Infantile Basal Ganglia Stroke after Mild Head Trauma Associated with Mineralizing Angiopathy of Lenticulostriate Arteries: An Under Recognized Entity.

Basal ganglia infarction in young children, mostly after mild head trauma, has been repeatedly reported. The pathogenesis and the risk factors are not fully understood. Lenticulostriate vasculopathy, usually referred to as basal ganglia calcification, is discussed as one of them. We describe five young (7-13 months old on presentation) male children who suffered from hemiparesis due to ischemic stroke of the basal ganglia, four of them after minor head trauma. All of them had calcification in the basal ganglia visible on computed tomography or cranial ultrasound but not on magnetic resonance imaging. Follow-up care was remarkable for recurrent infarction in three patients. One patient had a second symptomatic stroke on the contralateral side, and two patients showed new asymptomatic infarctions in the contralateral basal ganglia on imaging. In view of the scant literature, this clinic-radiologic entity seems under recognized. We review the published cases and hypothesize that male sex and iron deficiency anemia are risk factors for basal ganglia stroke after minor trauma in the context of basal ganglia calcification in infants. We suggest to perform appropriate targeted neuroimaging in case of infantile basal ganglia stroke, and to consider prophylactic medical treatment, although its value in this context is not proven.

Does lenticulostriate vasculopathy predipose to ischemic brain infarct? A case report.

Lenticulostriate vasculopathy (LSV) is a sonographic finding in infancy with obscure etiology and variable diagnostic and prognostic significance. Ischemic infarct in the territory of the lenticulostriate vessels after mild head trauma is a rare pathology. There are no publications on LSV followed by ischemic infarct. We present the case of an 8-month-old boy who suffered mild head trauma and developed an ischemic brain infarct in the territory of preexisting LSV. It is speculated that LSV might be a predisposing factor for ischemic brain infarct after mild head trauma in infants.

Bilateral caudate nucleus infarction associated with a missing A1 segment.

We describe a case of bilateral caudate nucleus infarction caused by cardioembolic stroke associated with a variant circle of Willis. The patient was an 81-year-old man with atrial fibrillation who presented with a sudden disturbance of consciousness. When he became more alert a few days later, he was abulic with no spontaneous speech or activity. A magnetic resonance imaging scan of the brain revealed cerebral infarction of bilateral caudate nucleus heads and the left frontal lobe. The left A1 segment was absent on 3-dimensional computed tomography angiography. One year later, abulia had completely resolved. Bilateral caudate nucleus infarction with variant circle of Willis is rare.

Aquaporins in cerebrovascular disease: a target for treatment of brain edema?

In cerebrovascular disease, edema formation is frequently observed within the first 7 days and is characterized by molecular and cellular changes in the neurovascular unit. The presence of water channels, aquaporins (AQPs), within the neurovascular unit has led to intensive research in understanding the underlying roles of each of the AQPs under normal conditions and in different diseases. In this review, we summarize some of the recent knowledge on AQPs, focusing on AQP4, the most abundant AQP in the central nervous system. Several experimental models illustrate that AQPs have dual, complex regulatory roles in edema formation and resolution. To date, no specific therapeutic agents have been developed to inhibit water flux through these channels. However, experimental results strongly suggest that this is an important area for future investigation. In fact, early inhibition of water channels may have positive effects in the prevention of edema formation. At later time points during the course of disease, AQP is important for the clearance of water from the brain into blood vessels. Thus, AQPs, and in particular AQP4, have important roles in the resolution of edema after brain injury. The function of these water channel proteins makes them an excellent therapeutic target.

Embolization of a ruptured lenticulostriate artery aneurysm.

Aneurysms arising from the lenticulostriate artery (LSA) are rare. So far, only 23 cases have been reported in the literature (Ahn et al. 2007 [1], Gandhi et al. 2008 [2], Harreld et al. 2010 [3]). Early detection and treatment of these aneurysms is difficult because of their small size, deep location and complex surrounding vasculature. The majority of reported cases were treated surgically, and only two were treated with endovascular embolization (Harreld et al. 2010 [3], Larrazabal et al. 2001 [4]). We present here a case of an LSA aneurysm that was successfully embolized with n-butyl cyanoacrylate (n-BCA) with no recurrence after 1 year of follow-up.

Diagnostic and therapeutic challenge in intracerebral hemorrhage due to aneurysm of distal lenticulostriate artery.

