Application of high-resolution magnetic resonance vessel wall image in the treatment of M1 segment stenosis of middle cerebral artery.

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.

Application of 3.0T high-resolution magnetic resonance imaging for the diagnosis of stenotic vessel wall plaques in the middle cerebral artery: a study on fitness of professional athletes

Objective: To investigate the value of 3.0T high-resolution magnetic resonance imaging (HR-MRI) in the diagnosis of plaque in the vessel wall of middle cerebral artery stenosis. Methods: 41 patients with middle cerebral artery stenosis admitted from January 2018 to January 2020 were selected for the study, all of whom underwent HR-MRI, and the diagnostic results of digital subtraction angiography (DSA) were used as the gold standard to compare HR-MRI findings in middle cerebral artery stenosis with DSA diagnostic results. The NWI and responsible plaque heights of non-ischemic stroke and ischemic stroke patients at 6 months, 12 months, 18 months and 24 months after discharge were compared. Results: 41 patients were found to have stenosis in 49 middle cerebral arteries by DSA, including 33 cases of unilateral stenosis and 8 cases of bilateral stenosis. The diagnostic accuracy, specificity and sensitivity of HR-MRI in middle cerebral artery stenosis were 93.90% (77/82), 90.91% (30/33), 95.92% (47/49). There was no obvious distinction in NWI and responsible plaque height at 6, 12, 18 and 24 months after discharge in patients with ischemic stroke (P > 0.05). When comparing NWI and responsible plaque height at corresponding time points after discharge in non-ischemic stroke patients, the distinctions were not obvious (P > 0.05). Compared with the group of ischemic stroke, the non-ischemic stroke group NWI was lower at corresponding time points (P < 0.05). No obvious distinctions were found between the group of ischemic stroke and the group of non-ischemic stroke in terms of responsible plaque height at 6, 12, 18 and 24 months after discharge (P > 0.05). (AU)

Nomogram to Predict Cognitive Impairment in Patients with Asymptomatic Middle Cerebral Artery Stenosis.

Purpose: This study aims to investigate the characteristics and influencing factors of cognitive impairment in patients with asymptomatic middle cerebral artery stenosis (aMCAS) and to construct a nomogram to predict the risk of cognitive impairment in patients with aMCAS. Patients and Methods: We collected 54 patients with aMCAS and 35 healthy controls to investigate the impaired cognitive domains and pathogenesis in patients with aMCAS. All patients underwent a cranial MRI, CT perfusion, transcranial Doppler ultrasound, blood tests, and a comprehensive neuropsychological evaluation. According to the MoCA score, patients were divided into cognitively normal and cognitively impaired groups. To construct the nomogram, we conducted univariate and multivariate logistic regression analyses to identify factors that affect cognitive function. And the performance of nomogram was evaluated by ROC curves, calibration curves, decision curve analysis (DCA), and clinical impact curve (CIC). Results: In 54 patients with aMCAS, 24 patients presented with cognitive normal, and 30 patients presented with cognitive impairment. The results of multivariate logistic regression suggested that perfusion decompensation, middle cerebral artery mean flow velocity, and LDL-cholesterol levels were independent influencing factors of cognitive impairment. In the following step, a nomogram was constructed. The AUC of the nomogram is 0.862. Calibrating curves show good agreement between nomogram predictions and actual observations, while DCA and CIC show great clinical usefulness. Conclusion: Patients with aMCAS have cognitive impairment in multiple cognitive domains, and impaired executive function was observed during the perfusion compensation period. Furthermore, a nomogram was constructed and validated to predict the risk of cognitive impairment in patients with aMCAS, which can help clinicians to identify at an early stage and improve the management of patients.

Truncal dystonia with isolated middle cerebral artery ischemia: A case report of revascularization therapy for dystonia.

