Search Results (58)

Background: Endothelial dysfunction plays a critical role in ischemic stroke. The Endothelial Activation and Stress Index (EASIX), calculated from creatinine, lactate dehydrogenase (LDH), and platelet levels, reflects endothelial injury. This study aimed to investigate the relationship between EASIX and 90-day mortality in patients with posterior circulation ischemic stroke (PCIS) treated with mechanical thrombectomy. Methods: Fifty-eight patients with acute ischemic stroke who underwent mechanical thrombectomy (MT) or MT combined with intravenous thrombolysis (intravenous tissue plasminogen activator (tPA)) for posterior circulation ischemic stroke (PCIS) were included. EASIX was calculated using 24 h laboratory values of creatinine, LDH, and platelets. Its association with 90-day mortality, length of hospital stay, intubation, and parenchymal hemorrhage was analyzed. Results: In patients receiving reperfusion therapy, the Endothelial Activation and Stress Index (EASIX) showed modest ability to predict 90-day mortality (AUC = 0.583, 95% CI 0.428–0.739, p = 0.295). Higher EASIX values were linked to a 6.58-fold increase in mortality risk. Patients with elevated EASIX were generally older, had more frequent hyperlipidemia, had higher 24 h National Institutes of Health Stroke Scale (NIHSS) scores, had greater need for intubation, and had higher in-hospital mortality. Conclusions: EASIX is a simple, inexpensive, and non-invasive marker that may reflect endothelial dysfunction and help predict mortality in PCIS patients undergoing reperfusion therapy. Higher EASIX values are associated with poorer prognosis. Early identification of high-risk patients may support secondary prevention strategies. Full article

Background/Objectives: Post-varicella arteriopathy (PVA) is a significant cause of pediatric arterial ischemic stroke (AIS) that typically involves previously healthy children within 12 months of primary varicella infection, mostly with a monophasic course. Diagnosis is based on clinical and imaging findings, and cerebrospinal fluid analysis may confirm it; treatment is empirical and heterogeneous. We describe a typical case of PVA and present a systematic review of its clinical, radiological, therapeutic, and outcome features. Methods: Following PRISMA 2020 and AMSTAR-2 guidelines, data on demographics, clinical presentation, imaging, laboratory confirmation, treatment, and outcomes were extracted across databases (PubMed, Embase, Scopus). Results: Forty-seven studies, encompassing 312 pediatric patients, were included. Mean age was 4 years with a median latency of 3.82 months from varicella to neurologic symptoms. Common presentation included hemiparesis, language impairment, and seizures. Imaging findings showed unilateral focal involvement of anterior circulation arteries, basal ganglia infarctions, and, rarely, bilateral or posterior circulation involvement. CSF VZV-DNA PCR and anti-VZV IgG were positive in 39% and 48% of tested patients. Treatment included intravenous acyclovir (34%), corticosteroids (20%), and low-dose aspirin (77%); two patients underwent acute reperfusion therapy (rt-PA or thrombectomy). Outcomes tended to be moderately favorable: 43% achieved full recovery, 45% had residual deficit, and 11% experienced recurrence. Prothrombotic state was reported, and it may influence disease severity. Conclusions: PVA is a rare distinct cause of pediatric stroke, with a generally favorable prognosis quoad vitam. Standardized guidelines and prospective studies are needed to establish evidence-based management. Clinicians should maintain a high suspicion for its diagnosis. Full article

