Bilateral Occipital Lobe Infarction Presenting as Bilateral Inferior Altitudinal Defects

PURPOSE: Horizontal visual field defects are generally caused by lesions before the optic chiasm, but we report a case with bilateral inferior altitudinal defects secondary to bilateral occipital lobe infarction. CASE SUMMARY: A 57-year-old male with a history of diabetes and hypertension presented with a month of blurring in the inferior visual field. His corrected visual acuity was 1.0 in the right eye and 0.63 in the left eye, and the intraocular pressure was normal in each eye. Pupillary response, ocular movement, and color vision tests were normal in both eyes. There was no specific finding of the optic disc and macula on fundus examination. Visual field examination revealed an inferior congruous homonymous hemianopia with horizontal meridian sparing and a left incongruous homonymous quadrantanopia. Optical coherence tomography for peripapillary retinal nerve fiber layer thickness revealed a mild decrease in the inferior disc of both eyes. Brain magnetic resonance imaging confirmed the presence of an acute infarction confined with upper medial calcarine fissures of bilateral occipital lobe and the right splenium of the corpus callosum, which were consistent with inferior altitudinal hemianopia and left superior incongruous quadrantanopia, respectively. Brain magnetic resonance angiography showed multiple stenosis of bilateral posterior cerebral arteries. CONCLUSIONS: The altitudinal visual field defects could be caused by the occipital lesion medial to the calcarine fissure, and unusual visual defects could be due to a combination of multiple lesions.

Therapeutic effect of early directional catheterization on malignant middle cerebral artery infarction / 中华急诊医学杂志

Objective@#To investigate the efficacy and safety of cuboid stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction in the elderly patients.@*Methods@#Sixteen elderly patients with malignant middle cerebral artery infarction were selected from June 2017 to January 2019 in our hospital. Patients were followed up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS).@*Results@#The 30-day mortality was 18.75%. Among the 16 elderly patients, 6 (37.5%) had an mRS score of 3 (defined as moderate disability), 6 (37.5%) had an mRS score of 4 (defined as moderate to severe disability), 1 (6.25%) had an mRS score of 5 (defined as severe disability), and 3 (18.75%) had an mRS score of 6. The probability of 6-month favorable outcome, defined as an mRS score of ≤3, was 37.5%, and the 6-month mortality was 18.75%.@*Conclusions@#It is a simple, minimally invasive, effective and safe method to treat malignant middle cerebral artery infarction in the elderly patients with cuboid stereotactic aspiration of necrotic brain tissue, which needs to be confirmed by further randomized controlled studies.

Therapeutic effect of early directional catheterization on malignant middle cerebral artery infarction / 中华急诊医学杂志

Objective To investigate the efficacy and safety of cuboid stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction in the elderly patients.Methods Sixteen elderly patients with malignant middle cerebral artery infarction were selected from June 2017 to January 2019 in our hospital.Patients were followed up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS).Results The 30-day mortality was 18.75％.Among the 16 elderly patients,6 (37.5％) had an mRS score of 3 (defined as moderate disability),6 (37.5％) had an mRS score of 4 (defined as moderate to severe disability),1 (6.25％) had an mRS score of 5 (defined as severe disability),and 3 (18.75％) had an mRS score of 6.The probability of 6-month favorable outcome,defined as an mRS score of ≤ 3,was 37.5％,and the 6-month mortality was 18.75％.Conclusions It is a simple,minimally invasive,effective and safe method to treat malignant middle cerebral artery infarction in the elderly patients with cuboid stereotactic aspiration of necrotic brain tissue,which needs to be confirmed by further randomized controlled studies.

Paradoxical Motor and Cognitive Function Recovery in Response to Zolpidem in a Patient with Hypoxic-ischemic Brain Injury: A Case Report

We report an extremely rare case of a patient with hypoxic-ischemic brain injury who recovered consciousness and motor and cognitive functions due to paradoxical response after zolpidem administration. A 32-year-old woman who had attempted suicide by hanging was admitted. The patient had stabilized in a state of drowsy mentality, quadriparesis, dysphagia, and impaired cognition. Brain magnetic resonance imaging was suggestive of hypoxic ischemic brain injury and unilateral infarction in the right posterior cerebral artery territory. Due to sleep disturbance, zolpidem was administered, and paradoxically consciousness level and function returned to near-normal during the duration of the drug-effect. In addition to previous reports, our case characteristically showed remarkable motor and cognitive function recovery, not only consciousness level. The drug-effect time was gradually decreased after 18 months and absent after 3 years. We have reviewed related literature and discussed possible neuropharmacological and neurobiological mechanism.

