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Objectives: To investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions., Design: Registry-based study., Setting: We used the National Inpatient Sample (NIS) database, which covers a wide range of hospitals within the USA., Participants: The NIS was queried for patients with MCA strokes between 2016 and 2020. In total, 35 231 patients were included., Outcome Measures: Outcome measures were postprocedural complications, length of stays (LOSs), in-hospital mortality and non-routine discharge. Propensity score matching using all available baseline variables was performed to reduce confounders when comparing patients with and without concomitant COVID-19., Results: Mechanical thrombectomy (MT) was performed in 48.4%, intravenous thrombolysis (IVT) in 38.2%, and both MT and IVT (MT+IVT) in 13.4% of patients. A gradual increase in the use of MT and an opposite decrease in the use of IVT (p<0.001) was detected during the study period. Overall, 25.0% of all patients were admitted for MCA strokes during the pandemic period (2020), of these 209 (2.4%) were concomitantly diagnosed with COVID-19. Patients with MCA strokes and concomitant COVID-19 were significantly younger (64.9 vs 70.0; p<0.001), had significantly worse NIH Stroke Severity scores, and worse outcomes in terms of LOS (12.3 vs 8.2; p<0.001), in-hospital mortality (26.3% vs 9.8%; p<0.001) and non-routine discharge (84.2% vs 76.9%; p=0.013), as compared with those without COVID-19. After matching, only in-hospital mortality rates remained significantly higher in patients with COVID-19 (26.7% vs 8.5%; p<0.001). Additionally, patients with COVID-19 had higher rates of thromboembolic (12.3% vs 7.6%; p=0.035) and respiratory (11.3% vs 6.6%; p=0.029) complications., Conclusions: Among patients with MCA stroke, those with concomitant COVID-19 were significantly younger and had higher stroke severity scores. They were more likely to experience thromboembolic and respiratory complications and in-hospital mortality compared with matched controls., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Endovascular treatment (EVT) performed in the early time window has been shown to decrease the incidence of malignant middle cerebral artery infarction (MMI). However, the incidence of MMI in patients undergoing EVT during the late time window is unclear. This study aimed to investigate the prevalence of MMI in patients undergoing late EVT and compare it with that in patients undergoing early EVT., Methods: We retrospectively analyzed consecutive patients with anterior large vessel occlusion stroke who underwent EVT at Xuanwu Hospital between January 2013 and June 2021. Eligible patients were divided into early EVT (within 6 h) and late EVT (6-24 h) groups according to the time from their stroke onset to puncture and compared. The occurrence of MMI post-EVT was the primary outcome., Results: A total of 605 patients were recruited, of whom 300 (50.4%) underwent EVT within 6 h and 305 (49.6%) underwent EVT within 6-24 h. A total of 119 patients (19.7%) developed MMI. 68 patients (22.7%) in the early EVT group and 51 patients (16.7 %) in the late EVT group developed MMI (p = 0.066). After adjusting for covariate variables, late EVT was independently associated with a lower incidence of MMI (odds ratio, 0.404; 95% confidence interval, 0.242-0.675; p = 0.001)., Conclusion: MMI is not an uncommon phenomenon in the modern thrombectomy era. Compared with the early time window, patients selected by stricter radiological criteria to undergo EVT in the late time window are independently associated with a lower incidence of MMI., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background and Purpose: Assisted reproductive technologies (ART) induce premature vascular aging in human offspring. The related alterations are well-established risk factors for stroke and predictors of adverse stroke outcome. However, given the young age of the human ART population there is no information on the incidence and outcome of cerebrovascular complications in humans. In mice, ART alters the cardiovascular phenotype similarly to humans, thereby offering the possibility to study this problem., Methods: We investigated the morphological and clinical outcome after ischemia/reperfusion brain injury induced by transient (45 min) middle cerebral artery occlusion in ART and control mice., Results: We found that stroke volumes were almost 3-fold larger in ART than in control mice (P < 0.001). In line with these morphological differences, neurological performance assessed by the Bederson and RotaRod tests 24 and 48 h after artery occlusion was significantly worse in ART compared with control mice. Plasma levels of TNF-alpha, were also significantly increased in ART vs. control mice after stroke (P < 0.05). As potential underlying mechanisms, we identified increased blood-brain barrier permeability evidenced by increased IgG extravasation associated with decreased tight junctional protein claudin-5 and occludin expression, increased oxidative stress and decreased NO-bioactivity in ART compared with control mice., Conclusions: In wildtype mice, ART predisposes to significantly worse morphological and functional stroke outcomes, related at least in part to altered blood-brain barrier permeability. These findings demonstrate that ART, by inducing premature vascular aging, not only is a likely risk factor for stroke-occurrence, but also a mediator of adverse stroke-outcome., Translational Perspective: This study highlights that ART not only is a likely risk factor for stroke-occurrence, but also a mediator of adverse stroke-outcome. The findings should raise awareness in the ever-growing human ART population in whom these techniques cause similar alterations of the cardiovascular phenotype and encourage early preventive and diagnostic efforts., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Purpose: Decompressive hemicraniectomy (DH) reduces mortality of large middle cerebral artery (MCA) territory infarcts. Survivors are at high risk of poststroke seizures (PSSs). This study aims to describe the incidence of PSSs, to identify associated factors, and to assess their impact on long-term outcomes., Methods: We included consecutive patients who underwent DH for large MCA infarcts from May 2005 to December 2019 at Lille University Hospital. Patients were followed up at 3 months, 1 year, and 3 years. We analysed (i) the incidence and associated factors of early onset PSSs (EPSSs) with logistic regression models; (ii) the incidence and associated factors of late onset PSSs (LPSSs) in survivors at 7 days with a univariate Cox proportional hazard regression model for interval-censored data; and (iii) the impact of PSSs (EPSSs and LPSSs) on mortality with univariate and multivariate Cox proportional hazard regression models and modified Rankin Scale at 1 and 3 years, with univariate and adjusted multivariate ordinal logistic regression analyses., Results: Of 248 patients (150 men, 60.5%; mean age = 50.4 ± 9.6 years), 106 (42.7%) presented PSSs (six inaugural seizures, 22 EPSSs, 78 LPSSs) during follow-up. The PSS cumulative incidence was 12.3% at 7 days, 24.9% at 3 months, 49.8% at 1 years, and 54.8% at 3 years. No predictor was significantly associated with either EPSSs or LPSSs. PSSs did not significantly impact mortality and long-term functional outcome., Conclusions: The incidence of PSSs after DH is high, reaching more than 50% 3 years after stroke, but PSSs did not influence long-term mortality or functional outcome., (© 2021 European Academy of Neurology.)

Background: This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome., Methods: We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries., Results: Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042-1.447; P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively., Conclusions: Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.

Abstract: Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5 mm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR] = 6.362, 95% confidence interval [CI] = 1.444-28.023, P = .0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence interval = 1.107-28.399, P = .0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Etiologies of acute ischemic stroke in young adults are heterogeneous. Middle cerebral artery (MCA) stenosis is a common finding in Asians which may be an important cause of stroke in young adults. However, studies of stroke in young Asian populations are rare. Our study was to investigate the prevalence and outcome of young stroke patients with MCA stenosis in Chinese populations., Methods: Young patients with MCA territory infarction between January 2013 and September 2018 were retrospectively recruited. Subjects were defined as stenosis group (MCA stenosis ≥50%) and no-stenosis group (MCA stenosis<50% or no stenosis) by their MCA stenosis. For patients in stenosis group, they were categorized as uni-MCA stenosis subgroup and multiple stenosis subgroup. Demographic data, risk factors, imaging feature and complications were compared between groups. Prevalence of MCA stenosis and risk factor score (score ≥ 2 or 3) in different age groups were investigated. Modified Rankin Scale (mRS) was used for evaluating functional outcome at discharge (unfavorable outcome: 3-6). Binary logistic regression was performed to determine independent risk factors of unfavorable outcome., Results: Two hundred forty-nine young stroke patients were included in our study and 110 (44.2%) patients were defined as stenosis group. 55 (50%) patients were categorized as uni-MCA stenosis subgroup and 55 (50%) were multiple stenosis subgroup. The most common traditional vascular risk factors included hypertension, hyperlipemia, smoking, hyperhomocysteinemia and alcohol consumption. Prevalence of risk factor score ≥ 2 or 3 increased with age, but not incidence of MCA stenosis. By TOAST classification, the most common etiologies were large-artery atherosclerosis (41.0%) and small vessel disease (33.7%). Compared with no-stenosis group, patients in stenosis group were more likely to have large territorial infarct, develop complications and have unfavorable outcome. No significant difference was found between patients in uni-MCA stenosis and multiple stenosis subgroups except history of stroke/TIA, risk factor score ≥ 3 and silent infarct. By logistic regression, hypertension (OR = 3.561; 95%CI, 1.494 to 8.492; p = 0.004), NIHSS scores at admission (OR = 1.438; 95%CI, 1.276 to 1.620; p = 0,000) and infarct size (p = 0.015) independently predicted unfavorable outcome., Conclusions: Forty-four point two percent young Chinese adults with MCA territory infarction had MCA stenosis. Prevalence of MCA stenosis did not increase with age. Patients with MCA stenosis had worse clinical outcome, however, only hypertension, NIHSS scores at admission and infarct size were independent predictors.