Background: Non-arteritic anterior ischemic optic neuropathy (NAION) is a neuroophthalmological disorder characterized by impaired blood flow to the optic nerve head. There is uncertainty about whether, in some cases, NAION may be caused by proximal embolism of the posterior ciliary arteries. Diffusion-weighted magnetic resonance imaging (DWI-MRI) can provide evidence of concurrent cerebral infarction that may indicate a common embolic etiology. Methods: Adults with ophthalmological diagnosis of NAION who underwent cerebral DWI-MRI within 14 days from onset of visual impairment were included in a retrospective cohort study (2013–2021). DWI-MRI images were assessed for presence, location, and type of ischemic stroke by a board-certified neuroradiologist blinded for clinical patient data. Results: Among 122 patients (mean age 64.6 ± 11.9 years), DWI-MRI indicated acute/subacute ischemic stroke in three cases (2.5%), all located within the anterior circulation in the territory of the left middle cerebral artery and ipsilateral to the affected eye in two cases (1.6%). Ischemic stroke location was cortical in one case (0.8%) and subcortical in two cases (1.6%). Acute ischemic stroke indicated by a hyperintense DWI signal and corresponding low ADC was present in one patient (0.8%). Two patients (1.6%) had subacute ischemic stroke (hyperintense DWI signal and normal or elevated ADC signal). Only one NAION patient (0.8%) had acute embolic stroke corresponding to the vascular territory of the affected eye. Conclusions: Concurrent embolic ischemic stroke in NAION is exceedingly rare. Our findings support the prevailing pathophysiological theory of NAION as a non-embolic disease. Full article

Background/Objectives: Superior cerebellar artery (SCA) infarction is a rare but clinically significant subtype of posterior circulation stroke. Extensive swelling in the SCA territory may cause downward brainstem compression and appear as brainstem hypodensity on computed tomography, potentially leading to premature treatment withdrawal. Methods: We report the case of a 50-year-old woman with acute SCA-territory infarction (NIHSS = 7) presenting with vertigo, dysphagia, dysarthria, and diplopia. Initial computed tomography suggested extensive brainstem infarction, prompting withdrawal of treatment. Diffusion-weighted MRI revealed reversible edema with brainstem sparing. The patient underwent suboccipital decompressive craniectomy and ventricular drainage with favorable neurological recovery. In addition, a systematic literature search was conducted according to PRISMA 2020 guidelines in PubMed, Web of Science, and Scopus (studies published since 1 January 2015). Fifteen studies met predefined eligibility criteria. Results: Magnetic resonance imaging findings were decisive in avoiding a falsely dismal prognosis and inappropriate withdrawal of care. Across the literature, infarct volume (>30–35 mL), brainstem involvement and bilateral cerebellar infarction emerged as key predictors of malignant course. Early decompressive surgery was consistently associated with improved survival, though functional outcomes varied. Fast magnetic resonance imaging techniques and volumetric imaging improved risk stratification and surgical decision-making. Conclusions: SCA infarction can mimic brainstem infarction on computed tomography due to secondary compression rather than true ischemia. Magnetic resonance imaging is essential to guide treatment and prevent avoidable mortality. Multimodal imaging combined with interdisciplinary management allows for accurate prognostication and optimized surgical timing in malignant SCA infarction. Full article

Background: Extracranial vertebral artery aneurysms (EVAAs) are exceptionally rare vascular lesions and an uncommon cause of posterior circulation stroke. Their diagnosis is often delayed due to nonspecific symptoms, yet prompt recognition is essential to guide management. Objective: This study aimed to report a rare case of an extracranial vertebral artery dissecting aneurysm presenting as a posterior circulation stroke in a young adult, successfully managed with flow-diverter stenting. Clinical Case: A 33-year-old woman presented with sudden-onset dysarthria, vertigo, nausea, and vomiting. Brain magnetic resonance imaging revealed infarcts in the left occipital lobe, cerebellar peduncle, and both cerebellar hemispheres. Computed tomography angiography (CTA) demonstrated a fusiform aneurysm in the V2 segment of the left vertebral artery, and digital subtraction angiography (DSA) confirmed a dissecting aneurysm. The patient was successfully treated with a flow-diverting stent and remained stable at 6 months’ follow-up with mRS 1. Results: EVAA are uncommon but can manifest as posterior circulation ischemic events in young patients. Endovascular treatment with flow-diverting stents has been reported as a feasible option in selected cases, although evidence remains limited to case reports and small series. Conclusions: This case underscores the importance of considering rare yet potentially treatable etiologies of vertebrobasilar stroke in young patients and highlights the value of a multidisciplinary approach to management. Full article