OBJECTIVE: To present an atypical case of deep intracerebral hemorrhage caused by the rupture of an aneurysm of the distal lenticulostriate artery. A 42-year-old woman presenting with right-sided mild hemiparesis was diagnosed with an acute left-sided hemorrhage within the basal nuclei. Cerebral angiography revealed a microaneurysm of the distal portion of the left lenticulostriate artery. Conservative treatment under close neurological surveillance was recommended. After a few days of hospital stay, the patient's neurological symptoms improved, and she was discharged. The patient has remained asymptomatic for more than 6 months. Aneurysms of the distal lenticulostriate artery are extremely rare.

OBJETIVO: Presentar un caso atípico de hemorragia intracerebral profunda causada por la ruptura de un aneurisma de la arteria lenticuloestriada distal; se revisa la bibliografía y se analizan la fisiopatología y el tratamiento. Se presentó a la sala de emergencias una mujer de 42 años con hemiparesia leve del hemicuerpo derecho. Se la diagnosticó con una hemorragia aguda en los núcleos de la base izquierdos. La panangiografía cerebral reveló un microaneurisma de la porción distal de la arteria lenticuloestriada izquierda. Se recomendó tratamiento conservador bajo estrecha vigilancia neurológica. Después de unos cuantos días de hospitalización, los síntomas neurológicos de la paciente mejoraron y la paciente recibió el alta. La paciente ha permanecido asintomática durante más de seis meses. Los aneurismas de la arteria lenticuloestriada distal son extremadamente raros.

A new Modified Intracerebral Hemorrhage score for treatment decisions in basal ganglia hemorrhage--a randomized trial.

OBJECTIVES: To develop a Modified Intracerebral Hemorrhage (MICH) score to determine optimal cut-offs for conservative treatment vs surgical intervention for basal ganglia hemorrhage and to predict outcomes. DESIGN: Prospective randomized trial. SETTING: A 1,720-bed medical center affiliated with a university. PATIENTS: In all, 226 patients with basal ganglia hemorrhage who presented at our hospital from 2001-2005. INTERVENTIONS: Group A (n = 113) underwent endoscopic surgery; group B (n = 113) underwent conservative treatment. Score differences on the Glasgow Outcome Scale and 1-yr Barthel Index were analyzed by chi-square test and Student's t-tests. Cut-offs for MICH scoring were evaluated using receiver operating characteristic curves for calculating the Youden Index. The treatment odds ratio was analyzed by univariate, multivariate, and multiple logistic regressions. MEASUREMENTS AND MAIN RESULTS: The optimal cut-off point for mortality was a MICH score > or = 3 in which the Youden Index is 0.66 (sensitivity, 76.3%; specificity, 89.8%; area under the receiver operating characteristic curve, 0.897). The positive and negative predictive values were 81.8% and 86.3%, respectively. The treatment odds ratio for surgical treatment was 6.87 (95% confidence interval, 3.13-14.5) at MICH scores > or = 3. The best cut-off for good functional outcomes (Glasgow Outcome Scale > or = 4 or Barthel index > or = 55) was MICH > or = 2. Conservative treatment achieved a better mean Barthel Index at MICH = 0 or 1 than surgical treatment, p < .01. At MICH scores = 3 or 4, 6-month mortality for conservative treatment was higher than for surgical treatment, p < .01 and p = .04, respectively. At MICH scores of 5, all patients died. CONCLUSIONS: MICH scoring provides a simple, reliable system for treatment decisions regarding basal ganglia hemorrhage and may accurately predict functional outcomes. Conservative treatment is recommended for basal ganglia ICH patients with low MICH scores (0, 1) to preserve neurologic function. Surgery is recommended for patients with a midlevel MICH score to obtain better functional outcomes (MICH = 2) and to reduce mortality (MICH = 3 or 4). At MICH scores = 5, there are no indications for surgery.

Brain abscess formation at the site of intracerebral hemorrhage secondary to central nervous system vasculitis.

Brain abscess is a rare but very dangerous neurosurgical lesion. Prompt diagnosis and emergency surgical evacuation are the hallmarks of therapy. Brain abscess following ischemic and hemorrhagic stroke is a rare entity. These cases are often preceded by episodes of bacteremia, sepsis, and local infection. The authors report the case of a 30-year-old woman who presented with a cerebral abscess at the site of a recent intraparenchymal hemorrhage.

Effect of immunocorrection on surgical outcomes in patients with autoimmune-aetiology vasculitis and vasculopathies.