Long-Term Outcomes of FIM Motor Items Predicted From Acute Stage NIHSS of Patients With Middle Cerebral Artery Infarct

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.

Infarction location for predicting cerebral infarction progressive motor nerve function deficits in middle cerebral artery area / 重庆医学

Objective To investigate the correlation between the infarction location and progressive motor deficits (PMD) occurrence.Methods The patients with middle cerebral artery(MCA) infarction within 24 h of onset without thrombolytic therapy were included.The National Institutes of Health Stroke Scale(NIHSS) motor item score increase ≥2 points of the base line within 7 d after stroke onset served as the PMD diagnostic criteria.The differences in clinical and laboratory data,and infarction location were compared between the PMD group and non-PMD group.The multivariate Logistic regression analysis predicted the risk factors of PMD occurrence.Results A total 121 patients with MCA acute cerebral infarction were included in the study and divided into the PMD group (45 cases) and non-PMD group (76 cases).The internal watershed infarction occurrencerate in the PMD group was higher than that in the non-PMD group (26.7 ％ vs.5.3％,p=0.001).The occurrence rate of penetrating arterial infarction (PAI) had no statistical difference between the PMD group and non-PMD group(42.2％ vs.35.5％,P=0.463).PAI was further divided into perforating branch atheromatous disease (BAD) and lipohyalinitic degeneration (LD).The occurrence rate of BAD in the PMD group was significantly higher than that in the non-PMD group (28.9％ vs.9.2％,P=0.005).The stepwise Logistic regression analysis indicated that watershed infarction [odds ratio (OR):9.750,95 ％ confidence interval(CI):2.828-33.612,P=0.000] and BAD lesion (OR:6.036,95 ％ CI:2.119-17.190,P =0.001) were the independent risk factors contributing to PMD.Conclusion Internal watershed infarction and BAD lesion may predict the PMD occurrence.The infarct location is conducive to find the high risk population of cerebral infarction progress.

The loss of motor unit and it's influencing factors in patients with middle cerebral artery infarction / 中国神经精神疾病杂志

Objective To investigate the loss of motor unit and it's influencing factors in the lower motor neurons after middle cerebral artery infarction. Method Forty patients with first onset and unilateral middle cerebral artery infarction were divided into cortical-basal ganglia(26)and basal ganglia(14)groups and 10 healthy controls were served as control group.All included patients were scored by National Institute of Health stroke scale(NIHSS),modified Rankin scale (mRS), Fugl-Meyer Assessment (FMA) at 48 hours of admission. Nerve conduction study on the limb and motor unit number estimation (MUNE) on abductor pollicis brevis were performed at 2-4 weeks after onset, and the data of single motor action potential (SMUAP) were collected. SPSS 20.0 software was used to statistical analysis. Result The MUNE on were significantly lower and the amplitude and area of SMUAP were significantly increased in ipsilateral than contralateral sides (cortical-basal ganglia group:95.85±26.82 vs. 143.65±38.86, P<0.001; basal ganglia group: 126.71± 44.13 vs. 157.36±56.72, P=0.001). The affected MUNE was significantly decreased in the cortex-basal ganglia than in basal ganglia groups (95.85±26.82 vs.161.40±48.90,P=0.027). The MUNE was negatively correlated with NIHSS score (r=-0.362,P=0.022)and mRS score(r=-0.339,P=0.032).NIHSS score(β=-1.603,P=0.032,95%CI:-3.064~-0.142)and mRS score(OR=2.885,P=0.025,95%CI:1.139~7.158)on admission could predict the loss of MUNE on the affected side. Conclusion This study reveals the loss of motor unit and the compensation of remained motor unit on the affected side after middle cerebral artery infarction,NIHSS score and mRS score on admission may predict the loss of MUNE after stroke.

Complete occlusion of the right middle cerebral artery associated with Mycoplasma pneumoniae pneumonia / 소아과

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.

Complete occlusion of the right middle cerebral artery associated with Mycoplasma pneumoniae pneumonia / 소아과

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.