Purpose: Single subcortical infarction (SSI) in the middle cerebral artery (MCA) territory can be classified into proximal SSI (pSSI) and distal SSI (dSSI) based on the heterogeneous pathogenesis. It is hypothesized that pSSI is more relevant with atherosclerosis, as low-density lipoprotein cholesterol (LDL-C) is the major atherogenic lipoprotein, we conducted the present study to investigate the association between LDL-C levels and pSSI in comparison with dSSI., Patients and Methods: This study is a subset of the Chinese Intracranial Atherosclerosis study. A total of 380 with SSI in the MCA territory classified as small artery occlusion stroke were enrolled in this study. 3.0-T magnetic resonance imaging (MRI) was performed to categorize the participants into two groups, pSSI (extending to the basal surface of MCA) and dSSI (not extending to the basal surface of MCA)., Results: Out of the 380 enrolled participants (273 men and 107 women), the proportion of pSSI and dSSI were 53.2% (202/380) versus 46.8% (178/380) based on MRI. The results of univariate and multivariate logistic regression were both at the borderline level of statistical significance. Further stratified analyses revealed that age is an interaction factor (P = 0.03), the association between LDL-C levels and the pSSI in participants aged over 65 had a significant positive relation (OR: 1.56; 95%CI: 1.14-2.12)., Conclusion: LDL-C level is an independent risk factor for pSSI in patients aged over 65. Our result is in accordance with the hypothesis that pSSI is more relevant with atherosclerosis, thus appropriate treatment should be applied differently to pSSI and dSSI., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI., Methods: We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients., Results: A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm 2 (range, 74.75-132.32 cm 2 ). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days)., Conclusions: The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Purpose: Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce., Methods: We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017., Results: The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients., Conclusion: Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background and Purpose- Collateral circulation status at baseline is associated with functional outcome after ischemic stroke and effect of endovascular treatment. We aimed to identify clinical and imaging determinants that are associated with collateral grade on baseline computed tomography angiography in patients with acute ischemic stroke due to an anterior circulation large vessel occlusion. Methods- Patients included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n=500) and MR CLEAN Registry (n=1488) were studied. Collateral status on baseline computed tomography angiography was scored from 0 (absent) to 3 (good). Multivariable ordinal logistic regression analyses were used to test the association of selected determinants with collateral status. Results- In total, 1988 patients were analyzed. Distribution of the collateral status was as follows: absent (7%, n=123), poor (32%, n=596), moderate (39%, n=735), and good (23%, n=422). Associations for a poor collateral status in a multivariable model existed for age (adjusted common odds ratio, 0.92 per 10 years [95% CI, 0.886-0.98]), male (adjusted common odds ratio, 0.64 [95% CI, 0.53-0.76]), blood glucose level (adjusted common odds ratio, 0.97 [95% CI, 0.95-1.00]), and occlusion of the intracranial segment of the internal carotid artery with occlusion of the terminus (adjusted common odds ratio 0.50 [95% CI, 0.41-0.61]). In contrast to previous studies, we did not find an association between cardiovascular risk factors and collateral status. Conclusions- Older age, male sex, high glucose levels, and intracranial internal carotid artery with occlusion of the terminus occlusions are associated with poor computed tomography angiography collateral grades in patients with acute ischemic stroke eligible for endovascular treatment.

Malignant cerebral edema (MCE) is a life-threatening complication of acute cerebral stroke. To date, the focus has been on symptomatic treatment, rather than on prevention. Therefore, to identify high-risk patients and explore potential therapeutic approaches, we investigated the possible predictors of MCE. Specifically, we performed a meta-analysis to identify the potential predictors of MCE in patients with acute cerebral infarction. We searched the MEDLINE, Embase, Cochrane, China National Knowledge Infrastructure, Wanfang Data, and VIP databases from their inception to July 2018 for cohort and case control studies on the predictors of MCE in patients with cerebral infarction. Forty-seven eligible studies containing a total of 45,826 patients were included. Our results suggest that the risk of MCE is higher in case of severe clinical symptoms and large infarct volumes. Additionally, male sex, older age, and a history of stroke and smoking were protective factors against MCE in cerebral infarction patients. Furthermore, thrombolytic therapy and recanalization substantially decreased the risk of MCE in patients with acute stroke. Higher admission temperature (in the subgroup with admission ≤12 h after onset), higher admission blood pressure, and admission leukocytes were also MCE predictors. Our findings facilitate the early prediction of MCE and may contribute to potential therapeutic approaches., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To investigate predictive factors and develop an outcome assessment tool to determine clinical outcome after endovascular mechanical thrombectomy (EMT) in patients presenting with large vessel occlusion (LVO)., Methods: A retrospective analysis was carried out of a prospective cohort of patients presenting with LVO who underwent EMT after adoption of an expanded time window of ≤24 hours. Final cerebral infarction volume (CIV) after EMT was estimated using magnetic resonance imaging segmentation software. Stepwise linear regression models were used to identify factors that determined clinical outcome and to develop a predictive scale., Results: Ninety patients underwent EMT over 19 months (68 within 6 hours and 22 between 6 and 24 hours). Clinical outcome determined using modified Rankin Scale (mRS) score at discharge and 3 months was no different among these subcohorts. A threshold of 16.99 mL of CIV, using the Youden index, resulted in a sensitivity of 90.5% and specificity of 58.1% for predicting mRS score of 0-2. A regression model identified gender, age, diabetes mellitus status, CIV, and smoking status as outcome determinants, which were used to develop the GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) scoring system to predict good clinical outcome. Using the GADIS score, <6 predicted mRS score 0-2 at discharge with a sensitivity of 83.3% and specificity of 80.6%., Conclusions: The GADIS score for patients with LVO-related acute ischemic stroke includes CIV after EMT and helps in early short-term prognostication. It is not intended to predict preintervention patient selection or outcome prediction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery., Methods: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported., Results: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02)., Conclusions: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy of endovascular therapy (EVT) with that of medical treatment in 'real-world 'patients with M2 occlusion., Methods: This was a post hoc analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2. Among 2420 patients in the registry, we evaluated patients with isolated M2 occlusion and those with functional independence before the stroke. Multivariable logistic regression analysis was used to evaluate and compare clinical outcomes between EVT and medical treatment. Additional propensity score-matched (PSM) analyses were performed. We performed subgroup analyses of the primary outcome (modified Rankin Scale score 0-2 at 90 days) using forest plots of treatment effects., Results: Overall, 372 patients with M2 occlusion (n=184 EVT; n=188, medical treatment) were evaluated. The EVT group had a higher baseline National Institutes of Health Stroke Scale score (median (IQR), 15 [9-19] vs 10 [5-16]) and earlier onset to hospital door time (110 [50-258] vs 150 [60-343] min) than the medical treatment group. After adjustment, EVT was significantly associated with higher odds of primary outcome (adjusted OR=2.09; 95% CI 1.26 to 3.47) and lower odds of mortality at 90 days (adjusted OR= 0.27; 95% CI 0.08 to 0.93). After PSM analyses (184 patients were 1:1 matched with each group), EVT was effective and safe relative to medical treatment. Effects favoring EVT were present in several subgroups of interest., Conclusion: In patients with M2 occlusion, our registry suggests that EVT is effective and safe., Competing Interests: Competing interests: MM reports no disclosures. SY discloses research grants from Medtronic, Medicos Hirata, Termo, Bristal-Myers Squibb, and Otsuka and lecturer’s fees from Boehringer-Ingelheim, Daiichi Sankyo, Otsuka, Bayer, Sanofi, Phizer, Bristal-Myers Squibb, Stryker, Medtronic, and Mitsubishi Tanabe. NS reports research a grant from Termo; lecturer’s fees from Jimro, Otsuka, Johnson & Johnson, Medtronic, Stryker, and Medicos Hirata; and membership of the advisory boards for Medtronic and Jimro. HY discloses research grants from Bristol-Myers Squibb; lecturer’s fees from Bayer, Daiichi-Sankyo, Bristol-Myers Squibb, Boehringer Ingelheim, and Striker; and membership of the advisory boards for Daiichi-Sankyo, Bayer, and Boehringer Ingelheim. KU reports lecturer’s fees from Nihon Medi-Physics. YN reports no disclosures. TM reports a research grant from Nexis; lecturer’s fees from AbbVie, AstraZeneca, Daiichi Sankyo, Kyorin, Mitsubishi Tanabe, and Phizer; manuscript fee from Pfizer; and membership of the advisory boards for Asahi Kasei, Boston Scientific, and Bristal-Myers Squibb., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Stroke is the fourth leading cause of disability worldwide. The present study was designed to assess functional disability in middle cerebral artery (MCA) territory ischemic stroke patients by applying standard scales for stroke severity, cognitive impairment, disability, dependency and depression. We also wanted to study whether baseline assessment predicts outcome at 1 month., Methodology: After institutional ethics committee approval, patients were enrolled from the inpatients of the Department of Medicine at Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai from July 2014 to December 2015. Various clinical parameters were recorded on admission. On day 5(±1) the National Institutes of health Stroke Scale (NIHSS), Mini Mental state examination (MMSE) were administered. On 1 month follow up, these were repeated along with Modified Rankin scale, Barthel's index (BI) and Hospital Anxiety and Depression Scale (HADS). Presence of certain risk factors for stroke were reviewed at 1 month., Results: 75 patients were enrolled. There was a delay in reaching the hospital and therefore imaging, in a greater majority. Only 4% could be imaged within the first 3 hours. Mean NIHSS score at day-5 was 9 and at day-30 was 6. Thus it had significantly reduced over 1 month. The MMSE remain unchanged at day 5 and at day 30. Lower baseline MMSE scores correlated with poorer outcomes on NIHSS, BI and mRS at 1 month. Both BI and mRS at 1 month indicated that about 60% of the cases had poor outcome. Amongst 48 of the non-aphasic MCA strokes, 11(22.92%) had depression. An NIHSS score of 6 or above on day 5, predicted poor outcome at 1 month. Presence of aphasia, dominant lobe affection and female sex were associated with a higher disability at 1 month. Around 30% cases had at least 1 risk factor uncontrolled at 1 month follow-up., Conclusions: Our findings show that disability assessment late in the first week after onset of stroke using NIHSS accurately forecast outcome at one month after onset of stroke. The MMSE too is not expected to change at 1 month. Those with aphasia are expected to have greater disability. Based on or study we recommend that stroke patients should be assessed with NIHSS and MMSE before discharge, to explain the prognosis of the patient. Also more intense counselling on controlling blood pressure and diabetes as well as abstinence from smoking should be undertaken routinely., (© Journal of the Association of Physicians of India 2011.)

