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Takotsubo cardiomyopathy (TCM) is characterized as left ventricular apical ballooning in the absence of coronary occlusion. The most common trigger for TCM is emotional stress, but more cases are being reported demonstrating the association of TCM with intracranial pathologies. The pathophysiology of TCM is poorly understood but may be related to a surge of catecholamines, multivessel myocardial spasms, or neurologically mediated myocardial stunning. This case study describes the development of TCM after an ischemic stroke and establishes a possible association between the region of stroke and the development of TCM. We present the case of a 75-year-old woman who suffered a stroke of the left insular part (M2) of the middle cerebral artery (MCA) and subsequently experienced cardiac arrest with pulseless electrical activity and echocardiogram findings concerning for TCM within 24 hours. TCM should be recognized as a potential risk in the initial hours following a cerebral ischemic stroke, particularly when the insular region is affected. Prompt diagnosis and proper management of post-stroke TCM are essential for every patient presenting with new-onset cardiac dysfunction in stroke centers.

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In the present report, we describe two cases of right-sided M1 segment middle cerebral artery dissection in a 51-year-old Asian female and in a 28-year-old Caucasian male patient with no previous history of ischemic stroke or known intracranial atherosclerosis presenting with acute unilateral headache progressing to severe multifocal hemispheric infarction with nearly complete one-sided motor paralysis. In both patients, a middle cerebral artery dissection was detected on angiography; they were given exclusively medical therapy: patient 1 was not eligible to reperfusive therapies and was treated with a three-month course of acetylsalicylic acid and clopidogrel combined with low-dose enoxaparin, while patient 2 was initially treated with intravenous alteplase with no hemorrhagic complications and was later shifted to single antiplatelet therapy. Despite an initial worsening of clinical severity and an extensive ischemic lesion in both patients, neurologic function improved over time, eventually allowing recovery of unaided gait. Therefore, in the absence of signs of hemorrhage, intravenous thrombolysis or dual antiplatelet regimens could be considered in strokes related to middle cerebral artery dissection.

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One of the most brutal dictators in humanity's history, Joseph Stalin forged the Soviet Union into a massive superpower, crushing the lives of millions of his own citizens along the way. His sudden death in March 1953 from a stroke took the world by surprise and led to a frantic power struggle within the ranks of the Soviet government. In recent years, researchers have proposed that Stalin's stroke was not natural and was potentially caused by one of his lieutenants poisoning him with warfarin or a similar anticoagulant. After examining the evidence, this article concludes that both Stalin's disease course and the properties of warfarin make it highly unlikely that he was deliberately assassinated.

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Methods for assessing the loss of hand function post-stroke examine limited aspects of motor performance and are not sensitive to subtle changes that can cause deficits in everyday object manipulation tasks. Efficiently lifting an object entails a prediction of required forces based on intrinsic features of the object (sensorimotor integration), short-term updates in the forces required to lift objects that are poorly predicted (sensorimotor memory), as well as the ability to modulate distal fingertip forces, which are not measured by existing assessment tools used in clinics for both diagnostic and rehabilitative purposes. The presented research examined these three components of skilled object manipulation in 60 chronic, unilateral middle cerebral artery stroke participants. Performance was compared to age-matched control participants, and linear regressions were used to predict performance based on clinical scores. Most post-stroke participants performed below control levels in at least one of the tasks. Post-stroke participants presented with combinations of deficits in each of the tasks performed, regardless of the hemisphere damaged by the stroke. Surprisingly, the ability to modulate distal forces was impaired in those patients with damage ipsilateral (right hemisphere) to the hand being used. Sensorimotor integration was also impaired in patients with right hemisphere damage, though they performed at control levels in later lifts, whereas left-hemisphere-damaged patients did not. Lastly, during a task requiring sensorimotor memory, neither patient group performed outside of control ranges on initial lifts, with patients with right hemisphere damage showing impaired performance in later lifts suggesting they were unable to learn the mapping novel mapping of color and mass of the objects. The presented research demonstrates unilateral MCA stroke patients can have deficits in one or more components required for the successful manipulation of hand-held objects and that skillful object lifting requires intact bilateral systems. Further, this information may be used in future studies to aid efforts that target rehabilitation regimens to a stroke survivor's specific pattern of deficits.

