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A rare case of a hypoplastic internal carotid artery (ICA) terminating in the ophthalmic artery with multiple intracranial saccular aneurysms in the contralateral ICA, anterior communicating artery fenestration and triple A2 was identified. The aetiology and pathogenesis of ICA hypoplasia are subjected to certain hypotheses. Developing several collaterals to preserve the blood supply of the ipsilateral cerebral hemisphere could result in aneurysm formation due to flow overload on the contralateral vasculature, but it could also result in hemicranial hypoplasia, cerebral atrophy and deep watershed infarcts, as in our case.

Introduction Transcranial Doppler ultrasonography (TCD) is a technique that allows measurement of blood flow from the basal intracerebral vessels. It is relatively inexpensive, non-invasive, can be performed at the bedside, and allows monitoring in acute emergency settings and for prolonged periods with a high temporal resolution, making it ideal for studying the haemodynamics within the intracranial arteries in neuro-Behcet's disease (NBD) and neuro-psychiatric lupus (NPSLE). Our aim was to assess the cerebral haemodynamic patterns in patients with NBD and NPSLE using TCD, while brain lesions were examined using magnetic resonance imaging (MRI). Material and methods Case–control prospective study of 30 neuro-Behcet's disease patients, 25 neuro-psychiatric lupus patients and 26 healthy age-matched volunteers. All patients and healthy controls were examined by TCD. Only the groups of patients underwent cranial magnetic resonance imaging (MRI). Results Transcranial Doppler (TCD) values for middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery (PCA), vertebral artery (VA) and basilar artery (BA) in NBD, NPSLE and control groups were measured. The results showed that there was a significant decrease in mean blood flow velocities in all the arteries examined in NBD and NPSLE patients. There was also a significant increase in the pulsatile index of PCA, VA and BA between NBD and NPSLE patients. The same results were obtained when comparing NBD versus controls. However, there was no significant difference between the NPSLE patients and the control group. The MRI lesions described were parenchymal lesions in 14 patients (46.7%), and vascular lesions in 4 patients (13.3%). Vascular lesions co-existed with parenchymal lesions (mixed lesion). Parenchymal lesions were in white matter (40%), thalamus (26.7%), brain stem (26.7%) and cerebellum (20%). While, in NPSLE, 23 patients were normal (92%) and only two patients had a vascular lesion (8%). Conclusion There was a significant decrease in mean blood flow and a significant increase in the pulsatile index among both NBD and NPSLE patients, according to the TCD values.

Background: Commonly, arterial anatomic variants are reported as single entities. However, different such variants can occur in a single patient. Materials and methods: During a retrospective study of computed tomography angiograms of 52 adult patients, two cases were found with unilateral maxillofacial trunks. In each case different other anatomic variants were documented. Results: The maxillofacial trunk in the first case was associated with bilateral posterior kinks of the internal carotid artery which passed beyond the transverse processes of the atlas vertebra and indented and displaced the internal jugular veins. Common carotid origins of the superior thyroid arteries were found, as well as a high origin of the contralateral facial artery. In the second case a plethora of variants were associated with a unilateral maxillofacial trunk: (1) direct occipital-vertebral arterial anastomosis; (2) ipsilateral atresia of the distal vertebral artery and of the A1 segment of the anterior cerebral artery; (3) bilateral atresia of posterior communicating arteries; (4) linguofacial and labiomental trunks; (5) terminal trifurcation of the external carotid artery. Conclusions: The arterial anatomical variants of the head and neck should be carefully documented prior to specific surgical and interventional procedures, as well as for understanding the compensatory anatomical pathways of circulatory insufficiencies.