Background: Dystonia is a rare movement disorder with some cases being difficult to treat. Although dystonia can occur as a symptom of moyamoya disease, few studies have reported truncal dystonia occurring with middle cerebral artery (MCA) stenosis. Here, we report a case of truncal dystonia with MCA occlusion. Case Description: The patient was a 48-year-old female clerical worker who lived alone. An abnormal cervical posture initially appeared 7 years before (right flexion). Symptoms improved with medication and botulinum toxin injection. Five years before this report, her symptoms worsened, so the dose of oral medication was increased and botulinum treatment was performed, but the symptoms did not improve. The patient showed decreased cerebral blood flow (CBF) in the cortical areas but not in the basal ganglia. We performed superficial temporal artery-MCA bypass surgery because we believed that the dystonia was due to right MCA stenosis. The patient's symptoms improved immediately after surgery, except for her mild cervical backbend. Seven months after the surgery, the patient's involuntary movements showed further improvement, and symptoms have not worsened even after 2 years. Conclusion: Revascularization therapy improved CBF and truncal dystonia and could be a viable treatment option for dystonia with ischemia in the MCA region. Extensive cerebral ischemia can result in cortical inhibition loss or over-adapted cerebral plasticity and cause dystonia. Revascularization therapy may be useful for patients with dystonia and decreased CBF in the MCA region.

Evaluating iron deposition in gray matter nuclei of patients with unilateral middle cerebral artery stenosis using quantitative susceptibility mapping.

Iron mediated oxidative stress is involved in the process of brain injury after long-term ischemia. While increased iron deposition in the affected brain regions was observed in animal models of ischemic stroke, potential changes in the brain iron content in clinical patients with cerebral ischemia remain unclear. Quantitative susceptibility mapping (QSM), a non-invasive magnetic resonance imaging technique, can be used to evaluate iron content in the gray matter (GM) nuclei reliably. In this study, we aimed to quantitatively evaluate iron content changes in GM nuclei of patients with long-term unilateral middle cerebral artery (MCA) stenosis/occlusion-related cerebral ischemia using QSM. Forty-six unilateral MCA stenosis/occlusion patients and 38 age-, sex- and education-matched healthy controls underwent QSM. Clinical variables of history of hypertension, diabetes, hyperlipidemia, hyperhomocysteinemia, smoking, and drinking in all patients were evaluated. The iron-related susceptibility of GM nucleus subregions, including the bilateral caudate nucleus (CN), putamen (PU), globus pallidus (GP), thalamus, substantia nigra (SN), red nucleus, and dentate nucleus, was assessed. Susceptibility was compared between the bilateral GM nuclei in patients and controls. Receiver operating characteristic curve analysis was used to evaluate the efficacy of QSM susceptibility in distinguishing patients with unilateral MCA stenosis/occlusion from healthy controls. Multiple linear regression analysis was used to evaluate the relationship between ipsilateral susceptibility levels and clinical variables. Except for the CN, the susceptibility in most bilateral GM nucleus subregions was comparable in healthy controls, whereas for patients with unilateral MCA stenosis/occlusion, the ipsilateral PU, GP, and SN exhibited significantly higher susceptibility than the contralateral side (all P < 0.05). Compared with controls, susceptibility of the ipsilateral PU, GP, and SN and of contralateral PU in patients were significantly increased (all P < 0.05). The area under the curve (AUC) was greater for the ipsilateral PU than for the GP and SN (AUC = 0.773, 0.662 and 0.681; all P < 0.05). Multiple linear regression analysis showed that the increased susceptibility of the ipsilateral PU was significantly associated with hypertension, of the ipsilateral GP associated with smoking, and of the ipsilateral SN associated with diabetes (all P < 0.05). Our findings provide support for abnormal iron accumulation in the GM nuclei after chronic MCA stenosis/occlusion and its correlation with some cerebrovascular disease risk factors. Therefore, iron deposition in the GM nuclei, as measured by QSM, may be a potential biomarker for long-term cerebral ischemia.

Value of IMA, IMAR, the IMA Index, and Other Hematological Features in Predicting AIS Caused by MCA Stenosis/Occlusion.