Background: In acute ischemic stroke (AIS) collaterals correlate with infarct size, recanalization rate and clinical outcome. We aimed to identify factors associated with better collateral status in a large series of AIS patients with middle cerebral artery (MCA) occlusion., Methods: In the Acute STroke Registry and Analysis of Lausanne (ASTRAL) from 2003 to 2016, we identified all consecutive AIS with proximal MCA occlusion on CT-angiography performed < 24 h. Collaterals were scored from 0 (absent) to 3 (≥ 100%) and related to multiple demographic, clinical, metabolic and radiological variables in a multivariate regression analysis (MVA)., Results: The 857 included patients had a median age of 72.3 years, 48.4% were female and median admission NIHSS was 16. Better collaterals were associated with younger age (OR 0.99; 95% CI 0.98-1.00), hemineglect (OR 1.35; 95% CI 1.03-1.76), absence of visual field defects (OR 0.64; 95% CI 0.46-0.90), eye deviation (OR 0.58; 95% CI 0.43-0.79) and decreased vigilance (OR 0.62; 95% CI 0.44-0.88). Better collaterals were also associated with dyslipidemia (OR 1.57; 95% CI 1.16-2.13), no previous statin use (OR 0.69; 95% CI 0.50-0.95), and lower creatinine levels (OR 0.99; 95% CI 0.99-1.00). On neuroimaging, better collaterals related to higher ASPECTS score (OR 1.27; 95% CI 1.20-1.35) and higher clot burden score (OR 1.09; 95% CI 1.03-1.14)., Conclusions: Younger age, dyslipidemia and lower creatinine levels were predictors of better collaterals in AIS patients from proximal MCA occlusions. Greater degree of collaterals related to lower stroke severity on admission. On neuroimaging, better collaterals were independently associated with minor early ischemic changes and lower clot burden. These data may add knowledge on pathophysiology of collaterals development and may help to identify patients with better collaterals for late or aggressive recanalization treatments.

Background and Purpose- Malignant brain edema after ischemic stroke has high mortality but limited treatment. Therefore, early prediction is important, and we systematically reviewed predictors and predictive models to identify reliable markers for the development of malignant edema. Methods- We searched Medline and Embase from inception to March 2018 and included studies assessing predictors or predictive models for malignant brain edema after ischemic stroke. Study quality was assessed by a 17-item tool. Odds ratios, mean differences, or standardized mean differences were pooled in random-effects modeling. Predictive models were descriptively analyzed. Results- We included 38 studies (3278 patients) with 24 clinical factors, 7 domains of imaging markers, 13 serum biomarkers, and 4 models. Generally, the included studies were small and showed potential publication bias. Malignant edema was associated with younger age (n=2075; mean difference, -4.42; 95% CI, -6.63 to -2.22), higher admission National Institutes of Health Stroke Scale scores (n=807, median 17-20 versus 5.5-15), and parenchymal hypoattenuation >50% of the middle cerebral artery territory on initial computed tomography (n=420; odds ratio, 5.33; 95% CI, 2.93-9.68). Revascularization (n=1600, odds ratio, 0.37; 95% CI, 0.24-0.57) were associated with a lower risk for malignant edema. Four predictive models all showed an overall C statistic >0.70, with a risk of overfitting. Conclusions- Younger age, higher National Institutes of Health Stroke Scale, and larger parenchymal hypoattenuation on computed tomography are reliable early predictors for malignant edema. Revascularization reduces the risk of malignant edema. Future studies with robust design are needed to explore optimal cutoff age and National Institutes of Health Stroke Scale scores and to validate and improve existing models.

Background and Purpose- Early selection of patients with acute middle cerebral artery infarction at risk for malignant edema is critical to initiate timely decompressive surgery. Net water uptake (NWU) per brain volume is a quantitative imaging biomarker of space-occupying ischemic edema which can be measured in computed tomography. We hypothesize that NWU in early infarct lesions can predict development of malignant edema. The aim was to compare NWU in acute brain infarct against other common predictors of malignant edema. Methods- After consecutive screening of single-center registry data, 153 patients with acute proximal middle cerebral artery occlusion fulfilled the inclusion criteria. A total of 29 (18.2%) patients developed malignant edema defined as end point in follow-up imaging leading to decompressive surgery and death as a direct implication of mass effect. Early infarct lesion volume and NWU were quantified in multimodal admission computed tomography; time from symptom onset to admission imaging was recorded. Results- Mean time from onset to admission imaging was equivalent between patients with and without malignant infarcts (mean±SD: 3.3±1.4 hours and 3.3±1.7 hours, respectively). Edematous tissue expansion by NWU within infarct lesions occurred across all patients in this cohort (NWU: 9.1%±6.8%; median, 7.9%; interquartile range, 8.8%; range, 0.1%-35.6%); 7.0% (±5.2) in nonmalignant and 18.0% (±5.7) in malignant infarcts. Based on univariate receiver operating characteristic curve analysis, NWU >12.7% or an edema rate >3.7% NWU/h identified malignant infarcts with high discriminative power (area under curve, 0.93±0.02). In multivariate binary logistic regression, the probability of malignant infarct was significantly associated with early infarct volume and NWU. Conclusions- Computed tomography-based quantitative NWU in early infarct lesions is an important surrogate marker for developing malignant edema. Besides volume of early infarct, the measurements of lesion water uptake may further support identifying patients at risk for malignant infarction.