Background: Gerstmann syndrome (GS) is characterised by the tetrad of agraphia, acalculia, finger agnosia, and right-left disorientation, which was first described by Josef Gerstmann in 1924 and is conventionally linked to lesions of the dominant angular gyrus. Contemporary neuroimaging and lesion mapping research indicates that a more dispersed parietal and occipito-temporal network may be involved. Bilateral parietal lobe infarcts are uncommon and usually arise from embolic events or small artery pathology, frequently resulting in multifocal cognitive and perceptual impairments. Method: This case report describes a 52-year-old male presented with acute confusion, perseverative speech, and an inability to follow commands. The neurological examination indicated the presence of the complete Gerstmann tetrad. The Magnetic Resonance Imaging (MRI brain) revealed bilateral parieto-occipital infarcts, with greater severity on the left, indicative of ischaemia in the territory of the posterior cerebral artery (PCA). The medical team provided supportive care and implemented secondary stroke prevention, leading to partial neurocognitive recovery over a period of three weeks. Results: This case highlights a rare presentation of Gerstmann syndrome due to bilateral parieto-occipital infarcts and emphasises that the syndrome can arise from bilateral or widespread parietal injury rather than lesions limited to the angular gyrus. Conclusions: The prompt identification of the Gerstmann constellation helps localise the lesion, enhances diagnostic accuracy, and aids in rehabilitation planning. Full article

Introduction: The rates of pediatric ischemic stroke incidence have more than doubled over the past 3–4 decades; however, pediatric posterior circulation strokes are even more uncommon. These rising incidence rates have led to increasing awareness of pediatric strokes and the development of institutional guidelines regarding these patients to optimize outcomes when possible. Case Report: We describe a rare case of acute ischemic posterior circulation stroke in a 14-year-old previously healthy adolescent boy who presented with right-sided facial droop, dysarthria, and right-sided hemiplegia. An MRI of the brain demonstrated an acute infarct in the brainstem, and an echocardiogram demonstrated a patent foramen ovale (PFO). We also discuss how to localize brainstem lesions to a specific location within the brainstem and associated blood supply using symptomatology. Conclusions: All stroke patients require evaluation for possible etiologies of stroke and possible underlying risk factors. Nearly half of patients who suffer from cryptogenic stroke are found to have a PFO, and adult studies have shown that PFO closure is associated with reduced recurrent cryptogenic strokes, although pediatric-specific data is lacking. If a posterior stroke is suspected, specifically in the brainstem, then the Brainstem Rules of Four may be utilized to localize these lesions and identify blood supply using simplified knowledge of the brainstem anatomy. Full article

Background: Hemorrhagic transformation (HT) is a major complication of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Objectives: To investigate the factors as sociated with HT in patients with successful recanalization and examine the impact of collateral status (CS) on ischemic progression and outcomes. Methods: We retrospectively analyzed patients with AIS with successful recanalization (modified treatment in cerebral infarction (mTICI) 2B-3) who underwent dual-energy CT (DECT) within 24 h and MRI within 10 days post-EVT. Patients with posterior circulation stroke, missing multiphase CT angiography (CTA) collateral scores, or missing 3-month modified ranking scale scores were excluded from the study. Results: Among the 86 patients, those with HT had a significantly lower proportion of 3-month excellent outcomes and worse imaging scores, including non-contrast CT (NCCT)-Alberta Stroke Program Early CT Score (ASPECTS), virtual non-contrast (VNC)-ASPECTS, and diffusion-weighted imaging (DWI)-ASPECTS. Patients with HT with poor CS had a significantly lower proportion of 3-month excellent outcomes, poorer post-EVT National Institutes of Health Stroke Scale (NIHSS) score, worse imaging scores, including VNC-ASPECTS, and DWI-ASPECTS. In the predictive factor analysis, post-EVT NIHSS and VNC-ASPECTS scores were significantly associated with 3-month excellent functional outcomes (modified Rankin Scale (mRS) 0-1). Conclusions: In patients with successfully recanalized AIS, HT with poor CS was associated with poorer functional outcomes and worse imaging scores, and a 24 h combined measure (post-EVT NIHSS and DECT VNC-ASPECT) show promise for early risk stratification; prospective external validation is warranted before routine use. Full article