OBJECTIVE: In this study, we investigated the relationship between serum ischemic modified albumin (IMA) levels and other hematologic features and middle cerebral artery (MCA) severe stenosis/occlusion in acute ischemic stroke (AIS) patients. METHODS: The levels of serum IMA and Albumin (ALB) of 169 AIS patients were measured, and the ratio of IMA to albumin (IMAR) and the albumin-adjusted ischemia-modified albumin index (IMA index) were calculated. Different combinations of other hematologic changes and clinical features of the patients were analyzed. RESULTS: The results indicated that the levels of blood IMA and IMAR were significantly higher in the group with severe intracranial stenosis/occlusion than in the group with non-severe stenosis/ occlusion in AIS patients, while the CHE levels were significantly lower than those in the other groups. In the MCA severe stenosis/occlusion group, the levels of blood IMA and IMAR were significantly higher than that in the other vascular severe stenosis/occlusion groups, while the IMA index, ALB, and CHE were significantly lower than that in the other groups. Multiple linear regression analysis showed a significant negative correlation between IMA and albumin. A combined diagnostic ROC curve analysis showed that among AIS patients, the best combination for determining severe stenosis/occlusion of the great intracranial arteries was the admission NIHSS score + CHE (AUC = 0.783). The best combination for determining severe stenosis or occlusion of the MCA in AIS patients was IMAR combined with the admission NIHSS score and CHE (AUC = 0.827). CONCLUSION: The combined use of IMA, IMAR, and the IMA index has some diagnostic value in AIS caused by severe stenosis or occlusion of the MCA. IMAR, CHE, and the admission NIHSS scores are the best combinations to determine whether an AIS patient has severe stenosis or occlusion of the MCA.

Microsurgical treatment of middle cerebral artery stenosis or occlusion: a single center experience and literature review.

BACKGROUND: To investigate the effect of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in the treatment of MCA stenosis or occlusion. METHODS: The clinical and imaging data of 31 MCA stenosis or occlusion patients with STA-MCA bypass were analyzed retrospectively. The operation was performed by STA-MCA M4 segment bypass via the frontotemporal approach. Modified Rankin Scale (mRS) was used to evaluate the neurological function of patients. RESULTS: After operation, head computed tomography (CT) showed that there was no new infarction or hemorrhage in the operation area. CTA and CTP showed that the bypass vessel was unobstructed in 29 cases and the cerebral perfusion was improved in 31 cases. Among the 31 patients, 7 patients had postoperative complications and 13 patients had improvement of clinical symptoms. The other patients had no complications and the clinical symptoms remained unchanged. The mRs score of 31 patients after operation indicated that the neurological function was significantly improved than pre-operation. Of the 31 patients, 23 cases were followed up. The mRs score showed that the neurological function of these 23 patients was further improved than that at discharge. In addition, DSA (or CTA) and CTP showed that the bypass vessel was unobstructed and the cerebral perfusion was further improved. CONCLUSION: STA-MCA bypass was an effective method for the treatment of MCA stenosis or occlusion. However, the results should be further verified by large sample, multi-center and long-term follow-up.

Neurosyphilis presenting with focal middle cerebral artery stenosis and acute ischemic stroke: A case report.

Despite widespread screening and active management of syphilis infection, the rate of secondary and tertiary syphilis has increased over the past decade in the United States, especially with human immunodeficiency virus co-infection. We report a case of ischemic strokes in the middle cerebral artery (MCA) territory with focal stenosis of the left M1 segment of the MCA resulting from neurosyphilis with manifestation of subacute intermittent right-sided hemi-body numbness and transient word finding difficulties in a young adult with no prior known history of syphilis or significant cerebrovascular risk factors. A diagnostic cerebral angiogram was done which was initially concerning for possibility of reversible cerebral vasoconstriction syndrome (RCVS). The serum Treponema pallidum RPR testing resulted positive (1:32 titer) as well as subsequent reactive cerebrospinal fluid (CSF) VDRL test (ratio, 1:8). The patient was treated with intravenous ceftriaxone as well as verapamil and recovered without any residual deficits. To the best of our knowledge, this is the first reported evidence of possible RCVS in a case of neurosyphilis and related ischemic stroke. This case underscores the importance of evaluation for syphilis in young patients with fewer known vascular risk factors, who present with an ischemic stroke. Given the higher rates of stroke recurrence in neurosyphilis relative to few other stroke risk factors, early diagnosis, and treatment is furthermore essential to prevent disease progression.

