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We aimed to evaluate the physiological variation in common pulsed-wave Doppler (PWD) indices of impedance to determine the number of waveforms to be averaged to minimise variability to 5%. A single-centre, prospective, cross-sectional cohort study of uncomplicated singleton pregnancies at 20–37 week's gestation. From each patient 100 PWD waveforms were acquired including the umbilical artery (UA), middle cerebral artery (MCA) and uterine arteries (UtAs), with 30 waveforms acquired from the ductus venosus. Each waveform was individually measured using the machine's in-built software in automated mode. The variability was assessed using coefficient of variation. The number of waveforms to be averaged was calculated using the moving average and standard error of mean. From a cohort of 200 pregnancies, a total of 189 were analysed. The pulsatility index (PI) demonstrated greater variability compared with the resistance index (RI) in all vessels studied. A minimum of 14 UA and MCA, and 13 UtA PWD waveforms were required to reduce PI variability to 5%, while only 2 RI waveforms were required for UA, 1 for MCA and 8 for UtAs. The variability shown across all PWD indices and between vessels means that PWD indices results should be interpreted cautiously and averaged over multiple waveforms. Consideration should be given to adoption of RI, as it showed greater stability than PI for maternal-fetal Doppler. [ABSTRACT FROM AUTHOR]

The transorbital approach (TOA) has a unique advantage to the more common lateral approaches as it provides direct access to the anterior middle fossa and medial sylvian fissure (SF) without significant dissection or retraction. However, when to use the TOA for surgical treatment of middle cerebral artery (MCA) aneurysms remains unclear. This study details the feasibility of clipping unruptured MCA aneurysms via the TOA by highlighting the anatomic features that either facilitate or hinder the approach. Virtual reality (VR) models of 25 MCA aneurysms from computed tomography angiograms of actual patients were rendered with the relevant anatomic structures, including the neighboring temporal lobe and SF. TOA was performed on the models in VR and the globe was translated medially and inferiorly, replicating retraction used intraoperatively. Anatomic data, including the area of surgical freedom (AOF) at the aneurysm, were recorded. Trials of aneurysm clipping were conducted in VR and each aneurysm was classified as "possible" or "impossible" candidates for clipping via TOA. Separately, the relationship between surgical view and SF visualized was analyzed. Sixteen aneurysms were eliminated as candidates for TOA treatment either through VR clip trial and/or because the SF was inaccessible. The remaining 9 (36%) were candidates for TOA. Comparing the details of these 2 aneurysm categories with Mann Whitney U tests, there was a statistically significant difference in the AOF of the TOA approach and the width of the aneurysm dome. A clinical case report is also provided highlighting the VR rehearsal similarity with surgery. Given the minimally invasive, technically challenging approach, the feasibility and safety of TOA for MCA aneurysms must be evaluated before wide clinical adoption. This study identified AOF, aneurysm width, and SF accessibility as three features that may significantly impact the possibility of clipping MCA aneurysms via TOA. [ABSTRACT FROM AUTHOR]

To prospectively assess the value of a test bolus of diluted contrast medium (CM) combined with a personalized contrast protocol in craniocervical computed tomography angiography (cc-CTA) with low radiation and CM doses. Eighty-six consecutive subjects were divided into two groups at random (43 in each one): group A: 100/Sn140 kVp, filtered back-projection reconstruction, iopromide (370 mgI/ml) 50 ml; group B: 80/Sn140 kVp, iterative reconstruction, iodixanol (270 mgI/ml). In group B, the test bolus contained 27 ml of diluted CM, a personalized protocol with low-concentration CM was used for angiography, and the test bolus injection duration in angiography remained the same. Artery values over 200 Hounsfield units were considered significant. Image quality for all cases was found to be diagnostic. No significant differences were found in the arterial densities of the ascending aorta or basilar artery between the groups. The values of the common carotid artery, internal carotid artery, and middle cerebral artery in group B were significantly lower. The effective dose and average iodine uptake were significantly lower in group B. With double-low-dose cc-CTA, test bolus scanning based on diluted CM combined with a personalized contrast protocol can yield diagnostic-quality images and significantly reduce the radiation and CM doses. • Test bolus with diluted contrast medium (CM) allows for precise anticipation of the scan trigger time. • A personalized CM protocol made it feasible to further reduce iodine uptake. • The double low dose protocol can get images with diagnostic quality in craniocervical computed tomography angiography. [ABSTRACT FROM AUTHOR]

For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period. A set of 41 individuals with symptomatic stenosis in the MCA who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed. A total of 41 individuals successfully underwent stenting, respectively. After stenting, the extent of stenosis was decreased from 71.8% (56–87.8%) to 24.9% (0–45%). The mean follow-up period is 36.9 ± 13.68 months (range, 11–67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CT angiography was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively. In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty and stenting are demonstrated to be technically feasible and safe. Its early and long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny. [ABSTRACT FROM AUTHOR]

To examine the association between cerebral artery stenosis and depressive symptoms in elderly patients. The study participants were 365 patients aged ≥65 years who visited the psychiatric outpatient clinic, Samsung Medical Center between January 1, 2000, and December 31, 2019, and were diagnosed with depressive disorder. They had brain imaging tests including magnetic resonance angiography (MRA), psychological evaluations including the 15-item Geriatric Depression Scale (GDS-15), and lab tests. Individuals' cerebral artery stenosis was identified and the association with significant depressive symptoms was examined. Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.6 %). The mean score of GDS-15 in the stenosis group was 8.1 (SD, 3.8), higher than the mean GDS-15 score of 6.5 (SD, 4.0) for the group without stenosis (p < 0.001). Compared to no middle cerebral artery (MCA) stenosis, having MCA stenosis was associated with significant depressive symptoms (p = 0.005). Compared to no posterior cerebral artery (PCA) stenosis, having left PCA stenosis was associated with significant depressive symptoms (p = 0.022). In the multivariable linear regression analysis, only bilateral MCA stenosis had a positive association with the score of GDS-15 (p = 0.013). Bilateral MCA stenosis and left PCA stenosis are associated with significant depressive symptoms among elderly patients, with bilateral MCA stenosis positively associated with the severity of depression. • Cerebral artery stenosis was associated with depressive symptoms among elderly patients. • Bilateral middle cerebral artery stenosis was associated with significant depressive symptoms and the severity. • Left posterior cerebral artery stenosis was associated with significant depressive symptoms. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied. In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up. Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality. Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar. [ABSTRACT FROM AUTHOR]

The M1 middle cerebral artery (MCA) commonly bifurcates into M2 superior and M2 inferior segments. However, MCA anatomy is highly variable rendering classification for mechanical thrombectomy trials difficult. This study explored safety and effectiveness of M2 MCA stroke thrombectomy stratified by M2 MCA anatomy. Cases of large vessel occlusion strokes treated by mechanical thrombectomy between February 2016 and August 2022 were reviewed (N = 784). M1 (n = 431) and M2 (n = 118) MCA occlusions were assessed. Among M2 MCA occlusions, only prototypical MCA bifurcation anatomy cases were included (n = 99). Dominance was assessed based on angiography. Procedural and outcome data were compared between M1, M2 superior, and M2 inferior MCA occlusions. Baseline demographics and periprocedural criteria of M2 superior (n = 56) and M2 inferior (n = 43) occlusion mechanical thrombectomies were comparable. The occluded branch was dominant in 41/43 (95.3%) M2 inferior cases, but in only 37/56 (66.1%) M2 superior cases (P < 0.001). The 90-day favorable functional outcome (modified Rankin Scale score 0–2) and mortality (modified Rankin Scale score 6) rates were 60.0% and 8.9% in M2 superior, 42.9% and 32.6% in M2 inferior, and 44.1% and 26.0% in M1 (n = 431) cases. Compared with M2 superior cases, in M2 inferior cases, favorable outcome rates were lower (P = 0.094) and mortality rates were higher (P = 0.003) and resembled M1 rates (P = 0.750 and P = 0.355, respectively). In the setting of prototypical MCA bifurcation anatomy, thrombectomy of dominant M2 inferior occlusions had outcome rates similar to M1 occlusions. In contrast, M2 superior occlusions had significantly lower mortality rates and a trend toward better favorable functional outcome rates. [ABSTRACT FROM AUTHOR]