The present study was undertaken to investigate and compare the outcomes of three options of preoperative preparation and postoperative management of patients presenting with autoimmune-aetiology vasculitis and vasculopathies, who had been subjected to angiosurgical interventions over a 7-year period. According to the aetiopathogenetic sign, the majority of the patients appeared to have thromboangiitis obliterans, non-specific aortoarteritis, primary and secondary vasculopathies. All the patients were age- and sex-matched and well comparable by the underlying disease, the level of lesions of the vascular bed, and the ischaemia burden. The study was performed retrospectively. A total of three options of preoperative preparation and management of the postoperative period were used: option one - treatment comprising plasmapheresis, immunoglobulins and biological immunomodulators; option two - using cytostatic agents and hormone therapy; and option three - consisting of conventional basic vascular therapy alone. The comparative analysis performed demonstrated a clear advantage of immunocorrection and efferent techniques of treating patients presenting with the pathology concerned. The use of the therapeutic-and-diagnostic algorithm we are suggesting herein would make it possible to avoid complications in the immediate postoperative period, to reduce the duration of the patients' hospital stay averagely by 10 days, and to prolong persistence of the obtained positive results by 11.5%.

Embolization of Ruptured Distal Lenticulostriate Artery Aneurysms.

OBJECTIVE: To describe the critical role of endovascular treatment and safety for the patients who presented with intraventricular hemorrhage owing to rupture of the distal lenticulostriate artery aneurysms. METHODS: Three patients who underwent endovascular treatment for distal lenticulostriate artery aneurysms related to intraventricular hemorrhage were selected and retrospectively reviewed. RESULTS: Patients were treated successfully using endovascular embolization without any complications. CONCLUSIONS: Endovascular therapy is available and safe as a treatment option for distal lateral lenticulostriate artery aneurysms.

Lenticulostriate aneurysms: a case series and review of the literature.

INTRODUCTION: Aneurysms of lenticulostriate artery (LSA) perforators are uncommon. There are few data on their natural history, and opinions differ on the treatment strategies. OBJECTIVE: We report a case series and summarize the most recent literature with current treatment recommendations. We propose an anatomical classification for these entities. METHODS: A retrospective review of all patients who were diagnosed with an LSA aneurysm on cerebral angiogram was performed. An extensive online literature search was performed to identify other studies reporting on the diagnosis and management of ruptured and unruptured lenticulostriate aneurysms. RESULTS: 48 cases were identified in the literature and reviewed: 27 patients were treated surgically; five cases were treated with endovascular therapy; two cases underwent gamma knife radiosurgery; and 13 cases were managed conservatively. We classified these aneurysms into three types: type 1 describes aneurysms arising from the middle cerebral artery next to a perforating LSA; type 2 is an LSA aneurysm from which the perforating artery or arteries arise-the type 2A subtype is one in which the aneurysm neck incorporates the origin of the perforating arteries and the type 2B describes perforating arteries arising from the dome of the aneurysm; and type 3 describes a fusiform aneurysm beyond the first loop or turn of an LSA. CONCLUSIONS: LSA aneurysms are rare entities that present several treatment challenges. We have summarized the cumulative experience with these lesions and proposed a classification scheme that has treatment implications.

Spontaneous Dissecting Lenticulostriate Artery Aneurysm in Children: Radiologic Findings and Clinical Management.

BACKGROUND: Aneurysms involving the lenticulostriate artery (LSA) are rare. The majority of LSA aneurysms reported are idiopathic. We present 2 paediatric cases of dissecting distal LSA aneurysm. An 8-year-old girl and 9-year-old boy presented with basal ganglia infarction. History and imaging identified dissection as the most likely aetiology. The clinico-radiological features, aetiology and management involving are discussed. Conservative treatment with careful clinico-radiological monitoring may be a feasible therapeutic strategy.

Controversy in the management of lenticulostriate artery dissecting aneurysm: a case report and review of the literature.