The safety and efficacy of the Neuroform EZ stent for the treatment of symptomatic atherosclerotic stenosis in the middle cerebral artery.

OBJECTIVE: To evaluate the safety and efficacy of Neuroform EZ stent placement for patients with symptomatic atherosclerotic stenosis of the middle cerebral artery (MCA). METHOD: We retrospectively reviewed the clinical data of 70 patients (36 males and 34 females; mean age: 62.5 ± 1.25 years) with symptomatic atherosclerotic stenosis of the MCA who underwent Neuroform EZ stent insertion between January 2018 and June 2020. We reviewed the clinical data of each patient so that we could evaluate outcomes and angiographic findings at follow-up. RESULTS: The technical success rate for the 70 patients was 100%. The mean rate of stenosis improved from 82.6 ± 6.5% (pre-stenting) to 21.11 ± 2.6% (post-stenting). During the post-stenting follow-up period, the 1-year frequencies of stroke, transient ischemic attack, and death, were all 0%. 42 patients were reviewed in hospital by DSA or CTA. Of the patients undergoing DSA or CTA review, four patients were found to have in-stent restenosis. CONCLUSION: Our analysis indicates that the Neuroform EZ stent represents a valuable endovascular treatment option for patients with severe stenosis of the MCA. Additional studies are now needed to evaluate the long-term outcomes arising from the use of this technique.

Cerebral Circulation Time Is a Potential Predictor of Disabling Ischemic Cerebrovascular Events in Patients With Non-disabling Middle Cerebral Artery Stenosis.

Patients with non-disabling middle cerebral artery (MCA) stenosis (ND-MCAS) are at risk for disabling ischemic cerebrovascular events (DICE) despite aggressive medical therapy. In this study, we aimed to verify whether cerebral circulation time (CCT) was a potential predictor of DICE in patients with ND-MCAS. From January 2015 to January 2020, 46 patients with ND-MCAS treated with aggressive medical therapy were enrolled for digital subtraction angiography (DSA) in this convenience sampling study. They were divided into the DICE (-) and DICE (+) groups based on the occurrence of DICE within 3 months after DSA. The CCT was defined as the time from the appearance of the MCA to the peak intensity of the Trolard vein during DSA. The rCCT (relative CCT) was defined as the ratio of the CCT of the stenotic side (sCCT) to the CCT of the healthy side (hCCT). The differences in sCCT, hCCT, and rCCT between the two groups were analyzed with Mann-Whitney U tests. Logistic regression analysis was performed to evaluate the association between the risk factors and DICE. Receiver operating characteristic (ROC) curves were constructed to assess the predictive value of rCCT in identifying DICE in ND-MCAS patients. The results showed that DICE appeared in 5 of the 46 patients within 3 months. rCCT were significantly increased in the DICE (+) group compared with the DICE (-) group [1.08 (1.05, 1.14) vs. 1.30 (1.22, 1.54), p < 0.001]. Logistic regression analysis found that prolonged rCCT was an independent positive prognostic factor for DICE (odds ratio = 1.273, p = 0.019) after adjustment for potential confounders (age, diabetes, antithrombotic use, and stenosis degree). ROC analysis showed that rCCT provided satisfactory accuracy in distinguishing the DICE (+) group from the DICE (-) group among ND-MCAS patients (area under the curve = 0.985, p < 0.001), with an optimal cutoff point of 1.20 (100% sensitivity, 97.6% specificity). In conclusion, prolonged rCCT is independently associated with the occurrence of DICE in ND-MCAS patients and may be used to identify individuals at risk of DICE.

Prevalence and outcome of young stroke patients with middle cerebral artery stenosis.

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

Neurocognitive improvement after angioplasty in patients with chronic middle cerebral artery stenosis and cerebral ischemia.

