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A 53-year-old woman was admitted to our hospital because of increasingly frequent transient speech disturbance and left upper limb weakness. Brain magnetic resonance imaging and angiography revealed multiple intracranial stenoses, including the proximal right middle cerebral artery (MCA), without evidence of infarction. The diagnosis of primary angiitis of the central nervous system was established based on circumferential vascular wall thickening with contrast enhancement observed in the right MCA. Following the administration of dual antiplatelet therapy and intravenous methylprednisolone pulse therapy, the patient experienced complete cessation of symptoms, and the stenosis gradually improved without infarction. The risk of infarct development in crescendo transient ischemic attacks may differ between inflammatory vascular stenosis and atherosclerosis.

Background:  Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases., Methods:  After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees., Results:  Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed., Conclusion:  Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To investigate the application of high-resolution magnetic resonance vessel wall image (HRMR-VWI) in treating middle cerebral artery (MCA) M1 segment stenosis., Methods: We retrospectively analyzed preoperative clinical data, imaging data, preoperative evaluation, stent procedure, and postoperative complications in 35 patients with atherosclerotic stenosis of the MCA M1 segment. And the 30-day postoperative mortality and disability and the 12-month restenosis were followed up., Results: There were 21 males and 14 females, with a median age of 55 and a median duration of 1 month from onset to stenting. DSA confirmed that the stenosis locates in the M1 segment, with a stenosis degree of (75.00 ± 17.15) %, a stenosis length of (4.34 ± 1.51) mm, and a blood vessel diameter of (2.25 ± 0.42) mm. After the operation, there was 1 case of death after a craniotomy to remove hematoma + decompression due to reperfusion hemorrhage. There were two technical complications during the procedure (1 case of asymptomatic occlusion of the A1 segment due to the covering of stent at the initial part of A1, 1 case of intraparenchymal hematoma in the temporal lobe due to penetrating distal small blood vessel with guide wire)., Conclusion: HRMR-VWI is of great value in observing plaques' location, morphology, and stability. It can improve the safety and effectiveness of stenting treatment of MCA M1 segment stenosis., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests to report., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: None of the previous studies have investigated the pathologic authenticity of affected arteries in moyamoya disease (MMD) and Quasi-MMD diagnosed by angiography. This study aimed to confirm the angiographic diagnosis of moyamoya as well as investigate the pathologic mechanisms in angiographically proven MMD and Quasi-MMD using high-resolution magnetic resonance imaging (MRI) in a large sample., Methods: We prospectively studied 116 patients who had angiographically proven MMD and Quasi-MMD. Each affected internal carotid artery, and middle cerebral artery was independently evaluated. In addition, clinical features and postoperative outcomes were compared between hemispheres with MMD and moyamoya syndrome (MMS)., Results: Among 116 patients analyzed, 88 and 22 patients had angiographically proven MMD and Quasi-MMD, respectively. high-resolution magnetic resonance imaging confirmed bilateral MMD in 73 (83.0%) patients, 1 hemisphere with MMD and the other with intracranial atherosclerotic disease (ICAD) in 10 (11.4%) patients, and bilateral hemispheres with different vasculopathies in 5 (5.7%) patients. Detailed analysis of 204 affected hemispheres showed that several combinations of different vasculopathies were observed in the internal carotid artery and middle cerebral artery of the same hemisphere, such as ICAD-ICAD, ICAD-MMD, dissection-ICAD, and dissection-MMD. Hemispheres were assigned to MMD and MMS groups according to their vasculopathies. Transient ischemic attack occurred more frequently in hemispheres with MMD (48.1% versus 21.1%, P =0.024), whereas symptomatic ischemia was more common in hemispheres with MMS (57.9% versus 24.9%, P =0.002). However, postoperative cerebral infarction, symptom improvement and neo-formative collaterals showed no significant difference between hemispheres with MMD and MMS ( P >0.05)., Conclusions: Patients with angiographically proven MMD or Quasi-MMD needed more accurate evaluation combined with high-resolution magnetic resonance imaging. Highly selected patients with MMS might also obtain benefits from surgical revascularization., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Ischemic stroke remains the predominant cause of mortality and functional impairment among the adult populations globally. Only a minority of ischemic stroke patients are eligible to receive intravascular thrombolysis or mechanical thrombectomy therapy within the optimal time window. Among those stroke survivors, around two-thirds suffer neurological dysfunctions over an extended period. Establishing a stable and repeatable experimental ischemic stroke model is extremely significant for further investigating the pathophysiological mechanisms and developing effective therapeutic strategies for ischemic stroke. The middle cerebral artery (MCA) represents the predominant location of ischemic stroke in humans, with the MCA occlusion serving as the frequently employed model of focal cerebral ischemia. In this protocol, we describe the methodology of establishing the distal MCA occlusion (dMCAO) model through transcranial electrocoagulation in C57BL/6 mice. Since the occlusion site is located at the cortical branch of MCA, this model generates a moderate infarcted lesion restricted to the cortex. Neurological behavioral and histopathological characterization have demonstrated visible motor dysfunction, neuron degeneration, and pronounced activation of microglia and astrocytes in this model. Thus, this dMCAO mouse model provides a valuable tool for investigating the ischemiastroke and worth of popularization.

Purpose: The anatomical association between the lesion and the perforating arteries supplying the pyramidal tract in insulo-opercular glioma resection should be evaluated. This study reported a novel method combining the intra-arterial administration of contrast medium and ultrahigh-resolution computed tomography angiography (UHR-IA-CTA) for visualizing the lenticulostriate arteries (LSAs), long insular arteries (LIAs), and long medullary arteries (LMAs) that supply the pyramidal tract in two patients with insulo-opercular glioma., Methods: This method was performed by introducing a catheter to the cervical segment of the internal carotid artery. The infusion rate was set at 3 mL/s for 3 s, and the delay time from injection to scanning was determined based on the time-to-peak on angiography. On 2- and 20-mm-thick UHR-IA-CTA slab images and fusion with magnetic resonance images, the anatomical associations between the perforating arteries and the tumor and pyramidal tract were evaluated., Results: This novel method clearly showed the relationship between the perforators that supply the pyramidal tract and tumor. It showed that LIAs and LMAs were far from the lesion but that the proximal LSAs were involved in both cases. Based on these results, subtotal resection was achieved without complications caused by injury of perforators., Conclusion: UHR-IA-CTA can be used to visualize the LSAs, LIAs, and LMAs clearly and provide useful preoperative information for insulo-opercular glioma resection., (© 2023. The Author(s).)

Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57-44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03-1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85-58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37-237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ., (© 2023. The Author(s).)

