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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.

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A 79-year-old man presented to the emergency room with sudden onset of dysarthria followed by coma. Eight months before admission, he had undergone C1-C2 posterior fusion. Brain MRI showed multiple posterior circulation infarcts. He experienced resolution of symptoms after intravenous thrombolysis. CT angiography revealed the irregularity of the V3 segment of the right vertebral artery where the cervical screw contacted. Although the dual antiplatelet therapy with aspirin and clopidogrel had been started, he developed severe consciousness disturbance, quadriplegia, and decerebrate posturing to painful stimuli on the 24th hospital day. His eyes were fixed in the midline. Diffusionweighted imaging revealed a subtle hyperintense lesion in the pons, and MR angiography showed basilar artery occlusion. He underwent mechanical thrombectomy. Complete recanalization was achieved on the second attempt using a stent retriever, and the patient s condition recovered to pretreatment level. Heparin and cilostazol were started after the discontinuation of aspirin and clopidogrel. On the 52nd hospital day, the right vertebral artery sacrifice with coil embolization was performed to prevent recurrences. Cerebral infarction could occur as a long-term complication of C1-C2 posterior fusion. A vertebral artery injury at the site of cervical screw contact could be one of the causes of the complication. Endovascular parent artery occlusion should be considered in ischemic stroke patients who have vertebral artery legions after cervical spine surgery.