Background: Randomized clinical trials have proven mechanical thrombectomy (MT) to be a highly effective and safe treatment in acute stroke. The purpose of this study was to compare neurothrombectomy data from the Czech Republic (CR) with data from the HERMES meta-analysis., Methods: Available nationwide data for the CR from 2016 from the Safe Implementation of Treatments in Stroke-Thrombectomy (SITS-TBY) registry for patients with terminal internal carotid artery (ICA) and/or middle cerebral artery (MCA) occlusions were compared with data from HERMES. CR and HERMES patients were comparable in age, sex, and baseline National Institutes of Health Stroke Scale scores., Results: From a total of 1053 MTs performed in the CR, 845 (80%) were reported in the SITS-TBY. From these, 604 (72%) were included in this study. Occlusion locations were as follows (CR vs HERMES): ICA 22% versus 21% (P=0.16), M1 MCA 62% versus 69% (P=0.004), and M2 MCA 16% versus 8% (P<0.0001). Intravenous thrombolysis was given to 76% versus 83% of patients, respectively (P=0.003). Median onset to reperfusion times were comparable: 232 versus 285 min, respectively (P=0.66). A modified Thrombolysis in Cerebral Infarction score of 2b/3 was achieved in 74% (433/584) versus 71% (390/549) of patients, respectively (OR 1.17, 95% CI 0.90-1.5, P=0.24). There was no statistically significant difference in the percentage of parenchymalhematoma type 2 (OR 1.12, 95% CI 0.66-1.90, P=0.68). A modified Rankin Scale score of 0-2 at 3 months was achieved in 48% (184/268) versus 46% (291/633) of patients, respectively (OR 0.92, 95% CI 0.71-1.18, P=0.48)., Conclusions: Data on efficacy, safety, and logistics of MT from the CR were similar to data from the HERMES collaboration., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Purpose: The impact of smoking on prognosis after stroke is controversial. We aimed to assess the relationship between smoking status and stroke outcome after intravenous thrombolysis in a large cohort study by adjusting for potential confounders and incorporating recanalization rates., Methods: In a prospective observational multicenter study, we analyzed baseline and outcome data of consecutive patients with acute ischemic stroke treated with intravenous thrombolysis. Using uni- and multivariable modeling, we assessed whether smoking was associated with favorable outcome (modified Rankin Scale score of 0-1) and mortality. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage and recanalization of middle cerebral artery. Patients reporting active cigarette use were classified as smokers., Results: Of 1865 patients, 19.8% were smokers (n=369). They were younger (mean 63.5 versus 71.3 years), less often women (56% versus 72.1%), and suffered less often from hypertension (61.3% versus 70.1%) and atrial fibrillation (22.7% versus 35.6%) when compared with nonsmokers. Favorable outcome and 3-month mortality were in favor of smokers in unadjusted analyses (45.8% versus 39.5% and 9.3% versus 15.8%, respectively), whereas symptomatic intracranial hemorrhage was comparable in both cohorts. Smoking was not associated with clinical outcome and mortality after adjusting for confounders (odds ratio, 1.20; 95% confidence interval, 0.91-1.61; P =0.197 and odds ratio, 1.08; 95% confidence interval, 0.68-1.71; P =0.755, respectively). However, smoking still independently predicted recanalization of middle cerebral artery in multivariable analyses (odds ratio, 2.68; 95% confidence interval, 1.11-6.43; P =0.028)., Conclusions: Our study suggests that good outcome in smokers is mainly related to differences in baseline characteristics and not to biological effects of smoking. The higher recanalization rates in smokers, however, call for further studies., (© 2018 American Heart Association, Inc.)

Background and Purpose: This study aimed to evaluate the occurrence rate of the internal carotid artery pseudo-occlusion (ICA-PO) on 4-dimensional-computed tomography angiography and to investigate its relationship with clinical outcome after reperfusion therapy., Methods: In this case-control study, we retrospectively reviewed our prospectively collected database for consecutive acute ischemic stroke patients who received reperfusion therapy between June 2009 and February 2017. ICA-PO was defined when the arterial segment was not opacified on peak arterial phase yet was subsequently patent after artery peak phase on 4-dimensional-computed tomography angiography. Poor outcome was defined as 3-month modified Rankin Scale of 4 to 6. Binary logistic regression was used to investigate the relationship of ICA-PO with poor outcome and the rate of reperfusion, respectively., Results: A total of 143 patients with isolated middle cerebral artery occlusion were included and 30 (21.0%) had ICA-PO. Patients with ICA-PO were more likely to have poor outcome (80.0% versus 37.2%; P <0.001) and a lower rate of reperfusion (45.8% versus 69.0%; P =0.033) than those without. Binary logistic regression revealed that ICA-PO was independently associated with poor outcome (odds ratio, 7.957; 95% confidence interval, 1.655-34.869; P =0.009) and reperfusion at 24 hours (odds ratio, 0.150; 95% confidence interval, 0.045-0.500; P =0.002) after adjustment. Among patients with no reperfusion, all ICA-PO patients obtained poor outcome, whereas only 45.2% non-PO patients underwent poor outcome ( P =0.001)., Conclusions: Four dimensional-computed tomography angiography is a useful noninvasive technique to identify ICA-PO. Patients with ICA-PO are prone to undergo poor outcome from reperfusion therapy, especially when reperfusion is not achieved., (© 2018 American Heart Association, Inc.)

Background: Few data exist on malignant middle cerebral artery infarction (MMI) among patients with acute ischemic stroke (AIS) after endovascular treatment (ET). Numerous predictors of MMI evolution have been proposed, but a comprehensive research of patients undergoing ET has never been performed. Our purpose was to find a practical model to determine robust predictors of MMI in patients undergoing ET., Methods: Patients from a prospective single-center database with AIS secondary to large intracranial vessel occlusion of the anterior circulation, treated with ET, were retrospectively analyzed. We investigated demographic, clinical, and radiological data. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI., Results: 98 patients were included in the analysis, 35 of whom developed MMI (35.7%). No differences in the rate of successful reperfusion and time from stroke onset to reperfusion were found between the MMI and non-MMI groups. The following parameters were identified as independent predictors of MMI: systolic blood pressure (SBP) on admission (p=0.008), blood glucose (BG) on admission (p=0.024), and the CTangiography (CTA) Alberta Stroke Program Early CT Score (ASPECTS) (p=0.001). A scoreof ≤5 in CTA ASPECTS was the best cut-off to predict MMI evolution (sensitivity 46%; specificity 97%; positive predictive value 78%; negative predictive value 65%)., Conclusions: in our study a clinical and radiological features-based model was strongly predictive of MMI evolution in AIS. High SBP and BG on admission and, especially, a CTA ASPECTS ≤5 may help to make decisions quickly, regardless of time to treatment and successful reperfusion., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Purpose: The aim of the present study was to investigate atherosclerotic plaque characteristics in patients with artery-to-artery (A-to-A) embolic infarction by whole-brain high-resolution magnetic resonance imaging., Methods: Seventy-four patients (mean age, 54.7±12.1 years; 59 men) with recent stroke in the territory of middle cerebral artery because of intracranial atherosclerotic disease were prospectively enrolled. Whole-brain high-resolution magnetic resonance imaging was performed in all the patients both precontrast and postcontrast administration by using a 3-dimensional T1-weighted vessel wall magnetic resonance imaging technique known as inversion-recovery prepared sampling perfection with application-optimized contrast using different flip angle evolutions. Patients were divided into A-to-A embolic infarction and non-A-to-A embolic infarction groups based on diffusion-weighted imaging findings. The characteristics of the intracranial atherosclerotic plaques were compared between groups., Results: A total of 74 intracranial atherosclerotic plaques were analyzed (36 in A-to-A embolism group and 38 in non-A-to-A embolism group). Hyperintense plaques (HIPs) were more frequently observed in A-to-A embolism group (75.0% versus 21.1%; P <0.001). Eighteen of the 27 HIPs (66.7%) demonstrated hyperintense spots or areas located adjacent to the lumen versus 9 HIPs (33.3%) located within the plaque in A-to-A embolism group. Furthermore, a higher prevalence of plaque surface irregularity was also observed in A-to-A embolism group (41.7% versus 18.4%; P =0.029). Logistic regression analysis showed that HIP was the most powerful independent predictor of A-to-A embolic infarction ( P <0.001), with the odds ratio of 11.2 (95% confidence interval, 3.5-36.2)., Conclusions: A-to-A embolic infarction has distinct vulnerable plaque characteristics compared with non-A-to-A embolic infarction. HIP and plaque surface irregularity may predict A-to-A embolic infarction., (© 2018 American Heart Association, Inc.)