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BACKGROUND: Acute bilateral occlusion of the middle cerebral artery (MCA) is a very rare condition, and most cases are accompanied by a poor prognosis. However, mechanical thrombectomy (MT) for bilateral MCA is challenging. Here, we report a case of acute unilateral MCA occlusion with sequential acute occlusion of the bilateral MCA during intravenous thrombolysis (IVT). We urgently performed bilateral MT of the MCA and effective recanalization. CASE PRESENTATION: The patient is a 73-year-old man who complained of a sudden adverse influence on speech and an inability to move his left limb for 2 h. He had a history of paroxysmal atrial fibrillation, but had never used any anticoagulants before. Head and neck computed tomography angiography (CTA) showed embolism in the right M1 MCA. During intravenous alteplase thrombolytic therapy, the patient suddenly became unconscious. Cerebral angiography showed occlusion of the M1 segment of the bilateral MCA in the patients. MT of the bilateral MCA was performed using a combination of a stent retriever and an aspiration catheter with mTici 3 revascularization. On the second day, the patient became conscious, although he had remaining symptoms of speech insufficiency and weakness of the left limb. The mRS score was 2 90 days after the operation. CONCLUSIONS: Acute bilateral occlusion of the M1 segment of the MCA is extremely rare and is accompanied by high morbidity and high mortality. Intravenous alteplase thrombolysis can increase the risk of atrial thrombus shedding in patients with atrial fibrillation, so patients with acute bilateral MCA occlusion in the M1 segment chose direct MT or bridging therapy, which remains controversial, and the sequence of MT remains to be discussed. Nevertheless, early endovascular treatment can decrease the morbidity and mortality of such patients.

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OBJECTIVES: Large middle cerebral artery (MCA) strokes remain a major cause for mortality and morbidity all over the world, and therefore early identification of patients with the highest risk for malignant cerebral edema is crucial for early intervention. Neutrophils to lymphocytes ratio (NLR) and peripheral total white blood cell (WBC) count are inflammatory markers done routinely for all patients, and this study evaluated the use of NLR and elevated white blood cell count within the first 24 h of MCA ischemic stroke onset, with the absence of significant hemorrhagic transformation, to predict malignant cerebral edema. MATERIALS AND METHODS: A total of 156 patients with large MCA strokes were included. We collected demographic, clinical, radiological data, and NLR and WBCs within the first 24 h from admission.We excluded patients who had any underlying infections diagnosed 7 days before or within 72 h after admission. We used a body temp of 38 C or more, abnormal CXR or abnormal urine analysis within the first 72 h to exclude patients with possible infections.We excluded immune-compromised patients and patients on steroid therapy. We compared the NLR and WBC count in patients who developed malignant cerebral edema versus the patients who did not. NLR > 3.5 and < 3.5 was used for comparison. We then conducted multivariate logistic regression models to explore the relationship between cerebral edema, WBCs and NLR count simultaneously. RESULTS: NLR, WBC, radiological involvement of more than 50% of MCA territory infarction on presentation, hyperdense MCA sign, and NIH stroke scale were all significantly higher in patients with malignant cerebral edema within the first 24 h. Using univariate logistic regression, NLR performs better than WBC when predicting the occurrence of malignant cerebral edema (AUC = 0.74 vs. 0.62). However, NIH stroke scale scores, and radiological involvement of more than 50% of MCA territory infarction on the first 24 h of presentation on CT scan both showed better discriminative performance for malignant cerebral edema than NLR (AUC = 0.84 and 0.76, respectively). When combined, NLR > 3.5 paired with the NIH stroke scale score had the best predictive performance (AUC = 0.87). CONCLUSION: NLR > 3.5 can be used for early prognostication in patients with large vessel MCA ischemic strokes with no significant hemorrhagic transformation within the first 24 h regardless if they had reperfusion therapy or not. Combining NLR of > 3.5 in addition to high NIHSS provided the best predictive model in our study. Further studies are needed to further develop the best predictive model in diverse populations.