In accordance with technique advancement and minimal invasiveness surgical approaches, the minipterional has progressively replaced the standard pterional approach for treatment of unruptured middle cerebral artery (MCA) aneurysms. Nowadays, multimodal intraoperative resources including microDoppler and microflow probes, indocyanine green videoangiography, and neurophysiologic monitoring constitute a fundamental prerequisite for increasing the safety of the clipping procedure. Our study investigated and compared in a single-center experience the effect of the evolution of a minimally invasive and multimodal approach in unruptured MCA aneurysm surgery by measuring postoperative complication rate, recovery time, and long-term neuropsychological and functional outcomes. One hundred and thirty-one patients who underwent surgical treatment for unruptured MCA aneurysms at our institution were evaluated retrospectively. Patients' clinical, radiologic, and surgical reports were collected. Cognitive evaluation and quality of life were assessed through validated tests in telephone interviews. Patients who met the inclusion criteria were divided into 2 groups: "PT (pterional)" and "MPT (minipterional)." Ninety-two patients were included in the analysis. A significant reduction of postoperative complication rates and new-onset postoperative seizures was recorded in the MPT group (P value = 0.006). Severe cognitive deficits were lower in the MPT group, although without a clear statistical correlation. Decreased complication rates, faster recovery time, and a trend toward better cognitive and functional performances were documented for the MPT group of patients. In our experience, the minipterional approach with multimodality-assisted microsurgery reduced neurologic complications and recovery time and improved long-term cognitive outcome and quality of life. [ABSTRACT FROM AUTHOR]

Prediction of outcomes in perinatal arterial ischemic stroke (PAIS) is challenging. We performed a systematic review and meta-analysis to determine whether infarct characteristics can predict outcomes in PAIS. A systematic search was conducted using five databases in January 2023. Studies were included if the sample included children with neonatal or presumed PAIS; if infarct size, location, or laterality was indicated; and if at least one motor, cognitive, or language outcome was reported. The level of evidence and risk of bias were evaluated using the Risk of Bias in Non-Randomized Studies of Interventions tool. Meta-analyses were conducted comparing infarct size or location with neurological outcomes when at least three studies could be analyzed. Eighteen full-text articles were included in a systematic review with nine included in meta-analysis. Meta-analyses revealed that small strokes were associated with a lower risk of cerebral palsy/hemiplegia compared with large strokes (risk ratio [RR] = 0.263, P = 0.001) and a lower risk of epilepsy (RR = 0.182, P < 0.001). Middle cerebral artery (MCA) infarcts were not associated with a significantly different risk of cerebral palsy/hemiplegia compared with non-MCA strokes (RR = 1.220, P = 0.337). Bilateral infarcts were associated with a 48% risk of cerebral palsy/hemiplegia, a 26% risk of epilepsy, and a 58% risk of cognitive impairment. Larger stroke size was associated with worse outcomes across multiple domains. Widely heterogeneous reporting of infarct characteristics and outcomes limits the comparison of studies and the analysis of outcomes. More consistent reporting of infarct characteristics and outcomes will be important to advance research in this field. [ABSTRACT FROM AUTHOR]

Objective To investigate the role of sea-level cerebral blood flow (CBF) in predicting acute mountain sickness (AMS) using three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL). Methods Forty-eight healthy volunteers reached an altitude of 3,650 m by air after undergoing a head magnetic resonance imaging (MRI) including 3D-pCASL at sea level. The CBF values of the bilateral anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) territories and the laterality index (LI) of CBF were compared between the AMS and non-AMS groups. Statistical analyses were performed to determine the relationship between CBF and AMS, and the predictive performance was assessed using receiver operating characteristic (ROC) curves. Results The mean cortical CBF in women (81.65 ± 2.69 mL/100 g/min) was higher than that in men (74.35 ± 2.12 mL/100 g/min) (P < 0.05). In men, the cortical CBF values in the bilateral ACA, PCA, PICA, and right MCA were higher in patients with AMS than in those without. Cortical CBF in the right PCA best predicted AMS (AUC = 0.818). In women, the LI of CBF in the ACA was different between the AMS and non-AMS groups and predicted AMS with an AUC of 0.753. Conclusion Although the mechanism and prediction of AMS are quite complicated, higher cortical CBF at sea level, especially the CBF of the posterior circulatory system, may be used for prediction in male volunteers using non-invasive 3D-pCASL. [ABSTRACT FROM AUTHOR]

• GM1 attenuates neurological dysfunction in ischemic stroke rats. • The neuroprotective effect of GM1 is related to SPTBN1-mediated signaling. • SPTBN1 may be a potential target in ischemic stroke and related diseases. Monosialoganglioside GM1 (GM1) has long been used as a therapeutic agent for neurological diseases in the clinical treatment of ischemic stroke. However, the mechanism underlying the neuroprotective function of GM1 is still obscure until now. In this study, we investigated the effects of GM1 in ischemia and reperfusion (I/R) brain injury models. Middle cerebral artery occlusion and reperfusion (MCAO/R) rats were treated with GM1 (60 mg·kg−1·d−1, tail vein injection) for 2 weeks. The results showed that GM1 substantially attenuated the MCAO/R-induced neurological dysfunction and inhibited the inflammatory responses and cell apoptosis in ischemic parietal cortex. We further revealed that GM1 inhibited the activation of NFκB/MAPK signaling pathway induced by MCAO/R injury. To explore its underlying mechanism of the neuroprotective effect, transcriptome sequencing was introduced to screen the differentially expressed genes (DEGs). By function enrichment and PPI network analyses, Sptbn1 was identified as a node gene in the network regulated by GM1 treatment. In the MCAO/R model of rats and oxygen-glucose deprivation and reperfusion (OGD/R) model of primary culture of rat cortical neurons, we first found that SPTBN1 was involved in the attenuation of I/R induced neuronal injury after GM1 administration. In SPTBN1 -knockdown SH-SY5Y cells, the treatment with GM1 (20 μM) significantly increased SPTBN1 level. Moreover, OGD/R decreased SPTBN1 level in SPTBN1 -overexpressed SH-SY5Y cells. These results indicated that GM1 might achieve its potent neuroprotective effects by regulating inflammatory response, cell apoptosis, and cytomembrane and cytoskeleton signals through SPTBN1. Therefore, SPTBN1 may be a potential target for the treatment of ischemic stroke. [ABSTRACT FROM AUTHOR]

Aneurysms located in the distal middle cerebral artery (DMCA) are relatively rare and lack an established treatment strategy. For DMCA aneurysms, we performed a one-stage combined procedure of endovascular parent artery occlusion (PAO) with coils and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in a hybrid operating room (HOR). The aim of this study was to evaluate the safety and efficacy of this procedure. Cases of unruptured DMCA aneurysms treated with the one-stage combined PAO and STA-MCA bypass in HOR were retrospectively examined, and patients' and aneurysmal backgrounds, surgical procedures, and treatment outcomes were analyzed. Six patients were included in the study. The average maximum diameter of the aneurysms was 14.4 mm. One aneurysm was located at M2 and five at M3. All aneurysms had a fusiform shape. No cases were associated with infection, trauma, or malignant tumors. In all 6 cases, the combined PAO and STA-MCA bypass was successfully completed. No postoperative hemorrhagic complications occurred. A symptomatic ischemic complication occurred in 1 case whose symptom disappeared in a week. Three months after surgery, complete obliteration of the aneurysm and patency of the bypass was confirmed in all cases. The one-stage combined PAO and STA-MCA bypass in the HOR is safe and effective for DMCA aneurysms, potentially serving as a treatment option for this complex aneurysm. [ABSTRACT FROM AUTHOR]

Delayed enhancing white matter lesions are a rare complication that develops after endovascular treatment of cerebral aneurysms, the etiology of which remains unclear. We present a 52-year-old female patient who was symptomatic with a seizure-like condition and showed reversible cranial parenchymal changes with high-dose cortisone treatment after endovascular stent-assisted coil embolization for an unruptured aneurysm in the internal cerebral artery. Clinicians should be alert to this rare complication and should follow patients for a long time due to its fluctuating and long-term course. [ABSTRACT FROM AUTHOR]