To investigate the predictive value of T2 star-weighted angiography (SWAN) combined with 3-dimensional (3D) arterial spin labeling (3D-ASL) to assess cerebral perfusion status and clinical prognosis in chronic unilateral middle cerebral artery (MCA) M1 occlusion. This study included 55 patients diagnosed with chronic unilateral MCA M1 occlusion using 3D time-of-flight magnetic resonance angiography between January 2018 and July 2022. Based on the prominent vessel sign (PVS) shown in the SWAN sequence, the patients were divided into PVS-positive (n = 26) and PVS-negative (n = 29) groups. Cerebral blood flow (CBF) was selected in the affected regions of the frontal, parietal, and temporal lobes (regions of interest = 200 ± 20 mm2) using pseudo-color maps in the 3D-ASL sequence. Each patient was followed up for ischemic cerebrovascular disease within 12 months of diagnosis. The collected data were statistically analyzed to evaluate the predictive value of SWAN and 3D-ASL for the clinical prognosis of patients with chronic unilateral MCA M1 occlusion. Patients were divided into 2 groups based on the occurrence of an ischemic cerebrovascular event within 12 months (ischemic cerebrovascular event [acute ischemic stroke + transient ischemic attack] and non-ischemic cerebrovascular event groups, including 30 and 25 cases, respectively). The incidence of ischemic cerebrovascular events within 12 months was significantly higher in the PVS-positive group than in the PVS-negative group (92.31% vs 20.69%). Furthermore, the CBF values of the affected frontal, parietal, and temporal lobes were significantly lower in the ischemic cerebrovascular event group than in the non-ischemic cerebrovascular event group (P < .05). According to the receiver operating characteristic curve, the CBF values of the affected frontal, parietal, and temporal lobes in patients with chronic unilateral MCA M1 occlusion strongly correlated with ischemic cerebrovascular disease within 12 months. PVS-negative display and good collateral circulation were closely related to clinical prognosis in patients with chronic unilateral MCA M1 occlusion., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Atherosclerotic plaques of carotid artery (CA) and middle cerebral artery (MCA) are important causes of acute ischemic stroke (AIS). This study was designed to jointly assess the plaque distribution and features of CA and MCA in AIS patients with pial infarction (PI) and perforating artery infarction (PAI), and to investigate the associations between plaque characteristics and ischemic infarction patterns., Methods: Imaging data of sixty-five patients from a cross-sectional study were reviewed. All the patients had acute infarction in the MCA territory on diffusion weighted imaging (DWI) and underwent CA and MCA vessel wall imaging (VWI). The CA and MCA plaque presence and high-risk features on the ipsilateral side of infarction were analyzed. The brain infarction lesions were divided into PI group vs. non-PI group, and PAI group vs. non-PAI group. Different plaque distribution types and plaque features were compared in each two groups, and their associations were investigated using binary logistic regression., Results: Sixty-five patients (mean age, 54.6 ± 10.1 years; 61 men) were included. The CA high-risk plaque (OR: 5.683 [1.409-22.929], P = 0.015) and MCA plaque presence (OR: 3.949 [1.397-11.162], P = 0.010) were significantly associated with PI. MCA plaques that involved the orifice of the perforating arteries were significantly associated with PAI (OR: 15.167 [1.851-124.257], P = 0.011)., Conclusion: CA and MCA plaques show distinct distribution and high-risk features in patients with PI and PAI. Combined intracranial and extracranial arteries imaging should be considered for the evaluation of the symptomatic ischemic patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The effect of arteriosclerotic intracranial arterial vessel wall enhancement (IAVWE) on downstream collateral flow found in vessel wall imaging (VWI) is not clear. Regardless of the mechanism underlying IAVWE on VWI, damage to the patient's nervous system caused by IAVWE is likely achieved by affecting downstream cerebral blood flow. The present study aimed to investigate the effect of arteriosclerotic IAVWE on downstream collateral flow., Methods: The present study recruited 63 consecutive patients at the Second Hospital of Hebei Medical University from January 2021 to November 2021 with underlying atherosclerotic diseases and unilateral middle cerebral artery (MCA) M1-segment stenosis who underwent an magnetic resonance scan within 3 days of symptom onset. The patients were divided into 4 groups according to IAVWE and the stenosis ratio (Group 1, n = 17; Group 2, n = 19; Group 3, n = 13; Group 4, n = 14), and downstream collateral flow was analyzed using three-dimensional pseudocontinuous arterial spin labeling (3D-pCASL) and RAPID software. The National Institutes of Health Stroke Scale (NIHSS) scores of the patients were also recorded. Two-factor multivariate analysis of variance using Pillai's trace was used as the main statistical method., Results: No statistically significant difference was found in baseline demographic characteristics among the groups. IAVWE, but not the stenosis ratio, had a statistically significant significance on the late-arriving retrograde flow proportion (LARFP), hypoperfusion intensity ratio (HIR), and NIHSS scores ( F = 20.941, P <0.001, Pillai's trace statistic = 0.567). The between-subject effects test showed that IAVWE had a significant effect on the three dependent variables: LARFP ( R2 = 0.088, F = 10.899, P = 0.002), HIR ( R2 = 0.234, F = 29.354, P <0.001), and NIHSS ( R2 = 114.339, F = 33.338, P <0.001)., Conclusions: Arteriosclerotic IAVWE significantly reduced downstream collateral flow and affected relevant neurological deficits. It was an independent factor affecting downstream collateral flow and NIHSS scores, which should be a focus of future studies., Trial Registration: ChiCTR.org.cn, ChiCTR2100053661., (Copyright © 2023 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

Background: Early neurological deterioration (END) sometimes occurs in patients with penetrating artery territory infarction (PATI) and leads to poor prognosis. In this study, we analyzed clinical and neuroimaging characteristics of PATI, and focused on the infarct patterns on diffusion-weighted imaging (DWI). We tried to investigate whether the "island sign" pattern is associated with END., Methods: We enrolled consecutive patients admitted with acute PATI within 48 h after onset from May 2020 to July 2022. They were divided into with and without the "island sign" pattern on DWI. According to infarct location, all the patients were classified into two groups: the territories of the lenticulostriate arteries (LSA) and paramedian pontine arteries (PPA). The patients in each group were further divided into two groups according to whether they developed END or not. Through analyzing the clinical and neuroimaging characteristics of the patients, we tried to identify the factors that might associated with the "island sign" pattern and the potential predictors of END within the LSA and PPA groups., Results: Out of the 113 patients enrolled in this study, END was found in 17 patients (27.9%) in the LSA group and 20 patients (38.5%) in the PPA group. The "island sign" was found in 26 (23%) patients. In the multivariate analysis, the independent predictors of END in the LSA group were the "island sign" (OR 4.88 95% CI 1.03-23.2 P = 0.045) and high initial National Institute of Health Stroke Scale (NIHSS) (OR 1.79 95% CI 1.08-2.98 P = 0.024) and in the PPA group was the presence of lesions extending to the ventral pontine surface (OR 7.53 95% CI 1.75-32.37 P = 0.007)., Conclusions: The predictive factors for END were different in the LSA and PPA groups. The "island sign" was particularly associated with END in the LSA group., (© 2023. BioMed Central Ltd., part of Springer Nature.)

This study aims to analyze the imaging features of atherosclerotic plaques in the middle cerebral artery (MCA) of patients with recurrent ischemic stroke using vessel wall magnetic resonance imaging (VWMRI) and investigate the correlation between these imaging features and the recurrence of ischemic stroke. Consecutive patients with ischemic stroke caused by atherosclerotic stenosis of the MCA were collected. The patients were divided into recurrent and non-recurrent ischemic stroke groups. We obtained VWMRI images of MCA plaques using 3.0T MRI by black-blood sequences, and the differences in VWMRI characteristics and clinical information between the two groups were compared. A binary Logistic regression model was used to analyze the VWMRI characteristics and clinical information related to ischemic stroke recurrence. 179 patients were collected from August 2018 to May 2020, and 81 patients were included in the study. The recurrent ischemic stroke group patients had a higher stenosis rate (0.69 vs 0.64). Meanwhile, the rate of centripetal wall thickening was significantly higher in patients with recurrent ischemic stroke (33.3% vs 11.7%). Binary Logistic regression analysis showed that sex (P=0.036, OR:2.983, CI:1.075-8.279), stenosis rate (P=0.038, OR:148.565, CI:1.331-16583.631), and vessel wall thickening pattern (P=0.012, OR:0.171, CI:0.043-0.678) were related to ischemic stroke recurrence. The patients with ischemic stroke caused by atherosclerotic stenosis of MCA, female patients, and those with concentric wall thickening and a high degree of stenosis have a higher risk of recurrence. Our results suggest that VWMRI is a valuable tool for predicting the risk of ischemic stroke recurrence in patients with MCA plaques.