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A normal daily routine turns critical in seconds, and a biophysical maneuver that is instinctual leads to a rapid decline in a young healthy patient without any warning or precipitating signs. The Valsalva maneuver is a commonly used term for the act of bearing down that affects the vagus nerve, resulting in systemic changes primarily within the autonomic nervous system. This paper reviews a case in which a young man engaging in the Valsalva maneuver was later found unconscious and presented to the emergency department. Neuroimaging revealed a large middle cerebral artery stroke along with an undiagnosed temporal arachnoid cyst, without any significant historical medical records. The resulting course of this disease remained an interesting area of inquiry. This case highlights a rare but intricate interplay of several major physiological functions that collectively contribute to the unexpected demise of a young and healthy patient.

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Background and Purpose: Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain. Materials and Methods: We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data. Results: Surgical procedure was performed 24-96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9-15) and 19.7 ± 2.3 (range 18-23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2-6). Mean follow-up was 18.1 months (range 12-34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed (P < 0.05). Conclusion: Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.

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BACKGROUND: Bilateral hemispheric dysfunction is devastating to consciousness. We present a unique case of a patient who developed bilateral middle cerebral artery infarcts with significant neurological improvement post bilateral thrombolysis in cerebral infarction (TICI) 3 thrombectomies. CASE DESCRIPTION: The patient is a 64-year-old woman who presented 3 hours after her husband was awakened and found her with left hemiplegia. She had a history of atrial fibrillation and had her apixaban held for 5 days before the coronary angiogram that she received the day before arrival. Upon presentation, she was antigravity on the right side and withdrawing on the left side. Computed tomography angiogram showed a right M1 occlusion and an left M2 occlusion. Computed tomography perfusion revealed a mismatch with large penumbra, and she was taken for mechanical thrombectomy. Mechanical thrombectomy was performed using a combination of stent retriever and aspiration catheter with a TICI 3 revascularization. By the following morning, the patient was full strength on the right and antigravity on the left with a left facial droop. The patient recovered her speech and was fully oriented before leaving for rehabilitation on postoperative day 3. CONCLUSIONS: The transient hypercoagulable state that was created with the withdrawal of apixaban likely increased our patient's risk of stroke. The literature supports continuing oral anticoagulants for endovascular procedures. The devastating consequences of thromboembolic events, whether stroke or pulmonary embolism, can be catastrophic, but luckily, mechanical thrombectomy provides the means to minimize the morbidity and mortality from bilateral infarctions.

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BACKGROUND: Malignant middle cerebral artery infarctions are large space-occupying infarctions involving massive edema, herniation, and frequently death. Survivors are disabled. Management involves medical treatment, with or without decompressive hemicraniectomy and later duraplasty. This meta-analysis aimed to determine whether surgery is worthwhile with particular regard to views on quality of life of professionals and patients. METHODS: A Medline search was performed with the search terms "decompressive surgery," "craniectomy," "hemicraniectomy," "decompressive hemicraniectomy," and "middle cerebral artery," "MCA," "infarct,*" "stroke,*" "embolus," "emboli," "thrombosis," "occlusion," "infarction," and "middle cerebral artery stroke," A second search was also done for views on postoperative quality of life. Studies retrieved were randomized controlled trials, observational studies, and reviews. We compared patients who received only medical treatment with those who had decompressive surgery. Participants were adult patients presenting with malignant middle cerebral artery infarction. RESULTS: 270 abstracts were reviewed. 40 articles were identified: 8 randomized controlled trials and 4 observational studies. There were a total of 692 patients: 268 surgical and 424 medical. The 2 groups were comparable, with similar demographics. In most trials, mortality was lower with surgery. However, morbidity tended to be higher, particularly in the elderly population. Morbidity was lower with medical treatment. Twelve articles on postoperative quality of life were reviewed; views differed between professionals, and survivors and caregivers. A patient-level comparison could not be made between all studies. CONCLUSIONS: Surgical decompression results in lowered mortality but high morbidity, especially in the elderly. There is an increase in Quality Adjusted Life Years but at high costs. Professionals think that surgery is not worth the high disability rate. However, patients and caregivers are satisfied with their postoperative quality of life. Survey data from healthy study participants who are not professionals in stroke care were not available. The decision to treat surgically needs to be decided on an individual basis.

