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Background: Stroke presents as the second most prominent factor contributing to global mortality. Immediate brain imaging can be valuable for assessing functional recovery potential. This study investigated the association between Alberta Stroke Program Early CT Score (ASPECTS) and functional outcomes in patients with left and right-hemisphere strokes. Methods: A prospective cohort study was conducted in July-Dec2 022, at a tertiary care hospital in Karachi including patients of either gender presenting within 2 days of stroke while excluding posterior circulation strokes, TIA & unwilling patients using a non-probability consecutive sampling technique. A total of 152 patients with acute ischemic stroke involving anterior circulation were analyzed and patients were categorized into two groups: the left hemisphere group (n=76) and the right hemisphere group (n=76) accordingly. ASPECTS scores were calculated from brain CT scans, while functional outcomes were measured using the modified Rankin Scale (mRS) at the three-month mark. Descriptive analysis and chi-square test were applied using SPSS vr25. Results: Patients (n=152) had a mean age of 61.75 ± 13 years, with males comprising 67% of the cohort. ASPECTS scores were notably higher in left hemisphere strokes (median 9, IQR 2) than right hemisphere strokes (median 8, IQR 3) (p=0.036). Higher ASPECTS scores (≥7) correlated with improved outcomes (mRS ≤2) in both hemispheres. There was no statistically significant difference in both groups’ functional outcomes (p=0.182). Conclusion: ASPECTS predicts functional outcomes in acute ischemic strokes equally well regardless of the affected hemisphere.

Introduction: In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). Methods: Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. Results: Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. Conclusion: In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. Clinical trial registration information: German Clinical Trials Register (URL: https://www.drks.de; Unique Identifier: DRKS00000624). [ABSTRACT FROM AUTHOR]

Local ischemia in the cerebra leads to vascular injury and necrosis. Ferroptosis is involved in the pathophysiological process of many diseases and widely exists when ischemia-reperfusion injury occurs in many organs. The aim of this study was to evaluate the effect of Butylphthalide (NBP) on middle cerebral artery occlusion (MCAO) rats model-caused neuron injury. Sprague Dawley Rats were randomly allocated to receive sham and MCAO operation. NBP low-dose (40 mg/kg b.w), and high-dose (80 mg/kg b.w) were administrated in MACO rats. Results showed NBP improves infarct volume, attenuates neuronal apoptosis in the brain tissue of MCAO rats. The tumor necrosis factor (TNF-α), IL-6, and malondialdehyde (MDA) levels decreased after NBP administration, while the activity of superoxide dismutase (SOD) and the ratio of GSH/GSSG in MACO rats increased. MACO caused non-heme iron accumulation in the brain tissue and Perl's staining confirmed NBP attenuates ferroptosis in MACO rats. The protein expressions of SCL7A11 and glutathione peroxidase 4 (GPX4) decreased following MCAO, and NBP treatment subsequently increased the expression of SCL7A11 and GPX4. In vitro analysis in cortical neuron cells indicated that the GPX4 inhibitor reverses the inhibition of ferroptosis by NBP, which suggested that the SCL7A11/GPX4 pathway majorly contributed to the NBP ferroptosis protection effect. [ABSTRACT FROM AUTHOR]

To evaluate the clinical outcomes of patients with malignant middle cerebral artery (MCA) infarction who underwent wide decompressive hemicraniectomy. Fifty-two patients with large MCA infarcts were retrospectively evaluated, and 12 patients who underwent extensive decompressive hemicraniectomy and duraplasty with a bone flap extending beyond the infarct borders were included in the study. The degree of stroke (stroke volume), preoperative and postoperative midline shift of the craniectomy area and improvement in midline shift were calculated on computed tomography. Preoperative and postoperative neurologic examination scores were determined using the modified Rankin Scale. The mean age was 63 (min: 41, max: 79) years. There was left MCA infarction in one patient and right MCA infarction in 11 patients. The postoperative follow-up period of the operated patients ranged from 14 to 90 days. The neurological examination of seven patients (58.3%) showed significant improvement. Eight (66.6%) patients survived. Postoperatively, the mean midline deviation value of 12 patients decreased from 11.04 to 4.8. It is considered that wide decompressive craniectomy performed in young patients in the early period with strict radiological and clinical follow-up can increase survival and functional recovery. [Med-Science 2023; 12(1.000): 286-90]