Introduction: Early decompression craniectomy (within 48 hours of stroke onset) in acute and malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality and increases the proportion of patients with favorable functional outcome. Various cultural and social issues among Asians lead to some differences in clinical practice, especially when surgical interventions are involved. Accordingly, decompressive craniectomy in Asian patients with stroke is often delayed., Materials and Methods: Data for all patients with acute IS hospitalized in our center were entered into a prospectively maintained registry. In this retrospective analysis, data for all patients with malignant MCA IS who underwent decompressive craniectomy were extracted. Various demographic, clinical, and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale score of 0-3 points., Results: From January 2005 to December 2014, a total of 75 patients with acute MCA IS underwent decompressive craniectomy. Median age was 55 years (interquartile range 44-64) with male preponderance (66%) and median National Institute of Health Stroke Scale score 21 points (interquartile range 18-24). A considerable proportion of these patients (38.7%) received intravenous thrombolysis. The majority (70%) of patients suffered right MCA IS, and decompressive surgery was performed within 48 hours of symptom onset in 50 (67%) of the patients. Favorable functional outcome was achieved in 25 (33.3%) patients at 6 months. Right MCA stroke (odds ratio 9.158; 95% confidence interval 1.881-44.596, P = 0.006) and early decompression surgery (odds ratio 4.011; 95% confidence interval 1.058-15.208, P = 0.041) were independent predictors of favorable functional outcome at 6 months., Conclusions: Early decompression craniectomy, especially in right MCA ischemic stroke, is associated with better favorable functional outcome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Although the Woven EndoBridge (WEB [Sequent Medical, Aliso Viejo, California, USA]) is a highly innovative technique for the endovascular treatment of wide-necked bifurcation aneurysms (WNBAs), there are no studies available comparing this technique with surgical results or other endovascular results of stent-assisted coiling or balloon-assisted coiling for WNBAs. The purpose of this study was to assess complications, complete occlusion rate, and morbidity and mortality of the WEB in WNBA treatment., Methods: Published literature citing embolization results for WNBAs using the WEB was reviewed. A systematic review was performed to evaluate the complications, complete occlusion rate, and morbidity and mortality., Results: We identified 19 studies, including 935 patients. The most frequent aneurysm locations were the bifurcation of the middle cerebral artery (MCA) (42.8%), the anterior communicating artery (23%), and the basilar bifurcation (20.8%). The technical success rate of the WEB was 97% (95% confidence interval [CI], 96%-98%). The thromboembolic complication rate was 8% (95% CI, 6%-11%). The thromboembolic complication rate was 10% (95% CI, 7%-13%) in cases before 2013, which was higher than in cases after 2013 (6%; 95% CI, 4%-9%; P = 0.045). MCA bifurcation aneurysm has a higher thromboembolic complication rate than posterior circulation aneurysm. The overall bleeding complication rate of the WEB was 2% (95% CI, 1%-3%). The adequate occlusion rate was 81% (95% CI, 76%-85%). Morbidity during follow-up was 3% (95% CI, 1%-4%) (I 2  = 30.4%), and mortality was 2% (95% CI, 1%-3%)., Conclusions: Adequate aneurysm occlusion was found in 81% of WEB cases with low morbidity and mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Stroke is one of the most common causes of disability-adjusted life years worldwide. The aim of this study is to identify variables associated with dependence at 3 months and also after the first 3 months after the first-ever ischemic stroke (IS) in middle cerebral artery (MCA) territory submitted to intravenous thrombolysis (IVT)., Methods: A single-center cohort study of patients with first-ever MCA IS treated with IVT at the Hospital de Clínicas, Universidade Federal do Paraná, was followed over 5 years. Logistic regression was performed to determine predictors of early and late dependence., Results: A total of 144 patients were included; 48.6% women, and 47.2% were dependent at 3 months after stroke. NIHSS at admission (OR = 1.3, 95%CI = 1.16-1.45, p < 0.001), large artery atherosclerosis (LAA) stroke (OR = 4.11, 95%CI = 1.31-12.85, p = 0.014) and pneumonia during hospitalization (OR = 9.17, 95%CI = 1.42-59.07, p = 0.019) were predictors for early dependence. For the late dependence analyses, 99 patients were included; 49.5% women and 39.4% were dependent after 3 months of stroke. NIHSS at admission (OR = 1.33, 95%CI = 1.15-1.54, p < 0.001), pneumonia during hospitalization (OR = 11.08, 95%CI = 1.45-84.73, p = 0.019) and seizure after discharge (OR = 5.82, 95%CI = 1.06-32.01, p = 0.040) were predictors for late dependence., Discussion: .Dependence is an important indicator of the efficacy of stroke care. Besides it was not possible to evaluate rehabilitation, this is the first study on predictors of post-stroke dependence that focus exclusively on patients with first-ever MCA IS submitted to IVT. NIHSS, LAA stroke, in-hospital pneumonia and seizures after discharge were associated with dependence after first-ever MCA IS submitted to IVT.

Cerebral amyloid angiopathy (CAA) is a common cause of cognitive impairment in older individuals. This study aimed to investigate predictors of dementia in CAA patients without intracerebral hemorrhage (ICH). A total of 158 non-demented patients from the Stroke Service or the Memory Clinic who met the modified Boston Criteria for probable CAA were included. At baseline, neuroimaging markers, including lobar microbleeds (cerebral microbleeds (CMBs)), white matter hyperintensities (WMH), cortical superficial siderosis (cSS), magnetic resonance imaging (MRI)-visible centrum semiovale perivascular spaces (CSO-PVS), lacunes, and medial temporal atrophy (MTA) were assessed. The overall burden of small vessel disease (SVD) for CAA was calculated by a cumulative score based on CMB number, WMH severity, cSS presence and extent and CSO-PVS severity. The estimated cumulative dementia incidence at 1 year was 14% (95% confidence interval (CI): 5%-23%), and 5 years 73% (95% CI: 55%, 84%). Age (hazard ratio (HR) 1.05 per year, 95% CI: 1.01-1.08, p = 0.007), presence of MCI status (HR 3.40, 95% CI: 1.97-6.92, p < 0.001), MTA (HR 1.71 per point, 95% CI: 1.26-2.32, p = 0.001), and SVD score (HR 1.23 per point, 95% CI: 1.20-1.48, p = 0.030) at baseline were independent predictors for dementia conversion in these patients. Cognitive deterioration of CAA patients appears attributable to cumulative changes, from both vasculopathic and neurodegenerative lesions.

Recent studies based on experimental animal models of stroke have suggested that uncoupling protein 2 (UCP2), an inner mitochondrial membrane protein that is thought to regulate energy metabolism and reduce reactive oxygen species generation, provides protection against reperfusion damage. We aimed to investigate whether -866G/A polymorphism in the promoter of the UCP2 gene, which enhances its transcriptional activity, is associated with functional prognosis in patients with embolic ischemic stroke after early recanalization. We investigate a hospital-based prospective cohort of patients with acute ischemic stroke due to occlusion of the middle cerebral artery diagnosed by transcranial Doppler who obtained a partial/complete recanalization 24 h after administration of intravenous thrombolysis. The main end point of the study was functional independence defined as modified Rankin Scale 0-2 on day 90. A total of 80 patients were enrolled. The UCP2-866G/A polymorphism was determined by polymerase chain reaction-restriction fragment length polymorphism technique (14 genotype A/A (18%), 45 genotype A/G (56%) and 21 genotype G/G (26%). The percentage of patients with good functional outcome at 3 months was significantly higher in patients harboring the A/A genotype than in those with A/G or G/G genotypes (85 vs 41%, p = 0.01). The A/A genotype was found to be an independent marker of good prognosis after adjustment for secondary variables (age, sex, glucose level, NIHSS score at baseline, complete recanalization and early neurological improvement) in a logistic regression analysis (OR 0.05, 95% CI 0.01-0.48, p = 0.01). Our results suggest that the AA genotype of UCP2-866 may predict a better functional outcome in ischemic stroke after recanalization of proximal MCA occlusion.

Background and Purpose: The presence of intracranial artery calcification is associated with an increased risk for stroke. However, calcified atherosclerotic plaques are also known to be less vulnerable to rupture. Given this discrepancy, we investigated whether the vulnerability of intracranial arterial atherosclerosis differed based on the presence or absence of calcification., Methods: We considered consecutive patients with acute stroke in the unilateral middle cerebral artery (MCA) territory. Patients with any stenotic MCAs were included in this study. Symptomatic MCA was defined as the occurrence of infarctions relevant to the stenotic MCA. The presence of calcification in the MCA was evaluated on noncontrast thin-section computed tomography images using a 3dimensional software package. Generalized estimating equations were used to compare the frequency of calcification between symptomatic and asymptomatic stenosis., Results: Of the 1066 MCAs examined in 533 patients, 645 MCAs were stenotic and were included in the study. Among the 645 stenotic MCAs, 406 MCAs (62.9%) were symptomatic. Calcification was observed in 36 MCAs (5.6%). Calcification in the MCA was more frequently observed in the asymptomatic group (7.9% versus 4.2%; P =0.032). On multivariable analysis, the presence of calcification in MCA atherosclerosis was less frequent in the symptomatic group (odds ratio, 0.46; 95% confidence interval, 0.23-0.92; P =0.027)., Conclusions: This study showed that calcified atherosclerosis in the MCA was less frequently symptomatic., (© 2017 American Heart Association, Inc.)

Background: Cortical microinfarcts (CMIs) have been correlated to cognitive decline and dementia. It was previously considered only visible on microscope, but was recently reported to be visible on 3.0 Tesla magnetic resonance imaging (MRI) and linked to presence of intracranial stenosis. We aimed to investigate CMIs on 3.0 Tesla MRI in patients with M1 middle cerebral artery (MCA-M1) stenosis., Methods: Patients with a recent non-cardioembolic ischemic stroke or transient ischemic attack and an atherosclerotic MCA-M1 stenosis were recruited. The severity of MCA stenosis was defined as moderate (50%-69%) or severe (70%-99% or focal flow void) on time-of-flight MR angiography (MRA). The distal to proximal signal intensity ratio (SIR) of MCA stenosis was measured on time-of-flight MRA to represent its hemodynamic significance. The presence of CMI(s) in the ipsilateral hemisphere was assessed on axial T1- or T2-weighted images and T2-weighted fluid-attenuated inversion-recovery images., Results: Overall, 86 patients (mean age: 62.8 years; 77.9% males) were analyzed, 66 (76.7%) and 20 (23.3%), respectively, having moderate and severe MCA-M1 stenoses. The median SIR was .91. Forty-five (52.3%) patients had ipsilateral CMI(s). Multivariate logistic regression showed a history of dyslipidemia (odds ratio [OR] = 6.83, P = .008), and an SIR lower than the median (OR = 4.73, P = .014) were independently associated with presence of CMI(s) in ipsilateral hemisphere to an MCA-M1 stenosis., Conclusions: Patients with stroke and intracranial stenosis had a high burden of CMI. Except for a history of dyslipidemia, the hemodynamic significance of the arterial stenosis may contribute to the presence of ipsilateral CMI(s) in these patients, which warrants further investigation in prospective, longitudinal studies., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

The misidentification of one's own limb (LM) after right hemisphere stroke is a striking phenomenon that is incompletely understood. The authors prospectively studied the natural history and anatomy of LM in 36 patients with hyperacute right middle cerebral artery infarct. Unlike in previous studies, rapid clinical assessment was prioritized. The authors found LM to be common and transient, involving 61% at onset, evolving to 15% at 1 week. Voxel-based lesion-symptom mapping found supramarginal gyrus (SMG) damage associated with LM. This substantiates the SMG's importance in LM and has broader implications for lesion analysis: timing matters. Rapid assessment of transient disorders minimizes false negatives, which can improve lesion analysis.