Background: When treating acute ischemic stroke patients, evaluation of collateral flow to the ischemic area is essential. Blood-oxygen-level-dependent imaging, including T2 star (T2∗), can identify elevated deoxyhemoglobin levels, reflecting an increase in the oxygen extraction fraction. Prominent veins on T2∗ represent increased deoxyhemoglobin and cerebral blood volume. This study compared asymmetrical vein signs (AVSs) on T2∗ and digital subtraction angiography findings during mechanical thrombectomy (MT) in patients with hyperacute middle cerebral artery occlusion., Methods: Clinical and imaging data of 41 patients with occlusion of the horizontal segment of the middle cerebral artery who underwent MT were collected. Patients were divided into 2 groups based on angiographic occlusion sites as: proximal and distal to the lenticulostriate artery (LSA). AVSs on T2∗ were divided into asymmetrical cortical vein sign (cortical AVS) and asymmetrical deep/medullary vein sign (deep/medullary AVS), and were compared with the findings of intraoperative digital subtraction angiography., Results: Twenty-seven patients had AVSs. Cortical AVS was the only parameter with a significant association with poor angiographic collateral supply. In terms of occlusion site, deep/medullary AVS was the only parameter with a significant association with occlusion proximal to the LSA., Conclusions: In patients with occlusion of the horizontal segment of the middle cerebral artery, presence of the cortical AVS on T2∗ suggests a poor angiographic collateral supply, while presence of the deep/medullary AVS suggests impaired blood flow to the basal ganglia through LSAs. Both these signs contribute to poor outcomes in patients undergoing MT., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Geometrical parameters, including arterial bifurcation angle, tortuosity, and arterial diameters, have been associated with the pathophysiology of intracranial aneurysm (IA) formation. The aim of this study was to investigate whether these parameters were present before or if they resulted from IA formation and growth., Methods: Patients from nine academic centers were retrospectively identified if they presented with a de novo IA or a significant IA growth on subsequent imaging. For each patient, geometrical parameters were extracted using a semi-automated algorithm and compared between bifurcations with IA formation or growth (aneurysmal group), and their contralateral side without IA (control group). These parameters were compared at two different times using univariable models, multivariable models, and a sensitivity analysis with paired comparison., Results: 46 patients were included with 21 de novo IAs (46%) and 25 significant IA growths (54%). The initial angle was not different between the aneurysmal and control groups (129.7±42.1 vs 119.8±34.3; p=0.264) but was significantly wider at the final stage (140.4±40.9 vs 121.5±34.1; p=0.032), with a more important widening of the aneurysmal angle (10.8±15.8 vs 1.78±7.38; p=0.001). Variations in other parameters were not significant. These results were confirmed by paired comparisons., Conclusion: Our study suggests that wider bifurcation angles that have long been deemed causal factors for IA formation or growth may be secondary to IA formation at pathologic bifurcation sites. This finding has implications for our understanding of IA formation pathophysiology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The main access route for middle cerebral artery (MCA) aneurysms is the transsylvian approach. Although Sylvian fissure (SF) variations have been assessed, none have examined how this affects MCA aneurysm surgery. The objective of this study is to investigate how SF variants affect clinical and radiological outcomes for surgically-treated unruptured MCA aneurysms., Methods: This retrospective study examined consecutive unruptured MCA aneurysms in 101 patients undergoing SF dissection and aneurysm clipping. SF anatomical variants were categorized using a novel functional anatomical classification: Type I: Wide straight, Type II: Wide with frontal and/or temporal opercula herniation, Type III: Narrow straight, and Type IV: Narrow with frontal and/or temporal opercula herniation. The relationships between SF variants and postoperative edema, ischemia, hemorrhage, vasospasm, and Glasgow Outcome Scale (GOS) were analyzed., Results: Study included 101 patients (53.5% women), 60.9 ± 9.4 (range 24-78) years. SF types were 29.7% Type I, 19.8% Type II, 35.6% Type III, and 14.9% Type IV. The SF type with the highest proportion of females was Type IV (n = 11, 73.3%), while it was Type III for males (n = 23, 63.9%) (P = 0.03). There were significant differences between SF types, ischemia, and edema (P < 0.001, P = 0.008, respectively). Although narrow SF types had poorer GOS scores (P = 0.055), there were no significant differences between SF types and GOS, postoperative hemorrhage, vasospasm, or hospital stay., Conclusions: Sylvian fissure variants may impact intraoperative complications during aneurysm surgery. Thus, presurgical determination of SF variants can predict surgical difficulties, thereby potentially reducing morbidity for patients with MCA aneurysms and other pathologies requiring SF dissection., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Branch atheromatous disease (BAD) is a type of cerebral infarction caused by stenosis or occlusion at the entrance of the penetrating branch due to the presence of plaque. Despite its clinical significance, it is not clear how these plaques are formed. Focal geometrical characteristics are expected to be as important as vascular risk factors in the development of atherosclerosis. This study aimed to analyze the association between middle cerebral artery (MCA) geometric features and the onset of BAD. Shear stress results from the blood flow exerting force on the inner wall of the vessels and places with low wall shear stress may be prone to atherosclerosis. At the curvature of blood vessels, the shear stress is weak on the inside of the curve and plaque is likely to form. When this is applied to the MCA M1 segment, downward type M1 is likely to form plaques on the superior side. Because the lenticulostriate artery usually branches off from the superior side of the MCA M1 segment, in downward type M1, a plaque is likely to be formed at the entrance of the penetrating branch, and for that reason, BAD is likely to onset., Methods: We retrospectively reviewed hospitalized stroke patients with BAD and investigated the morphology of their MCA using magnetic resonance imaging. The M1 segment was classified as straight or curved. Additionally, we compared the difference between the symptomatic and the asymptomatic side. Data regarding patients' medical history were also collected., Results: A total of 56 patients with lenticulostriate artery infarctions and BAD were analyzed. On the symptomatic side, downward type M1 accounted for the largest proportion at 44%, whereas on the asymptomatic side, it was the lowest, at 16%., Conclusion: A downward type MCA may be associated with the onset of BAD and the morphological characteristics might affect the site of plaque formation. J. Med. Invest. 70 : 411-414, August, 2023.