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The eye-tracking study aimed at assessing spatial biases in visual exploration in patients after acute right MCA (middle cerebral artery) stroke. Patients affected by unilateral neglect show less functional recovery and experience severe difficulties in everyday life. Thus, accurate diagnosis is essential, and specific treatment is required. Early assessment is of high importance as rehabilitative interventions are more effective when applied soon after stroke. Previous research has shown that deficits may be overlooked when classical paper-and-pencil tasks are used for diagnosis. Conversely, eye-tracking allows direct monitoring of visual exploration patterns. We hypothesized that the analysis of eye-tracking provides more sensitive measures for spatial exploration deficits after right middle cerebral artery stroke. Twenty-two patients with right MCA stroke (median 5 days after stroke) and 28 healthy controls were included. Lesions were confirmed by MRI/CCT. Groups performed comparably in the Mini-Mental State Examination (patients and controls median 29) and in a screening of executive functions. Eleven patients scored at ceiling in neglect screening tasks, 11 showed minimal to severe signs of unilateral visual neglect. An overlap plot based on MRI and CCT imaging showed lesions in the temporo-parieto-frontal cortex, basal ganglia, and adjacent white matter tracts. Visual exploration was evaluated in two eye-tracking tasks, one assessing free visual exploration of photographs, the other visual search using symbols and letters. An index of fixation asymmetries proved to be a sensitive measure of spatial exploration deficits. Both patient groups showed a marked exploration bias to the right when looking at complex photographs. A single case analysis confirmed that also most of those patients who showed no neglect in screening tasks performed outside the range of controls in free exploration. The analysis of patients' scoring at ceiling in neglect screening tasks is of special interest, as possible deficits may be overlooked and thus remain untreated. Our findings are in line with other studies suggesting considerable limitations of laboratory screening procedures to fully appreciate the occurrence of neglect symptoms. Future investigations are needed to explore the predictive value of the eye-tracking index and its validity in everyday situations.

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In patients with malignant middle cerebral artery (MMCA) stroke, a vital clinically relevant question is determination of the speed with which infarction evolves to select the time for decompressive hemicraniectomy [DHC]. A retrospective, multicenter cross-sectional study of patients referred for DHC, based on the criteria of randomized controlled trials, was undertaken to identify factors for selecting the timing of DHC in MMCA stroke, stratified by time [< 48, 48-72, > 72 h]. Infarction volume and infarct growth rate [IGR] were measured on all CT scans. One hundred eighty-two patients [135 underwent DHC and 47 survived without DHC] were included in the analysis. After multivariate adjustment, factors showing the strongest independent association with DHC were patients < 55 years of age, septum pellucidum deviation, temporal lobe involvement, MCA with additional infarcts, and IGR on second CT. Of the five factors identified, different combinations of determining factors were observed in each subgroup. Both first and second IGRs were highest in the < 48, 48-< 72, and > 72 h [p < 0.001]. Patients who survived without surgery had the slowest IGRs. There was no association between time to DHC and infarct volume, although infarct volume was lower in patients who survived without DHC compared to the DHC subgroups. We identify the major risk factors associated with DHC in time-stratified subgroups of patients with MMCA. Evaluation of IGRs between the first and second scan and when possible second and third scan can help in selecting the timing of hemicraniectomy.