• The findings are consistent in showing greater deoxygenation in the muscles during exercise, reflecting the oxygen (O 2) utilization. • Muscle O 2 availability becomes compromised when an individual reaches the exhaustion point by reducing blood flow and decreasing muscle O 2 extraction. • Cerebral tissue experiences an increase in O 2 delivery with increased exercise intensity, suggesting a greater engagement of the brain areas to sustain the exercise. • At the exhaustion point, cerebral oxygenation reaches a plateau or decline, potentially resulting in motor failure during exercise. Near-infrared spectroscopy (NIRS) technology has allowed for the measurement of cerebral and skeletal muscle oxygenation simultaneously during exercise. Since this technology has been growing and is now successfully used in laboratory and sports settings, this systematic review aimed to synthesize the evidence and enhance an integrative understanding of blood flow adjustments and oxygen (O 2) changes (i.e., the balance between O 2 delivery and O 2 consumption) within the cerebral and muscle systems during exercise. A systematic review was conducted using PubMed, Embase, Scopus, and Web of Science databases to search for relevant studies that simultaneously investigated cerebral and muscle hemodynamic changes using the near-infrared spectroscopy system during exercise. This review considered manuscripts written in English and available before February 9, 2023. Each step of screening involved evaluation by 2 independent authors, with disagreements resolved by a third author. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the methodological quality of the studies. Twenty studies were included, of which 80% had good methodological quality, and involved 290 young or middle-aged adults. Different types of exercises were used to assess cerebral and muscle hemodynamic changes, such as cycling (n = 11), treadmill (n = 1), knee extension (n = 5), isometric contraction of biceps brachii (n = 3), and duet swim routines (n = 1). The cerebral hemodynamics analysis was focused on the frontal cortex (n = 20), while in the muscle, the analysis involved vastus lateralis (n = 18), gastrocnemius (n = 3), biceps brachii (n = 5), deltoid (n = 1), and intercostal muscle (n = 1). Overall, muscle deoxygenation increases during exercise, reaching a plateau in voluntary exhaustion, while in the brain, oxyhemoglobin concentration increases with exercise intensity, reaching a plateau or declining at the exhaustion point. Muscle and cerebral oxygenation respond differently to exercise, with muscle increasing O 2 utilization and cerebral tissue increasing O 2 delivery during exercise. However, at the exhaustion point, both muscle and cerebral oxygenation become compromised. This is characterized by a reduction in blood flow and a decrease in O 2 extraction in the muscle, while in the brain, oxygenation reaches a plateau or decline, potentially resulting in motor failure during exercise. [Display omitted] [ABSTRACT FROM AUTHOR]

Despite the fact that labor depends on too many interacting factors and no parameter can fully predict its outcome, fetal cerebral Doppler has emerged as the most reliable tool for prediction, in contrast with fetal weight, which performs significantly worse in the last weeks of pregnancy. The importance of the cerebral Doppler follows the inverse pathway of fetal weight increasing its performance in the last weeks of pregnancy and reaching its highest ability prior to labor. A combination of cerebral flow, fetal weight, and selected clinical information may obtain moderate predictions of labor outcome, provided the interval to labor is not long. [ABSTRACT FROM AUTHOR]

• pMCAO induces cognitive symptoms that are highly disabling. • Combined cerebrolysin and nicotinamide reduced infarct and cognitive symptoms. • Cerebrolysin and nicotinamide combination promoted dendritic growth in hippocampal neurons. • BDNF levels increased after cerebrolysin and nicotinamide acute combined administration. Stroke is one of the leading causes of disability worldwide, where the Hippocampus (HPC) is affected. HPC organizes memory, which is a cognitive domain compromised after a stroke, where cerebrolysin (CBL) and Nicotinamide (NAM) have been recognized as potentially therapeutic. In this study, we aimed to evaluate the efficacy of a combined administration of CBL and NAM in a rat stroke model. Male Sprague-Dawley rats (n = 36) were divided into four groups: saline (pMCAO − Saline), CBL (pMCAO + CBL), NAM (pMCAO + NAM), and experimental (pMCAO + CBL-NAM) (n = 9 per group). A permanent middle cerebral artery occlusion (pMCAO) was induced through electrocauterization of the middle cerebral artery, followed by the administration of CBL (2.5 ml/kg), NAM (500 mg/kg) or combined immediately after skin suture, as well as at 24, 48, and 72 h post-surgery. The rats were evaluated in the novel object recognition test; hippocampal infarct area measurement; reconstruction of neurons from CA1 for Sholl analysis; and, measurement of brain-derived neurotrophic factor (BDNF) levels near the infarct zone. Our findings revealed that the administration of CBL or NAM induced infarct reduction, improved cognition, and increased BDNF levels. Moreover, a combination of CBL and NAM increased dendritic intersection in CA1 pyramidal neurons. Thus, the combined administration of CBL and NAM can promote cognitive recovery after a stroke, with infarct reduction, cytoarchitectural changes in HPC CA1 neurons, and BDNF increase. Our findings suggest that this combination therapy could be a promising intervention strategy for stroke. [ABSTRACT FROM AUTHOR]

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery has been widely adopted in treating moyamoya disease (MMD). Geometric variations including high tortuosity and stenosis exist in many cases, but the hemodynamic effects have not been comprehensively evaluated. We aim to evaluate the hemodynamic effects of bypass geometry variations based on patient-specific data. In total, 17 patients with MMD who underwent STA-MCA bypass surgery with highly tortuous bypass geometry were included. For each patient, the original 3-dimensional structure of STA-MCA bypass was reconstructed from clinical imaging data. The bypass structure was virtually improved by removing the tortuosity and stenosis. Computational fluid dynamics simulation was performed on both bypass structures under identical patient-specific condition. The simulated hemodynamic parameters of the bypass and its distal branches were compared between the original and virtually improved bypass geometries in all cases using paired t -test or Wilcoxon signed-rank test. The changes of hemodynamic parameters were compared between the cases with and without mild-to-moderate stenosis (44.0–70.3% in diameter) in the bypass using t -test or Mann-Whitney U test. The virtual improvement of bypass geometry significantly increased the flow rate of the bypass and its distal branches (P < 0.05) and decreased the transcranial flow resistance (P < 0.05). The hemodynamic changes in cases with stenosis removal were significantly greater than those without stenosis (P < 0.05). High tortuosity and stenosis can significantly change the hemodynamics of STA-MCA bypass, and the optimization of bypass geometry deserves further consideration. [ABSTRACT FROM AUTHOR]

To compare the efficacy and safety of intravenous thrombolysis, direct endovascular therapy (EVT), and bridging therapy (BT = intravenous thrombolysis + EVT) for acute basilar artery occlusion cerebral infarction. One hundred and fourteen patients with acute basilar artery occlusion cerebral infarctions admitted between January 2020 and August 2023 were selected. Differences in the reperfusion rate, prognosis, incidence of stroke-associated pneumonia, and mortality rate were compared among the 3 groups. There was no statistically significant difference in the percentage of patients who achieved successful reperfusion (86.8% vs. 84.2%) or complete reperfusion (72.1% vs. 68.4%) between the direct EVT and BT groups (both P > 0.05). There were no statistically significant differences in the rates of symptomatic intracranial hemorrhage (3.7% vs. 10.3% vs. 10.5%, P = 0.763). There were statistically significant differences in the rates of good prognosis (modified ranking scale score 0–2) (59.3% vs. 30.9% vs. 26.3%, P = 0.021), stroke-related pneumonia (29.6% vs. 66.2% vs. 36.8%, P = 0.002), and mortality (14.8% vs. 48.5% vs. 42.1%, P = 0.010) among the 3 treatment groups. According to the binary logistic regression analysis, a good prognosis was independently associated with a baseline National Institutes of Health Stroke Scale score ≤ 10 (odds ratio, 3.714; 95% confidence interval, 1.207–11.430; P = 0.022) and the incidence of stroke-associated pneumonia (odds ratio, 0.640; 95% confidence interval, 0.484–0.845; P = 0.002). Although there were differences in prognosis, mortality, and incidence of complications among the 3 treatment groups, after adjusting for confounding factors, prognosis was independently correlated only with the baseline NIHSS score and stroke-associated pneumonia but not with treatment methods. [ABSTRACT FROM AUTHOR]