To evaluate the clinical outcomes of patients with malignant middle cerebral artery (MCA) infarction who underwent wide decompressive hemicraniectomy. Fiftytwo patients with large MCA infarcts were retrospectively evaluated, and 12 patients who underwent extensive decompressive hemicraniectomy and duraplasty with a bone flap extending beyond the infarct borders were included in the study. The degree of stroke (stroke volume), preoperative and postoperative midline shift of the craniectomy area and improvement in midline shift were calculated on computed tomography. Preoperative and postoperative neurologic examination scores were determined using the modified Rankin Scale. The mean age was 63 (min: 41, max: 79) years. There was left MCA infarction in one patient and right MCA infarction in 11 patients. The postoperative follow-up period of the operated patients ranged from 14 to 90 days. The neurological examination of seven patients (58.3%) showed significant improvement. Eight (66.6%) patients survived. Postoperatively, the mean midline deviation value of 12 patients decreased from 11.04 to 4.8. It is considered that wide decompressive craniectomy performed in young patients in the early period with strict radiological and clinical follow-up can increase survival and functional recovery. [ABSTRACT FROM AUTHOR]

Introduction: Decompressive hemicraniectomy (DCE) is routinely performed for intracranial pressure control after malignant middle cerebral artery (MCA) infarction. Decompressed patients are at risk of traumatic brain injury and the syndrome of the trephined until cranioplasty. Cranioplasty after DCE is itself associated with high complication rates. Single-stage surgical strategies may eliminate the need for follow-up surgery while allowing for safe brain expansion and protection from environmental factors. Research question: Assess the volume needed for safe expansion of the brain to enable single-stage surgery. Materials and methods: We performed a retrospective radiological and volumetric analysis of all patients that had DCE in our clinic between January 2009 and December 2018 and met inclusion criteria. We investigated prognostic parameters in perioperative imaging and assessed clinical outcome. Results: Of 86 patients with DCE, 44 fulfilled the inclusion criteria. Median brain swelling was 75.35 mL (8.7–151.2 mL). Median bone flap volume was 113.3 mL (73.34–146.1 mL). Median brain swelling was 1.62 mm below the previous outer rim of the skull (5.3 mm to –2.19 mm). In 79.6% of the patients, the volume of removed bone alone was equivalent to or larger than the additional intracranial volume needed for brain swelling. Discussion and conclusion: The space provided by removal of the bone alone was sufficient to match the expansion of the injured brain after malignant MCA infarction in the vast majority of our patientsA subgaleal space-expanding flap with a minimal offset can provide protection from trauma and atmospheric pressure without compromising brain expansion.

The purpose of this study was to investigate the feasibility of hematoma evacuation (HE) with decompressive craniectomy (DC) and to evaluate whether HE with DC is associated with improvement of clinical outcomes in patients with parenchymal hematoma type 2 (PH2) after middle cerebral artery (MCA) infarction. Between March 2007 and August 2020, 73 patients with PH2 after MCA infarction underwent DC. The HE group (n = 28) consisted of subjects who underwent HE with DC and the non-HE group (n = 45) consisted of subjects who underwent only DC without HE. The clinical outcomes were analyzed and compared between groups. Significant differences in clinical outcomes were not observed between the groups at discharge (P = 0.648) and 12-month follow-up (P = 0.346). Mortality rate within 12 months was not significantly different between the groups (log-rank, P = 0.685). There were 12 reoperations in the HE group (42.9%) and three reoperations in the non-HE group (6.7%; P = 0.037). Logistic regression analysis showed the initial National Institutes of Health Stroke Scale score (OR, 2.320; 95% CI, 1.128–5.965; P = 0.046) and the infarction volume (OR, 1.876; 95% CI, 1.935–11.892; P = 0.041) were independently associated with mortality (modified Rankin Scale, 6) within the 12 months. In patients with PH2 of hemorrhagic transformation after MCA infarction, HE with DC does not change the clinical outcomes or mortality but might increase the reoperation risk. [ABSTRACT FROM AUTHOR]

