ratio (area under curve, 0.884 versus 0.806; P =.008). CONCLUSIONS: The MCA plaque hyperintensity on T2-weighted vessel wall imaging is independently associated with ischemic stroke and adds value to symptomatic MCA plaque classification. Measuring the normalized signal intensity may serve as a practical and integrative approach to the analysis of intracranial atherosclerotic plaque.


Assuntos
Arteriosclerose Intracraniana/complicações , Arteriosclerose Intracraniana/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Neuroimagem/métodos , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Isquemia Encefálica/patologia , Constrição Patológica/complicações , Constrição Patológica/diagnóstico por imagem , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/patologia , Placa Aterosclerótica/complicações , Placa Aterosclerótica/diagnóstico por imagem , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/patologia
19.
Stroke ; 50(10): 2790-2798, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31495328

RESUMO

Background and Purpose- Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke. Methods- Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients' computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion. Results- CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60-80). Median processing time was 158 seconds (IQR, 150-167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion. Conclusions- The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.


Assuntos
Algoritmos , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada/métodos , Interpretação de Imagem Assistida por Computador/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Sensibilidade e Especificidade , Acidente Vascular Cerebral/patologia
20.
Eur J Radiol ; 118: 271-276, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31439254

RESUMO

PURPOSE: To characterize the orifices of lenticulostriate arteries (LSAs) in vivo by using three-dimensional (3D) time-of-flight magnetic resonance angiography (TOF-MRA) and to investigate the spatial relationship between LSA orifices and atherosclerotic plaques in patients with lacunar infarcts (LI). METHOD: Seventeen healthy volunteers and fifteen patients with LI underwent 3D TOF-MRA and 3D vessel wall imaging (VWI) at 7 T. The orifices of LSAs and the locations of atherosclerotic plaques on MCA walls were categorized based on the involvement of the superior, inferior, ventral or dorsal sides of MCA wall. The distribution quadrants of LSA orifices on MCA walls were compared among different groups. RESULTS: Most orifices were located on the superior side of MCA firstly (46 of 95, 48.4%), followed by the dorsal side (22 of 95, 23.2%). In patients with LI, the visible numbers of ventral and inferior orifices on the ipsilateral side were significantly lower than healthy controls (p = 0.039 for ventral side, p = 0.002 for inferior side). Similarly, plaques occurred more frequently at the ventral (7 of 20, 35.0%) and the inferior (7 of 20, 35.0%) sides of MCA walls. CONCLUSIONS: TOF-MRA at 7 T is capable of imaging orifices of LSA on MCA. In patients with LI, the decreased number of LSA orifices on the ventral and inferior sides corresponded with the distribution of MCA plaques. The results may indicate the vulnerability of LSA orifices in intracranial atherosclerosis, which was supposed to be the cause of LI in basal ganglia.


Assuntos
Arteriosclerose Intracraniana/patologia , Angiografia por Ressonância Magnética/métodos , Placa Aterosclerótica/patologia , Acidente Vascular Cerebral Lacunar/patologia , Adolescente , Adulto , Idoso , Gânglios da Base/patologia , Feminino , Voluntários Saudáveis , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/patologia , Adulto Jovem
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