BACKGROUND: The use of middle cerebral artery (MCA) angioplasty compared with drug therapy has been controversial. Few studies have reported the correlations between cognitive function improvement and MCA angioplasty. This study aimed to explore neurocognitive function after angioplasty in patients with middle cerebral artery stenosis (MCAS) and objective cerebral ischemia. METHODS: We identified 14 patients diagnosed with MCAS aged 45-65 years. Neurocognitive function evaluation was performed by 2 independent clinical psychologists using the Mini-Mental State Examination (MMSE), Montreal cognitive assessment scale (MoCA), and Multi-Dimensional Psychology. All patients received general anesthesia, underwent diagnostic cerebral angiography (DSA) via the femoral route and angioplasty, and then were sent to the neurologic intensive care unit (NICU) for overnight hemodynamic and neurologic monitoring. Aspirin and clopidogrel treatments were continued for 3 months after successful intervention. Complete neurologic examinations, including assessment with the National Institutes of Health Stroke (NIHSS), and modulate RANK score (MRS) were conducted by 2 independent neurologists. The patients received a family follow-up at 1 week, 1 month, and 3 months after the interventional procedure. Neurologic sequelae, intracranial hemorrhages, and deaths were recorded as an endpoint. Follow-up clinical and imageological examinations were scheduled at 6 months after the intervention. Follow-up brain computed tomography (CT) perfusion or magnetic resonance angiography (MRA) perfusion scans performed by 2 imageological scanners were scheduled 6 months after the procedure. RESULTS: Angioplasty technical success was achieved in 14 parents (100%). We found that 10 patients did not have recurrent MCAS in the angioplasty site and had significant improvements in the associated brain perfusion situation and cognitive founction as compared before and after angioplasty. Also, 4 patients had evident restenosis in the angioplasty site. In the nonstenosis group, we found significant improvements in the MMSE, 3-dimensional (3D) mental rotation, simple calculation, and spatial working memory. In the recurrent stenosis group, we found no statistically significant changes in cognitive function compared with the baseline and after a 6-month follow up. There were high correlations between the changes in perfusion and the changes in word and picture memory. There was a significant correlation between the change in perfusion with MMSE (-0.522), spatial working memory (0.655), and Raven's progressive matrices test (0.637); a moderate correlation with 3D rotation (0.413), and simple calculation (-0.359); and weak correlation with visual tracking (0.026) and MoCA (0.279). CONCLUSIONS: Angioplasty surgery significantly improves neurocognitive function in patients with middle cerebral artery stenosis (MCAS) and objective cerebral ischemia.

Improvement of Cerebrovascular Reserve by Percutaneous Transluminal Angioplasty for Symptomatic Middle Cerebral Artery Stenosis.

Objective: The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Methods: Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results: The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). Conclusions: PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.

T-Configuration Stent Placement for Carotid Bifurcation Stenosis Co-Existing with Ipsilateral Intracranial Stenosis: A Case Report and Literature Review.

In patients with carotid bifurcation stenosis co-existing with ipsilateral intracranial artery stenosis, combined treatment with carotid artery stenting (CAS)/carotid endarterectomy (CEA) and extracranial-to- intracranial (EC-IC) bypass can be a useful option to prevent future ischemic stroke events. EC-IC bypass requires a sufficient antegrade flow in the ipsilateral external carotid artery. However, standard CAS/CEA occasionally lead to external carotid artery occlusion. Herein, we present a case of successful one-stage endovascular revascularization of both the antegrade internal and external carotid artery flow using the carotid T-stent technique for carotid bifurcation stenosis co-existing with ipsilateral middle cerebral artery stenosis.

Transcranial Color-Coded Sonography Criteria for Moderate and Severe Middle Cerebral Artery Stenosis.

This study aimed to establish optimal criteria for evaluation of moderate (50%-69%) and severe (70%-99%) middle cerebral artery (MCA) stenosis with transcranial color-coded sonography (TCCS). A total of 375 cases provided 409 TCCS/digital subtraction angiography vessel pairs. Peak systolic velocity (PSV), end-diastolic velocity (EDV) and mean flow velocity (MFV) of the MCA were measured. The stenotic/distal MFV ratios (SDRs) were calculated. With digital subtraction angiography as a reference, for 50%-69% MCA stenosis, the optimal combined criteria were PSV ≥180 cm/s (sensitivity 95.7%, specificity 64.9% and overall accuracy 69.7%); EDV ≥75 cm/s (90.0%, 66.4% and 68.7%); MFV ≥110 cm/s (95.7%, 64.0% and 69.4%); and SDR ≥2.5 (88.6%, 71.3% and 76.3%). Criteria for 70%-99% MCA stenosis were PSV ≥240 cm/s (93.5%, 89.9% and 85.5%); EDV ≥100 cm/s (96.8%, 89.0% and 87.3%); MFV≥160 cm/s (91.9%, 92.8% and 92.2%); and SDR ≥4 (87.1%, 92.2% and 91.4%). Parameters of the MCA detected by TCCS, especially SDR, may increase accuracy in diagnosis of 50%-69% and 70%-99% MCA stenosis.