BackgroundDecompressive craniectomy (DC) improves the survival and functional outcomes in patients with malignant cerebral infarction. Currently, there are no objective intraoperative markers that indicates adequate decompression. We hypothesise that closure intracranial pressure (ICP) correlates with postoperative outcomes.MethodsThis is a multicentre retrospective review of all 75 DCs performed for malignant cerebral infarction. The patients were divided into inadequate ICP (iICP) and good ICP (gICP) groups based on a suitable ICP threshold determined with tiered receiver operating characteristic and association analysis. Multivariable logistic regression was performed for various postoperative outcomes.ResultsAn ICP threshold of 7 mmHg was determined, with 36 patients (48.0%) and 39 patients (52.0%) in the iICP and gICP group, respectively. After adjustment, postoperative osmotherapy usage was more likely in the iICP group (OR 6.32, p = 0.003), and when given, was given for a longer median duration (iICP, 4 days; gICP, 1 day, p = 0.003). There was no difference in complications amongst both groups. When an ICP threshold of 11 mmHg was applied, there was significant difference in the duration on ventilator (ICP ≥11 mmHg, 3–9 days, ICP

Objective: We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction. Material and Methods: The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations. Results: In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 cm2 and 20%, whereas these values for surviving patients were 149 ± 29 cm2 and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 cm2 and 22.2%, whereas these values for patients without severe disability were 159 cm2 ± 26 and 28.4% (P = 0.001), respectively. Conclusion: In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy.

Mesenchymal stromal cells (MSCs) are characterized by paracrine and immunomodulatory functions capable of changing the microenvironment of damaged brain tissue toward a more regenerative and less inflammatory milieu. The authors conducted a phase 2, single-center, assessor-blinded randomized controlled trial to investigate the safety and efficacy of intravenous autologous bone marrow-derived MSCs (BMMSCs) in patients with subacute middle cerebral artery (MCA) infarct. Patients aged 30–75 years who had severe ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 10–35) involving the MCA territory were recruited within 2 months of stroke onset. Using permuted block randomization, patients were assigned to receive 2 million BMMSCs per kilogram of body weight (treatment group) or standard medical care (control group). The primary outcomes were the NIHSS, modified Rankin Scale (mRS), Barthel Index (BI) and total infarct volume on brain magnetic resonance imaging (MRI) at 12 months. All outcome assessments were performed by blinded assessors. Per protocol, analyses were performed for between-group comparisons. Seventeen patients were recruited. Nine were assigned to the treatment group, and eight were controls. All patients were severely disabled following their MCA infarct (median mRS = 4.0 [4.0–5.0], BI = 5.0 [5.0–25.0], NIHSS = 16.0 [11.5–21.0]). The baseline infarct volume on the MRI was larger in the treatment group (median, 71.7 [30.5–101.7] mL versus 26.7 [12.9–75.3] mL, P = 0.10). There were no between-group differences in median NIHSS score (7.0 versus 6.0, P = 0.96), mRS (2.0 versus 3.0, P = 0.38) or BI (95.0 versus 67.5, P = 0.33) at 12 months. At 12 months, there was significant improvement in absolute change in median infarct volume, but not in total infarct volume, from baseline in the treatment group (P = 0.027). No treatment-related adverse effects occurred in the BMMSC group. Intravenous infusion of BMMSCs in patients with subacute MCA infarct was safe and well tolerated. Although there was no neurological recovery or functional outcome improvement at 12 months, there was improvement in absolute change in median infarct volume in the treatment group. Larger, well-designed studies are warranted to confirm this and the efficacy of BMMSCs in ischemic stroke. [ABSTRACT FROM AUTHOR]

