Infarction in the anterior choroidal artery territory: clinical progression and prognosis factors

Intravenous thrombolysis plus tirofiban versus tirofiban alone in Caucasian patients with acute anterior choroidal or paramedian pontine infarction

BACKGROUND

Tirofiban has been shown to be superior to aspirin in achieving functional independence at 3 months for acute ischemic stroke of atheromatous or microatheromatous origin. As intravenous thrombolysis (IVT) has previously been shown to be nonsuperior to aspirin in achieving functional independence at 3 months for anterior choroidal or paramedian pontine infarction (ACI/PPI), we aimed to compare the outcomes of Caucasian patients receiving IVT plus tirofiban (IVT + T) with those receiving tirofiban alone for acute ACI/PPI.

METHODS

A retrospective study was conducted in patients aged ≥ 18 years with ACI/PPI treated in our stroke unit between December 1, 2020, and April 30, 2023, who received therapeutic intervention within 9 hours of symptom onset or after awakening with stroke symptoms. Modified Rankin Scale (mRS) ≤ 1 at 3 months was the primary endpoint. Secondary endpoints were National Institutes of Health Stroke Scale (NIHSS) ≤ 2 at day 7 or discharge and post-procedural neurological deterioration (PPND) within 72 hours. Symptomatic intracranial hemorrhage (SICH) and major systemic bleeding (MSB) were the safety measures of the study.

RESULTS

A total of 24 patients were enrolled in the tirofiban group and 43 patients in the IVT + T group. Compared to tirofiban alone, IVT + T was associated with a higher probability of achieving mRS ≤1 at 3 months (adjusted odds ratio [aOR], 8.79; 95% confidence interval [CI], 2.06-37.52; P = 0.003) and National Institutes of Health Stroke Scale ≤2 at day 7 or discharge (aOR, 3.70; 95% CI, 1.05-12.99; P = 0.041). No significant difference was seen between the two groups in preventing postprocedural neurological deterioration. One case of SICH and two cases of MSB occurred in the IVT + T group and no cases in the tirofiban group. One case of inhospital mortality was recorded in the IVT + T group.

CONCLUSIONS

Our results showed that IVT + T may be safe and effective in Caucasian patients with acute ACI/PPI.

European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke

A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.

Physiotherapy Approach to an Internal Capsule Infarct With Upper Motor Neuron Facial Nerve Palsy: A Case Report

The internal capsule (IC) is a vital brain structure housing descending and ascending fiber tracts, with traditional assumptions about the corticobulbar and corticospinal tracts descending through the genu and anterior third of the posterior limb of internal capsule (PLIC), respectively. However, observations of IC infarctions reveal that symptoms often deviate from the expected fiber pattern, prompting a deeper exploration of these complexities. The posterior limb of the IC receives its blood supply from the lenticulostriate branches of the middle cerebral artery and the anterior choroidal artery (AChA). AChA infarctions present a diverse array of symptoms beyond the classic triad, reflecting the intricate vascular supply and lesion patterns within this region. We present a case of a 74-year-old male farmer with right-hand dominance, who experienced a fall resulting in head and right lower limb injuries. Subsequently, he developed weakness in his left upper and lower limbs, facial deviation, slurred speech, and swelling in the right lower limb. Following these symptoms, his family promptly brought him to the hospital on November 30, 2023. Extensive investigations, including magnetic resonance imaging (MRI), revealed a hyper-acute infarct in the posterior limb of the left IC. The patient was admitted to the intensive care unit (ICU) for three days and later shifted to the neurology ward where medical management was commenced, including physiotherapy protocol that was started on December 2, 2023. Physiotherapy interventions were designed to address the patient's weakness, altered sensation, and diminished reflexes. Therapeutic goals focused on preventing complications, improving posture, enhancing range of motion (ROM), and mitigating breathing difficulties and mobility issues. The physiotherapy aimed to enhance the patient's overall physical and mental well-being, emphasizing independence and improved quality of life. Regular assessments and adjustments to the therapeutic interventions were made based on the patient's progress. This case underscores the importance of tailored physiotherapy interventions in addressing the diverse manifestations of IC infarctions, contributing to a comprehensive understanding of rehabilitation strategies in neurologically compromised individuals.