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BACKGROUND: Large ischemic stroke in the very elderly population is presumed to invariably carry a poor prognosis and clinicians may refrain from continuing intensive care. Many elderly patients are not surgical candidates, and there is a paucity of data outlining the real-world outcomes of continued medical management. Our objective is to identify the factors associated with the outcome of very elderly patients with large hemispheric infarction (LHI) treated with medical management alone. METHODS: We performed a retrospective review of all consecutive adults ≥ 70 years of age with LHI identified from a single center stroke registry between 2012 and 2016. Mean volume of infarction was calculated using the ABC/2 method. RESULTS: Of a total of 2335 patients, 71 (mean age 81 ± 7 years,) met inclusion criteria. Forty-one were women (58%). Mean admission National Institute of Health Stroke Score (NIHSS) was 21 ± 6. Intravenous tPA was administered in 30 (42%) and 9 (13%) patients underwent thrombectomy. Mean infarct volume was 175 ± 75 cc. Twenty-seven patients (38%) survived to hospital discharge; 6 (9%) eventually went home (albeit with mRS 4) and one (1%) went to assisted living. Multivariate logistic regression analysis found that admission NIHSS ≥ 20 (p = 0.0007) and mechanical ventilation within 48 h of admission (p = 0.0396) were independently associated with poor outcome. CONCLUSION: Ten percent of medically managed patients (≥ 70 years of age) with LHI can go home or to assisted living, but with a mRS of 4. Whether this is an acceptable outcome must be individualized on a case-by-case basis; however, poor prognosis should not be automatically presumed solely based on the combination of older age and a large stroke.

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BACKGROUND: In this case series, functional magnetic resonance imaging was used to examine brain networks that mediate different aspects of language function in 4 young adults (17-22 years) with a history of left middle cerebral artery (MCA) stroke in childhood (40 years of age). Although it is widely believed that altered lateralization patterns are more likely to occur following early brain injuries compared with later brain injuries, the presumed plasticity of the young brain has been challenged in recent years, particularly in the domain of language. METHODS: We explored this issue by contrasting the brain activation patterns of individuals with childhood left MCA stroke and adult left MCA stroke while performing two language tasks: verb generation and picture-word matching. Importantly, both groups showed significant recovery of language function, based on standard clinical indicators. RESULTS: Controls showed left lateralized activation for both tasks, although much more pronounced for verb generation. Adult stroke patients also showed left lateralization for both tasks, though somewhat weaker than controls. Childhood stroke patients exhibited significantly weaker lateralization than the adult group for verb generation, but there was no significant group difference for picture-word matching. CONCLUSIONS: These preliminary findings suggest that successful reorganization of language function is more likely to involve bilateral recruitment following left MCA stroke in childhood than in adulthood. Of importance, although childhood stroke patients had primarily subcortical lesions, there were substantial alterations in cortical activation patterns.

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The effects of primary somatosensory cortex (S1) injury on recovery of contralateral upper limb reaching and grasping were studied by comparing the consequences of isolated lesions to the arm/hand region of primary motor cortex (M1) and lateral premotor cortex (LPMC) to lesions of these same areas plus anterior parietal cortex (S1 and rostral area PE). We used multiple linear regression to assess the effects of gray and white matter lesion volumes on deficits in reaching and fine motor performance during the first month after the lesion, and during recovery of function over 3, 6 and 12months post-injury in 13 monkeys. Subjects with frontoparietal lesions exhibited larger deficits and poorer recovery as predicted, including one subject with extensive peri-Rolandic injury developing learned nonuse after showing signs of recovery. Regression analyses showed that total white matter lesion volume was strongly associated with initial post-lesion deficits in motor performance and with recovery of skill in reaching and manipulation. Multiple regression analyses using percent damage to caudal M1 (M1c), rostral S1 (S1r), LPMC and area PE as predictor variables showed that S1r lesion volumes were closely related to delayed post-lesion recovery of upper limb function, as well as lower skill level of recovery. In contrast, M1c lesion volume was related primarily to initial post-lesion deficits in hand motor performance. Overall, these findings demonstrate that frontoparietal injury impairs hand motor function more so than frontal motor injury alone, and results in slower and poorer recovery than lesions limited to frontal motor cortex.

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Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions-both medical and surgical-exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

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