PURPOSE: To investigate the relationship between changes in the posterior and anterior circulation, as seen at angiography, and the frequency and extent of cerebral infarction revealed by MR imaging in moyamoya disease. MATERIALS AND METHODS: This study involved 34 patients (22 females and 12 males, aged 2-52years) in whom cerebral angiography revealed the presence of moyamoya disease (bilateral: unilateral=24:10; total hemispheres=58) and who also underwent brain MR imaging. To evaluate the angiographic findings, we applied each angiographic staging system to the anterior and posterior circulation. Leptomeningeal collateral circulation from the cortical branches of the posterior cerebral artery (PCA) was also assigned one of four grades. At MR imaging, areas of cerebral cortical or subcortical infarction in the hemisphere were divided into six zones. White matter and basal ganglionic infarction, ventricular dilatation, cortical atrophy, and hemorrhagic lesions were also evaluated. To demonstrate the statistical significance of the relationship between the angiographic and the MR findings, both the Mantel-Haenszel chi-square test for trend and the chi-square test were used. RESULTS: The degree of steno-occlusive PCA change correlated significantly with the internal carotid artery (ICA) stage (p<0.0001). As PCA stages advanced, the degree of leptomeningeal collaterals from the PCA decreased significantly (p<0.0001), but ICA stages were not significant (p>0.05). The prevalence of infarction showed significant correlation with the degree of steno-occlusive change in both the ICA and PCA. The degree of cerebral ischemia in moyamoya patients increased proportionally with the severity of PCA stenosis rather than with that of steno-occlusive lesions of the anterior circulation. Infarctions tended to be distributed in the anterior part of the hemisphere at PCA stage I or II , while in more advanced PCA lesions, they were also found posteriorly, especially in the territories of the posterior middle cerebral artery (MCA), the posterior border zone, and the PCA (p<0.0001). The frequency of infarctions in the territories of the anterior cerebral artery (ACA) and the anterior MCA was unrelated to the degree of steno-occlusive ICA and PCA lesions (p>0.05). CONCLUSION: The degree of steno-occlusive lesions of the PCA correlated with the ICA stage. Progressive changes in steno-occlusive lesions of the ICA and PCA are associated with the extent and distribution of cerebral infarction. The degree of cerebral ischemia in moyamoya patients increased proportionally with the severity of PCA stenosis rather than with that of steno-occlusive lesions of the anterior circulation. In these patients, the presence of stenotic or occlusive PCA lesions appears to be significantly related to the occurrence of cerebral infarction.
Angiography ; Anterior Cerebral Artery ; Atrophy ; Brain ; Brain Ischemia ; Carotid Artery, Internal ; Cerebral Angiography ; Cerebral Infarction* ; Collateral Circulation ; Constriction, Pathologic ; Dilatation ; Female ; Ganglion Cysts ; Humans ; Infarction ; Magnetic Resonance Imaging ; Male ; Middle Cerebral Artery ; Moyamoya Disease* ; Passive Cutaneous Anaphylaxis ; Posterior Cerebral Artery ; Prevalence

The clinical manifestations of vertebral artery (VA) injury (VAI) after cervical trauma range from asymptomatic to fatal cerebral infarction. Thrombotic occlusion and embolization to the distal arteries can cause cerebellar and brain stem infarction within days after trauma. We report a 64-year-old man who underwent arthrodesis surgery for C1 and C2 fractures. He had left VAI at the C2 transverse foramen site but was asymptomatic. The patient experiences brainstem and cerebellar infarction 3 months after injury to the VA, and we are here to discuss the treatment of VAI after cervical trauma.
Arteries ; Arthrodesis ; Brain Stem ; Brain Stem Infarctions ; Cerebellum* ; Cerebral Infarction ; Humans ; Infarction* ; Ischemia ; Middle Aged ; Vertebral Artery*