Purpose Endovascular treatment is technically challenging as distal anterior cerebral artery (DACA) aneurysms have distal location, small-caliber parent artery, and small size/wide neck. This study evaluated the feasibility and safety of the transradial approach (TRA) with a radial-specific neurointerventional guiding sheath as the first-line technique for DACA aneurysms. Methods We retrospectively analyzed an institutional database of consecutive patients with DACA aneurysm who underwent coil embolization using TRA. Ten consecutive patients were included in this study. After the radial-specific 6F Simmons guiding sheath (0.088″ inner diameter) was completely engaged into the target common carotid artery, a quadraxial system (6F Simmons guiding sheath/6F intermediate catheter/3.2F intermediate catheter/single microcatheter) was used for embolization. Then, we assessed for procedural success, angiographic outcomes, and procedure-related or vascular access site complications. Results Embolization procedures were conducted using simple coiling in eight and stent-assisted coiling with the trans-cell approach in two patients. The embolization procedure was successful in all patients (n = 10). Moreover, none presented with catheter kinking, parent artery flow stagnation, or system instability during the procedure. Immediate postprocedural angiography revealed complete obliteration in six and residual neck in four patients. Then, eight patients underwent follow-up angiography at a mean of 7.1 months, and none developed recanalization or required retreatment. The postprocedural course was uneventful, and there were no complications. Conclusion The transradial quadraxial system had the ability to achieve sufficient stability and kink resistance in DACA aneurysm embolization. Thus, this method was feasible and safe and had a high success rate.

The observation of endovascular treatment of acute tandem occlusion of internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) in combination with the thrombosis of the right ICA and the critical stenosis of the left vertebral artery is presented.Man, 61 years old. He was delivered to the Center of endovascular neuroradiology, NAMS of Ukraine on January 15, 2021 with an ischemic stroke clinic in the left internal carotid artery basin. He fell ill acutely ‒ against the background of complete well-being, sensorimotor aphasia and right-sided hemiplegia appeared. Upon admission on the NIHSS (National Institutes of Health Stroke Scale) ‒ 18 points. On the performed initial multispiral computed tomography of the brain according to ASPECTS (Alberta Stroke Program Early CT score) ‒ 8 points. In the endovascular operating room, cerebral angiography was performed, followed by surgery aimed at restoring cerebral blood flow. The time from the onset of the disease to the puncture was 330 minutes, the duration of the operation was 135 minutes, thus the time from the onset of the disease to reperfusion was 465 minutes. Angiography revealed acute thrombosis of the left ICA starting from the orifice, M1-segment of the left MCA and A2-segment of the left ACA. Partial compensation of the basin through the supra-block anastomosis (external carotid artery ‒ ICA), as well as from the vertebro-basilar system through the network of leptomeningeal arteries. Collaterals ‒ ACG 3. Thrombosis of the right ICA and critical stenosis (95 %) of the V1-segment of the left vertebral artery were also revealed. The operation was performed ‒ recanalization of thrombosis of the left ICA orifice followed by balloon angioplasty, thrombectomy from the MCA and ACA pools. The end result is eTICI 2c reperfusion. There were no complications during this operation. The patient was discharged the next day (transferred to the neurological department at the place of residence). Control multispiral computed tomography of the brain showed positive dynamics (ASPECTS ‒ 1 point).

A 60-year-old woman, who experienced progressive right visual loss, was diagnosed with an unruptured large cerebral aneurysm. Magnetic resonance imaging (MRI) and angiography revealed a large partially thrombosed anterior communicating artery (Acom) aneurysm. The aneurysmal neck was located at the junction of the left A1–A2 segments, and the aneurysmal dome communicated with the right A1–A2 junction by the Acom. Endovascular treatment using the flow alteration technique was selected. Following an oral antiplatelet therapy for 9 days, balloon test occlusion (BTO) of the medial portion of the left A1 segment was performed under local anesthesia. After confirming the tolerance of the BTO, internal trapping of the medial portion of the left A1 segment by detachable coils was performed following intra-aneurysmal coil embolization. Oral antiplatelet treatment was continued for 19 days postoperatively. Within 3 months following the operation, her right visual acuity dramatically improved to the original level. Owing to aneurysmal recanalization and the disappearance of the thrombus, the second and third embolization was performed through the Acom route, 4 months and 3 years following the first embolization, respectively, and followed up for an additional 7 years by MRI; no deterioration of her visual acuity and no aneurysmal recanalization was observed. Thus, endosaccular embolization combined with flow alteration is considered a useful alternative treatment for large and partially thrombosed Acom aneurysms.