Cerebral Arterial Calcification Is an Imaging Prognostic Marker for Revascularization Treatment of Acute Middle Cerebral Arterial Occlusion / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: To study the significance of intracranial artery calcification as a prognostic marker for acute ischemic stroke patients undergoing revascularization treatment after middle cerebral artery (MCA) trunk occlusion. METHODS: Patients with acute MCA trunk occlusion, who underwent intravenous and/or intra-arterial revascularization treatment, were enrolled. Intracranial artery calcification scores were calculated by counting calcified intracranial arteries among major seven arteries on computed tomographic angiography. Patients were divided into high (HCB; score > or =3) or low calcification burden (LCB; score <3) groups. Demographic, imaging, and outcome data were compared, and whether HCB is a prognostic factor was evaluated. Grave prognosis was defined as modified Rankin Scale 5-6 for this study. RESULTS: Of 80 enrolled patients, the HCB group comprised 15 patients, who were older, and more commonly had diabetes than patients in the LCB group. Initial National Institutes of Health Stroke Scale (NIHSS) scores did not differ (HCB 13.3+/-2.7 vs. LCB 14.6+/-3.8) between groups. The final good reperfusion after revascularization treatment (thrombolysis in cerebral infarction score 2b-3, HCB 66.7% vs. LCB 69.2%) was similarly achieved in both groups. However, the HCB group had significantly higher NIHSS scores at discharge (16.0+/-12.3 vs. 7.9+/-8.3), and more frequent grave outcome at 3 months (57.1% vs. 22.0%) than the LCB group. HCB was proven as an independent predictor for grave outcome at 3 months when several confounding factors were adjusted (odds ratio 4.135, 95% confidence interval, 1.045-16.359, P=0.043). CONCLUSIONS: Intracranial HCB was associated with grave prognosis in patients who have undergone revascularization for acute MCA trunk occlusion.

Research progress of decompressive hemicraniectomy application as treatment for malignant middle cerebral artery infarction / 天津医药

A large ischemic stroke caused by malignant middle cerebral artery infarction can lead to severe cerebral edema, even cerebral hernia. This condition deteriorates and progresses rapidly, usually leading to death. Due to limitations of conservative treatments, decompressive hemicraniectomy becomes a favored option in clinic. Recent years, a series of ex?perimental studies and clinical trials achieved reliable evidence that decompressive hemicraniectomy is an effective treat?ment for patients who suffer from malignant middle cerebral artery infarction. With the successful surgical procedure, most patients benefit from a reduced mortality and improved functional outcome without severe disability. Nevertheless, plenty of issues about decompressive hemicraniectomy still need to be solved. Here, we reviewed researches of early diagnosis of ma?lignant middle cerebral infarction and the application of decompressive hemicraniectomy as its treatment.

A Case of Spontaneous Spinal Epidural Hematoma Misidentified as a Middle Cerebral Artery Infarction

Spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of spinal cord compression. Early diagnosis and appropriate management are important, however, diagnosis is often difficult due to variable neurologic deficit. We report on the case of a 69-year-old female patient in right hemiparesis. She was treated with thrombolysis therapy for acute cerebral infarction before being transferred to our hospital. Findings on a cervical spine magnetic resonance image showed spinal epidural hematoma and cord compression. She was prepared to undergo decompressive surgery, however, neurologic deficits began to show improvement. She was managed conservatively and was discharged without deficits approximately nine days after onset.

Alien Hand Syndrome in Stroke: Case Report & Neurophysiologic Study

Alien Hand Syndrome is defined as unwilled, uncontrollable, but seemingly purposeful movements of an upper limb. Two major criteria for the diagnosis are complaint of a foreign limb and complex, autonomous, involuntary motor activity that is not part of an identifiable movement disorder. After a cerebrovascular accident in the corpus callosum, the parietal, or frontal regions, various abnormal involuntary motor behaviors may follow. Although different subtypes of Alien Hand Syndrome have been distinguished, this classification clearly does not cover the wide clinical variety of abnormal motor behaviors of the upper extremity. And there are few known studies about the neurophysiology of this syndrome using transcranial magnetic stimulation (TMS). We recently experienced 2 rare cases of Alien Hand Syndrome which occurred after anterior cerebral artery (ACA) infarction. A 72 year-old male with right hemiplegia following a left ACA infarct had difficulty with voluntarily releasing an object from his grasp. A 47 year-old female with left hemiplegia following a right ACA infarct had a problem termed 'intermanual conflict' in which the two hands appear to be directed at opposing purposes. Both of them had neurophysiologic studies done, and showed reduced amplitude by single pulse MEP and a lack of intracortical inhibition (ICI) by paired pulse TMS. No abnormalities were found in SSEP.