BACKGROUND: Intracranial arterial dissection is an uncommon but well-recognized entity. Treatment remains variable, ranging from observation to intervention via the use of either surgical or endovascular techniques. Aneurysms along the lenticulostriate artery have been reported in only 41 patients. With the current case study we illustrate the effectiveness of observation in the context of a dissecting lenticulostriate aneurysm and discuss other approaches that have been used in the treatment of this particular entity. CLINICAL SUMMARY: An accomplished mountain climber presented, after coitus, with acute headache, mild facial weakness, and forgetfulness. Vascular imaging studies revealed a right putaminal hemorrhage secondary to a 3-mm lenticulostriate artery dissecting aneurysm. Clinically, the patient did well, with marked improvement in presenting symptoms enabling his return to mountain climbing. Follow-up angiography showed spontaneous resolution of the arterial dissecting aneurysm. Among the 41 reported cases, 19 were idiopathic, 5 associated with hypertension, and 17 related to various conditions such as Moyamoya disease, arteriovenous malformation, systemic vasculitis, intraventricular tumor, or substance abuse. Of the 42 cases, including the present case, 28 were surgically or endovascularly managed and 12 observed. Only one of the reported cases, a 33-year-old man with Moyamoya disease, who was managed conservatively, died of rebleeding. CONCLUSION: There is no common consensus in the literature on a single treatment strategy for a lenticulostriate artery aneurysm. The present case illustrates that observation and follow-up vascular imaging can be an important treatment strategy, allowing healing of the vessel wall and disappearance of the dissecting aneurysm.

Effect of micro lesions of the basal ganglia on ballistic movements in patients with deep brain stimulation.

Bradykinesia and hypokinesia are the prominent symptoms of substantia nigra degeneration in Parkinson's disease (PD). In segmental dystonia, movements of not affected limbs are not impaired. Here we studied the impact of the mere implantation of stimulation electrodes on the performance of fast movements in these two groups. We investigated 9 PD patients with subthalamic electrodes and 9 patients with segmental dystonia with electrodes in the globus pallidus internum. Patients were studied on the first postoperative day without electrical stimulation of the electrodes. Subjects had to perform boxing movements with either touching the target or stopping the fist in front of the target. PD subjects performed significantly faster movements in the touch-task only as compared to dystonic patients. No difference was seen in the stopping task. In conclusion, our findings suggest that a small subthalamic lesion in individuals with PD specifically reverses bradykinesia during simple ballistic movements (touch) but not during complex ones requiring more pre-programming (no-touch paradigm).

Embolization of an unruptured distal lenticulostriate aneurysm associated with moyamoya disease.

Lenticulostriate aneurysms are rare and usually present with intracranial hemorrhage, limiting understanding of their natural course. We describe an unusual case of an unruptured rapidly growing distal LSA aneurysm in the setting of Moyamoya disease, successfully embolized with n-BCA following functional neurologic testing with amobarbital.

Preprocedural basal ganglionic infarction increases the risk of hemorrhagic transformation but not worse outcome following successful recanalization of acute middle cerebral artery occlusions.

OBJECTIVE: We recently demonstrated that the preprocedural magnetic resonance imaging (MRI) pattern of deep middle cerebral artery (MCA) territory injury predicts poor prognosis. We postulate that the structures of the deep MCA field are particularly vulnerable to hemorrhagic transformation (HT) following reperfusion. METHODS: We reviewed all cases of acute occlusions involving the M1 segment of the MCA with diffusion restriction of at least 50% of the deep MCA field on MRI (M1a pattern) that underwent endovascular therapy. We compared those with and without recanalization in regards to HT and disability on discharge. RESULTS: Thirty-five patients met inclusion criteria. The recanalized M1a group (n=27) had higher rates of HT (67% vs. 25%, P=0.05) and a trend toward more parenchymal HT (37% vs. 0%, P=0.07) and symptomatic HT (22% vs. 0%, P=0.12) than those M1a patients who failed to recanalize (n=8). Clinical improvement in the National Institutes of Health Stroke Scale by discharge was better in the survivors of the recanalized group. CONCLUSIONS: Among patients with the preintervention M1a MRI pattern of advanced basal ganglionic injury, successful recanalization predicts a higher risk of HT but better outcome.

Neurotransplantation of fetal porcine cells in patients with basal ganglia infarcts: a preliminary safety and feasibility study.

BACKGROUND: Cell transplantation is safe in animal models and enhances recovery from stroke in rats. METHODS: We studied the safety and feasibility of fetal porcine transplantation in 5 patients with basal ganglia infarcts and stable neurological deficits. To prevent rejection, cells were pretreated with an anti-MHC1 antibody and no immunosuppressive drugs were given to the patients. RESULTS: The first 3 patients had no adverse cell, procedure, or imaging-defined effects. The fourth patient had temporary worsening of motor deficits 3 weeks after transplantation, and the fifth patient developed seizures 1 week after transplantation. MRI in both patients demonstrated areas of enhancement remote from the transplant site, which resolved on subsequent imaging. Two patients showed improvement in speech, language, and/or motor impairments over several months and persisted at 4 years. The study was terminated by the FDA after the inclusion of 5 patients. CONCLUSION: This is the first report on the transplantation of nontumor cells in ischemic stroke patients.