Background: Thrombus migration (TM) in intracranial vessels during ischemic stroke has been reported in the form of case reports, but its incidence, impact on the technical success of subsequent endovascular thrombectomy and patients' outcome have never been studied systematically., Methods and Results: Retrospective analysis was done of 409 patients with isolated middle cerebral artery occlusions treated with endovascular thrombectomy. TM was observed (1) by analyzing discrepancies between computed tomographic angiography and digital subtraction angiography and (2) by comparing infarct pattern in the striatocapsular region with exact, angiographically assessed thrombus location within the M1-segment and the involvement of the middle cerebral artery perforators. Preinterventional infarction of discrepant regions (infarction in regions supplied by more proximal vessels than those occluded by the clot) was ensured by carefully reviewing available preinterventional multimodal imaging. Adequate imaging inclusion criteria were met by 325 patients. Ninety-seven patients showed signs of TM (26 with direct evidence, 71 with indirect evidence). There was no difference in the frequency of preinterventional intravenous recombinant tissue plasminogen activator administration between patients with TM and those without (63.9% vs 64.9%, P =0.899). TM was associated with lower rates of complete reperfusion (Thrombolysis in Cerebral Infarction score 3) (adjusted odds ratio 0.400, 95% CI 0.226-0.707). Subsequently, preinterventional TM was associated with lower rates of substantial neurologic improvement (adjusted odds ratio 0.541, 95% CI 0.309-0.946)., Conclusions: Preinterventional TM does not seem to be facilitated by intravenous recombinant tissue plasminogen activator and often occurs spontaneously. However, TM is associated with the risk of incomplete reperfusion in subsequent thrombectomy, suggesting increased clot fragility. Occurrence of TM may thereby have a substantial impact on the outcome of endovascularly treated stroke patients., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Purpose: To investigate the correlation between middle cerebral atherosclerosis and capsular warning syndrome (CWS) and assess the value of higher-resolution magnetic resonance imaging (MRI) in prognostication., Materials and Methods: In all, 97 transient ischemic attack (TIA) patients who underwent an MRI from February 2010 to December 2013 were included in the retrospective study and divided into either a CWS or middle cerebral artery (MCA) TIA group according to their eventual clinical diagnosis. 3T MRI included fast-spin echo T 2 -weighted imaging, double-inverse recovery T 1 -weighted imaging, and T 1 contrast-enhanced scan sequences. Baseline characteristics, MRI results in terms of MCA plaque formation, plaque characteristics such as enhancement, and development of infarction were compared between the two groups to study the distribution and characteristics of cerebral atherosclerotic plaques. Multivariate analysis identified factors associated with infarction 1 week after plaque identification., Results: Based on the MR images, 76% of both groups of patients had middle cerebral atherosclerosis. Compared to TIA patients, the median age of CWS patients was younger (58 [range 42-73] vs. 67 [36-84] years, P = 0.003), and CWS patients had a lower rate of stroke history (10.9% vs. 41.2%, P = 0.001). Infarction was more common in CWS patients than in TIA patients (52.2% vs. 20.5%, P = 0.003) and a superior plaque was correlated with infarction occurrence (odds ratio 5.674, 95% confidence interval 1.112-28.958)., Conclusion: Patients with CWS have large arterial plaques, including MCA plaques. There was a correlation between CWS and the MCA plaque location. J. Magn. Reson. Imaging 2016;44:1277-1283., (© 2016 International Society for Magnetic Resonance in Medicine.)

Background: Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children., Methods: Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined., Results: Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%)., Conclusions: Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Poor leptomeningeal collateral flow is related to worse clinical outcome in acute ischemic stroke, but the factors that determine leptomeningeal collateral patency are largely unknown. We explored the determinants of leptomeningeal collateral flow and assessed their effect on the relation between leptomeningeal collateral flow and clinical outcome., Methods: We included 484 patients from the Dutch acute stroke study (DUST) with a middle cerebral artery (MCA) occlusion. The determinants of poor leptomeningeal collateral flow (≤50 % collateral filling) were identified with logistic regression. We calculated the relative risk (RR) of poor leptomeningeal collateral flow in relation to poor clinical outcome (90-day modified Rankin Scale 3-6) using Poisson regression and assessed whether the determinants of leptomeningeal collateral flow affected this relation., Results: Leptomeningeal collateral flow was poor in 142 patients (29 %). In multivariable analyses, higher admission glucose level (odds ratio (OR) 1.1 per mmol/L increase (95 % CI 1.0-1.2)), a proximal MCA occlusion (OR 1.9 (95 % CI 1.3-3.0)), and an incomplete posterior circle of Willis (OR 1.7 (95 % CI 1.1-2.6)) were independently related to poor leptomeningeal collateral flow. Poor leptomeningeal collateral flow was related to poor clinical outcome (unadjusted RR 1.7 (95 % CI 1.4-2.0)), and this relation was not affected by the determinants of leptomeningeal collateral flow., Conclusion: Our study shows that admission glucose level, a proximal MCA occlusion, and an incomplete ipsilateral posterior circle of Willis are determinants of leptomeningeal collateral flow that represent a combination of congenital, acquired, and acute factors. After adjustment for these determinants, leptomeningeal collateral flow remains related to clinical outcome., Competing Interests: Compliance with ethical standards We declare that all human studies have been approved by the medical ethics committee of the University Medical Center Utrecht, The Netherlands, and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all participants gave informed consent prior to inclusion in this study; however, the medical ethics committee waived informed consent for patients who died before informed consent could be obtained. Conflict of interest We declare that we have no conflict of interest.

Background: An impairment of amyloid-β (Aβ) clearance has been suggested in Alzheimer's disease. Perivascular drainage along cerebrovascular vessels is considered an important amyloid clearance pathway., Objective: This study examined the effect of reduced arterial pulsation that could cause an impairment in cerebral amyloid drainage on the prevalence of cortical microbleeds (CMBs), a surrogate marker for cerebral amyloid angiopathy (CAA)., Methods: Patients who lost depiction of either side of the carotid artery or the middle cerebral artery on magnetic resonance angiography were studied. Those who showed acute cerebral infarction or a previous cortical cerebral infarction were excluded. The number of CMBs was counted on the occluded and non-occluded sides of the brain in each subject. The number of subjects who showed more CMBs on the occluded side of the brain was compared with the number of subjects who showed more CMBs on the non-occluded side of the brain., Results: Twenty-eight patients were studied. The extent of lacunar infarction and white matter lesions was not different, irrespective of the occluded vessels or the distribution of CMBs. The prevalence of CMBs was not different between the occluded and non-occluded sides of the brain., Conclusion: In this cross-sectional study, reduction of arterial pulsation was not associated with a higher prevalence of CAA. Therefore, reduced arterial pulsation alone may not be enough to promote CAA.

Objective: To identify the different subtypes of acute ischemic stroke, and estimate the frequency of various risk factors among these patients., Methods: In this retrospective, cross-sectional study, we reviewed the medical records of patients admitted with the diagnosis of acute ischemic stroke at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia from March 2008 till December 2015. The demographic characteristics, subtypes of stroke, risk factors (hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, atrial fibrillation, valvular heart disease) and other relevant data were documented on pre-defined data sheets., Results: The records of 343 patients were included in the study; 64.4% were male and 35.6% were female. The mean age was 59.3+/-13.6 (mean+/-SD) years for males, and 66.8+/-14.9 years for females. Small vessel occlusion was the most common etiologic subtype of ischemic stroke (32.1%), followed by cardio embolic (21.9%), and large artery atherosclerosis (14.6%). The middle cerebral artery was the most commonly affected territory. Hypertension was found in 78.1%, diabetes mellitus in 62.7%, hyperlipidemia in 54.8%, and ischemic heart disease in 24.2% of patients., Conclusion: Small vessel occlusion was the most common etiology in our cohort. The onset of stroke at a relatively younger age group in the male population is of great concern and needs to be verified by further epidemiological studies. Adequate control of modifiable risk factors may help in reducing the disease burden caused by stroke.