Acute Anterior Choroidal Artery Territory Infarction: A Case Series Report

Due to the occlusion of the anterior choroidal artery (AChA), ischemic strokes are described with the classic clinical triad, namely hemiplegia, hemianesthesia, and homonymous hemianopsia. The aim of this study is to document the characteristic clinical presentation and course of AChA infract cases. We describe five cases with acute infarction in the distribution of the AChA, admitted to the Neurological Department of the University General Hospital of Larissa. Results: All cases presented with hemiparesis and lower facial nerve palsy, while four of them had dysarthria, and two patients exhibited ataxia. Two cases underwent intravenous thrombolysis. A notable feature was the worsening of the clinical course, specifically the exacerbation of upper limb weakness within 48 h. Stabilization occurred after the third day, with the final development of a more severe clinical presentation than the initial one. Additionally, muscle weakness was more severe in the upper limb than in the lower limb. The recovery of upper limb function was poor in the three-month follow-up for the four cases. While vascular brain episodes are characterized by sudden onset, in AChA infraction, the clinical onset can be gradually developed over a few days, with a greater burden on the upper limb and poorer recovery.

Elevated neutrophil-related immune-inflammatory biomarkers in acute anterior choroidal artery territory infarction with early progression

OBJECTIVE

The anterior choroidal artery territory (AChA) infarction has a high rate of progression and poor functional prognosis. The aim of the study is to search for fast and convenient biomarkers to forecast the early progression of acute AChA infarction.

METHODS

We respectively collected 51 acute AChA infarction patients, and compared the laboratorial index between early progressive and non-progressive acute AChA infarction patients. The receiver-operating characteristics curve (ROC) analysis was used to determine the discriminant efficacy of indicators that had statistical significance.

RESULTS

The white blood cell, neutrophil, monocyte, white blood cell to high-density lipoprotein cholesterol ratio, neutrophil to high-density lipoprotein cholesterol ratio (NHR), monocyte to high-density lipoprotein cholesterol ratio, monocyte to lymphocyte ratio, neutrophil to lymphocyte ratio (NLR), and hypersensitive C-reaction protein in acute AChA infarction are significantly higher than healthy controls (P < 0.05). The NHR (P = 0.020) and NLR (P = 0.006) are remarkably higher in acute AChA infarction patients with early progression than non-progression. The area under the ROC curve of NHR, NLR, the combine of NHR and NLR are 0.689 (P = 0.011), 0.723 (P = 0.003), 0.751 (P < 0.001), respectively. But there are no significant differences in efficiency between NHR and NLR and their combined marker in predicting progression (P > 0.05).

CONCLUSION

NHR and NLR may be significant predictors of early progressive patients with acute AChA infarction, and the combination of NHR and NLR could be a preferable prognostic marker for AChA infarction with early progressive course in acute stage.

Acute Anterior Choroidal Artery Territory Infarction: A Retrospective Study

OBJECTIVES

To explore the clinical features, risk factors, etiopathogenesis, mechanism of progression, effect of intravenous thrombolysis therapy (IVT) and prognosis of acute ischemic stroke (AIS) in the anterior choroidal artery (AChA) territory.

PATIENTS AND METHODS

A total of 113 AChA infarction patients were enrolled in the current study retrospectively. The demographic and clinical characteristics were collected and analyzed in all patients. The clinical characteristics were compared between clinical progression and no clinical progression groups, good and poor outcome groups, as well as with and without intravenous rt-PA groups.