BACKGROUND: Posterior cerebral artery infarction simulates middle cerebral artery infarction in approximately 17% of patients. The distinction is difficult when the hemiplegia is not associated with symptoms indicating a midbrain lesion. Occlusion of the proximal posterior cerebral artery results in paramedian and anterolateral midbrain infarction. Paramedian infarction results in oculomotor and pupillary disturbances, while anterolateral midbrain infarction results in hemiplegia. Distinguishing between these two infarctions is important given the potential implications for treatment and outcome. CLINICAL CASE: A 67-year-old male patient with the clinical expression of Weber syndrome -which is a crossed or alternating clinical syndrome- as part of a proximal occlusion of the posterior cerebral artery. CONCLUSIONS: It is essential to consider the existence of a posterior cerebral artery infarction in patients with acute hemiparesis-hemiplegia associated with oculomotor abnormalities, drowsiness, and variations in the level of consciousness. [ABSTRACT FROM AUTHOR]

Background:Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke.Aims:To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location.Study Design:Cross-sectional study.Methods:We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ≥3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short- and long-term outcomes of the patients were evaluated.Results:Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p

Objective: We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction. Material and Methods: The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations. Results: In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 ² and 20%, whereas these values for surviving patients were 149 ± 29 cm2 and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 ² and 22.2%, whereas these values for patients without severe disability were 159 cm² ± 26 and 28.4% (P = 0.001), respectively. Conclusion: In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy. [ABSTRACT FROM AUTHOR]

Background: A hyper-intense vessel sign on fluid attenuated inversion recovery magnetic resonance imaging (FHV) represents slow blood flow in the cerebral arteries. Purpose: To investigate the relationship between the proximal FHV (pFHV) on initial magnetic resonance imaging (MRI) and the status of the culprit vessel (stenosis, obstruction) in hyper-acute strokes affecting the territory of the middle cerebral artery (MCA). Material and Methods: The study participants consisted of 105 patients presenting to the emergency department (ED) with acute MCA infarction within 4.5 h of onset of symptoms. Patients underwent brain MRI within 45 min of arrival at the ED and angiography within 2 h of arrival. Culprit vessel status and presence of a pFHV on initial MRI were investigated retrospectively. Results: The pFHV was observed in 71/105 (67.6%) patients who presented with a hyper-acute MCA infarction. All patients with hyper-acute MCA infarction caused by internal carotid artery (90.6% caused by M1 occlusion, 92.9% caused by M2 occlusion) showed a pFHV on initial MRI. After logistic regression analysis, the presence of a pFHV showed significant positive correlation with large vessel occlusion (adjusted odds ratio [OR] 34.533, 95% confidence interval [CI] 9.781–121.926; P < 0.001). A pFHV was not associated with severe large vessel stenosis. Conclusion: A pFHV is independently representative of the acute occlusion of intervention-eligible proximal arteries within the territory of the MCA. If a patient with a hyper-acute MCA infarction shows a pFHV, aggressive flow augmentation strategies and early activation of intervention team should be warranted for best patient outcome. [ABSTRACT FROM AUTHOR]