Background and Objectives: Although the main mechanisms of stroke in patients with intracranial atherosclerotic disease (ICAD)-perforating artery occlusion (PAO) and artery-to-artery embolism (AAE)-have been identified and described, relatively little is known about the morphology of the symptomatic plaques and how they differ between these 2 mechanisms., Methods: We prospectively recruited patients with acute ischemic stroke in the posterior circulation that was attributable to ICAD. Fifty-one eligible patients were enrolled and underwent magnetic resonance imaging before being assigned to the PAO or AAE group according to probable stroke mechanism. Plaque morphological properties including plaque length, lumen area, outer wall area, plaque burden, plaque surface irregularity, vessel wall remodeling, and plaque enhancement were assessed using high-resolution MRI. Plaque morphological parameters of both PAO and AAE groups were compared using nonparametric tests. A binary logistic regression model was used to identify independent predictors while a receiver operating characteristic curve tested the sensitivity and specificity of the model., Results: Among patients who met the imaging eligibility criteria, 38 (74.5%) had PAO and 13 (25.5%) had AAE. Plaque length was shorter (6.39 interquartile range [IQR, 5.18-7.7]1 mm vs 10.90 [IQR, 8.18-11.85] mm, p < 0.01) in patients with PAO. Plaque burden was lower in PAO group (78.00 [IQR, 71.94-86.35] % vs 86.37 [IQR, 82.24-93.04] %, p = 0.04). The proportion of patients with plaque surface irregularity was higher in patients with AAE than in patients with PAO (19/38, 50.00% vs 12/13, 92.30%, p = 0.008). Plaque length was significantly associated with the PAO mechanism (adjusted OR 0.57, 95% CI, 0.41-0.79)., Discussion: Intracranial atherosclerotic plaque morphology differs between patients with PAO and those with AAE. Plaque with shorter length, lower plaque burden, and regular surface is more likely to cause PAO., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

This study aimed to identify the high-resolution magnetic resonance imaging (HRMRI) features of moyamoya disease (MMD) patients with anterior intracerebral hemorrhage (ICH) and attempted to reveal potential mechanisms of anterior ICH. Eligible adult MMD patients were consecutively included, and the morphological features of lenticulostriate arteries (LSAs), vessel wall structure of terminal internal carotid artery (ICA) and periventricular anastomosis were evaluated by HRMRI. 78 MMD patients containing 21 patients with anterior ICH, 31 ischemic patients and 26 asymptomatic patients were included. The mean value of total length of LSAs in anterior ICH group (90.79 ± 37.00 mm) was distinctively lower (p < 0.001) compared with either ischemic group (138.04 ± 46.01 mm) or asymptomatic group (170.50 ± 39.18 mm). Lumen area of terminal ICA was significantly larger (p < 0.001) in hemorrhagic group (4.33 ± 2.02 mm 2 ) compared with ischemic group (2.29 ± 1.17 mm 2 ) or asymptomatic group (3.00 ± 1.34 mm 2 ). Multivariate analysis revealed the total length of LSAs (OR 0.689, 95%CI, 0.565-0.840; p < 0.001) and lumen area of terminal ICA (OR 2.085, 95%, 1.214-3.582; p = 0.008) were significantly associated with anterior ICH. Coexistence of reduced LSAs and relatively preserved lumen area of terminal ICA with an AUC of 0.901 (95%CI, 0.812-0.990) could be a potential predictor of anterior ICH in MMD patients.

Objective: A combined surgery of direct and indirect revascularization has been frequently performed in patients with moyamoya disease, though the efficacy of indirect revascularization surgery in adult patients with moyamoya disease has not been established. This study aimed to evaluate superficial temporal artery (STA) and deep temporal artery (DTA) diameters 1 day and 3 months after combined revascularization surgery in patients with moyamoya disease. We also investigated clinical factors related to DTA enlargement after surgery., Methods: We examined 78 cerebral hemispheres in 57 adult and pediatric patients with moyamoya disease who underwent combined revascularization surgery [STA-MCA bypass and encephalo-duro-myo-synangiosis] in our institution. STA and DTA diameters were measured on axial magnetic resonance angiography images at 1 day and 3 months after surgery., Results: DTA diameter increased in 64 hemispheres (82.1%). DTA diameter increase in association with STA diameter decrease was found in 39 hemispheres (50%). The proportion of hemispheres with a reduction in STA diameter was significantly higher in hemispheres with DTA enlargement than in hemispheres with DTA reduction (P = 0.0088). Among the 64 hemispheres with DTA enlargement, 51 (79.7%) showed cerebrovascular reserve (CVR) impairment in the anterior cerebral artery (ACA) territory before surgery. CVR impairment in the ACA territory was the only clinical factor related to DTA enlargement (P < 0.001)., Conclusion: The DTA frequently enlarges after combined revascularization surgery, even in adult patients with moyamoya disease. In patients with impaired CVR in the ACA territory, blood supply from the DTA to the ACA territory can be expected after combined revascularization surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Two different stroke mechanisms are involved in small vessel disease: branch atheromatous disease (BAD) and lipohyalinotic degeneration (LD). We compared mechanisms of stroke in lenticulostriate arteries (LSA) vs. anterior pontine arteries (APA) and verified factors associated with stroke mechanisms, including shape of middle cerebral artery (MCA) and basilar artery (BA). We retrospectively reviewed patients with acute ischemic stroke with penetrating artery territory confirmed by MRI. The mechanisms of stroke were categorized based on diffusion-weighted imaging; BAD was defined as lesion larger than 10 mm in LSA and lesions involving basal pontine in APA. Other lesions were classified as LD. The shapes of MCA and BA were classified as straight, with one angle, or with two angles (U, C or S shape, respectively) using anterior-posterior view. The study included 221 patients. LD was more common in LSA infarcts, but BAD was more common in APA infarcts (p < 0.001). Low initial National Institutes of Health Stroke Scale [Adjusted Odds ratio (aOR) = 0.78; p < 0.001], absence of hyperlipidemia [aOR = 0.31; p = 0.002], previous statin use [aOR = 4.35; p = 0.028] LSA infarcts [reference = APA territory; aOR = 11.07; p < 0.001], and S-shaped vessels (reference = straight shaped vessels; aOR = 3.51; p = 0.004) were independently associated with LD. Angulations in the mother vessels may be more associated with true small vessel disease more with LD than BAD., (© 2022. The Author(s).)

Objective: A comprehensive understanding of atherosclerotic middle cerebral artery (MCA) plaques aids physicians in diagnosis and treatment of ischemic stroke. High-resolution magnetic resonance imaging (MRI) has been used to identify imaging biomarkers of symptomatic MCA plaque. We performed this systematic review and meta-analysis to evaluate which characteristics of MCA plaque are markers of culprit lesions., Materials and Methods: The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for publications up to March 2022. Two independent reviewers extracted data on study design, high-resolution MRI parameters, and imaging end points. Odds ratios (ORs) for the prevalence of stroke with atherosclerotic MCA plaque features were pooled in the meta-analysis by using a random-effects model. Subgroup analysis, sensitivity analysis, and evaluation of publication bias were also conducted., Results: Seventeen articles were included in this review. Symptomatic MCA plaques were significantly associated with contrast enhancement (OR, 9.4; 95 % CI, 4.3-20.4) and T1 hyperintensity (OR, 6.2; 95 % CI, 2.7-14.3). However, there was no association between symptomatic plaques and T2 hyperintensity (OR, 1.4; 95 % CI, 0.8-2.3). Plaque enhancement was significantly associated with downstream ischemic events in subgroup analyses based on different study designs and MR sequence types., Conclusion: Based on current evidence, contrast enhancement and T1 hyperintensity on high-resolution MRI have high potential as imaging biomarkers of patients with MCA plaques at risk of ischemic events. Future prospective, longitudinal studies of intracranial-plaque high-resolution MRI are required to improve decision-making for the management of intracranial atherosclerotic plaques., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Younger stroke patients may suffer worse outcomes than older patients; however, the extent to which age at stroke impacts remote areas of the brain remains unclear. The objective of this study was to determine thalamic volume changes ipsilateral to middle cerebral artery territory strokes based on age at acute ischemic stroke onset. Methods: Acute ischemic stroke patients <9 years, 9-18 years, and >18 years old were retrospectively recruited from a large quaternary care system. Each subject underwent an acute (<72 hours from AIS) and chronic (>90 days) magnetic resonance imaging (MRI) scan. Manual thalamic segmentation was performed. Results: Younger and older children had significantly greater stroke-side thalamic volume loss compared to adults (48.2%, P  = .022; 40.7%, P  = .044, respectively). Conclusions: Stroke-side thalamic volumes decreased across the age spectrum but to a greater degree in pediatric patients. This observation can affect functional and cognitive outcomes post stroke and warrants further research.