Objective: To investigate risk factors for neonatal arterial ischemic stroke (NAIS), and compare them with those present in term controls and infants with hypoxic-ischemic encephalopathy (HIE)., Study Design: Antepartum and intrapartum data were collected at presentation from 79 infants with NAIS and compared with 239 controls and 405 infants with HIE. The relationships between risk factors and NAIS were explored using univariable and multivariable regression., Results: Compared with controls, infants with NAIS more frequently had a family history of seizures/neurologic diseases, primiparous mothers, and male sex. Mothers of infants with NAIS experienced more intrapartum complications: prolonged rupture of membranes (21% vs 2%), fever (14% vs 3%), thick meconium (25% vs 7%), prolonged second stage (31% vs 13%), tight nuchal cord (15% vs 6%), and abnorm8al cardiotocography (67% vs 21%). Male sex (OR 2.8), family history of seizures (OR 6.5) or neurologic diseases (OR 4.9), and ≥1 (OR 5.8) and ≥2 (OR 21.8) intrapartum complications were independently associated with NAIS. Infants with NAIS and HIE experienced similar rates though different patterns of intrapartum complications. Maternal fever, prolonged rupture of membranes, prolonged second stage, tight nuchal cord, and failed ventouse delivery were more common in NAIS; thick meconium, sentinel events, and shoulder dystocia were more frequent in HIE. Abnormal cardiotocography occurred in 67% of NAIS and 77.5% of infants with HIE. One infant with NAIS and no infant with HIE was delivered by elective cesarean (10% of controls)., Conclusions: NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum events may play a more significant role in the pathogenesis of NAIS than previously recognized., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: In this study, we sought to examine the prevalence and clinical relevance of deep tiny flow voids (DTFV) in patients with steno-occlusive middle cerebral artery (MCA) disease on high-resolution MRI (HRMRI)., Methods: We retrospectively reviewed the HRMRI and clinical data of 477 patients with MCA steno-occlusive disease. The presence and distribution of DTFV, defined as 3 or more flow voids along the affected MCA on at least 2 consecutive T2-weighted image slices on HRMRI, were observed. The relationships among DTFV, the degree of stenosis (mild <50%, moderate 50%-70%, severe 70%-99%, and occlusion), and infarctions were analyzed. To clarify the difference between DTFV and moyamoya collaterals, we compared the HRMRI findings of the patients with DTFV and 102 patients with moyamoya disease., Results: The prevalence of DTFV was 1.4% in mild stenosis, 12.8% in moderate stenosis, 40.6% in severe stenosis, and 50.7% in MCA occlusions. Of the 112 patients with DTFV, 57 (50.9%) had all 4 quadrants (superior, inferior, dorsal, and ventral sides) of the MCA involved. DTFV were more common in asymptomatic patients than in symptomatic patients with severe stenosis (49.3% vs 30.9%, p = 0.025) and occlusions (68.0% vs 41.7%, p = 0.033). Obvious flow voids in the basal ganglia region were observed in 58 patients (56.9%) with moyamoya disease but in none of the patients with DTFV (p < 0.001)., Conclusions: DTFV are common in patients with severe steno-occlusive MCA disease, especially in asymptomatic patients. We hypothesize that DTFV originate from new vessel network formation in response to chronic cerebral ischemia., (© 2016 American Academy of Neurology.)

We aimed to investigate the overall prevalence and possible factors influencing the occurrence of crossed cerebellar diaschisis after acute middle cerebral artery infarction using whole-brain CT perfusion. A total of 156 patients with unilateral hypoperfusion of the middle cerebral artery territory formed the study cohort; 352 patients without hypoperfusion served as controls. We performed blinded reading of different perfusion maps for the presence of crossed cerebellar diaschisis and determined the relative supratentorial and cerebellar perfusion reduction. Moreover, imaging patterns (location and volume of hypoperfusion) and clinical factors (age, sex, time from symptom onset) resulting in crossed cerebellar diaschisis were analysed. Crossed cerebellar diaschisis was detected in 35.3% of the patients with middle cerebral artery infarction. Crossed cerebellar diaschisis was significantly associated with hypoperfusion involving the left hemisphere, the frontal lobe and the thalamus. The degree of the relative supratentorial perfusion reduction was significantly more pronounced in crossed cerebellar diaschisis-positive patients but did not correlate with the relative cerebellar perfusion reduction. Our data suggest that (i) crossed cerebellar diaschisis is a common feature after middle cerebral artery infarction which can robustly be detected using whole-brain CT perfusion, (ii) its occurrence is influenced by location and degree of the supratentorial perfusion reduction rather than infarct volume (iii) other clinical factors (age, sex and time from symptom onset) did not affect the occurrence of crossed cerebellar diaschisis., (© The Author(s) 2015.)

Background: There are a variety of intensive care therapies in the treatment of malignant middle cerebral artery infarction (MMI) besides hemicraniectomy (HC), the only treatment with proven efficacy. It is, however, not known how HC and conservative treatments are utilized in German hospitals, Furthermore, data on the care-situation of patients with MMI in Germany is scarce., Methods: An anonymous questionnaire was sent to 297 neurological and 133 neurosurgical hospitals in Germany., Results: The Response rate was 24,7%. Most respondents indicated personal experience in the treatment of MMI (83,3%). HC is usually performed early on site (83,3%). Indication to HC is confirmed on a high level of hierarchy and profession using clinical and radiological criteria in 78,2% of hospitals. Inherent standardized treatment protocols are established in 70,8% of hospitals. Patients are treated on an intensive care unit in 74,5% of hospitals after DHC and in 42,5% of hospitals under non-surgical treatment. Intracranial pressure monitoring is not performed on a regular basis. Differing opinions were observed concerning diagnosis and treatment of MMI without recognizable consensus., Conclusion: Basically, structural requirements for the treatment of MMI exist in the participating hospitals. Heterogeneity in the treatment of MMI is striking. The implementation of treatment protocols and adherence to guidelines are desirable steps to optimize treatment.

Objective: To assess whether the association between reperfusion and improved clinical outcomes after stroke differs depending on the site of the arterial occlusive lesion (AOL)., Methods: We pooled data from Solitaire With the Intention for Thrombectomy (SWIFT), Solitaire FR Thrombectomy for Acute Revascularisation (STAR), Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2), and Interventional Management of Stroke Trial (IMS III) to compare the strength of the associations between reperfusion and clinical outcomes in patients with internal carotid artery (ICA), proximal middle cerebral artery (MCA) (M1), and distal MCA (M2/3/4) occlusions., Results: Among 710 included patients, the site of the AOL was the ICA in 161, the proximal MCA in 389, and the distal MCA in 160 patients (M2 = 131, M3 = 23, and M4 = 6). Reperfusion was associated with an increase in the rate of good functional outcome (modified Rankin Scale [mRS] score 0-2) in patients with ICA (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.7-7.2) and proximal MCA occlusions (OR 6.2, 95% CI 3.8-10.2), but not in patients with distal MCA occlusions (OR 1.4, 95% CI 0.8-2.6). Among patients with M2 occlusions, a subset of the distal MCA cohort, reperfusion was associated with excellent functional outcome (mRS 0-1; OR 2.2, 95% CI 1.0-4.7)., Conclusions: The association between endovascular reperfusion and better clinical outcomes is more profound in patients with ICA and proximal MCA occlusions compared to patients with distal MCA occlusions. Because there are limited data from randomized controlled trials on the effect of endovascular therapy in patients with distal MCA occlusions, these results underscore the need for inclusion of this subgroup in future endovascular therapy trials., (© 2016 American Academy of Neurology.)