RESULTS

Hemiparesis was the most common clinical manifestation (92.9%), followed by dyslexia (54.9%), hemianesthesia (43.4%) and other syndromes. Forty-nine patients (43.4%) suffered from clinical progression and showed a higher rate with multiple risk factors together than patients without clinical progression (30.6% vs.14.1%, P = 0.039). Moreover, more patients with progression were found with carotid plaques (73.5% vs. 51.6%, P = 0.018) or carotid artery stenosis (18.4% vs. 6.3%, P = 0.045) than patients without progression. 69.9% of patients got good prognosis at 6-months. In good prognosis group, the proportion of patients with atrial fibrillation, clinical progression and large infarct size were significantly lower than in poor prognosis group (1.3% vs. 11.8%, P = 0.047; 23.9% vs. 67.6%, P = 0.001; 15.2% vs. 38.2%, P = 0.007). No significant difference was found on rate of clinical progression and good prognosis between patients with and without IVT.

CONCLUSION

Motor deficits are the most frequent and typical symptoms in AChA infarcts. Although small artery disease was considered to be the important etiopathogenesis of the AChA infarcts, large vascular disease may be associated with clinical progression in AChA infarcts. Additionally, prognosis of AChA infarcts is correlated with clinical progression, infarct size and atrial fibrillation. IVT does not seem to prevent the clinical progression and improve prognosis of AChA infarcts.

Intravenous tirofiban therapy for patients with capsular warning syndrome

Background

Capsular warning syndrome (CWS) is defined as recurrent episodes of transient ischaemic attacks ≥3 times during a short time frame. There is no effective therapy to stop these attacks. We, herein, report our experience of using intravenous tirofiban to treat CWS.

Methods

All patients with CWS in our hospital from January 2013 to September 2017 were reviewed. Patients in tirofiban group (T-group) were treated by intravenous tirofiban at 0.4 μg/kg/min for 30 min followed by 0.1–0.15 µg/kg/min infusion. Other treatments (non-T-group) included thrombolytic, oral antiplatelet agents and anticoagulant. Intracerebral haemorrhage (ICH), systematic bleeding, new attacks after treatment, National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours and modified Rankin Scales (mRSs) at 3 months were recorded. Descriptive statistics were used for analysis.

Results

Of 23 patients qualified (15 in T-group, 8 in non-T-group), the duration of symptoms ranged from 2 to 100 min before treatments. After treatment, in T-group, four patients (26.7%) had recurrent attacks, and NIHSS scores were 0 in 11 patients (73.3%) at 24 hours. All patients reached a favourable outcome (mRS ≤2 at 3 months. In non-T-group, five patients (62.5%) had new attacks. NIHSS scores were 0 in two patients (25%) at 24 hours. At 3 months, seven patients (87.5%) reached a favourable outcome. Neither ICH nor systematic bleeding or thrombocytopaenia occurred in both groups of patients.

Conclusions

Intravenous tirofiban can be a potentially effective and safe therapy to stop early symptomatic fluctuations and shorten the duration of functional deficits in patients with CWS.

Immediate Reversal of Dabigatran by Idarucizumab Prior to Laboratory and Imaging Results in Acute Stroke

We report a case of intravenous thrombolysis in acute ischemic stroke of anterior choroidal artery following the antagonization of dabigatran with idarucizumab. No secondary complication, like hemorrhagic or thrombotic/thrombembolic event, of neither idarucizumab nor subsequent intravenous thrombolysis emerged. The recent approval of idarucizumab enables intravenous thrombolysis despite preexisiting oral anticoagulation with dabigatran, but raises the question of the optimal management and work flow of patients under medication with dabigatran and with acute neurological deficit, highly suspicious for an acute cerebrovascular event. In contrast to hitherto case reports and series, here, we explicitly refrained from awaiting the results of the thrombin time, as a marker for present anticoagulation by dabigatran, as well as the results of cerebral imaging before administration of idarucizumab. Based on the presented case we propose this approach to minimize door-to-needle time of intravenous thrombolysis in acute ischemic stroke and thus to enhance the chance for a good outcome.