The relationship between brain lesions and stroke outcomes is crucial for advancing patient prognosis and developing effective therapies. Stroke is a leading cause of disability worldwide, and it is important to understand the neurological basis of its varied symptomatology. Lesion-symptom mapping (LSM) methods provide a means to identify brain areas that are strongly associated with specific symptoms. However, inner variations in LSM methods can yield different results. To address this, our study aimed to characterize the lesion-symptom mapping variability using three different LSM methods. Specifically, we sought to determine a lesion symptom core across LSM approaches enhancing the robustness of the analysis and removing potential spatial bias. A cohort consisting of 35 patients with either right- or left-sided middle cerebral artery strokes were enrolled and evaluated using the NIHSS at 24 h post-stroke. Anatomical T1w MRI scans were also obtained 24 h post-stroke. Lesion masks were segmented manually and three distinctive LSM methods were implemented: ROI correlation-based, univariate, and multivariate approaches. The results of the LSM analyses showed substantial spatial differences in the extension of each of the three lesion maps. However, upon overlaying all three lesion-symptom maps, a consistent lesion core emerged, corresponding to the territory associated with elevated NIHSS scores. This finding not only enhances the spatial accuracy of the lesion map but also underscores its clinical relevance. This study underscores the significance of exploring complementary LSM approaches to investigate the association between brain lesions and stroke outcomes. By utilizing multiple methods, we can increase the robustness of our results, effectively addressing and neutralizing potential spatial bias introduced by each individual method. Such an approach holds promise for enhancing our understanding of stroke pathophysiology and optimizing patient care strategies. [ABSTRACT FROM AUTHOR]

Two major drawbacks of 4D-MR angiography based on superselective pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-S-PACK) are the low temporal resolution and long scanning time. We investigated the feasibility of increasing the temporal resolution and accelerating the scanning time on 4D-S-PACK by using CS-SENSE and PhyZiodynamics, a novel image-processing program that interpolates images between phases to generate new phases and reduces image noise. Seven healthy volunteers were scanned with a 3.0 T MR scanner to visualize the internal carotid artery (ICA) system. PhyZiodynamics is a novel image-processing that interpolates images between phases to generate new phases and reduces image noise, and by increasing temporal resolution using PhyZiodynamics, inflow dynamic data (reference) were acquired by changing the labeling durations (100–2000 msec, 31 phases) in 4D-S-PACK. From this set of data, we selected seven time intervals to calculate interpolated time points with up to 61 intervals using ×10 for the generation of interpolated phases with PhyZiodynamics. In the denoising process of PhyZiodynamics, we processed the none, low, medium, high noise reduction dataset images. The time intensity curve (TIC), the contrast-to-noise ratio (CNR) were evaluated. In accelerating with CS-SENSE for 4D-S-PACK, 4D-S-PACK were scanned different SENSE or CS-SENSE acceleration factors: SENSE3, CS3–6. Signal intensity (SI), CNR, were evaluated for accelerating the 4D-S-PACK. With regard to arterial vascular visualization, we evaluated the middle cerebral artery (MCA: M1–4 segments). In increasing temporal resolution, the TIC showed a similar trend between the reference dataset and the interpolated dataset. As the noise reduction weight increased, the CNR of the interpolated dataset were increased compared to that of the reference dataset. In accelerating 4D-S-PACK, the SI values of the SENSE3 dataset and CS dataset with CS3–6 were no significant differences. The image noise increased with the increase of acceleration factor, and the CNR decreased with the increase of acceleration factor. Significant differences in CNR were observed between acceleration factor of SENSE3 and CS6 for the M1–4 (P < 0.05). Visualization of small arteries (M4) became less reliable in CS5 or CS6 images. Significant differences were found for the scores of M2, M3 and M4 segments between SENSE3 and CS6. With PhyZiodynamics and CS-SENSE in 4D-S-PACK, we were able to shorten the scan time while improving the temporal resolution. • PhyZiodynamics improves temporal resolution maintaining TIC and high CNR. • By using CS-SENSES, scan time of 4D-S-PACK can be reduced by 1 min. • 4D-S-PACK with PhyZiodynamics and CS-SENSE may rival the 4D-DSA of diagnostic power. [ABSTRACT FROM AUTHOR]

The use of the maxillary artery (MA) as a donor has increasingly become an alternative method for cerebral revascularization. Localization difficulties emerge due to rich infratemporal anatomical variations and the complicated relationships of the MA with neuromuscular structures. We propose an alternative localization method via the interforaminal route along the middle fossa floor. Five silicone-injected adult cadaver heads (10 sides) were dissected. Safe and effective localization of the MA was evaluated. The MA displayed anatomical variations in relation to the lateral pterygoid muscle (LPM) and the mandibular nerve branches. The proposed L-shaped perpendicular 2-step drilling technique revealed a long MA segment that allowed generous rotation to the intracranial area for an end-to-end anastomosis. The first step of drilling involved medial-to-lateral expansion of foramen ovale up to the lateral border of the superior head of the LPM. The second step of drilling extended at an angle approximately 90° to the initial path and reached anteriorly to the foramen rotundum. The MA was localized by gently retracting the upper head of the LPM medially in a posterior-to-anterior direction. Considering all anatomical variations, the L-shaped perpendicular 2-step drilling technique through the interforaminal space is an attainable method to release an adequate length of MA. The advantages of this technique include the early identification of precise landmarks for the areas to be drilled, preserving all mandibular nerve branches, the deep temporal arteries, and maintaining the continuity of the LPM. [ABSTRACT FROM AUTHOR]

Middle Cerebral Artery Bifurcation Aneurysm (MbifA) is associated with a high risk of rupture and poor overall prognosis in patients once it ruptures. Morphological, geometric, and hemodynamic parameters have been identified as factors contributing to the rupture of intracranial aneurysms. However, there are no studies that combine these 3 types of parameters to specifically target MbifA rupture. This study enrolled all patients with MbifAs diagnosed at our treatment center from 1 April 2021 to 31 July 2023 who met the study criteria. All patients underwent digital subtraction angiography examination to obtain 3D rotational angiography data. We imported the complete image data into the Aneurysm/Artery Reconstruction and Analysis machine to obtain 13 morphological parameters (D neck , D dome , Height, D max , D artery , aspect ratio [AR], size ratio, dome-neck-ratio [DNR], height-artery-ratio, bottleneck factor, Inflow Angle, Incline Angle, Arterial Angle), 5 geometric parameters (V,S,undulation index [UI], ellipticity index [EI],nonsphericity index [NSI]), and 5 hemodynamic parameters (wall shear stress [WSS], the maximum WSS, the parent artery WSS, the normalized WSS [NWSS], oscillatory shear index [OSI]). All the above significant parameters were tested by univariate and multivariate analyses to find out the independent discriminatory factors. A total of 49 MbifAs (16 ruptured and 33 unruptured) from 44 patients were included in the study. Height (P = 0.033), AR (P = 0.007), DNR (P = 0.011), EI (P = 0.042), NSI(P = 0.030), UI(P = 0.027), WSS(P = 0.033), and NWSS(P = 0.002) were all associated with MbifA rupture in univariate analyses, but only NWSS was an independent risk factor (P = 0.036, OR = 0.046, 95% CI: 0.003–0.815) in multivariate logistic regression analysis. Height, AR, DNR, EI, UI, NSI, WSS, and NWSS may be correlated with MbifA rupture, but only NWSS was an independent risk factor. A lower NWSS was associated with a higher risk of MbifA rupture. No significant differences were observed in the angle parameters, including the Inflow Angle, between ruptured and unruptured MbifAs. OSI was significantly increased at the dome of the aneurysm but the mean OSI was not found to be associated with MbifA rupture. [ABSTRACT FROM AUTHOR]

We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4–6 weeks favored unruptured cases (P < 0.0001–0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (−0.7 ± 1.2 vs. −0.04 ± 1.2, P = 0.0215). Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era. [ABSTRACT FROM AUTHOR]

Vascular neurosurgical procedures require temporary or permanent surgical clips to treat cerebral aneurysms, arteriovenous malformations, or bypass surgery. In this scenario, surgical clips should have specific characteristics such as high-quality material, proper design, closing force, and biocompatibility. Due to these characteristics, the price of these clips does not allow their availability at the experimental surgery laboratory worldwide. We describe here the technique for manufacturing handcrafted clips of low cost, using dental stainless steel or titanium wire of 0.18 mm, 0.20 mm, or 0.22 mm in diameter. We must complete six steps to obtain the clip using our hands and small electrician needle nose pliers for wire molding. These clips have a closing force of 30–60 gr/cm2 (depending on the wire diameter). They can be used in the experimental surgery laboratory to clip arteries or veins during vascular microsurgery procedures. Also, they can be used as temporary clips with confidence in low-flow bypass (v.gr. superficial temporal artery to middle cerebral artery or occipital artery to posterior inferior cerebellar artery anastomoses). Making practical low-cost clips for use in laboratory procedures or during low-flow anastomosis as temporary clips is possible. The main advantages are the low cost and the worldwide availability of the basic materials. The main disadvantage is the learning curve to get the ability to master the manufacturing of these clips. [ABSTRACT FROM AUTHOR]