Objective: To investigate the etiology of intracranial artery stenosis and the distribution characteristics of intracranial artery atherosclerotic stenosis using high-resolution magnetic resonance imaging (HR-MRI)., Methods: A total of 262 patients with intracranial artery stenosis that underwent HR-MRI from November 2019 to December 2020 were retrospectively enrolled. The etiology of intracranial anterior and posterior circulation artery stenosis was analyzed, and the relationship between the location of plaques and the distribution characteristics of plaques and the occurrence of ischemic stroke was summarized., Results: A total of 276 plaques were identified with HR-MRI. There were 101 cases (36.59%) in the middle cerebral artery (MCA), 14 cases (5.07%) in the posterior cerebral artery (PCA), 90 cases (32.62%) in vertebral artery (VA), and 71 cases (25.72%) in the basilar artery (BA). The infarct rate of ventral and superior wall MCA plaques was higher than that of dorsal and inferior wall (63.33% vs 31.25% P = 0.021) (100.00% vs 50% P = 0.022). MCA with plaques throughout the course had the greatest degree of stenosis (P < 0.001). Sphenoid segment (M1) of MCA was most susceptible (85 cases, 84.16%), MCA plaques were most common in the proximal M1 segment (35 cases, 34.65%), and most BA plaques were found in the distal segment (28 cases, 39.44%). PCA plaques were most frequently involved in traffic anterior segment (P1) (7 cases, 50.00%)., Conclusion: HR-MRI could provide accurate imaging reference for clinical evaluation of intracranial arterial stenosis and formulation of treatment plans. The intracranial arterial plates mostly appeared in the middle cerebral artery and vertebral artery. Middle cerebral arteries with atherosclerotic plaques are more likely to narrow., (© 2022. Fondazione Società Italiana di Neurologia.)

Purpose: High-resolution MR vessel wall imaging (HRVWI) can characterise vessel wall pathology affecting intracranial circulation and helps in differentiating intracranial vasculopathies. The aim was to differentiate intracranial pathologies involving middle cerebral artery (MCA) in patients with ischemic stroke and characterise the high-risk plaques in intracranial atherosclerotic disease (ICAD) using HRVWI., Methods: Patients with ischemic stroke with isolated MCA disease with ≥ 50% luminal narrowing by vascular imaging were enrolled within 2 weeks of onset and underwent high-resolution (3 T) intracranial vessel wall imaging (VWI). The pattern of vessel wall thickening, high signal on T1-weighted images, juxtaluminal hyperintensity, pattern and grade of enhancement were studied. The TOAST classification before and after HRVWI and the correlation of the recurrence of ischemic events at 3 months with imaging characteristics were analysed., Results: Of the 36 patients, the mean age was 49.53 ± 15.61 years. After luminal imaging, by TOAST classification, 12 of 36 patients had stroke of undetermined aetiology. After vessel wall imaging, lesions in MCA were analysed. Of them, 23 patients had ICAD, 8 had vasculitis, and 2 had partially occlusive thrombus in MCA. The ability of HRVWI to bring a change in diagnosis was significant (p = 0.031). Of the 23 patients with ICAD, 12 patients had recurrent strokes within 3 months. The presence of grade 2 contrast enhancement (p = 0.02) and type 2 wall thickening (p = 0.03) showed a statistically significant association with recurrent ischemic events., Conclusion: High-resolution MRVWI can help in identifying the aetiology of stroke. The HRVWI characteristics in ICAD can help in risk stratification., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Intracranial branch atheromatous disease often results in progressive motor deficits in the lenticulostriate arteries (LSA). In some patients with LSA infarction, magnetic resonance imaging (MRI) revealed single lesions at the LSA origin from the middle cerebral artery spreading in a scattered manner toward the distal area. This study aimed to elucidate the clinical characteristics of such cases., Materials and Methods: This was a single-center, retrospective study comprising 1,840 consecutive patients admitted to the Ina Central Hospital, Japan. Two neurologists selected patients with LSA infarctions on the basis of MRI data. Patients with a single mass of infarct lesion from the origin were classified as the single group, whereas patients with infarct lesions as a single mass at LSA origin but divided and independent as the infarct area extended distally were classified as the scattered group. We compared the clinical characteristics and outcomes in these groups., Results: The single and scattered groups included 119 and 35 patients, respectively. We defined worsening as an increase of one point or more on the National Institute of Health Stroke Scale. Univariate analysis demonstrated that patients in the scattered group showed significantly more worsening after hospitalization compared with those in the single group (48.6% vs. 28.6%; p < .05). Moreover, this can easily lead to increased disease severity (p < .016). In a multivariate analysis, group (odds ratio, 2.5 [95% CI, 1.11-5.74], p < .03) was an independent predictor of symptom worsening., Conclusions: Scattered infarction in the corona radiata is an aggravating factor leading to worse outcomes., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background and Aims: Evidence shows that artery geometries play a role in atherogenesis by influencing blood flow dynamics. However, whether upstream artery geometries influence downstream atherosclerosis remains unclear. We aimed to investigate whether carotid artery geometries were associated with middle cerebral artery (MCA) atherosclerosis., Methods: We reviewed our institutional database of 3-dimensional head-neck combined high-resolution magnetic resonance imaging. The carotid artery geometries, carotid atherosclerosis, MCA configurations, and MCA atherosclerosis were examined. The associations between carotid artery geometry and MCA atherosclerosis were also analyzed. A final model integrating carotid artery geometries was established, and the incremental diagnostic value was evaluated and compared to a basic model that included only traditional risk factors., Results: Among the 575 artery units of the ipsilateral carotid artery and MCA, the artery units with MCA plaques (n = 273) were associated with a larger bifurcation angle (odds ratio [OR], 1.138 per 10-degree increase; 95% confidential interval [CI], 1.023-1.264) and kinking-type extracranial internal carotid artery (ICA; OR, 2.193; 95%CI, 1.283-3.748) compared with those without MCA plaques (n = 302). These associations were independent of traditional risk factors, carotid atherosclerosis, and MCA configuration. A larger carotid bifurcation angle was also associated with tandem ICA and MCA atherosclerosis (OR, 1.211 per 10-degree increase; 95%CI, 1.110-1.321). The incremental diagnostic value of carotid artery geometry to traditional risk factors was revealed by comparing the area under the curves of the two diagnostic models (basic model, 0.673 vs. final model, 0.701; p = 0.016)., Conclusions: Carotid artery geometries are independently associated with ipsilateral MCA atherosclerosis, providing new insights into the pathophysiology of intracranial atherosclerosis., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Atherosclerotic stenosis of large intracranial arteries, especially the middle cerebral artery (MCA), is a common cause of stroke in Chinese patients. We aimed to describe the morphological features of atherosclerotic stenosis in the MCA and to investigate their relationship with cerebral infarcts from a postmortem series. Methods: We studied the morphological features of the MCAs in consecutive postmortem adults aged 45 years or above. The following parameters were evaluated by a single observer blinded to the clinical history: (1) thickness of fibrous cap; (2) extent of lipid area; (3) degree of luminal stenosis; (4) presence of intraplaque hemorrhage, neovasculature, thrombus and calcification. A semiquantitative assessment of macrophage and T lymphocyte infiltration was made by immunohistochemical staining for CD68 and CD45RO. Results: Seventy-six cases were recruited. Atherosclerotic plaques of more than 40% cross-sectional area luminal narrowing stenosis were found in 69 MCAs (45.4%, 69/152). The results demonstrated that the degree of luminal stenosis, the percentage of the plaques containing more than 40% lipid area and the prevalence of intraplaque hemorrhage, neovasculature and thrombus were higher in those plaques associated with infarct, and the mean index of both CD45RO and CD68 was higher among those associated with infarct (p < 0.01). Binary logistic regression showed that stenosis (p = 0.003; odds ratio, OR = 1.050), lipid area (p = 0.048, OR = 1.698) and presence of neovasculature (p = 0.040, OR = 3.471) were independent risk factors of MCA infarcts. Conclusions: Luminal stenosis caused by atherosclerotic plaque, percentage of lipid area and presence of intraplaque neovasculature may play a key role in leading to ischemic stroke. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Detection of multiple intracranial aneurysms (MIAs) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is common and the optimal management of the additional unruptured intracranial aneurysms (UIA) is often a matter of debate. We calculate the incidence and the factors associated with subsequent aSAHs from untreated additional aneurysms in a single-center group of patients with aSAH and MIAs., Methods: Charts of patients with MIAs admitted to our neurosurgery department for aSAH between January 2000 and March 2020 were retrospectively reviewed. Incidence rate and factors associated with subsequent aSAHs were calculated with univariable and multivariable analyses., Results: Of the unruptured aneurysms, 50% were preventively treated. During a median follow-up of 3 years, 20 of 174 patients (11.5%) presented with a second aSAH. Incidence of rupture of an additional untreated aneurysm was 18.05 per 1000 person/years (confidence interval, 10.69-30.47). Rupture incidence of an additional aneurysm located in the anterior circulation was 32.70 per 1000 person/years and 40.73 per 1000 person/years in the posterior circulation. Presence of untreated mirror and de novo aneurysms increased the risk of overall subsequent aSAHs by 16.9-fold and 7.6-fold, respectively. Most untreated additional aneurysms causing a subsequent aSAH were smaller than 7 mm (73.3%), with middle cerebral artery being the most frequent location (40.0%)., Conclusions: Incidence of subsequent aSAHs is high in patients with aSAH-MIA. Untreated mirror and de novo aneurysms are associated with higher rupture risk. Longer follow-up and prophylactic treatment of asymptomatic aneurysms at higher rupture risk are recommended to prevent the significant poor outcome of subsequent aSAHs., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Flow diversion of the distal anterior circulation cerebral vasculature may be used for management of wide necked aneurysms not amenable to other endovascular approaches. Follow-up angiography sometimes demonstrates neo-intimal hyperplasia within or adjacent to the stent, however there is limited evidence in the literature examining the incidence in MCA and ACA aneurysms. We present our experience with flow diversion of the distal vasculature and evaluate the incidence of neo-intimal hyperplasia., Materials and Methods: Retrospective review of patients who underwent Pipeline embolization device (PED) treatment for ruptured and unruptured anterior circulation aneurysms., Results: A total of 251 anterior circulation aneurysms were treated by pipeline flow diversion, of which 175 were ICA aneurysms, 14 were ACA aneurysms and 18 were MCA aneurysms. 6-month follow-up angiography was available in 207 patients. The incidence of neo-intimal hyperplasia was 15.9%, 21.4%, and 61.1% in ICA, ACA, and MCA aneurysms, respectively. MCA-territory aneurysms developed neo-intimal hyperplasia at a significantly higher rate than aneurysms in other vessel territories. Rates of aneurysmal occlusion did not significantly differ from those patients who did not exhibit intimal hyperplasia on follow-up angiography., Conclusion: In our experience, flow diversion of distal wide-necked MCA and ACA aneurysms is a safe and effective treatment strategy. The presence of neo-intimal hyperplasia at 6-month angiography is typically clinically asymptomatic. Given the statistically higher rate of neo-intimal hyperplasia in MCA aneurysms at 6-month angiography, we propose delaying initial follow-up angiography to 12-months and maintaining dual antiplatelet therapy during that time., (Copyright © 2021. Published by Elsevier Inc.)