Background/Objectives: Brainstem ischemic strokes comprise 10% of ischemic strokes and are challenging to diagnose due to small lesion size and complex presentations. Diffusion-weighted imaging (DWI) is crucial for detecting ischemia, yet it can miss small lesions, especially when only axial slices are employed. This study investigated whether ischemic lesions visible in a single imaging plane correspond to smaller volumes and whether coronal DWI enhances detection compared to axial DWI alone. Methods: This retrospective single-center study examined 134 patients with brainstem ischemic strokes between December 2018 and November 2023. All patients underwent axial and coronal DWI. Clinical data, NIH Stroke Scale (NIHSS) scores, and modified Rankin Scale (mRS) scores were recorded. Diffusion-restricted lesion volumes were calculated using multiple models (planimetric, ellipsoid, and spherical), and lesion visibility per imaging plane was analyzed. Results: Brainstem ischemic strokes were detected in 85.8% of patients. Coronal DWI alone identified 6% of lesions that were undetectable on axial DWI; meanwhile, axial DWI alone identified 6.7%. Combining both improved overall sensitivity to 86.6%. Ischemic lesions visible in only one plane were significantly smaller across all volume models. Higher NIHSS scores were strongly correlated with larger diffusion-restricted lesion volumes. Coronal DWI correlated better with clinical severity than axial DWI, especially in the midbrain and medulla. Conclusions: Coronal DWI significantly improves the detection of small brainstem infarcts and should be incorporated into routine stroke imaging protocols. Infarcts visible in only one plane are typically smaller, yet still clinically relevant. Combined imaging enhances diagnostic accuracy and supports early and precise intervention in posterior circulation strokes. Full article

Background/Objectives: Non-saccular aneurysms are a rare subtype of intracranial aneurysms with complex morphologies. Although treatment strategies for ruptured non-saccular and saccular aneurysms differ significantly, large-scale comparisons of the outcomes between the two types remain limited. We aimed to compare the clinical characteristics, procedure-related complications, and functional outcomes between patients with subarachnoid hemorrhage (SAH) caused by non-saccular or saccular aneurysms. Methods: We retrospectively analyzed 1176 consecutive patients with aneurysmal SAH from a population-based stroke registry in Kochi Prefecture, Japan. Aneurysms were classified as saccular or non-saccular based on the morphology, and clinical variables, radiological features, and treatment modalities were compared. Additionally, 840 patients who underwent intervention for their aneurysms within 3 days of onset were further investigated to evaluate the impact of the non-saccular aneurysm shape on poor functional outcomes, defined as a modified Rankin Scale score ≥ 3 at discharge. Results: Non-saccular aneurysms were more common in younger patients and located in the posterior circulation. Procedure-related ischemic complications were more likely to occur in non-saccular aneurysms than in saccular aneurysms (odds ratio [OR]: 2.57, 95% confidence interval [CI]: 1.56–4.97, p < 0.001). In a multivariable logistic regression analysis, a non-saccular morphology was an independent risk factor of poor outcomes (OR: 2.92, 95% CI: 1.34–6.32, p = 0.007) after adjustment for potential confounders. Interaction and subgroup analyses revealed that the negative effects of non-saccular aneurysms on functional outcomes were more prominent in younger patients aged ≤ 60 years. Conclusions: Non-saccular aneurysms are independently associated with ischemic complications and poor outcomes after SAH, particularly in younger patients. Full article