To investigate differences in iron deposition between infarct and normal cerebral arterial regions in acute ischaemic stroke (AIS) patients using quantitative susceptibility mapping (QSM). Forty healthy controls and 40 AIS patients were recruited, and their QSM images were obtained. There were seven regions of interest (ROIs) in AIS patients, including the infarct regions of responsible arteries (R1), the non-infarct regions of responsible arteries (R2), the contralateral symmetrical sites of lesions (R3), and the non-responsible cerebral arterial regions (R4, R5, R6, R7). For the healthy controls, the cerebral arterial regions corresponding to the AIS patient group were selected as ROIs. The differences in corresponding ROI susceptibilities between AIS patients and healthy controls and the differences in susceptibilities between infarcted and non-infarct regions in AIS patients were compared. The susceptibilities of infarct regions in AIS patients were significantly higher than those in healthy controls (p <0.0001). There was no significant difference in non-infarct regions between the two groups (p >0.05). The susceptibility of the infarct regions in AIS patients was significantly higher than those of the non-infarct region of responsible artery and non-responsible cerebral arterial regions (p< 0.01). Abnormal iron deposition detected by QSM in the infarct regions of AIS patients may not affect iron levels in the non-infarct regions of responsible arteries and normal cerebral arteries, which may open the door for potential new diagnostic and treatment strategies. • abnormal iron deposition were presented in the infarct region of AIS patients. • this may not affect iron levels in non-infarct regions of responsible artery. • this may not affect iron levels in normal cerebral arteries regions. [ABSTRACT FROM AUTHOR]

This study investigates the flow and hemodynamics of small perforator blood vessels that branch from the basilar artery (BA) in the brain. Using advanced imaging techniques and computational fluid dynamics (CFD) simulations, detailed 3D geometries of the perforators were acquired through barium contrast injection, micro-CT scans, and data processing. The hybrid geometry, combining micro-CT scans and mesh extraction algorithms, provided accurate vessel models. The influence of different types of finite volume on the analysis was examined, with polyhedral elements showing the most efficient ratio of the analysis time to convergence level. Additionally, the effect of boundary conditions on hemodynamic parameters was studied. Simulations using 0.0 mmHg pressure conditions at the outlets directed flow mainly through the BA, neglecting the perforator branches. In contrast, non-zero outlet pressure conditions significantly increased the flow in the perforators, leading to non-physiological flow velocities and overestimation of hemodynamic parameters. The assumption of pressure conditions of 0 mmHg at outlets was found to be valid for simple single vessel geometries, but not for more complex vascular systems. This research contributes valuable information on the complex flow patterns and hemodynamics of small perforator blood vessels in the brain and emphasizes the importance of accurately modeling geometry and boundary conditions in such studies. [ABSTRACT FROM AUTHOR]

Intracranial arteries have a high rate of variation, but a clear schematic overview is lacking. In this pictorial review we classify and depict all the variations and anomalies within the middle cerebral artery (MCA). PubMed was searched with the MeSH-term "Middle Cerebral Artery." Articles were selected based on their description of variants within the MCA. Cross-referencing was used to broaden the range of articles. The anatomical variants were then schematically drawn using the anteroposterior and lateral view during angiography of the internal carotid artery. A total of 29 unique medical illustrations were made, depicting variation in number of vessels; variation in vessel origin; and variation in morphology. The MCA provides vital blood supply to the frontal, parietal, temporal, and central brain structures. An overview of these variations is important to diagnose and treat patients with MCA-related pathology correctly and safely. They can aid in distinguishing pathology from normal anatomical variance; aid neurosurgeons during aneurysmal clipping or arteriovenous malformation resections; and aid interventional radiologists during thrombectomy or coiling. This article provides a summary regarding current knowledge of anatomical variations within the MCA, their prevalence and clinical relevance. A total of 29 unique illustrations were made, depicting currently known variants. We encourage all who diagnose, treat, and study the MCA to use this overview for a uniform and better understanding of its anatomy. [ABSTRACT FROM AUTHOR]

Twig-like middle cerebral artery (MCA) is a rare anomaly where the M1 MCA is partially or completely replaced by a plexiform network. It has been described in angiographic series from Asian and South-American cohorts, but has not yet been reported in a European population. The digital subtraction angiograms (DSAs) of adult patients referred to a single neurovascular center for a diagnostic hypothesis of moyamoya arteriopathy (MMA) from 2018 to 2023 were prospectively and retrospectively checked by experienced neuroradiologists for identifying patients with twig-like MCA. The angioarchitecture of twig-like MCA was systematically evaluated and described. Five of 30 (16.7%) male patients (mean age 55.8 + 14.7 years) of European ancestry were identified as having twig-like MCA. The clinical presentations were ischemic stroke (2 of 5), hemorrhagic stroke (1 of 5), and headache (2 of 5). All patients showed a unilateral involvement on DSA and in 1 of 5 (20%) an intracranial aneurysm was found. DSA was used to confirm the diagnosis of twig-like MCA and define the angioarchitecture and associated anomalies. An accessory MCA and recurrent artery of Heubner were found in 3 of 5 (60%) cases, feeding the network together with the anterior choroidal artery (4 of 5, 80%). Twig-like MCA is a rare vascular anomaly, but it seems to be less rare than expected among adult European patients with suspected MMA on noninvasive neuroimaging studies. DSA is fundamental for a reliable differential diagnosis and should not be omitted in these patients. [Display omitted] [ABSTRACT FROM AUTHOR]

[Display omitted] • Urolithin B effectively mitigates cerebral ischemia–reperfusion injury in rats. • Urolithin B attenuates oxidative stress via activation of the Nrf2 pathway. • We consider Urolithin B may also be beneficial in a clinical setting. Ischemia-reperfusion (IR) induces a wide range of irreversible injuries. Cerebral IR injury (IRI) refers to additional brain tissue damage that occurs after blood flow is restored following cerebral ischemia. Currently, no established methods exist for treating IRI. Oxidative stress is recognized as a primary mechanism initiating IRI and a crucial focal target for its treatment. Urolithin B, a metabolite derived from ellagitannins, antioxidant polyphenols, has demonstrated protective effects against oxidative stress in various disease conditions. However, the precise mechanism underlying UB's effect on IRI remains unclear. In our current investigation, we assessed UB's ability to mitigate neurological functional impairment induced by IR using a neurological deficit score. Additionally, we examined cerebral infarction following UB administration through TTC staining and neuron Nissl staining. UB's inhibition of neuronal apoptosis was demonstrated through the TUNEL assay and Caspase-3 measurement. Additionally, we examined UB's effect on oxidative stress levels by analyzing malondialdehyde (MDA) concentration, superoxide dismutase (SOD) activity, and immunohistochemistry analysis of inducible nitric oxide synthase (iNOS) and 8-hydroxyl-2′-deoxyguanosine (8-OHdG). Notably, UB demonstrated a reduction in oxidative stress levels. Mechanistically, UB was found to stimulate the Nrf2/HO-1 signaling pathway, as evidenced by the significant reduction in UB's neuroprotective effects upon administration of ATRA, an Nrf2 inhibitor. In summary, UB effectively inhibits oxidative stress induced by IR through the activation of the Nrf2/HO-1 signaling pathway. These findings suggest that UB holds promise as a therapeutic agent for the treatment of IRI. [ABSTRACT FROM AUTHOR]