BACKGROUND AND PURPOSE: Iterative model reconstruction (IMR) has shown to improve computed tomography (CT) image quality compared to hybrid iterative reconstruction (HIR). Alberta Stroke Program Early CT Score (ASPECTS) assessment in early stroke is particularly dependent on high‐image quality. Purpose of this study was to investigate the reliability of ASPECTS assessed by humans and software based on HIR and IMR, respectively. METHODS: Forty‐seven consecutive patients with acute anterior circulation large vessel occlusions (LVOs) and successful endovascular thrombectomy were included. ASPECTS was assessed by three neuroradiologists (one attending, two residents) and by automated software in noncontrast axial CT with HIR (iDose4; 5 mm) and IMR (5 and 0.9 mm). Two expert neuroradiologists determined consensus ASPECTS reading using all available image data including MRI. Agreement between four raters (three humans, one software) and consensus were compared using square‐weighted kappa (κ). RESULTS: Human raters achieved moderate to almost perfect agreement (κ =.557‐.845) with consensus reading. The attending showed almost perfect agreement for 5 mm HIR (κHIR =.845), while residents had mostly substantial agreements without clear trends across reconstructions. Software had substantial to almost perfect agreement with consensus, increasing with IMR 5 and 0.9 mm slice thickness (κHIR =.751, κIMR =.777, and κIMR0.9 =.814). Agreements inversely declined for these reconstructions for the attending (κHIR =.845, κIMR =.763, and κIMR0.9 =.681). CONCLUSIONS: Human and software rating showed good reliability of ASPECTS across different CT reconstructions. Human raters performed best with the reconstruction algorithms they had most experience with (HIR for the attending). Automated software benefits from higher resolution with better contrasts in IMR with 0.9 mm slice thickness. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study intended to assess the occurrence of early signs of middle cerebral artery (MCA) on multidetector computed tomography (MDCT) in correlation with duration of the clinical features of stroke. PATIENTS AND METHODS: This retrospective study analyzed the electronic records of 20 patients with MCA infarction. The detected signs studied according to the onset of the clinical features of stroke to the time of CT imaging. RESULTS: Out of 20 patients with MCA infarction included in this study, the results revealed a significant relationship between the presence of insular ribbon sign and/or subtle hypodensity and hyperacute infarction (P < 0.001 and 0.003, respectively). Results revealed significant relationship between the occurrence of hypodense area, effacement of the cortical sulci, and compression of the ipsilateral lateral ventricle with acute infarction (6–72 h), (P = 0.006, 0.007, and 0.002) (odds ratio = 0.047, 0.050 and 0.028) and (95% confidence interval = 0.004–0.552, 0.004–0.597 and 0.002–0.367) respectively. CONCLUSION: MDCT can detect nearly half of MCA infarctions in the first 6 h. Insular ribbon sign and subtle hypodensity were the most significant findings in the first 6 h of stroke. Hypodense area was a significant sign after 6 h. Diabetes mellitus and ischemic heart disease were the most common risk factors. Hemiparesis was the most common clinical finding in MCA infarction.

Objective To outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later. Methods Seventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group. Results Multivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item. Conclusion In combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living.

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The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent. [ABSTRACT FROM AUTHOR]

Acute ischemic stroke is a public health issue worldwide. Currently, the effective treatment for acute ischemic stroke is an intravenous recombinant tissue plasminogen activator (rt-PA). The follow-up CT brain after the rt-PA is still controversial. This study was a retrospective study with an aim to evaluate roles of CT brain after rt-PA treatment. The inclusion criteria were all consecutive adult patients diagnosed as acute ischemic stroke who received the rt-PA. The patients were categorized into two groups by the presence of the follow-up CT brain. For those who performed the CT brain, results of the CT brain or management were correlated with clinical status at 24 hours after the rt-PA and stroke types. There were 211 eligible patients. Of those, 86 patients (40.76%) performed the CT brain after the rt-PA treatment within 24 to 36 hours. For the CT brain group, hemorrhagic transformation occurred the highest in those without clinical improvement with the NIHSS at 24 hours over 10 (14/32 patients; 43.75%). The overall hemorrhagic transformation was 23 patients (26.74%). Regarding stroke type, the intracerebral hemorrhage was found mostly in large arterial stroke (16 patients). While, the malignant middle cerebral artery infarction was found in seven patients (8.14%); five patients with large arterial stroke and two patients with cardioembolic stroke. In conclusion, the follow-up CT brain after the rt-PA treatment may be performed in selected cases such as those without clinical improvement with the NIHSS of over 10 or large arterial/cardioembolic stroke. [ABSTRACT FROM AUTHOR]