Treatment of late-onset OCD following basal ganglia infarct.

Current consensus on the treatment of obsessive-compulsive disorder (OCD) includes cognitive behavior therapy (CBT) in the form of exposure and response prevention (ERP). However, the generalizability of these methods to elderly populations remains largely undocumented. This clinical case study examines the effectiveness of medications and intensive, inpatient ERP in an elderly patient with onset of OCD following basal ganglia infarcts. There was a dramatic reduction from baseline to follow-up in both obsessions and compulsions with Yale-Brown Obsessive-Compulsive Scale [YBOCS; Goodman et al., 1989] total scores decreasing by over 20 points. These gains were maintained up to 1 year post-treatment. Age-specific issues and the application of standard therapeutic methods to elderly clients are discussed.

Circuitos de manejos intra y extrahospitalario de la enfermedad cerebrovascular aguda en Andalucía. Proyecto EVASCAN / Intra and extrahospitalary management circuits for acute cerebrovascular disease in Andalucía. The EVASCAN project

El proyecto EVASCAN tiene por objeto la mejora asistencial de la enfermedad cerebrovascular aguda (ECVA) en Andalucía. Objetivo: El análisis clínico-epidemiológico y de práctica asistencial intra y extrahospitalaria de la ECVA. Métodos: Estudio observacional prospectivo transversal. Se incluyeron todos los pacientes con clínica de ECVA que acudieron a Urgencias de lso 24 hospitales de Andalucía participantes en el estudio los días 5, 15 y 25 de los meses comprendidos entre el 5 de marzo y el 25 de agosto de 1998. Las variables estudiadas fueron: edad, sexo, tipo de lesión, factores de riesgo, medios de acceso hospitalario, retraso asistencial desde el inicio de la clínica (retraso 1), demora en la realización de la tomografía computerizada (retraso 2), consumo de recursos y destino de los pacientes. Resultados: Muestra de 347 pacientes; edad, 71% > de 65 años; 81,8% de origen isquémico. Factores de riesgo: hipertensión arterial (55,8%), fibrilación auricular (16,5%). E 48,7% acudió por medios propios. Retraso 1: el 47,3% contactó en las tres primera horas. Retraso 2: en el 56,8% se realiza en las 3 primeras horas. Destino: el 59,9% ingresó en Neurología. Conclusiones: La ECVA en Andalucía mantiene un perfil epidemiológico y clínico similar al resto de España. Se hace necesario implantar circuitos específicos de manejo diagnóstico y terapéutico para esta patología, en especial en la de tipo isquémico, dado su retraso asistencial

The EVASCAN Project aims achieving an assistencial improvement for acute cerebrovascular disease (ACVD) in Andalusia. Objective: A clinico-epidemiological analysis of intra- and extrahospitalary practices in the case of ACVD in Andalusia. Methods: Cross.sectional prospective observational study. All patients were included who evidence clinical manifestations of ACVD and were seen at the Emergency Room in the 24 participating hospitals in Andalusia on the 5th, 15th and 25th of each month during the period from 5 March to 25 August 1998. The studied variables were: age, gender, type of lesion, risk factor, means used for access to the hospital, assistential delay from the first clinical manifestation (Delay 1), delay in performing a CT scan (Delay 2), resource usage and final destination of the patients. Results: The sample encompassed 347 patients, 71% of them aged over 65 years, and 81,6% with ischaemic lesions. The main risk factors were high blood pressure (55,8%) and atrial fibrillation (16,5%). Out of the total sample, 48,7% arrived at the hospital using their own transportation means. Delay 1: 47,3% of the cases were seen within the first three hours. Dealy 2: in 56,8% of the cases, the CT scan was performed within the first three hours. Destination: 59,9% of the cases were admitted to the Neurology Services. Conclusions: The Epidemiological and clinical profile of ACVD in Andalusia is similar to that in overall Spain. It is necessary to implement specific diagnostic and therapeutic management circuits for this condition, and particulary for the ischemic type, considering the observed assistential dealays