Moyamoya disease (MMD) is characterized by supraclinoid internal carotid artery narrowing causing cerebral parenchyma to starve. Direct and indirect revascularisation techniques are the treatment norm. We provide a clinicoradiological comparison of single and double barrel superficial temporal artery to middle cerebral artery (STA-MCA) bypass for MMD. The perfusion in cerebral hemispheres and vessel density in digital subtraction angiography (DSA) have been evaluated using novel algorithms. DSA, arterial spin labeling magnetic resonance imaging methods and Suzuki, Matsushima, Angiographic Outcome Score scales were used to quantify perfusion parameters; modified Rankin Score was used for clinical evaluation. A novel image processing algorithm was designed to perform analysis of arterial spin labeling sequences and compare perfusion. Vessel density was calculated using connected component analysis on thresholded DSA images. Fifty-four hemispheres with MMD underwent STA-MCA bypass 42(77.8%) single barrel and 12 (22.2%) double barrel. Clinical outcome—modified Rankin Score was significant with P < 0.001 in single barrel and P = 0.001 in double barrel groups. The overall Angiographic Outcome Score showed improvement postoperatively (P = 0.032). Perfusion analysis was performed in 20 hemispheres (13 single barrel; 7 double barrel). MCA territories showed significant improvement in single barrel (2.72%, P = 0.0294) and double barrel groups (12.89%, P = 0.025). Vessel density calculated in MCA territory, showed an overall postoperative improvement (P = 1.75 × 10–8). Double barrel STA-MCA bypass clinically as well as radiologically improves perfusion in the ACA as well as MCA territories in MMD. The novel image processing algorithm is an accurate, objective tool to evaluate perfusion in magnetic resonance images and vessel density in DSA images of MMD. [ABSTRACT FROM AUTHOR]

Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases. [ABSTRACT FROM AUTHOR]

Internal carotid complex aneurysms (ICCAs) management is challenging. Ligating the internal carotid artery (ICA) combined with Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) anastomosis is an effective treatment option. Balloon test occlusion (BTO) assessments for preoperative decision-making are unaffordable in developing countries. This article discusses the study of Willis polygon (WP) segments as an option and suggests a score for decision-making. Herein, we report the outcomes of a series of patients treated for ICCA aneurysms at a single institution. From September 2016 to December 2020, we conducted a retrospective cohort study that analyzed data from patients with ICCAs. Among them, 9 patients received treatment involving ICA ligation combined with STA-MCA anastomosis. Partial or total carotid ligation was determined by using the WP score (WPS). All Patients underwent STA-MCA anastomosis, in addition to total ICA ligation in 7 patients and partial ICA ligation in 2 patients with a WPS of 7 and 5, respectively. Patients with partially ligated carotid arteries were referred to an overseas neurointerventional center 12 months after surgery. As the BTO test was negative, they underwent ICA occlusion by coiling. Postoperative clinical outcomes did not change in 8/9 patients. In 1 patient, we reported a minor parietal stroke; the patient recovered completely after 6 months. Total aneurysm exclusion by thrombosis was achieved in 7/9 patients after total ICA ligation alone and in 2/9 patients after partial ICA ligation combined with coiling. Limited access to endovascular assessment techniques such as BTO poses challenges in managing ICCAs. The WPS for decision-making appears to be a simple and safe option. In addition to STA-MCA bypass surgery, total or partial ICA ligation may be proposed depending on the WPS. After 12 months, patients with low WPS who underwent partial ICA ligation combined with bypass had postoperative normal BTO. [ABSTRACT FROM AUTHOR]

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• RNF213 protein expression is upregulated in the ischemic penumbra. • Rnf213 knockout decreases infarct volume and alleviates neurological deficits. • Rnf213 knockout ameliorates neuronal apoptosis in the ischemic penumbra. • Rnf213 knockout activates the Akt/GSK-3β/β-catenin/Bcl-2 signalling pathway. Previous studies by us and others have shown that RING finger protein 213 (RNF213) is associated with cerebrovascular disease and systemic vasculopathy. Indeed, Rnf213 mRNA expression is increased in cerebral ischemia reperfusion injury (CIRI). The purpose of the present study was to investigate the role of Rnf213 in CIRI. Using the middle cerebral artery occlusion (MCAO) model, we confirmed that the expression of RNF213 protein was significantly upregulated in neurons in the ischemic penumbra. Rnf213 knockout mice were successfully generated using CRISPR/Cas9 technology. According to TTC staining and Bederson neurological scale, removal of Rnf213 decreased brain infarct volume and improved neurological deficit score, although the restoration of cerebral blood flow after MCAO was similar in WT and Rnf213−/− mice. In addition, the levels of p-Akt, p-GSK-3β, β-catenin and Bcl-2 were significantly increased 24 h after MCAO in the ischemic penumbra of the Rnf213−/− mice compared to WT mice, indicating that Rnf213 removal may ameliorate neuronal apoptosis by regulating the Akt/GSK-3β/β-catenin/Bcl-2 signaling pathway. Taken together, our study reveals that Rnf213 regulates neuronal apoptosis in CIRI, therefore impacting on brain infarct volume in brain ischemia. [ABSTRACT FROM AUTHOR]

Diabetes is one of the significant risk factors for ischemic stroke. Hyperglycemia exacerbates the pathogenesis of stroke, leading to more extensive cerebral damage and, as a result, to more severe consequences. However, the mechanism whereby the hyperglycemic status in diabetes affects biochemical processes during the development of ischemic injury is still not fully understood. In the present work, we record for the first time the real-time dynamics of H 2 O 2 in the matrix of neuronal mitochondria in vitro in culture and in vivo in the brain tissues of rats during development of ischemic stroke under conditions of hyperglycemia and normal glucose levels. To accomplish this, we used a highly sensitive HyPer7 biosensor and a fiber-optic interface technology. We demonstrated that a high glycemic status does not affect the generation of H 2 O 2 in the tissues of the ischemic core, while significantly exacerbating the consequences of pathogenesis. For the first time using Raman microspectroscopy approach, we have shown how a sharp increase in the blood glucose level increases the relative amount of reduced cytochromes in the mitochondrial electron transport chain in neurons under normal conditions in awake mice. [Display omitted] • A high glycemic status significantly exacerbates the consequences of the ischemic stroke. • A high glycemic status does not affect the generation of H 2 O 2 in the neurons of the ischemic core. • A sharp increase in the blood glucose level increases the loading of the mitochondrial electron transport chain in neurons. [ABSTRACT FROM AUTHOR]

The main treatment for moyamoya disease (MMD) is revascularization surgery. Most bypasses use the superficial temporal artery (STA) as the donor vessel. However, even if the STA–middle cerebral artery (MCA) bypass is functioning, the affected hemisphere can continue to be symptomatically malperfused. We sought to assess the efficacy of salvage direct revascularization surgery using the occipital artery (OA) as a donor vessel in patients with ischemic MMD who experience continued cerebral malperfusion despite previous successful STA-MCA bypass. We retrospectively analyzed the cerebrovascular databases of 2 surgeons and described patients in whom the OA was used as the donor vessel for direct revascularization. Seven patients were included (5 women). Previous STA-MCA bypasses were direct (n = 2), indirect (n = 3), or combined/multiple (n = 2). The mean (SD) interval between STA-MCA and OA-MCA procedures was 29.2 (13.1) months. Despite an intact STA-MCA bypass in all 7 cases, all 7 patients had recurrent symptoms and demonstrated residual impaired cerebral perfusion. All 7 patients underwent successful OA-MCA direct revascularization. Follow-up perfusion imaging was obtained for 6 of 7 patients. All 6 of these patients demonstrated improved cerebral blood flow to the revascularized hemispheres. All 7 patients demonstrated clinical improvement. Patients with ischemic MMD who have continued symptoms and cerebral malperfusion despite previous successful STA-MCA bypass present a challenging clinical scenario. Our series highlights the potential utility of the OA-MCA direct bypass as a salvage therapy for these patients. [ABSTRACT FROM AUTHOR]

The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs). With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length. We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA). The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed. [ABSTRACT FROM AUTHOR]

The significance of the intravascular enhancement sign (IVES) on high-resolution magnetic resonance vascular wall imaging (HR-VWI) remains unclear. This study aimed to investigate the correlation between the IVES and collateral assessment derived from digital subtraction angiography (DSA). A total of 75 patients with occlusion of the first segment of the middle cerebral artery (MCA) who underwent HR-VWI and DSA examinations at our research institution between November 2016 and February 2023 were included. The number of vessels with IVES, IVES-Alberta Stroke Program Early Computed Tomography Score (ASPECTS), American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral grade, and DSA collateral blood flow grade were retrospectively evaluated. Correlations between these indicators were assessed using Spearman's correlation. Interrater agreement was good for the assessment of HR-VWI and DSA indicators. After adjustments for age, degree of wall enhancement, and hypertension, a multivariable ordinal logistic regression model identified both the number of IVES vessels (OR = 1.37; 95%CI [1.06–1.78]; P = 0.017) and IVES-ASPECTS (OR = 2.00; 95%CI [1.03–3.87]; P = 0.041) as independent predictors of ischemic stroke. In the patient group with acute ischemic stroke, we found weak correlations between the number of IVES vessels and the ASITN/SIR collateral grade (rho = −0.35; P = 0.002) and between the IVES-ASPECTS and ASITN/SIR collateral grade (rho = −0.27; P = 0.02). Moreover, there were strong correlations between the number of IVES vessels and the DSA collateral blood flow grade (rho = −0.74; P < 0.001) and between the IVES-ASPECTS and the DSA collateral blood flow grade (rho = −0.65; P < 0.001). The number of IVES vessels correlated strongly with the IVES-ASPECTS (rho = 0.92, P < 0.001). We find that the IVES is closely associated with sluggish collateral blood flow, which further confirms the hemodynamic mechanism underlying the IVES in MCA occlusion. [ABSTRACT FROM AUTHOR]