Background: Symptomatic intracranial hemorrhage (sICH) is the most dreaded complication after reperfusion therapy for acute ischemic stroke. We performed a meta-analysis of randomized controlled trials to estimate and compare risks of sICH after mechanical thrombectomy (MT) depending on the location of the large vessel occlusion, concomitant use of intravenous thrombolysis, timing of treatment, and core size. Methods: Randomized controlled trials were included, following a comprehensive search of different databases from inception to 1 March 2024. Random-effect models in a meta-analysis were employed to obtain the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (95% CI) for sICH with MT, and were then compared to other reperfusion treatment regimens, including best medical treatment and intravenous thrombolysis (IVT). Results: MT in the anterior circulation was associated with a significantly higher risk of sICH as compared with no-MT (RR: 1.46; 95%CI: 1.03–2.07; p = 0.037). The risk of sICH was comparable between the MT and MT+IVT groups (RR: 0.77; 95%CI: 0.57–1.03; p = 0.079). There was no difference in sICH risk with MT as compared with no-MT within 6 h of last known well (RR: 1.14; 95%CI: 0.78–1.66; p = 0.485) and beyond that time (RR: 1.29; 95%CI: 0.80–2.08; p = 0.252); the risk of sICH was also comparable between MT conducted within 6 h of last known well and MT conducted beyond that time (p = 0.512). The sICH risk for MT in the posterior circulation (RR: 7.48; 95%CI: 2.27–24.61) was significantly higher than for MT in the anterior circulation (RR: 1.18; 95%CI: 0.90–1.56) (p = 0.003). MT was also associated with a significantly higher sICH risk than no-MT among patients with large core strokes (RR: 1.71; 95%CI: 1.09–2.66, p = 0.018). Conclusions: When evaluating cumulative evidence from randomized controlled trials, the risk of sICH is increased after MT compared with patients not treated with MT. Yet, the difference is largely driven by the greater risk of sICH in patients treated with MT for posterior circulation occlusions and, to a lesser degree, large core strokes. Concomitant use of intravenous thrombolysis and the use of MT in the extended therapeutic window do not raise the risk of sICH. Full article

Background/Objectives: Intracranial atherosclerosis (ICAS) is a major cause of ischemic stroke, disproportionately affecting populations with significant vascular risk factors. Although ICAS imposes a considerable health burden, research on this condition in Central Asia remains scarce, especially among the Kazakh population. This study analyzes demographic characteristics, treatment outcomes, and procedural challenges associated with ICAS in 216 patients treated at a single institution. Methods: This retrospective study included patients with ≥70% intracranial artery stenosis confirmed by imaging and presenting with ischemic symptoms. All patients underwent angioplasty and stenting with dual antiplatelet therapy (DAPT). Data collected included demographics, comorbidities, stenosis characteristics, procedural details, and outcomes assessed by the modified Rankin Scale (mRS). Results: The median age was 63.5 years (IQR: 57–68.6), and 73.7% were male. Hypertension was the most common comorbidity (98%), followed by ischemic heart disease (58%) and diabetes mellitus (40.9%). Multi-location ICAS was significantly associated with patients over 75 years of age (p = 0.025). Additionally, obesity and stenosis severity greater than 70% showed trends toward significance, with p-values of 0.064 and 0.079, respectively. Stenosis predominantly affected the internal carotid artery (54.5%) and vertebrobasilar system (31.6%). The average hospital stay was longer for posterior circulation stenosis (7.1 days) compared to anterior circulation (4.7 days). The periprocedural complication rate was 0.7%, with two deaths attributed to ischemic complications. At follow-up, four patients experienced worsening mRS scores (>2), particularly those with severe stenosis in the basilar artery and M1 segment. Conclusions: ICAS in the Kazakh population is strongly associated with hypertension and aging, with posterior circulation stenosis contributing disproportionately to worse outcomes. The low complication rates highlight the safety of modern endovascular techniques. However, further research is needed to optimize treatment strategies for severe and multi-location ICAS, particularly in Central Asian populations. Full article