High-Degree Middle Cerebral Artery Stenosis : Can Advanced 3D DSA-MRI Fusion Imaging Better Illustrate Plaques and Perforators?

PURPOSE: Endovascular treatment in severe middle cerebral artery (MCA) stenosis is controversial owing to high rates of periprocedural complications, especially occlusion of the lenticulostriate arteries (LSA). The characteristics of LSAs and the spatial relationships between MCA plaques and LSAs using the fusion of three-dimensional (3D) digital subtraction angiography (DSA) and magnetic resonance imaging (3D DSA-MRI fusion) were investigated. METHODS: We retrospectively analyzed data from 32 ischemic stroke or transient ischemic attack patients with severe MCA stenosis, who underwent MRI and DSA within 2 weeks after symptom onset. The patients were divided into culprit and non-culprit MCA stenosis groups. The 3D DSA-MRI fusion was performed on dedicated workstations, which allowed automated overlays of the target vessels. The characteristics of LSAs, plaque distribution and lesion patterns, and their relationships were evaluated. RESULTS: The 3D DSA-MRI fusion image was able to illustrate the spatial relationships between MCA plaques and LSA orifices. Of 42 LSA stems in 32 patients, 10 had MCA plaque over the LSA orifice and were all found in the culprit MCA stenosis group. Over half (51.9%) of the LSA stems in patients with culprit MCA stenosis originated from the stenotic MCA segment. The MCA plaque-LSA orifice spatial relationships were classified into four types, which were significantly different between the two groups (p = 0.016). CONCLUSION: The 3D DSA-MRI fusion technique enables visualization of the LSA orifice and MCA plaque and their spatial relationships. This classification of the type of spatial relationships can provide insights into the pathogenesis of MCA stroke and useful guides for treatment strategies.

Arterial spin labeling-MR may be an alternative to SPECT for evaluating cerebral perfusion in patients with unilateral middle cerebral artery stenosis.

OBJECTIVE: Cerebral blood flow (CBF) mapping of single-photon emission tomography (SPECT) is considered a gold standard for evaluating cerebral perfusion. However, invasiveness, high costs and strict technical requirements can limit its clinical use. We aimed to evaluate the concordance of CBF maps obtained from SPECT and pseudo-continuous arterial spin labeling magnetic resonance (PCASL-MR) imaging for evaluating cerebral perfusion. METHODS: PCASL-MR/SPECT-CBF maps were obtained from 16 eligible patients with unilateral middle cerebral artery stenosis (MCAS). Three slices (basal ganglia, semi-oval center and cerebellum) on both PCASL-MR and SPECT maps were divided into different regions of interest (ROIs) according to the ASPECT criterion, arterial territories, and cerebral hemispheres, respectively. The concordance of the two types of CBF maps and the specificity and sensitivity of PCASL-MR imaging on predicting regional hypoperfusion were calculated. RESULTS: A total of 448 ROIs were divided according to the ASPECT criterion, 192 ROIs partitioned in accordance with arterial territories, and 96 ROIs delineated based on cerebral hemispheres were analyzed. PCASL-MR imaging exhibited 83.78% to 100% sensitivity, 90.19% to 95.83% specificity for detection of hypoperfusion. Qualitative analyses revealed a strong concordance between PCASL-MR and SPECT on reflecting regional cerebral hypoperfusion (Kappa coefficient = 0.662-0.920, p < 0.01). Semi-quantitative analysis by ΔCBF revealed moderate consistency (Spearman correlation coefficient = 0.610-0.571). CONCLUSIONS: Our findings suggest that PCASL-MR may be a promising non-invasive, inexpensive alternative to SPECT for evaluating cerebral perfusion accurately in patients with symptomatic MCAS.