Protective efficacy of an Ecklonia cava extract used to treat transient focal ischemia of the rat brain / 대한해부학회지

Phlorotannins (marine algal polyphenols) have been reported to exhibit beneficial biological activities, serving as both antioxidants and anti-inflammatory agents. Among marine algae, Ecklonia cava, a member of the Laminariaceae, is a very popular food regarded as healthy in Korea and Japan. Recently, benefits afforded by phlorotannins in the treatment of various clinical conditions have been reported, but any therapeutic effects of such materials in the treatment of neurodegenerative diseases such as stroke remain unclear. Also, the mechanisms of action of the algal components remain poorly understood. In the present in vivo study, administration of Ecklonia cava polyphenols (ECP) at 10 mg/kg and 50 mg/kg intraperitoneally (i.p.) significantly decreased infarct size and the extent of brain edema in the rat after induction of transient focal ischemia via middle cerebral artery occlusion (MCAO). Further, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay revealed dose-dependent blockage of neuronal apoptosis upon intravenous ECP treatment. Neurobehavioral tests performed over the 6 days after MCAO revealed a reduction in neurological motor performance in control animals, but administration of ECP (50 mg/kg i.p.) prevented this decline. In vitro, a significant neuroprotective effect of ECP was evident when cell viability was assayed after induction of H2O2-mediated oxidative stress, upon retinoic acid treatment, in the differentiated neuroblastoma cell line SH-SY5Y. Interestingly, ECP blocked the rise in cytosolic calcium, in a dose-dependent manner, in differentiated SH-SY5Y cells exposed to H2O2. Together, the results suggest that ECP exerts neuroprotective effects in the focally ischemic brain by reducing Ca(2+)-mediated neurotoxicity.

The use of Stronger Neo-Minophagen C, a glycyrrhizin-containing preparation, in robust neuroprotection in the postischemic brain / 대한해부학회지

Stronger Neo-Minophagen C (SNMC) is a glycyrrhizin-containing preparation that is approved in Japan for the treatment of chronic hepatic diseases and is marketed in Japan, China, Korea, Taiwan, and India. Glycyrrhizin, a triterpene present in the roots and rhizomes of licorice (Glycyrrhiza glabra) has been shown to have anti-inflammatory, anti-oxidative, and anti-viral effects. In the present study, we demonstrated the marked neuroprotective effects of SNMC in the postischemic rat brain after middle cerebral artery occlusion (MCAO). We used 1 ml/kg of SNMC, which is within the dose range used for the treatment of patients with chronic hepatic disease. The administration of SNMC intravenously at 30 minutes before or 30 minutes and 3 hours after MCAO (60 minutes) reduces mean infarct volumes to 27.0+/-4.2%, 37.1+/-12.4%, and 67.8+/-5.8% of that of untreated controls, respectively. This neuroprotective effect is accompanied by improvements in motor impairment and neurological deficits. The administration of SNMC is shown to suppress microglia activation and neutrophil infiltration in the postischemic brain. In addition, SNMC suppresses lipopolysaccharide-induced nitrite production and proinflammatory cytokine induction in a microglia cell line, BV2. This indicates that the neuroprotective effect of SNMC might be due, at least in part, to an anti-inflammatiory effect. Interestingly, SNMC shows significantly higher neuroprotective potency compared to an equivalent dose of pure glycyrrhizin, in terms of reducing infarct volume and improving neurological deficits. Together these results indicate that SNMC, a glycyrrhizin-containing preparation developed for chronic liver disease, has a marked neuroprotective function in the postischemic brain via its anti-inflammatory effects.

Expression of neuroglobin after focal cerebral ischemia and its neuroprotective effect / 第二军医大学学报

Objective: To study the expression of neuroglobin (Ngb) in rat cerebral ischemia model and the neuroprotective effect of Ngb after ischemia and hypoxia. Methods: Totally 113 Sprague-Dawley rats were randomly divided into sham-operated group, middle cerebral artery occlusion (MCAO) group, hemorrhagic infarction (HI) group and hemin treatment group. The brain water content, infarcted tissue volume, neuropathologic changes (H-E staining) and expression of Ngb (immunocytochemical staining) were examined 3, 6, 12, and 24 h after model establishment. Results: The brain water contents and the infarcted tissue volumes in the hemin treatment group were significantly different from those of the MCAO group and HI group (P<0.01). The brain edema was obviously increased in HI group at 12 h. Neuropathologic examination showed that there were fewer necrotic neurons, milder edema and stronger Ngb expression in the Hemin treatment group than in the MCAO group and HI group. Immunocytochemical staining showed that the Ngb positive neurons in Hemin treatment group were more than those in the MCAO and HI groups. Conclusion: Earlier peak of brain edema may lead to aggravation of disease. Hemin-induced Ngb expression may relieve brain damage during focal cerebral ischemia.