Background/Objectives: Posterior circulation stroke (PCS) poses a diagnostic challenge due to the diverse and subtle clinical manifestations. While the FAST (Face, Arms, Speech, Time) mnemonic has proven effective in identifying anterior circulation stroke, its sensitivity to posterior events is less clear. Recently, the addition of Balance and Eyes to the mnemonic has been proposed as a more comprehensive tool for stroke recognition. Despite this, evidence directly comparing the effectiveness of BE-FAST and FAST in identifying PCS remains limited. Methods: A retrospective analysis was performed on stroke calls at a comprehensive stroke centre, Sydney, Australia. BE-FAST symptoms first assessed at an emergency department triage were recorded, along with automated acute computerised tomography perfusion (CTP) imaging findings. Haemorrhagic strokes were excluded from analysis. An ischaemic stroke diagnosis was confirmed 48–72 h later with magnetic resonance imaging (MRI) brain. The performance of 1. BE-FAST and FAST and 2. BE-FAST and CTP in the hyperacute detection of posterior circulation ischaemic stroke was compared. Results: Out of 164 identified ischaemic infarcts confirmed on MRIs, 46 were PCS. Of these, 27 were FAST-positive, while 45 were BE-FAST-positive. Overall, BE-FAST demonstrated a higher sensitivity compared to FAST in identifying PCS (97.8 vs. 58.7) but suffered from a lower specificity (10.0 vs. 39.8). Notably, 39.1% (n = 18) of patients with PCS would have been missed if only FAST were used. Furthermore, of the 26 PCS negative on CTP, 25 were BE-FAST-positive, and 14 were FAST-positive. Conclusions: The incorporation of Balance and Eye assessments into the FAST protocol improves PCS detection, although may yield more false positives. Full article

Background: Prehospital detection and triage of stroke patients mostly rely on the use of large vessel occlusion prediction scales to decrease onsite time. These quick but simplified scores, though useful, prevent prehospital providers from detecting posterior strokes and isolated symptoms such as limb ataxia or hemianopia. Case report: In the present case, an ambulance was dispatched to a 46-year-old man known for ophthalmic migraines and high blood pressure, who presented isolated visual symptoms different from those associated with his usual migraine attacks. Although the assessment advocated by the prehospital guideline was negative for stroke, the paramedic who assessed the patient was one of the few trained in the National Institutes of Health Stroke Scale assessment. Based on this assessment, the paramedic activated the fast-track stroke alarm and an ischemic stroke in the right temporal lobe was finally confirmed by magnetic resonance imaging. Discussion and conclusions: Current prehospital practice enables paramedics to detect anterior strokes but often limits the detection of posterior events or more subtle symptoms. Failure to identify such strokes delay or even forestall the initiation of thrombolytic therapy, thereby worsening patient outcomes. We therefore advocate a two-step prehospital approach: first, to avoid unnecessary delays, the prehospital stroke assessment should be carried out using a fast large vessel occlusion prediction scale; then, if this assessment is negative but potential stroke symptoms are present, a full National Institutes of Health Stroke Scale assessment could be performed to detect neurological deficits overlooked by the fast stroke scale. Full article

Ménière’s disease (MD) has an unclear cause. The microvascular dysregulation of the inner ear has been increasingly pointed out as a potential contributor. This study investigates the prevalence of cardiovascular risk factors (CVRFs) in MD patients compared to those with posterior circulation cerebral infarction (POCI). CVRFs like hypertension, diabetes, dyslipidemia, obesity, coronary heart disease, and smoking were assessed in both MD and POCI patients. Brain MRI identified POCI etiology as “small vessel occlusion” (SVO) or “other etiology” (OE). This study included 64 MD and 84 POCI patients. Compared to MD, POCI OE showed a higher prevalence of CVRFs across various age groups, including hypertension, diabetes, dyslipidemia, and smoking. Notably, the odds of having POCI OE were significantly higher for individuals with hypertension and smoking. On the other hand, POCI SVO showed a similar prevalence of CVRFs compared to MD. This study revealed no significant differences in CVRF prevalence between MD and smaller vessel POCI. However, a clear distinction emerged when comparing MD to POCI with the involvement of larger blood vessels. Further research is needed to confirm these findings and explore potential shared risk factors between POCI (SVO) and MD. Full article