Hemodynamic ischemia of the anterior choroidal artery and reversal by carotid artery stenting 10 years after ipsilateral superficial temporal artery-middle cerebral artery bypass for symptomatic left middle cerebral artery stenosis

The pathogenesis of anterior choroidal artery (AChA) territory infarction includes various mechanisms, but hemodynamic causes are rare and difficult to diagnose. 77- year-old man, who had moderate left ICA stenosis and he had treated with STA-MCA bypass surgery for severe symptomatic left MCA stenosis 10 years earlier, was admitted with right hemiparesis and confused state. On admission, magnetic resonance imaging and angiography demonstrated patent bypass, but severe stenosis of left ICA with no opacification of the left AChA and A1 portion of the left ACA. Diffusionweighted imaging demonstrated ischemic lesion in the left corona radiata. Together with clinical findings, hemodynamic ischemia of the AChA region was suspected and left carotid artery stenting resulted in prompt improvement of symptoms. Hemodynamic ischemia of the AChA territory is rare, however, should be considered as a potential target of treatment when the ipsilateral ICA, A1 and M1 show stenoocclusive lesions.

Clinical importance of the anterior choroidal artery: a review of the literature

The anterior choroidal artery (AChA) is a critical artery in brain physiology and function. The AChA is involved in many diseases, including aneurysm, brain infarct, Moyamoya disease (MMD), brain tumor, arteriovenous malformation (AVM), etc. The AChA is vulnerable to damage during the treatment of these diseases and is thus a very important vessel. However, a comprehensive systematic review of the importance of the AChA is currently lacking. In this study, we used the PUBMED database to perform a literature review of the AChA to increase our understanding of its role in neurophysiology. Although the AChA is a small thin artery, it supplies an extremely important region of the brain. The AChA consists of cisternal and plexal segments, and the point of entry into the choroidal plexus is known as the plexal point. During treatment for aneurysms, tumors, AVM or AVF, the AChA cisternal segments should be preserved as a pathway to prevent the infarction of the AChA target region in the brain. In MMD, a dilated AChA provides collateral flow for posterior circulation. In brain infarcts, rapid treatment is necessary to prevent brain damage. In Parkinson disease (PD), the role of the AChA is unclear. In trauma, the AChA can tear and result in intracranial hematoma. In addition, both chronic and non-chronic branch vessel occlusions in the AChA are clinically silent and should not deter aneurysm treatment with flow diversion. Based on the data available, the AChA is a highly essential vessel.

Perfusion Deficits and Association with Clinical Outcome in Patients with Anterior Choroidal Artery Stroke

BACKGROUND AND PURPOSE

Anterior choroidal artery (AChA) strokes have a varied pattern of tissue injury, prognosis, and clinical outcome. It is unclear whether perfusion deficit in AChA stroke is associated with the clinical outcome. This study aims to determine the frequency of perfusion abnormalities in AChA stroke and association with clinical outcome.

METHODS

The study cohort was derived from ischemic stroke patients admitted to 2 stroke centers between July 2001 and July 2014. All patients received an acute magnetic resonance imaging (MRI) scan. Patients with ischemic stroke restricted to the AChA territory were included in the study. Lesion size was measured as the largest diameter on diffusion-weighted imaging (DWI) or apparent diffusion coefficient and divided into 2 groups (<20 mm or ≥20 mm). Group comparisons were performed among patients with and without perfusion abnormalities and based on diffusion diameter. Favorable clinical outcome was defined as discharge to home.

RESULTS

A total of 120 patients were included in the study. Perfusion deficits were identified in 67% of patients. The admission National Institutes of Health Stroke Scale (NIHSS) was higher in patients with perfusion abnormalities (P = .027). Diameter lesion size on DWI was larger among patients with a perfusion deficit median [interquartile range], 1.63 [1.3-2.0], as compared with those without, 1.18 [1.0-1.7], P < .0001. Patients with a perfusion deficit were less likely to be discharged to home than those without (36% versus 60%, P = .013).

CONCLUSIONS

Two thirds of patients with an AChA stroke have a perfusion deficit on MRI, higher admission NIHSS, and larger DWI lesion size at presentation.