Delivering large therapeutic molecules via the blood-brain barrier to treat ischemic stroke remains challenging. NR2B9c is a potent neuroprotective peptide but it's safe and targeted delivery to the brain requires an efficient, natural, and non-immunogenic delivery technique. Small extracellular vesicles (sEVs) have shown great potential as a non-immunogenic, natural cargo delivery system; however, tailoring of its inefficient brain targeting is desired. Here, we coupled rabies virus glycoprotein 29 with sEVs surface via bio-orthogonal click chemistry reactions, followed by loading of NR2B9c, ultimately generating stroke-specific therapeutic COCKTAIL (sEVs-COCKTAIL). Primary neurons and Neuro-2a cells were cultured for in vitro and transient middle cerebral artery occlusion model was used for in vivo studies to evaluate neuron targeting and anti-ischemic stroke potential of the sEVs-COCKTAIL. Bio-clickable sEVs were selectively taken up by neurons but not glial cells. In the in vitro ischemic stroke model of oxygen-glucose deprivation, the sEVs-COCKTAIL exhibited remarkable potential against reactive oxygen species and cellular apoptosis. In vivo studies further demonstrated the brain targeting and increased half-life of bio-clickable sEVs, delivering NR2B9c to the ischemic brain and reducing stroke injury. Treatment with the sEVs-COCKTAIL significantly increased behavioral recovery and reduced neuronal apoptosis after transient middle cerebral artery occlusion. NR2B9c was delivered to neurons binding to post-synaptic density protein-95, inhibiting N -methyl- d -Aspartate receptor-mediated over production of oxidative stress and mitigating protein B-cell lymphoma 2 and P38 proteins expression. Our results provide an efficient and biocompatible approach to a targeted delivery system, which is a promising modality for stroke therapy. [Display omitted] [ABSTRACT FROM AUTHOR]

To investigate the impact of the deep learning reconstruction (DLR) technique on the image quality of CT angiography (CTA) derived from 80-kVp cerebral CT perfusion (CTP) data and compare it with hybrid-iterative reconstruction (HIR). Thirty-three patients underwent CTP at 80 kVp were prospectively enrolled. CTP data were reconstructed with HIR and DLR. Four image datasets were reconstructed: HIR peak and DLR peak were single arterial phase images derived from the time point showing the peak value, HIR tMIP and HIR tAve were time-resolved maximum intensity projection image and time-resolved average image derived from three time points with the greatest enhancement of HIR. The mean CT values, standard deviation, signal-to-noise ratio, and contrast-to-noise ratio of the internal carotid artery and basilar artery were compared among the four image dataset. Image quality was performed using a five-point rating scale. Arterial stenosis was evaluated. DLR peak had the highest CT value and contrast-to-noise ratio in the internal carotid artery and basilar artery (all p < 0.001). DLR peak showed the best subjective image quality and had the highest score (4.93 ± 0.4) compared to the other three HIR CTA images (all p < 0.001). The degree of vascular stenosis was consistent among the four evaluated sequences (HIR tAve , HIR peak , and HIR tMIP DLR peak). For CTA derived from 80-kVp cerebral CTP data, images reconstructed with deep learning showed better image quality and improved intracranial artery visualization than those processed with HIR and other currently used techniques. [ABSTRACT FROM AUTHOR]

Flow diverters are a promising new tool in the neurosurgeon's arsenal for aneurysm management. We sought to quantify the trends of flow diversion in comparison to traditional endovascular coiling and surgical clip ligation techniques in the United States from 2010 to 2020 with an emphasis on aneurysm location and preferences in usage for ruptured versus unruptured aneurysms. In this large cross-sectional study, patients aged 18 and older within the MARINER database were analyzed. Descriptive characteristics were calculated for all included patients. χ2 tests were used to compare categorical variables. P values < 0.05 were statistically significant. A total of 45,542 procedures were conducted in the United States from 2010 to 2020 (clipping: 14,491; coiling: 28,840; flow diversion: 2211). The Southern United States had the largest operative volume across all 3 intervention types, closely followed by the Midwest. Aneurysms of the middle cerebral artery were mostly clipped, whereas coiling and flow diversion techniques were most utilized for anterior communicating and posterior communicating artery aneurysms. Flow diversion is growing most rapidly in the treatment of unruptured aneurysms, though there were also significant increases in usage for ruptured aneurysm treatment from 2019 to 2020. Flow diverters have gained significant traction in the treatment for both unruptured and ruptured aneurysms. In the coming years, the indications and use of flow diversion will undoubtedly grow further, but excitement over their application should be tempered by the safety and efficacy data that continues to emerge. [ABSTRACT FROM AUTHOR]

• Long-term iTBS ameliorated neurological deficits and neurological damage. • Long-term iTBS could consistently improve the neuronal microenvironment. • iTBS treatment altered miRNA expression in the peri-infarcted area. • iTBS inhibit neuronal apoptosis via miR-34c-5p/p53/Bax signaling pathway. To investigate intermittent theta-burst stimulation (iTBS) effect on ischemic stroke and the underlying mechanism of neurorehabilitation, we developed an ischemia/reperfusion (I/R) injury model in Sprague-Dawley (SD) rats using the middle cerebral artery occlusion/reperfusion (MCAO/r) method. Next, using different behavioral studies, we compared the improvement of the whole organism with and without iTBS administration for 28 days. We further explored the morphological and molecular biological alterations associated with neuronal apoptosis and neuroinflammation by TTC staining, HE staining, Nissl staining, immunofluorescence staining, ELISA, small RNA sequencing, RT-PCR, and western blot assays. The results showed that iTBS significantly protected against neurological deficits and neurological damage induced by cerebral I/R injury. iTBS also significantly decreased brain infarct volume and increased the number of surviving neurons after 28 days. Additionally, it was observed that iTBS decreased synaptic loss, suppressed activation of astrocytes and M1-polarized microglia, and simultaneously promoted M2-polarized microglial activation. Furthermore, iTBS intervention inhibited neuronal apoptosis and exerted a positive impact on the neuronal microenvironment by reducing neuroinflammation in cerebral I/R injured rats. To further investigate the iTBS mechanism, this study was conducted using small RNA transcriptome sequencing of various groups of peri-infarcted tissues. Bioinformatics analysis and RT-PCR discovered the possible involvement of miR-34c-5p in the mechanism of action. The target genes prediction and detection of dual-luciferase reporter genes confirmed that miR-34c-5p could inhibit neuronal apoptosis in cerebral I/R injured rats by regulating the p53/Bax signaling pathway. We also confirmed by RT-PCR and western blotting that miR-34c-5p inhibited Bax expression. In conclusion, our study supports that iTBS is vital in inhibiting neuronal apoptosis in cerebral I/R injured rats by mediating the miR-34c-5p involvement in regulating the p53/Bax signaling pathway. [ABSTRACT FROM AUTHOR]

Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known. The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41. In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r2 = 0.51, p < 0.0001; HM3 "continuous-flow," r2 = 0.32, p = 0.0009; HM3 "artificial pulse," r2 = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients. The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs. [ABSTRACT FROM AUTHOR]