Objective: Ruptured anterior cerebral artery (ACA) trunk aneurysms and middle cerebral artery (MCA) trunk aneurysms are rare, and little is known about them. This study was conducted to determine the difference between these and other types of aneurysms.Methods: We performed a retrospective review of patients diagnosed with subarachnoid hemorrhage over an 8-year period at a single institution. We analyzed the characteristics, clinical factors, and radiological components of aneurysms at the trunk portion of A-1 and M-1. Descriptive analysis and univariate analysis for factors were performed to determine the differences of ACA A-1 portion trunk and MCA M-1 portion trunk aneurysms from other ACA and MCA aneurysms, respectively.Results: Univariate logistic regression modeling showed that trunk aneurysms in MCA M-1 had a smaller dome size (p=0.026) and dome/neck ratio (p=0.048) than other MCA aneurysms. Likewise, through univariate logistic regression modeling, the ACA group showed differences in dome size including age (p=0.001) as well as dome size (p=0.038) and dome neck ratio (p=0.041) in the A1 region.Conclusion: MCA M-1 and ACA A-1 trunk aneurysms are likely to have several different characteristics such as small in size and a lower dome/neck ratio. Also, due to their close locations to the perforator arteries, there is a high possibility of perforator artery injury when treating these aneurysms. Thus, careful attention is required when setting the treatment methods, and further studies about these aneurysms are needed.

BACKGROUND Aneurysm clipping simulation models are needed to provide tactile feedback of biological vessels in a nonhazardous but surgically relevant environment. OBJECTIVE To describe a novel system of simulation models for aneurysm clipping training and assess its validity. METHODS Craniotomy models were fabricated to mimic actual tissues and movement restrictions experienced during actual surgery. Turkey wing vessels were used to create aneurysm models with patient-specific geometry. Three simulation models (middle cerebral artery aneurysm clipping via a pterional approach, anterior cerebral artery aneurysm clipping via an interhemispheric approach, and basilar artery aneurysm clipping via an orbitozygomatic pretemporal approach) were subjected to face, content, and construct validity assessments by experienced neurosurgeons (n = 8) and neurosurgery trainees (n = 8). RESULTS Most participants scored the model as replicating actual aneurysm clipping well and scored the difficulty of clipping as being comparable to that of real surgery, confirming face validity. Most participants responded that the model could improve clip-applier-handling skills when working with patients, which confirms content validity. Experienced neurosurgeons performed significantly better than trainees on all 3 models based on subjective (P = .003) and objective (P

We present a case report of a middle-aged patient with a rare sinus venosus atrial septal defect (ASD) and ischemic stroke that developed due to paradoxical embolism. Occlusion of the anterior cerebral artery led to a stroke with cognitive impairment, acalculia, and apraxia. Diagnostic ultrasound features of this anomaly in suspected cases are discussed. In the presented case, verification of the stroke cause became possible due to the contrast-enhanced computed tomography of the heart. ASD detection made it possible to refer the patient to the surgical treatment necessary to prevent both recurrent cerebral accidents and the progression of pulmonary hypertension, and the prevention of the development of right ventricular heart failure.

Background. The assessment of clinical manifestations in patients with acute pre-circular infarction is important for verification of the lesion, the choice of the treatment program, prediction of the stroke consequences. The purpose is to investigate the clinical, neurological, and neuroimaging features of lacunar and non-lacunar carotid infarctions in acute ischemic stroke and to assess their short-term consequences. Materials and methods. There was performed a clinical and radiological analysis of carotid infarction in 540 patients with acute ischemic stroke, which were divided into two groups: 155 patients were verified for infarcts in the cortex and white matter of the brain in the vasculature of the anterior and middle cerebral artery; in 385 patients, infarct foci were found in the area of the deep hemispheres of the brain (subcortical-capsular infarcts). Results. Clinical neuroimaging analysis of patients with ischemic stroke in the vasculature of the cortical branches of the anterior and middle cerebral arteries of the anterior circulatory basin showed that acute cerebral circulatory disorders caused the development of small cortical infarctions in 89 (57.4 %) patients and 65 (41 %) — lacunar infarction, in one patient (0.7 %) with occlusion of the proximal anterior cerebral artery — total infarction. The neurological clinical picture of infarcts of varying localization, which was determined by the location and size of the lesion, was described. Conclusions. The obtained results showed that the consequences of anterior circular infarctions depended on the localization of the lesion of the arterial area, the caliber of the infarction of the dependent artery, the size of the infarct locus. For the most part, these factors determined the background severity of neurological deficit after the development of acute ischemic stroke.