Decompressive Craniectomy for Malignant Middle Cerebral Infarction / 대한뇌혈관외과학회지

Decompressive craniectomy is used to treat increased intracranial pressure due to brain swelling in middle cerebral artery infarction. Recently, 3 European multicenter, prospective, randomized trials and a pooled analysis were published. In the pooled analysis, decompressive craniectomy did not appear to increase the risk of complete dependency, misery, and hopelessness. Exactly 2 patients in the surgical and medical groups (5%) were bedbound and severely disabled (mRS 5) at 1 year. The proportion of patients alive with minimal-tomoderate disability (mRS 0-3), however, was significantly increased from 21% to 43%. Decompressive craniectomy resulted in a 49% absolute risk reduction in death, and an absolute increase in the proportion of patients rated as mRS 2 of 12%, mRS 3 of 10%, and mRS 4 of 29%. But, this can be applied in cases with relative young age and early surgical procedure. Therefore, the indication for decompressive craniectomy should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.

Use of decompressive craniectomy in the treatment of hemispheric infarction / Uso da craniectomia descompressiva no tratamento do acidente vascular cerebral isquêmico hemisférico

Decompressive craniectomy (DC) has demonstrated efficacy in reducing mortality in hemispheric infarction of the middle cerebral artery. The aim of our study was to compare the outcome of patients submitted to DC to patients treated in a conservative way. Eighteen patients were submitted to DC and 14 received conservative treatment. Neurological status was assessed by the Glasgow Coma Score and National Institutes of Health Stroke Scale score. Mortality, modified Rankin Scale and Barthel Index scores were assessed at 90 days to evaluate outcome. We did not observe reduction in overall mortality and functional outcome in patients submitted to DC. The differences between our group and previously published series are probably related to the neurological status of the patients at the time of therapeutic decision.

Craniectomia descompressiva (CD) tem demonstrado eficácia em reduzir a mortalidade em pacientes com infarto hemisférico (IH) da artéria cerebral média. Este estudo avaliou o prognóstico dos pacientes submetidos a CD comparando a pacientes com IH tratados de maneira conservadora. Dezoito pacientes foram submetidos a CD e 14 receberam tratamento conservador. Escala de Coma de Glasgow e Escala de AVC do National Institutes of Health foram utilizadas para graduar o déficit neurológico. A mortalidade, bem como os escores obtidos na escala modificada de Rankin e índice de Barthel foram avaliados em 90 dias. Não foi observada redução de mortalidade nos pacientes submetidos a CD. Essa diferença entre os nossos resultados e os estudos publicados previamente se deve, provavelmente, à decisão cirúrgica tardia em pacientes com sinais clínicos de herniação cerebral.

Clinical analysis of decompressive craniectomy and lobectomy in patients with malignant cerebral infarction / 대한뇌혈관외과학회지

OBJECTIVE: The use of decompressive craniectomy for treating massive cerebral infarction is attracting much attention because conventional medical treatment is associated with high mortality. The aim of this retrospective study was to evaluate the surgical treatment results and prognostic factors for patients suffering with malignant cerebral infarction. METHODS: We analyzed 9 consecutive patients who underwent decompressive craniectomy with or without temporal lobectomy after malignant cerebral infarction from 2000 to 2008. We reviewed the medical records, the radiological finding and the pre-operative clinical assessment using the Glasgow Coma scale (GCS). The postoperative functional outcome was assessed as the Barthel-Index (BI) and the modified Rankin scale (mRS). RESULTS: The male to female ratio was 3.5:1. The mean age was 50 years (range: 36-68). Eight patients (89%) showed involvement of the entire middle cerebral artery (MCA) territory and the concomitant anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory. The preoperative mean GCS was 8.3 (range: 5-12) and the mean time to surgery after the onset of symptoms was 47.7 hours (range: 4-168 hours). All the patients underwent decompressive craniectomy and duroplasty. Among them, four patients (45%) underwent temporal lobectomy. The mean followup period was 7.3 months (range: 1-26 months) and five patients died within this period. CONCLUSION: Decompressive craniectomy with or without lobectomy for patients with malignant cerebral infarction decreases the mortality rate and it improves the functional outcome. In the survived group, comparison of the two surgical modalities didn't show any statistically significant difference. However, the decompressive craniectomy with lobectomy group demonstrated a high survival rate (75%). Future studies are needed to investigate the proper treatment modalities for malignant cerebral infarction.

The Effect of Levodopa on Akinetic Mutism in Bilateral Anterior Cerebral Artery Infarction: A case report

Akinetic mutism is a clinical syndrome in which the patient is unable to speak (mutism) or move (akinesia). Various brain lesions can induce akinetic mutism. We attended a 71-year-old woman who presented with akinetic mutism caused by bilateral anterior cerebral artery infarction. The patient improved after the administration of levodopa com-bined with carbidopa, in response to visual and verbal stimuli. Increased verbal output and spontaneous motor activities were also noted. Levodopa may be helpful to the treatment of akinetic mutism.