Background: Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke. Aims: To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location. Study Design: Cross-sectional study. Methods: We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ≥3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short- and long-term outcomes of the patients were evaluated. Results: Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p<0.05). Pathological yawning was related to higher National Institutes of Health Stroke Scale scores. Patients with severe stroke (National Institutes of Health Stroke Scale score ≥10) presented with more pathological yawning than those with mild to moderate strokes (p<0.05). The clinical outcomes and mortality rates showed no significant relationship with the occurrence of pathological yawning. Conclusion: Pathological yawning in middle cerebral artery stroke was associated with stroke severity, presence of cortical involvement, and insular and opercular infarcts. However, no association was found with long-term outcome and mortality. [ABSTRACT FROM AUTHOR]

Aim: In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservative treatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate both the effect of decompression time and the size of craniectomy on the mortality in this patient group. Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. The demographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first 24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct (standard), or it was two centimeters larger than the size of infarct (larger). Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died due to malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgery was 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survived longer than the others, but the difference was non-significant (p=0.06). Conclusion: We suggested that not the approach of "surgery as soon as possible" but the surgery between 24-48th hours of the admission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have a less benefit on the outcome but also may lead several unnecessary complications. [ABSTRACT FROM AUTHOR]

We report a case of a 5-year-old girl who developed left hemiparesis and left facial palsy, 6 days after the initiation of fever and respiratory symptoms due to pneumonia. Chest radiography, conducted upon admission, showed pneumonic infiltration and pleural effusion in the left lung field. Brain magnetic resonance imaging showed acute ischemic infarction in the right middle cerebral artery territory. Brain magnetic resonance angiography and transfemoral cerebral angiography revealed complete occlusion of the right middle cerebral artery. Mycoplasma pneumoniae infection was identified by a 4-fold increase in IgG antibodies to M. pneumoniae between acute and convalescent sera by enzyme-linked immunosorbent assay. Fibrinogen and D-dimer levels were elevated, while laboratory exams in order to identify other predisposing factors of pediatric stroke were all negative. This is the first reported pediatric case in English literature of a M. pneumoniae-associated cerebral infarction involving complete occlusion of the right middle cerebral artery.

Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.

Background: Cerebral venous drainage might influence brain edema characteristics and functional outcome of patients with severe ischemic stroke. The purpose of the study was to evaluate whether hypoplasia of transverse sinuses or the internal jugular veins is associated with poor functional outcome in patients with space-occupying middle cerebral artery (MCA) infarction who underwent decompressive surgery.Methods: We performed a retrospective analysis of patients with space-occupying MCA infarction treated with decompressive surgery at our university hospital. The transverse sinuses and the internal jugular veins were evaluated on baseline images and categorized as normal, hypoplastic or occluded. We defined composite variables for ipsilateral, contralateral or any abnormal cerebral venous drainage. We assessed the functional outcome at 12 months with the modified Rankin scale (mRS) score and defined poor functional outcome as mRS scores 5 and 6.Results: We analyzed 88 patients with available baseline imaging data [mean [SD] patient age 53 (±9) years; median[IQR] time to decompressive surgery 31(22-51) h]. At 12 months 44 patients (50%) had a poor outcome. In univariate analysis neither ipsilateral (OR 1.98;95%CI: 0.75–5.40), nor contralateral (OR 1.56;95%CI: 0.59–4.24) or any (OR 1.6; 95%CI: 0.68–3.79) hypoplasia or occlusion of venous drainage were significantly associated with poor functional outcome. In multivariate analyses, higher patient age (OR 1.07;95%CI 1.01–1.14) and baseline stroke severity (OR 3.42;95%CI 1.31–9.40) were independent predictors of poor functional outcome, but not ipsilateral hypoplasia or occlusion of venous drainage (OR 1.31;95%CI 0.47–3.67).Conclusions: The cerebral venous drainage pattern was not significantly associated with poor functional outcome in our cohort of patients with space-occupying MCA infarction who underwent decompressive surgery.