Background: Single small subcortical infarctions (SSSIs) in the lenticulostriate artery territory can be classified as proximal single small subcortical infarction (pSSSI) or distal single small subcortical infarction (dSSSI) lesions depending on the involvement of the lowest part of the basal ganglia. It was reported that pSSSI lesions have more characteristics of large artery atherosclerosis, whereas dSSSI lesions are more characteristic of small vessel disease. Because infarction of small vessels is more likely to be distal and may result in small lesions, we hypothesized that the clinical features of dSSSI lesions might be heterogeneous and classified based on lesion size., Methods: Lenticulostriate SSSI patients admitted within 72 hours of stroke onset were included from a prospectively registered hospital-based stroke database. We determined the location (lowest slice [LS] involved) and size (total number of slices [TNS] involved) of SSSIs on magnetic resonance imagings. Based on lesion location, SSSIs were divided into pSSSI (LS ≤ 2) and dSSSI (LS > 2); the latter were further subdivided into distal and small SSSI (ds-SSSI, TNS ≤ 2) or distal and large SSSI (dl-SSSI, TNS > 2). The clinical characteristics were compared between different groups., Results: A total of 204 patients were included out of 1158 patients registered in the database. We found that ds-SSSI was most often associated with severe white matter hyperintensities. However, patients with dl-SSSI most often had a higher rate of additional concurrent atherosclerotic disease as coronary heart disease, compared to patients with ds-SSSI., Conclusions: The pathogenesis of dSSSI may be heterogeneous depending on lesion size., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate delayed stenosis of the vessels after endovascular thrombectomy using magnetic resonance (MR) angiography., Materials and Methods: Of 82 consecutive patients who underwent successful endovascular treatment for acute intracranial large vessel occlusion between October 2010 and October 2014 at a single institution, 57 patients for whom 3-month radiologic follow-up examinations using MR angiography were available were included in the analysis. MR angiography images were assessed to detect delayed stenosis, which was defined as a decrease in the diameter of treated vessels > 50% compared with MR angiography images obtained 24 hours after endovascular treatment., Results: MR angiography images obtained 3 months after endovascular treatment revealed delayed stenosis of treated vessels in five (8.8%) of 57 patients. All cases of delayed stenosis were asymptomatic and occurred in the middle cerebral artery (MCA). Further serial radiologic follow-up showed gradual improvement of all delayed stenosis over 12 months., Conclusions: Endovascular treatment poses a risk of delayed stenosis of treated vessels, especially in the MCA. MR angiography is a useful modality in long-term follow-up to evaluate delayed stenosis after endovascular treatment., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The CHA2DS2-VASc score is associated with severity and outcome of ischaemic stroke in patients with atrial fibrillation (AF). It was hypothesized that a high CHA2DS2-VASc score was related to severity and outcome because of its association with proximal artery occlusion (PAO). This study aimed to elucidate the relationship between the CHA2DS2-VASc score and PAO and to determine whether the effect of the CHA2DS2-VASc score on severity or outcome is independent of PAO., Methods: Acute stroke patients with AF were retrospectively enrolled. PAO was defined as occlusion at the internal carotid artery or proximal middle cerebral artery on admission magnetic resonance angiography. Multivariable analyses were performed to identify independent factors associated with PAO and determine the associations of the CHA2DS2-VASc score with the initial National Institutes of Health Stroke Scale (NIHSS) score and poor functional outcome (discharge modified Rankin scale score 4-6)., Results: In all, 213 patients [102 women; median age 80 (interquartile range 71-86) years; NIHSS score 16 (9-22)] were enrolled. On multivariable analysis, the CHA2DS2-VASc score (odds ratio 1.40, 95% confidence interval 1.12-1.76 per 1 point) was independently associated with PAO and correlated with the initial NIHSS score (standardized coefficient 0.198, P = 0.017). This association was not significant after further adjustment for PAO (0.080, P = 0.241). The CHA2DS2-VASc score was independently related to poor outcome even adjusted for PAO (odds ratio 1.39, 95% confidence interval 1.03-1.88)., Conclusion: The CHA2DS2-VASc score was associated with PAO in acute ischaemic stroke patients with AF. The CHA2DS2-VASc score may be correlated with the NIHSS score through the presence of PAO and with poor functional outcome independently of PAO., (© 2015 EAN.)

Background: Large intracranial occlusive vascular disease is a major contributor to the incidence of stroke worldwide, especially when it involves the middle cerebral artery (MCA). The data on the prognosis of symptomatic atherosclerotic MCA occlusions (MCAO) with concomitant intracranial arterial disease (MCAO-AIS) are limited. MCAO-AIS may reflect the extent of the atherosclerotic intracranial disease, we hypotheses that coexisting intracranial arterial disease influenced the prognosis of MCAO., Methods: Patients having survived at least one month after the initial ischemic stroke who suffered from atherosclerotic occlusion of the MCA were enrolled. According to their concomitant atherosclerotic intracranial arterial disease, the patients were assigned to one of two groups: the MCAO or the MCAO-AIS. All of the patients' cerebrovascular risk factors were recorded. Recurrent ischemic stroke and death were the end-point events during the follow-up., Results: A total of 232 patients (mean age 57.68 ± 9.50 years; 69% male) were analyzed. The mean follow-up time was 17.65 months. The end-point events occurred in 35 (15.09%) patients, resulting in an annual rate of 10.26%. The presence of MCAO- AIS was an independent risk factor associated with the patient's prognosis in the cohort (OR = 3.426, 95% CI 1.261 to 9.308; p = 0.016), as well as gender and diabetes mellitus. The MCAO-AIS were more likely to experience ipsilateral ischemic strokes, but the difference was not statistically significant., Conclusion: Concomitant intracranial arterial disease may influence the prognosis of patients with atherosclerotic MCAO. The result warrants further research in larger sample population.

Background: The risk factors and epidemiology of extracranial and intracranial atherosclerotic lesions may be different. We evaluated the importance of perioperative management of coronary atherosclerotic lesions in carotid endarterectomy (CEA) or carotid artery stenting (CAS) for extracranial cervical carotid artery stenosis and superior temporal artery (STA)-middle cerebral artery (MCA) bypass for intracranial severe MCA stenosis/occlusion., Methods: The medical records of patients who underwent cerebrovascular surgery at Aizu Chuo Hospital between January 2000 and September 2010 were retrospectively analyzed. Preoperative cardiovascular screening was performed for all patients to prevent perioperative ischemic heart disease-related complications. The number of patients requiring preoperative treatment of the coronary artery was compared., Results: A total of 320 patients underwent surgery for cervical carotid stenosis (IC group; 259 patients with CEA and 61 patients with CAS), and 92 patients underwent STA-MCA bypass for MCA stenosis/occlusion (MC group). Treatment for coronary lesions was required in 35 of 320 patients (10.9%) in the IC group and 14 of 92 patients (15.2%) in the MC group. Surgery was safely performed in both groups without any ischemic heart disease-related complications during the perioperative period., Conclusions: This study shows the importance of perioperative management of coronary atherosclerotic lesions for STA-MCA bypass, similar to that for CEA/CAS., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The significance of segmental heart wall motion abnormalities for stroke is unknown. The aims of the study included (1) comparison of the frequency and type of embolic signals in the middle cerebral artery in patients with segmental left ventricular wall hypokinesis due to coronary heart disease with and without stroke, and (2) determination of the relationship between inflammatory parameters, fibrinogen level, dyslipidemia and microembolic signals in the middle cerebral artery in patients with segmental heart hypokinesis., Material and Methods: The study included 68 patients with segmental heart hypokinesis (33 without stroke [group I] and 35 with stroke [group II]), as well as 37 healthy volunteers and a reference group of 30 patients. Echocardiography and carotid/transcranial Doppler with detection of microembolic signals were performed. Patients from group I and II had erythrocyte sedimentation rate, leucocyte count, triglycerides, total cholesterol, HDL, and LDL examined., Results: Embolic signals were detected in patients with segmental heart hypokinesis significantly more frequently than in the control and reference groups. The high number of embolic signals, signals of high intensity, hypokinesis of the distal part of the intraventricular septum, increased cholesterol levels, LDL and triglycerides were all found more frequently in patients from group II than in group I. Embolic signals were detected more frequently in patients with high fibrinogen levels and leukocytosis., Conclusions: Embolic signals in the middle cerebral artery in patients with segmental left ventricular hypokinesis have to be considered as a risk factor of stroke. The following changes are observed in patients with cardiogenic stroke: hypokinetic intraventricular septum, high intensity embolic signals, increased serum fibrinogen levels and leucocyte count. It may indicate the importance of these factors in the aetiology of stroke., (Copyright © 2014 Polish Neurological Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.)

Background: Transcranial Doppler (TCD) has been subjected to criticism for detecting vasospasm (VSP). Our study's aim is to derive criteria for middle cerebral artery (MCA) vasospasm (MCA-VSP) based on cerebral angiography (CA)., Methods: A prospective data of patients with aneurysmal subarachnoid hemorrhage (aSAH) from January 2004 to August 2009. TCD was performed daily from day 2 to 14 from symptom's onset. Follow-up CA was done at day 7-9. TCD mean flow velocities (MFV) of all vessels at baseline (b), middle (m) and before CA (preangio) were recorded. Several MCA MFV ratios were computed. Moderate to severe VSP on CA was defined as >1/3 luminal narrowing. Univariate and stepwise logistic regression analysis were performed., Results: One hundred sixty-nine patients (338 MCA) with aSAH were included, mean age: 54.8 ± 13, women: 103 (62%). Twenty-nine patients (8.6%) had angiographic MCA-VSP. TCD scoring system of 3 points for MCA-VSP was computed based on (a) bMCA MFV ≥ 120 cm/s (sensitivity: 59.3%, specificity: 85%, PPV: 36.4%, NPV: 93.5%, P < .001) (1 point), Preangio MCA MFV ≥ 150 cm/s (79.3%, 89.9%, 39%, 97.3%, <.001) (1 point), and affected preangio MCA/bMCA MFV ratio ≥ 1.5 (84%, 63%, 25.6%, 96.3%, .001) (1 point). The score of 3 has 96% sensitivity and 96% specificity (OR: 300) whereas the score of 1 has 12% sensitivity and 58% specificity (OR: 4.3) for identifying MCA-VSP., Conclusion: TCD stringent criteria for moderate to severe MCA-VSP are feasible and applicable in aSAH population., (Copyright © 2012 by the American Society of Neuroimaging.)