Preeclampsia, a hypertensive disorder of pregnancy, complicates up to 10 % of all pregnancies and increases the risk for perinatal stroke in offspring. The mechanism of this increase is unknown, but may involve vascular dysfunction. The goal of this study was to evaluate the effect of experimental preeclampsia (ePE) on cerebrovascular function in offspring to eludciate a possible mechanism for this association. Dams were fed a high cholesterol diet beginning on day 7 of gestation to induce experimental preeclampsia. Middle cerebral arteries (MCA) and the Vein of Galen (VoG) were isolated from pups from ePE dams and compared to pups from normal pregnant (NP) dams at postnatal days 16, 23, and 30 and studied pressurized in an arteriograph chamber. Markers of inflammation and oxidative stress were measured in serum. Our results suggest altered structure and function in both MCA and VoG of ePE pups. We also found evidence of systemic inflammation and oxidative stress in ePE pups. These findings provide a potential link between preeclampsia and the occurrence or severity of perinatal stroke., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Purpose: Perfusion imaging can risk stratify patients with symptomatic intracranial stenosis. We aim to determine the association between perfusion delay and length of hospital stay (LOS) in symptomatic middle cerebral artery (MCA) stenosis patients., Methods: This is a retrospective study of consecutive patients admitted to a comprehensive stroke center over 5 years with ischemic stroke or transient ischemic attack (TIA) within 7 days of symptom onset due to MCA stenosis (50-99%) and underwent perfusion imaging. Patients were divided into three groups: mismatch volume ≥ 15 cc based on T max > 6 second delay, T max 4-6 second delay, and <4 second delay. The outcome was LOS, both as a continuous variable and categorical (≥7 days [prolonged LOS] vs. <7 days). We used adjusted regression analyses to determine the association between perfusion categories and LOS., Results: One hundred and seventy eight of 194 patients met the inclusion criteria. After adjusting for age and NIHSS, T max >6 second mismatch was associated with prolonged LOS (OR 2.94 95% CI 1.06-8.18; P = .039), but T max 4-6 second was not (OR 1.45 95% CI .46-4.58, P = .528). We found similar associations when LOS was a continuous variable for T max > 6 second (β coefficient = 2.01, 95% CI .05-3.97, P = .044) and T max 4-6 second (β coefficient = 1.24, 95% CI -.85 to 3.34, P = .244)., Conclusion: In patients with symptomatic MCA stenosis, T max > 6 second perfusion delay is associated with prolonged LOS. Prospective studies are needed to validate our findings., (© 2021 American Society of Neuroimaging.)

Objective: This study investigated the diagnostic performance of MinIP images based on three-dimensional variable-flip-angle turbo spin echo T 1 weighted imaging (3D CUBE T 1 WI) from high-resolution vessel wall magnetic resonance imaging for detecting middle cerebral artery (MCA) stenosis., Methods: A total of 63 consecutive patients were included in this study. MinIP images were reconstructed using 3D CUBE T 1 WI as the source images. The degree and length of MCA stenosis were measured on MinIP images and were compared with digital subtraction angiography (DSA) as the reference standard., Results: The intra- and interobserver agreement for both the rate and length of MCA stenosis were excellent for the MinIP images. There was also excellent agreement in the degree of MCA stenosis calculated using MinIP images and DSA. MinIP images had a high sensitivity, specificity for diagnosing MCA stenosis. There was a good correlation between the two methods for measuring the rate and length of MCA stenosis., Conclusion: MinIP images based on 3D CUBE T 1 WI are highly consistent with DSA for evaluating the degree and length of MCA stenosis., Advances in Knowledge: MinIP images can be produced as a derivative from vessel wall imaging and implemented as an adjunct to vessel wall imaging without extra acquisition time.