• The first mathematical model is developed to simulate haemorrhagic transformation in the full brain. • This model is compared with real clinical images (MR CLEAN NO IV). • A reduction in perfusion after HT onset is found in the range of 5–16%. • Increased blood glucose level and high blood pressure potentially lead to more severe HT. Haemorrhagic transformation (HT) is one of the most common complications after ischaemic stroke. HT can be the result of stroke progression or a complication of reperfusion treatment for stroke. The aim of this study is to apply a previously proposed HT mathematical model within a computational whole brain model to determine the factors that affect the severity of HT. In addition, these simulations are directly compared with neuroimaging data. The MR CLEAN NO IV trial assessed the effect of endovascular therapy (EVT) alone compared with intravenous alteplase treatment (IVT) followed by EVT for patients with acute ischaemic stroke due to anterior circulation large vessel occlusion. We included imaging data of 15 HT patients from the MR CLEAN NO IV trial, 5 patients suffered from haemorrhagic infarction type 1, 5 from haemorrhagic infarction type 2 and 5 had parenchymal haematoma type 1. The comparison of simulations with patient image data is carried out by comparing the haematoma locations and haematoma volume. The parameters of the model are then optimised to improve agreement with clinical data. Finally, the model is used to investigate the factors that affect the severity of HT. Based on the computational whole brain model, we found that perfusion reduced by 5–16% after HT onset. The results are in good agreement with the clinical data. We then showed that 1% increase of blood viscosity reduces perfusion by 0.04% and increases haematoma volume by 10.35% from baseline, and 1% increase of blood pressure reduces perfusion by 0.80% and increases haematoma volume by 4.73% from baseline. These results indicate that increased blood glucose and hypertension (among other factors) both appear to lead to a higher severity of HT. This model, by enabling us to bridge the gap between the mathematical HT model and clinical imaging data, provides the first whole brain prediction model for HT severity assessment. [ABSTRACT FROM AUTHOR]

[Display omitted] • GPR81 is a widely distributed receptor that binds L-lactate and acts as a metabolic sensor. • In the brain, GPR81 couples energy metabolism, synaptic activity, and blood flow. • We propose GPR81 as a potential target in cerebral ischemia. GPR81 is a G-protein coupled receptor (GPCR) discovered in 2001, but deorphanized only 7 years later, when its affinity for lactate as an endogenous ligand was demonstrated. More recently, GPR81 expression and distribution in the brain were also confirmed and the function of lactate as a volume transmitter has been suggested since then. These findings shed light on a new function of lactate acting as a signaling molecule in the central nervous system, in addition to its well-known role as a metabolic fuel for neurons. GPR81 seems to act as a metabolic sensor, coupling energy metabolism, synaptic activity, and blood flow. Activation of this receptor leads to G i -mediated downregulation of adenylyl cyclase and subsequent reduction in cAMP levels, regulating several downstream pathways. Recent studies have also suggested the potential role of lactate as a neuroprotective agent, mainly under brain ischemic conditions. This effect is usually attributed to the metabolic role of lactate, but the underlying mechanisms need further investigation and could be related to lactate signaling via GPR81. The activation of GPR81 showed promising results for neuroprotection: it modulates many processes involved in the pathophysiology of ischemia. In this review, we summarize the history of GPR81, starting with its deorphanization; then, we discuss GPR81 expression and distribution, signaling transduction cascades, and neuroprotective roles. Lastly, we propose GPR81 as a potential target for the treatment of cerebral ischemia. [ABSTRACT FROM AUTHOR]

• Hypoxic postconditioning can improve neurological impairment after stroke. • Hypoxic postconditioning plays a neuroprotective role by promoting angiogenesis. • The effect of hypoxic postconditioning on angiogenesis is related to PLCλ and ALK5. Although hypoxic postconditioning (HPC) has a protective effect on ischemic stroke, its effect on angiogenesis after ischemic stroke is still unclear. This study was designed to investigate the effects of HPC on angiogenesis after ischemic stroke and to preliminarily study the mechanism involved. Oxygen-glucose deprivation (OGD)-intervened bEnd.3 (mouse brain-derived Endothelial cell. 3) was used to simulate cerebral ischemia. Cell counting kit-8 (CCK-8), Cell BrdU proliferation, wound healing, Transwell and tube formation assays were used to evaluate the effect of HPC on the cell viability, proliferation, migration (horizontal and vertical migration), morphogenesis and tube formation of bEnd.3. A middle cerebral artery occlusion (MCAO) model was made in C57 mice to simulate focal cerebral ischemia. Rod rotation test, corner test, modified neurological severity score (mNSS), and balance beam walking test were used to evaluate the effect of HPC on the neurological impairment of mice. Immunofluorescence staining was used to evaluate the effect of HPC on angiogenesis in mice. The angiogenesis-related proteins were evaluated and quantified using western blot. Results showed that HPC significantly promoted proliferation, migration and tube formation of bEnd.3. HPC significantly reversed the neurological deficit of MCAO mice. Moreover, HPC significantly promoted angiogenesis in the peri-infarct area, and angiogenesis was found to be positively correlated with the improvement of neurological impairment. The HPC mice showed higher PLCλ and ALK5 than did MCAO. We conclude that HPC improves the neurological deficit caused by focal cerebral ischemia by promoting angiogenesis. Furthermore, the effect of HPC on improving angiogenesis may be related to PLCλ and ALK5. [ABSTRACT FROM AUTHOR]

When treating acute ischemic stroke patients, evaluation of collateral flow to the ischemic area is essential. Blood-oxygen-level-dependent imaging, including T2 star (T2∗), can identify elevated deoxyhemoglobin levels, reflecting an increase in the oxygen extraction fraction. Prominent veins on T2∗ represent increased deoxyhemoglobin and cerebral blood volume. This study compared asymmetrical vein signs (AVSs) on T2∗ and digital subtraction angiography findings during mechanical thrombectomy (MT) in patients with hyperacute middle cerebral artery occlusion. Clinical and imaging data of 41 patients with occlusion of the horizontal segment of the middle cerebral artery who underwent MT were collected. Patients were divided into 2 groups based on angiographic occlusion sites as: proximal and distal to the lenticulostriate artery (LSA). AVSs on T2∗ were divided into asymmetrical cortical vein sign (cortical AVS) and asymmetrical deep/medullary vein sign (deep/medullary AVS), and were compared with the findings of intraoperative digital subtraction angiography. Twenty-seven patients had AVSs. Cortical AVS was the only parameter with a significant association with poor angiographic collateral supply. In terms of occlusion site, deep/medullary AVS was the only parameter with a significant association with occlusion proximal to the LSA. In patients with occlusion of the horizontal segment of the middle cerebral artery, presence of the cortical AVS on T2∗ suggests a poor angiographic collateral supply, while presence of the deep/medullary AVS suggests impaired blood flow to the basal ganglia through LSAs. Both these signs contribute to poor outcomes in patients undergoing MT. [ABSTRACT FROM AUTHOR]

Both craniotomy and interventional embolization are difficult and risky to treat complex middle cerebral artery (MCA) aneurysms in infants. Trapping with revascularization is a therapeutic option for giant aneurysms that cannot be clipped or coiled alone. We describe a technical method using revascularization with a natural Y-shaped palmar common digital artery interposition graft that provides a normal variation for a complex MCA aneurysm in an infant with intracerebral hemorrhage at 37 days of age. Conservative treatment was performed at that time. Seven months later, the patient was re-admitted to the hospital and was confirmed a large aneurysm in the M2 segment of the right MCA by cerebral angiography. A natural artery palmar common digital artery Y-graft was used as the graft and anastomosed to the M2 and both M3 trunks. The symptoms improved after surgery, and the mRS score of the patient was 1 after 5 years of follow-up. The palmar common digital artery can be an option for intracranial revascularization bypass in complex intracranial aneurysms. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the safety and efficacy of microvascular reconstruction combined with decompressive craniectomy (DHC) in patients with malignant middle cerebral artery infarctions (MMCA). We searched for patients with MMCA and aged＜60 years old, postoperative survival of more than 3 months, consistent with decompression of bone flap removal. Patients were divided into experimental group and control group according to whether they underwent emergency vascular revascularization within 5 days after onset of ischemic stroke. A total of sixpatients were included in the treatment group and 12 patients in the control group. The National Institutes of Health Stroke Scale (NIHSS) score of the treatment group was lower than that of the control group seven days after operation, but the difference was not statistically significant; 3 months after surgery, modified ranking scale (mRs) score in the treatment group was lower than that in the control group, the difference was statistically significant (P = 0.002); mRs scores of the treatment group 3 months after surgery were significantly different from those before surgery (P < 0.05), but no such difference was found in the control group. Compared with decompressive craniectomy, open surgical revascularization can improve early cerebral perfusion in MMCA patients, and neurological recovery is better at 3 months after operation. By ensuring that surgeons are properly trained and hospitals are equipped, open surgical revascularization can be a treatment option for patients with MMCA. [ABSTRACT FROM AUTHOR]