[Clinical findings of a patient with hemiballism after superficial temporal artery-middle cerebral artery anastomosis for idiopathic middle cerebral artery stenosis].

A 32-year-old woman experienced several episodes of transient numbness on the left side of her face and body. MR angiography revealed severe stenosis in the right middle cerebral artery (MCA). Abnormal collateral vessel networks were not observed, and idiopathic MCA stenosis was diagnosed. She underwent superficial temporal artery (STA)-MCA anastomosis of the right hemisphere. The surgery eliminated the transient ischemic attacks; however, she developed hemiballism in the left side of her face and left upper limb 2 weeks after the surgery. The ballism disappeared 1.5 years after onset without any treatments. A few patients with development of chorea after STA-MCA anastomosis has been reported in moyamoya disease, but not in those with MCA stenoses. It has been previsouly reported that the development of an involuntary movement might be associated with hypermetabolism in the contra lateral striatum after STA-MCA anastomosis. We considered that a similar mechanism may have caused hemiallism in our patient. We need to recognize that STA-MCA anastomosis could cause hemichorea or hemiballism.

Stenting for Middle Cerebral Artery Stenosis Associated with a Nonbifurcating Cervical Carotid Artery: Case Report and Naming Consideration.

BACKGROUND: A nonbifurcating cervical carotid artery (NBCCA) is a rare anatomic variation of the carotid artery which directly arises from the common carotid artery without forming a bifurcation. A rare case of an NBCCA associated with middle cerebral artery (MCA) stenosis is reported herein. CASE DESCRIPTION: A 70-year-old man was admitted to the hospital for fresh infarctions in the left frontoparietal lobe. The angiographic imaging showed severe atherosclerotic stenosis in the left MCA associated with an ipsilateral NBCCA. The origin of the left internal carotid artery (ICA) was occluded leaving a stump. A tortuous anastomotic vessel arose from the external carotid artery and continued as the cervical ICA. A stent was placed in the left MCA, and the patient recovered uneventfully and without further ischemia during follow-up. Embryogenesis and naming considerations are briefly discussed. CONCLUSIONS: This is the first report of an NBCCA accompanied by ipsilateral MCA stenosis. The name hypogenesis/agenesis of the proximal ICA might describe the congenital anatomic variation of an NBCCA more accurately than NBCCA.

Accuracy of high resolution MRI in measurement of vascular stenosis ratio in atherosclerotic middle cerebral artery / 中华全科医师杂志

Objective To evaluate the accuracy of measurements of atherosclerotic middle cerebral artery (MCA) stenosis with 3.0 T high-resolution magnetic resonance imaging (HR-MRI).Methods Forty patients with symptomatic atherosclerotic stenosis of middle cerebral artery (MCA) confirmed by digital subtraction angiography (DSA) in the Affiliated Hospital of Binzhou Medical College from September 2017 to May 2018 were enrolled in the study.Patients were scanned by HR-MRI sequence (including T1WI,T2WI,PDWI).The MCA M1 stenosis rate on HR-MR images was assessed by warfarin-aspirin symptomatic intracranial artery disease (WASID) method and area measurement algorithm,respectively,and based on the stenosis rate the degree of stenosis (semi-quantitative measurement) was determined.The accuracy of the two measurement methods was evaluated with DSA results as the gold standard.Results The HR-MRI images showed the structure of the vessel wall clearly in 30 patients meeting the measurement requirements.The inner edge of the vessel was clearly distinguishable and smooth,showing eccentric stenosis.The stenosis rate of MCA measured by DSA,WASID method and area measurement algorithm were (82± 17)％,(70± 12)％,(81 ± 16)％,respectively (P＞0.05).The result of area measurement algorithm was better correlated with DSA (r=0.893);and the coincidence of the stenosis degree rate of two measurement method was 90％(27/30).Conclusion The area measurement algorithm based on the HS-MRI has high accuracy in measuring the degree of MCA stenosis,which is of high clinical application value.