Background and Purpose: Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion., Methods: Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only., Results: Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0-2) for EVT (adjusted odds ratio, 0.96; adjusted P =0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P =0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P =0.032) in the EVT compared with the IVT only group., Conclusions: Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

The goal of this study was to analyze trends in the geometric parameters of blood vessels with age in a randomly selected group of 200 computed tomography angiography studies of radiologically healthy individuals using dedicated statistical techniques. A quantitative description of cerebral vascular geometry with numerical parameters (bifurcation angle, branching angle, co-planarity index, average curvature, and average torsion) was proposed. The changes and variability in geometry were analyzed according to age. The bifurcation angle, branching angle, and average curvature increased with age, whereas the co-planarity index and average torsion decreased with age. For equal-diameter branches, women comparing to men presented lower bifurcation angles in the 4th decade of life, and lower values for the co-planarity index in the 3rd and 4th decades of life. In non-equal-diameter branches, the opposite relationship was observed for bifurcation angle in the 4th decade of life comparing both groups. All analyzed parameters showed clearly visible trends with patient age. Deviations in specific decades of life were detected; these deviations could be linked to the development of aneurysms in specific age groups., (© 2020 Anatomical Society.)

Aim: This study investigated the protective effect of dimethyl fumarate (DMF) in rats by mediating glycogen synthase kinase 3β (GSK-3β)/Nrf2 using the middle cerebral artery embolization reperfusion (MCAO/R) rat model., Background: After an acute ischemic stroke (AIS), oxidative stress occurs. Dimethyl fumarate (DMF), a nuclear factor-E2-related factor 2 (Nrf2) activator, approved by the US Food and Drug Administration (FDA), was observed to regulate the Nrf2 pathway by acting as an anti-oxidative stress agent; however, whether this agent is involved in inhibiting GSK-3β remains to be established., Methods: DMF model was used to explore the effects of GSK-3β on Nrf2 expression level, Nrf2- ARE binding activity and Nrf2/ARE downstream expression level of anti-oxidant stress protein in Cerebral ischemia-reperfusion injury (CIRI). 60 rats were randomly divided into Sham group, MCAO/R group, solvent control group (DMSO group) and DMF treatment group, with 15 rats in each group. The MCAO/R, DMSO and DMF groups were considered in the MCAO/R model using the modified thread embolization method. In contrast, the Sham group was only anaesthetized and disinfected, and tissue muscle was dissected without inserting suture emboli. DMF group was gavaged with 45mg/kg per day of DMF, DMSO control group was gavaged with DMSO of equal volume, while MCAO/R group was only modeled without any intragastric treatment. The rats were treated seven days after the operation, and a neurological function Longa score was estimated. The rats were sacrificed seven days later, and the infarct volume was assessed by TTC staining. Hematoxylin- eosin (HE) staining was used to observe the pathological changes in rat brain tissue. Nissl staining was used to observe the expression of neurons in the infarcted cortex. Western blotting (WB) was used to observe the protein expression levels of GSK-3β, Nrf2, downstream heme oxygenase 1 (HO1) and NADPH quinone oxidoreductase 1 (NQO1) in four groups. The expression levels of GSK-3β and Nrf2 in the four groups were observed by immunohistochemistry and immunofluorescence., Results: (1) The Longa score of the MCAO/R, DMSO and DMF groups was found to be higher compared to the Sham group, indicating successful operation. The Longa score of the DMF group was lower than that of the other three groups 4-7 days after surgery (P<0.05). (2) HE and Nissl staining showed that the DMF group had lower neuron necrosis and higher gliosis compared to the control groups. (3) TTC staining results showed that the infarct volume of the DMF group was significantly smaller than the MCAO/R and DMSO groups. (4) Protein results showed that the GSK-3β expression in the DMF group was lower than that in all groups, while the expression of Nrf2, HO1 and NQO1 was higher compared to other groups., Conclusion: DMF can reduce neurological deficits and infarct size in the MCAO/R model. The protective effect may be related to decreased GSK-3β expression and increased Nrf2 expression, which may play a role in anti-oxidative stress., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Aims: Circular RNAs (circRNAs) have been shown to play crucial roles in various biological processes and human diseases. However, their exact functions in ischemic stroke remain largely unknown. In this study, we explored the functional role of circRNA HECTD1 (circ-HECTD1) and its underlying mechanism in cerebral ischemia/reperfusion injury., Methods: Mouse middle cerebral artery occlusion (MCAO) model and oxygen-glucose deprivation (OGD) model in HT22 cells were used to mimic the cerebral ischemia/reperfusion injury. Brain infarct volume, flow cytometry, caspase 3 activity, NF-κB activity, and TUNEL staining were performed to evaluate the function of circ-HECTD1. Luciferase report assay was used to explore the regulatory mechanism., Findings: The results showed that the expression of circ-HECTD1 and tumor necrosis factor receptor-associated factor 3 (TRAF3) was remarkably up-regulated, while miR-133b was down-regulated in oxygen-glucose deprivation (OGD)-induced HT22 cells and mouse middle cerebral artery occlusion (MCAO) model. circ-HECTD1 knockdown relieved OGD-caused neuronal cell death in vitro. Simultaneously, circ-HECTD1 knockdown improved cerebral infarction volume and neuronal apoptosis in MCAO mice. circ-HECTD1 was able to negatively regulate the expression of miR-133b, and TRAF3 is one of the targets of miR-133b. Upregulation of miR-133b inhibited the expression of TRAF3 in OGD-stimulated cells, whereas circ-HECTD1 upregulation reversed this effect. Furthermore, upregulation of miR-133 was able to inhibit OGD-caused cell apoptosis and NF-κB activation, whereas upregulation of circ-HECTD1 attenuated these effects of miR-133b mimics., Significance: Taken together, circ-HECTD1 knockdown inhibited the expression of TRAF3 by targeting miR-133b, thereby attenuating neuronal injury caused by cerebral ischemia., (Copyright © 2020 Elsevier Inc. All rights reserved.)

BACKGROUND The relative efficacy of carotid endarterectomy (CEA)/thromboendarterectomy (TEA) and carotid artery stenting (CAS) already has been compared in randomized controlled trials and a meta-analysis, but only limited data exist describing the status of cerebral metabolism before and after these interventions. The aim of the present study was to compare metabolic changes before and after treatment of carotid stenosis and assess their potential clinical implications.   MATERIAL AND METHODS Patients with asymptomatic unilateral critical internal CAS were imaged with proton 3T magnetic resonance spectroscopy (H-MRS) because the technique is more sensitive than regular magnetic resonance imaging for detection of the early signs of ischemic events. Abnormal metabolite ratios detected with H-MRS may precede actual morphological changes associated with hypoperfusion as well as reperfusion changes. Ipsilateral and contralateral middle cerebral artery vascular territories were both evaluated before and after vascular intervention. H-MRS was performed within 24 h before and after surgery. Correlations in the metabolic data from H-MRS for N-acetylaspartic acid (NAA)+N-acetylaspartylglutamate, creatinine (Cr)+phosphocreatinine, and phosphocholine+glycerophosphocholine (Cho) were sought. RESULTS H-MRS voxels from 11 subjects were analyzed. Values for dCho/CrI, dCho/CrC and Cho/Naal (P<0.001) were significantly higher ipsilaterally than contralaterally. Ratios for dNaa/ChoC and Cho/NaaC were significantly higher on the non-operated side (P<0.001). CONCLUSIONS H-MRS may be helpful for assessment of patients with CAS, particularly because unlike other modalities, it reveals postoperative changes in metabolic brain status. Initial results indicate the important role of perioperative neuroprotective treatment.