The symptoms and signs of stroke vary according to the location of the lesions. Middle cerebral artery territory infarction produces symptoms such as contralateral hemiparesis (worse in the arm than in the leg), hemihypesthesia, dysarthria, aphasia (left lesion), and hemineglect (right lesion). Anterior cerebral artery infarction produces hemiparesis worse in the leg than in the arm, abulia, apathy, and urinary incontinence. Posterior cerebral artery infarction produces hemianopia. An occlusion of small penetrating branches such as lenticulostriate arteries or thalamogeniculate arteries is responsible for the so-called lacunar syndrome : pure hemiparesis, ataxic-hemparesis, dysarthria clumsy hand syndrome, or pure sensory stroke. The symptoms and signs of the brain stem infarction also vary greatly according to the area of involvement. Generally, they are characterized by virtigo, dizziness, diplopia, and ataxia. Major occlusion of the basilar artery may produce grave conditions characterized by altered consciousness, quadriparesis, and horizontal gaze paresis. Intracerebral hemorrhage occur in the basal ganglia, thalamus, lobar area, pons, and the cerebellum, in order of decreasing frequency. The symptoms and signs are dependent on the location and the amount of hemorrhages. The symptoms of subarachnoid hemorrhages are characterized by sudden headache and neck stiffness.
Apathy ; Aphasia ; Arm ; Arteries ; Ataxia ; Basal Ganglia ; Basilar Artery ; Brain Stem Infarctions ; Cerebellum ; Cerebral Hemorrhage ; Consciousness ; Diplopia ; Dizziness ; Dysarthria ; Hand ; Headache ; Hemianopsia ; Hemorrhage ; Infarction ; Infarction, Anterior Cerebral Artery ; Infarction, Posterior Cerebral Artery ; Leg ; Middle Cerebral Artery ; Neck ; Paresis ; Pons ; Quadriplegia ; Stroke* ; Stroke, Lacunar ; Subarachnoid Hemorrhage ; Thalamus ; Urinary Incontinence

An unanesthetized cat model of acute focal cerebral ischemia has been establishes by the technique of transorbital snare ligature for middle cerebral artery (MCA) occlusion, The model was used to investigate patterns of changes of regional cerebral blood flow (rCBF) for up to 16 hours following MCA occlusion by the hydrogen clearance technique and to explore the correlation among microregional blood flow changes, neurological deficit, and pathological changes including size of infarct and severity of brain edema. The animals were divided into 2 groups according to size of infarct that was identified by 2% triphenyl tetrazolium chloride solution stain. The results were as follows : 1) Infarct larger than 10% of coronal section surface of the ipsilateral cerebral hemisphere was found in 18 cats( Group A), and smaller infarct was found in the remaining 7 cats (Group B). Between these 2 groups, there was a statistically significant difference in the average rCBF value of ipsilateral MCA territory during 16 hours of ischemia (Group A:6.5ml/100g/min, Group B:32.6ml/100g/min) (P<0.01). 2) Increasing grade of contralateral paralysis correlated well with decreasing rCBF in MCA territory of occlusion side and all animals showing complete paralysis belonged to Group A with their average rCBF from ipsilateral MCA territory below 10.0ml/100g/min. 3) Increasing grade of cerebral hemispheric swelling was directly proportional to increasing grade of paralysis and there was also a significant difference in hemispheric swelling between Group A and B, Correlation between grades of infarct size and severity of paralysis was not evident. 4) There patterns of charges of rCBF were observed :In 15 cats of Pattern I, MCA occlusion caused persistent severe ischemia, measuring less than 16-17ml/100g/min(average rCBF:6.28ml/100g/min), to produce large infarct, pronounced paralysis, and severe histological damage(Group A). 5) In 7 cats of Pattern I, persistent mild to moderate ischemia, maintaining more than 23-24ml/100g/min(average rCBF:32.6ml/100g/min), was noted in association with much smaller infarct and milder hemiparesis(Group B). 6) In the remaining 3 cats of Pattern I, MCA occlusion caused immediate severe ischemia followed by early postischemic hyperemia and death during 8 to 14 hours after MCA occlusion owing to marked brain swelling and transtentorial herniation (Group A). 7) During the initial stage of ischemia, significant decrease in rCBF of the contralateral hemisphere was observed in both groups, however, in Group A, rCBF gradually increased to preocclusion level. Only Group B presented further decrease in rCBF suggesting the presence of interhemispheric diaschisis. Thus Group B appeared to take advantage of diaschisis during the late phase of infarct development as well as substantial collateral flow from the surrounding posterior cerebral and anterior cerebral artery territories.
Animals ; Anterior Cerebral Artery ; Brain Edema ; Brain Ischemia ; Cats ; Cerebral Infarction* ; Cerebrum ; Hydrogen ; Hyperemia ; Infarction, Middle Cerebral Artery* ; Ischemia ; Ligation ; Middle Cerebral Artery* ; Paralysis ; SNARE Proteins

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.
Adult ; Brain Injuries ; Brain ; Cognition ; Consciousness ; Deglutition Disorders ; Female ; Humans ; Hypoxia-Ischemia, Brain ; Infarction ; Infarction, Posterior Cerebral Artery ; Magnetic Resonance Imaging ; Posterior Cerebral Artery ; Quadriplegia ; Suicide, Attempted

