Impact of basal ganglia damage after successful endovascular recanalization for acute ischemic stroke involving lenticulostriate arteries

Abstract

OBJECTIVERegional ischemic vulnerability of the brain reportedly differs between the cortex and basal ganglia and has been poorly assessed in the setting of endovascular mechanical thrombectomy. This study was conducted to determine the fate of an ischemic basal ganglia and its contribution to the clinical outcome after successful endovascular recanalization for acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.METHODSClinical and radiological findings were retrospectively analyzed in consecutive patients with acute ischemic stroke characterized by large vessel occlusion involving the lenticulostriate arteries. Mechanical thrombectomy was performed in all patients using a stent retriever. The fate of ischemic basal ganglia based on location (lentiform nucleus, caudate nucleus, and internal capsule) and insular cortex was assessed according to the Alberta Stroke Programme Early CT Score (ASPECTS).RESULTSOf 170 patients with large intracranial vessel occlusion who achieved successful endovascular recanalization, defined as a thrombolysis in cerebral infarction grade of ≥ 2B, involvement of the lenticulostriate arteries was seen in 55 patients (internal carotid artery, n = 35; proximal middle cerebral artery, n = 20). Preoperative infarction was detected in the lentiform nucleus (66.7%), internal capsule (11.1%), and caudate nucleus (33.3%), all of which showed secondary advancement despite successful recanalization (85.4%, 27.3%, and 54.5%, respectively; p < 0.05). Lenticulostriate arteries with a lateral proximal and/or medial proximal origin significantly affected the development of mature infarction in the lentiform nucleus. Postoperative hemorrhagic transformation was detected in 25 of 55 patients, mostly in the lentiform nucleus. Involvement of insular ribbon infarction was significantly high in patients with hemorrhagic transformation in the basal ganglia. Age, initial National Institutes of Health Stroke Scale (NIHSS) score, initial ASPECTS, postoperative ASPECTS, postoperative infarction in the insular ribbon, and lesions in the middle cerebral artery area (M1–M6) were significantly different between patients with good and poor modified Rankin Scale scores. Interestingly, no differences were detected in postoperative infarction or hemorrhagic transformation in the basal ganglia. Multivariate analysis showed that only age (p = 0.02, OR 0.88) and the initial NIHSS score (p = 0.01, OR 0.86) independently affected favorable clinical outcomes.CONCLUSIONSThe basal ganglia are vulnerable and readily develop secondary infarction and hemorrhagic transformation despite successful recanalization. However, this does not have a significant impact on the clinical outcome of acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

A non-human primate model of stroke reproducing endovascular thrombectomy and allowing long-term imaging and neurological read-outs

“…The reproducibility of the infarct core locations and the variability of their size were shown by lesion overlays in all animals (Figure 4(a)). Per-occlusion DWI lesions involved both superficial territories (frontal, temporal and parietal cortex) and deep structures (limbic system and basal ganglia), consistent with clinical findings 40 (Figure 4(b)). Localization patterns for per-occlusion PET ischemia, post-recanalization DWIþ and day-7 FLAIRþ ischemic lesions were close, but with region-specific changes (Figure 4(a) to (e), with individual cases in Figure S3 and in 3D in Movie S2).…”

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

“…The hemorrhage was confirmed postinterventionally in the infarct core in two of three cases and might be explained by the spatial relationship between the MCA division and lenticulostriate arteries, as these supply the internal capsule and basal ganglia, which are vulnerable and develop readily secondary infarction and hemorrhagic transformation despite successful recanalization. 17 In one patient, a perforation of the M1 segment was confirmed, and the early division of the MCA might have contributed to the pathogenesis. In those cases, predicting the length of the M1 segment in the pre-interventional NECT might be useful.…”

Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery

“…All PCAs originated from the basilar tip. Most patients (117/90%) were admitted directly and had a median NIHSS of 7 (IQR, [3][4][5][6][7][8][9][10][11][12]. Premorbid disability (mRS > 2) was present in 22 (16.9%) of patients, and the median premorbid mRS was 1 (range, 0-4).…”

“…Ischemic damage in vascular territories of proximal perforating arteries in the posterior circulation, i.e., brainstem and diencephalon, has a greater influence on neurological function and the National Institutes of Health Stroke Scale (NIHSS) compared to infarction in the rostral basal ganglia, i.e., caudate nucleus and putamen. Here, infarction occurs regularly even after clinically successful EVT ( 4 , 5 ) because these areas are particularly vulnerable due to reduced collateral blood supply ( 6 ). At the same time, cortical areas supplied by the anterior circulation, e.g., the central region, impact the NIHSS much more than those supplied by the posterior circulation, i.e., in the occipital lobe.…”