Introduction: Large hemispheric infarctions secondary to occlusion of middle cerebral artery (MCA) are termed "malignant MCA territory infarctions" due to high mortality and morbidity resulting from large infarction volume and herniation. Decompressive craniectomy has been found to improve the outcome in these patients. Objectives: To evaluate the outcome with surgical management in comparison with conservative management in the treatment of malignant MCA territory infarction. Materials and Methods: The patients with malignant MCA territory infarction admitted from August 2009 to January 2014 were included in the study. Clinical, laboratory, and radiological data were collected from hospital records. The outcome was measured at discharge and at last follow-up. Results: Out of 692 patients with MCA territory infarctions 66 had malignant MCA infarctions (9.53%). Among them 31 underwent surgical decompression (age 45.77 ± 15.33 years) and 35 were medically treated (age 56.11 ± 14.99 years). There was no significant difference in the sex ratio, comorbidities, blood sugars, incidence of hemorrhagic transformation, and herniation between the two groups. Admission Glasgow coma scale (GCS) was higher in surgically treated patients. In-hospital mortality among the patients in the surgical group was 19.35% and in the medical group was 17.34%. Thirteen patients were lost for follow-up. In the remaining 53 patients, there was statistically nonsignificant increase in the death and severe disability in medically treated patients (75% and 78.5%, respectively) in comparison with Surgically treated patients (52% and 68%, respectively). Conclusion: Decompressive craniectomy can improve long-term survival and functional outcome in the patients with malignant MCA territory infarctions.

Background Malignant infarction of the middle cerebral artery (MCI) is life threatening. It is associated with a mortality as high as 80%, and survival often at the expense of serious disability. Limited success of medical therapies has resulted in decompressive craniectomy (DC) being increasingly used as a treatment for MCI, although evidence of its efficacy is inconclusive. In this study, the efficacy of DC in improving survival, or survival free of severe disability, was assessed. Methods A meta-analysis was performed to approximate the efficacy of DC for treating MCI, considering age and time to surgery. A systematic literature review was conducted on Medline, Embase, and Cochrane library databases to August 1, 2018. Death and severe disability at 3, 6, 12, and 36 months follow-up were assessed, comparing best medical therapy with DC. Results 18 studies were eligible for inclusion and represented 987 individuals who received DC. Nine of these were randomized controlled trials (RCTs) (n = 374 DC). Early DC (<48 hours from onset of stroke) reduced mortality (odds ratio [OR] = 0.18, 95% confidence interval [CI] = 0.11, 0.29; P < 0.00001) but not unfavourable outcome (modified Rankin Scale [mRS] >4) (OR = 1.38, 95% CI = 0.47, 4.11; P = 0.56) at 12 months follow-up. This survival benefit was maintained regardless of age. Conclusion Early DC reduces mortality but does not appear to improve favourable outcomes in patients younger or older than 60 years after MCI. RCTs incorporating quality of life assessments are warranted for MCI patients, in addition to defining the optimal timing and benefits of DC in older patients. Highlights • Decompressive craniectomy within 48 hours of stroke onset reduces mortality in patients with middle cerebral infarction. • Decompressive craniectomy may not reduce poor functional outcomes in survivors. • The survival benefit of decompressive craniectomy is maintained in patients under and over age 60 years. • Further studies are required to establish the role of age as a predictor of poor outcome. [ABSTRACT FROM AUTHOR]