Moyamoya disease is a cerebrovascular disease of unknown etiology, which is characterized by bilateral stenosis or occlusion at terminal portion of internal carotid artery and at proximal portion of anterior cerebral artery and/or middle cerebral artery and abnormal vascular network in the vicinity of the arterial occlusions. It occurs frequently in Asian countries, particularly in Korea and Japan, but is rare in Western countries. To establish the etiology of moyamoya disease, much about the pathology from autopsies, factors involved in its pathogenesis, and its genetics have been studied. It may occur at any age from childhood to adulthood and in general, initial manifestation is cerebral ischemic symptoms in children and intracranial hemorrhage symptoms in adults. Because it progress and cause recurrent stroke, early diagnosis and proper management has been recognized. Cerebral angiography is essential for definitive diagnosis and treatment plan. Magnetic resonance imaging/magnetic resonance angiography is useful for diagnosis and follow-up tools after revascularization. Evaluation of the cerebral hemodynamics by single photon emission computed tomography and positron emission tomography is useful for diagnosis and assessment of the severity of cerebral ischemia in moyamoya patients. Surgical revascularization is effective for moyamoya disease manifesting as ischemic symptoms, to prevent further ischemia and infarction. In hemorrhagic type moyamoya disease, revascularization can be considered. Direct bypass, indirect synangiosis and combined methods are used. Outcomes of revascularization are excellent in preventing transient ischemic attacks in most patients.
Adult ; Angiography ; Anterior Cerebral Artery ; Asian Continental Ancestry Group ; Autopsy ; Brain Ischemia ; Carotid Artery, Internal ; Cerebral Angiography ; Cerebral Hemorrhage ; Child ; Constriction, Pathologic ; Early Diagnosis ; Follow-Up Studies ; Hemodynamics ; Humans ; Infarction ; Intracranial Hemorrhages ; Ischemia ; Ischemic Attack, Transient ; Japan ; Korea ; Magnetic Resonance Spectroscopy ; Middle Cerebral Artery ; Moyamoya Disease ; Positron-Emission Tomography ; Stroke ; Tomography, Emission-Computed, Single-Photon

OBJECTIVETo investigate the correlation between plasma fibrinogen level and cerebral infarction (CI) as well as the difference of fibrinogen among subtypes of CI.

METHODSA case-controlled study was conducted with 131 cases of CI and 148 controls. Plasma fibrinogen levels were detected by the Clauss method.

RESULTSHigh fibrinogen level (3.09 +/- 0.94 g/L) was correlated with CI (OR = 2.47, 95% CI: 1.51-4.04, P < 0.005) at the onset stage of the disease. Persistent high fibrinogen level (3.14 +/- 0.81 g/L) at 6-month after stroke onset was detected and correlated with CI (OR = 4.34, 95% CI: 1.80-10.51, P = 0.001). Higher fibrinogen level was correlated with total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), and posterior circulation infarction (POCI) (OR = 4.008, P < 0.001). Higher fibrinogen level was correlated with extracranial atherosclerosis (OR = 3.220, P < 0.05, but not with intracranial atherosclerosis.

CONCLUSIONFibrinogen level may be a risk factor of CI and probably correlates with subtypes of CI and distributions of atherosclerosis.

Aged ; Atherosclerosis ; blood ; Brain Infarction ; blood ; classification ; Case-Control Studies ; Cerebral Infarction ; blood ; classification ; Female ; Fibrinogen ; metabolism ; Humans ; Infarction, Anterior Cerebral Artery ; blood ; Infarction, Posterior Cerebral Artery ; blood ; Male ; Middle Aged