Competing Interests: Competing interests: None declared.

BACKGROUND Fat suppression is an important technique in magnetic resonance imaging (MRI). Comprehensive and quantitative assessment of the influence of fat suppression (FS) on T1-weighted imaging of intracranial vessel wall imaging is needed. In this study, we compared the three-dimensional (3D) variable-flip-angle turbo-spin-echo (CUBE) T1-weighted sequence with and without FS to investigate the differences between the 2 sequences in imaging of the middle cerebral artery (MCA) vessel walls. MATERIAL AND METHODS A 3D CUBE T1-weighted sequence with and without FS by 3.0T MRI was used to obtain intracranial vessel wall images of 105 MCA stenosis patients. The image signal intensity, signal-to-noise ratio, and contrast-to-noise ratio were calculated and compared. Two observers evaluated the image quality of the 2 sequences twice, and interobserver and intraobserver consistency were determined. Differences between the 2 sequences in the area of lumen and plaque were compared. RESULTS The signal intensity, signal-to-noise ratio, and contrast-to-noise ratio of the 3D CUBE T1-weighted sequence without FS were higher, whereas the noise level was lower. In terms of subjective scores, the 3D CUBE T1-weighted sequence without FS performed better. No significant difference was observed in the measurement of the vascular lumen area between the 2 sequences, although there were statistically significant differences in the measurement of plaque area (i.e., the measurement obtained with 3D CUBE T1-weighted sequence without FS was larger). CONCLUSIONS 3D CUBE T1-weighted sequence without FS performed better for MCA vessel walls imaging than 3D CUBE T1-weighted sequence with FS.

Tissue-type plasminogen activator (tPA) is characterized as an effective drug for early thrombolytic therapy in acute cerebral infarction (ACI). However, tPA will increase the risk of hemorrhage if it is used beyond the treatment time window. The study aims to explore the effects of neuroserpin (NSP) on the time window of tPA thrombolysis in ACI and the underlying mechanism. The middle cerebral artery occlusion (MCAO) model was constructed in rats, which were randomly divided into six groups: sham operation group, infarction group, 1-hour thrombolysis group, 1-hour thrombolytic + NSP intervention group, 4-hour thrombolytic group, and 4-hour thrombolysis + NSP intervention group. The neurological changes in rats were evaluated by modified neurological severity scores and rota-rod test. The brain edema and cerebral infarction area were evaluated by dry-wet method and triphenyl tetrazolium chloride staining. The blood-brain barrier (BBB) integrity was examined by Evans blue method. The expressions of malondialdehyde, superoxide dismutase, and glutathione peroxidase in brain were also investigated. The expression of caspase-3 and Bcl-2 in brain tissue and apoptosis of neurons were examined by Western blot analysis and toluidine blue staining. tPA thrombolysis significantly attenuated the neurological impairment in rats with MCAO at 1 hour. Conversely, the effect of tPA thrombolysis at 4 hours after MCAO did not significantly help the recovery of neurological function. However, a combination of tPA treatment and NSP treatment at 4 hours after MCAO markedly ameliorated the neurological impairment, cerebral edema, cerebral infarction volume, BBB injury, oxidative stress products, and neuron apoptosis. NSP can probably expand the time window for tPA treatment to reduce neurological impairment in ACI., (© 2020 Wiley Periodicals LLC.)

Introduction: We aim to report 3 cases of central nervous system (CNS) vasculitides, in which high-resolution magnetic resonance vessel wall imaging (HR-VWI) findings were instrumental in the diagnosis and management., Case Report: Case 1: A 41-year-old obese, smoker female with arterial hypertension presented with recurrent transient ischemic attacks. Computed topography angiography demonstrated bilateral middle cerebral artery (MCA) stenosis. HR-VWI revealed uniform enhancement and thickening of the arterial wall, suggestive of MCA vasculitis. The patient reported chronic calf rash that was biopsied and revealed unspecified connective tissue disease. With immunomodulation, patient remained asymptomatic and 6-month surveillance HR-VWI showed improved MCA stenoses.Case 2: A 56-year-old male with herpes simplex virus 1 encephalitis was treated with antiviral therapy and improved clinically. Two months later, the brain magnetic resonance imaging revealed new temporo-parietal edema and distal MCA hyperintense vessels. HR-VWI showed MCA concentric smooth contrast enhancement, that was attributed to postinfectious vasculitis and had resolved on follow-up HR-VWI.Case 3: A 41-year-old male presented with 1-week of headache and encephalopathy. Brain magnetic resonance imaging revealed punctate multifocal acute ischemic infarcts and no contrast-enhancement. HR-VWI showed multifocal diffuse enhancement of distal cerebral vasculature. Patient subsequently developed branch retinal artery occlusion and hearing loss and was diagnosed with Susac syndrome. No recurrent symptoms were noted after immunotherapy initiation., Conclusions: In these 3 cases, HR-VWI identified distinctive vascular inflammatory changes, which were crucial to guide the etiological workup, positive diagnosis, surveillance neuroimaging, and targeted treatment. HR-VWI is an important diagnostic tool in CNS vasculitides, by providing nuanced information about arterial wall integrity and pathology.

Despite successful clot retrieval in large vessel occlusion stroke, ∼50% of patients have an unfavorable clinical outcome. The mechanisms underlying this functional reperfusion failure remain unknown, and therapeutic options are lacking. In the thrombin-model of middle cerebral artery (MCA) stroke in mice, we show that, despite successful thrombolytic recanalization of the proximal MCA, cortical blood flow does not fully recover. Using in vivo two-photon imaging, we demonstrate that this is due to microvascular obstruction of ∼20%-30% of capillaries in the infarct core and penumbra by neutrophils adhering to distal capillary segments. Depletion of circulating neutrophils using an anti-Ly6G antibody restores microvascular perfusion without increasing the rate of hemorrhagic complications. Strikingly, infarct size and functional deficits are smaller in mice treated with anti-Ly6G. Thus, we propose neutrophil stalling of brain capillaries to contribute to reperfusion failure, which offers promising therapeutic avenues for ischemic stroke., Competing Interests: Declaration of Interests The authors declare no competing interests., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

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

Background: Isolated middle cerebral artery dissection is uncommon and occurs in patients reporting headaches as the only symptom. This makes intracranial artery dissection challenging to diagnose and treat.Case description: We describe two cases of positional headache caused by isolated middle cerebral artery dissection, confirmed using high-resolution magnetic resonance imaging. The two patients presented with sudden-onset headache, occurring when lying in the lateral decubitus position. When lying down in the decubitus position ipsilateral to the intracranial artery dissection, the headache aggravated and middle cerebral artery flow velocity increased on transcranial Doppler ultrasonography compared to when in the supine position. Both patients were treated with antiplatelet agents, and the headache completely resolved within 1-2 weeks., Conclusion: We recommend additional imaging studies evaluating intracranial artery dissection as a cause of positional headache.

Our perspective on anatomy frequently depends on how this anatomy is utilized in clinical practice, and by which methods knowledge is acquired. The thrombectomy revolution, of which the middle cerebral artery (MCA) is the most common target, is an example of a clinical paradigm shift with a unique perspective on cerebrovascular anatomy. This article reviews important features of MCA anatomy in the context of thrombectomy. Recognizing that variation, frequently explained by evolutionary concepts, is the rule when it comes to branching pattern, vessel morphology, territory, or collateral potential is key to successful thrombectomy strategy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

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