BACKGROUND & OBJECTIVE: Magnetic resonance angiography is helpful noninvasive evaluation of intracranial arteries and, in some patients, may spare invasive angiography which has potentially serious complication. However, it's diagnostic value in vertebrobasilar artery disease has not yet been evaluated. METHODS: MRA and axial brain MRI of 47 patients with acute cerebellar and/or brainstem ischemia, 26 patients with middle cerebral artery territory infarction, and 40 age matched normal controls were reviewed. Patients wit potential risks of cardiac embolization were excluded. MR Angiography was performed by three dimensional time-of-flight gradient-echo technique. Th diagnosis of vessel stenosis was made only when the lumen diameter was reduced by less than 50% on 3-D images to avoid overestimation of MR angiography. RESULTS: Forty-seven patients had cerebellar and/or brainstem infarction: with signal hyperintensities in T2-weighted MRI sequences. Pons was the most common infarcted site(28/47), followed by medulla (17/47), and cerebellum (11/47). The sensitivity of MR angiography in detecting vascular occlusive lesions of vertebrobasilar artery was 57.5% (28/47) in cerebellar and/or brainstem infarction patients, while 7 of 26 (26.9%) in middle cerebral artery territory infarction, and 2 of 40 (5%) in age matched control subjects showed occlusion or stenosis. MR angiography detected vascular occlusive lesions more frequently on vertebral arteries (25/47, 53.2%) than basilar artery (13/47, 27.7%). And occlusive or stenotic lesions of vertebral arteries were ipsilateral to ischemic lesion sites in 12 of 17 patients(70.6%), There was no difference between deep small lacunar stroke and perforator occlusion in pons. Absence of flow void on axial T2W imaging was seen only in 9 of 47 patients (19.1%). CONCLUSIONS: The results in this present study suggest that MR angiography is moderately sensitive diagnostic tool in vertebrobasilar occlusive disease although it has limitation in detection of smaller branches occlusion. Except vertebral arteries occlusion, absence of flow void in axial MR imaging is not a reliable findings.
Angiography ; Arteries ; Basilar Artery ; Brain ; Brain Stem Infarctions* ; Brain Stem* ; Cerebellum ; Constriction, Pathologic ; Diagnosis ; Humans ; Imaging, Three-Dimensional ; Infarction ; Ischemia ; Magnetic Resonance Angiography* ; Magnetic Resonance Imaging ; Middle Cerebral Artery ; Pons ; Stroke, Lacunar ; Vertebral Artery

BACKGROUND: Intravenous tissue-type plasminogen activator (tPA) is recognized as the standard treatment for ischemic stroke. However, its narrow therapeutic window and association with an increased risk of intracranial hemorrhage have required caution when used. In this context, several approaches are required to deal with the shortcomings of such a double-edged drug. Anesthetics are known to protect against ischemic reperfusion injury, and their protective role in ischemic post-conditioning is crucial for reducing ischemia-related injury. The aim of this study was to assess the effect of isoflurane post-treatment on intracranial hemorrhage and cerebral infarction after tPA treatment for transient cerebral ischemia. METHODS: Cerebral ischemia was modeled in male Sprague-Dawley rats (n = 32) by occluding the right middle cerebral artery for 1 h, followed by intravenous tPA administration. Rats were randomly divided into control and isoflurane post-treatment group, and isoflurane post-treatment group was post-treated by administering 1.5% isoflurane for 1 h from the start of reperfusion. Twenty-four h after reperfusion, neurobehavioral changes were assessed. The extent of cerebral infarction and intracranial hemorrhage were also assessed by quantification of infarction volume and cerebral hemoglobin concentration from brain tissue, respectively. RESULTS: Neurobehavioral testing showed better functional outcomes in the isoflurane post-treatment group than the control group. The extent of cerebral infarction and intracranial hemorrhage were both reduced in isoflurane post-treatment group compared to control group. CONCLUSIONS: Isoflurane post-treatment may mitigate infarction volume and intracranial hemorrhage in tPA-exaggerated brain injury. Our findings provide an encouraging novel approach for enhancing clinical outcomes in tPA-exaggerated brain injury.
Anesthetics ; Animals ; Brain ; Brain Injuries* ; Brain Ischemia ; Cerebral Infarction ; Humans ; Infarction ; Intracranial Hemorrhages ; Ischemic Attack, Transient ; Ischemic Postconditioning ; Isoflurane* ; Male ; Middle Cerebral Artery ; Rats* ; Rats, Sprague-Dawley ; Reperfusion ; Reperfusion Injury ; Stroke* ; Tissue Plasminogen Activator

Moyamoya disease is characterized by a narrowing or occlusion of both internal carotid arteries in the presence of an abnormal hemangiomatosis vascular network at the base of the brain. These patients increasingly present for surgical management to improve the cerebral circulation. However, surgery may be complicated by cerebral ischemia, and thus patients require particular care during the perioperative period. The risk factors of perioperative ischemic complications include the presence of a preoperative low density area by computed tomography, the occurrence of frequent preoperative transient ischemic attacks, or hypocapnia or hypotension. We describe one case of general anesthesia for superficial temporal artery to middle cerebral artery anastomosis (STA-MCA) with encephalomyosynangiosis (EMS) in a moyamoya disease patient. The patient expired because of a developing cerebral infarction on the fifth postoperative day.
Anesthesia, General ; Brain Infarction* ; Brain Ischemia ; Brain* ; Carotid Artery, Internal ; Cerebral Infarction ; Humans ; Hypocapnia ; Hypotension ; Ischemic Attack, Transient ; Middle Cerebral Artery ; Moyamoya Disease* ; Perioperative Period ; Risk Factors ; Temporal Arteries