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Background: Ischemic stroke is a medical emergency and the most common affection of the central nervous system (CNS). This is the second-leading cause of death worldwide and the first causes of morbidity. Ischemic stroke correspond to 85% of all strokes with a mortality of 10-50%. Large space-occupying infarction accounts for 1-10% of all supratentorial infarction with signs of elevated intracranial pressure (ICP) and brain herniation usually in the second to the fifth day leading to a mortality rate of 53% to 89%. Objective: To evaluate the clinical and radiological outcome of decompressive surgery in the setting of cerebral infarctions, and to study its effect in reducing the overall mortality rates of this fatal condition. Patients and methods: This study is descriptive and analytic clinical trial study for evaluating the clinical and functional outcomes of surgical cases with massive cerebral infarction. Over one year, Between January 2018 and January 2019, at Dar Alshifa Hospital, and Al-Azhar University Hospitals in Cairo. Results: Twenty cases with cerebral infarctions were included in this. In our study, there was 12 males (60%) and 8 females (40%) male: female ratio 1.5:1.The age of the cases ranged from 37 to 77 years. The mean age was 57.65 years. Four cases were less than 50 years (20%), 6 cases between 50 and 60 years (30%), 8 cases between 60 and 70 years (40%), and 2 cases above 70 years (10%). Eighteen cases had middle cerebral artery (MCA) infarctions (90/%), while 2 cases had both MCA and anterior cerebral artery (ACA) infarctions. eleven cases were right sided while 9 cases were having left-sided infarctions. Conclusion: The preoperative clinical condition , higher GCS score at presentation were strongly related to a favorable clinical outcome .Some ICU related complications such as contra lateral infarction, hemorrhagic infarction, pulmonary embolism, pneumonia can worse the patient outcome .Other complication related to the surgery such as CSF leak, wound infection did not effect on patient prognosis. Factors like patients’ age, sex, site of infarction, and preoperative midline shift did not affect the final outcome. A study with larger sample size and longer follow-up is recommended for better confirmation of these facts.

Introduction Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. Methods A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0–2). Secondary endpoints included complications and radiographic occlusion at follow-up. Results A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. Conclusion Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Introduction: Motor deficit is common following anterior cerebral artery (ACA) stroke. This study aimed to determine the impact on the motor outcome, given the location of descending corticofugal fiber tracts (from the primary motor cortex [M1], dorsal and ventral premotor area [PMdv], and supplementary motor area [SMA]) and the regional variations in collateral support of the ACA territory. Methods: Patients with ACA vessel occlusion were included. Disruption to corticofugal fibers was inferred by overlap of tracts with a lesion on computed tomography perfusion at the onset and on magnetic resonance imaging (MRI) poststroke. The motor outcome was defined by dichotomized and combined National Institute of Health Stroke Scale (NIHSS) sub-scores for the arm and leg. Multivariate hierarchical partitioning was used to analyze the proportional contribution of the corticofugal fibers to the motor outcome. Results: Forty-seven patients with a median age of 77.5 (interquartile range 68.0–84.5) years were studied. At the stroke onset, 96% of patients showed evidence of motor deficit on the NIHSS, and the proportional contribution of the corticofugal fibers to motor deficit was M1-33%, SMA-33%, and PMdv-33%. By day 7, motor deficit was present in Conclusion: Improvements in the motor outcome seen in ACA stroke may be due to the relative sparing of M1 fiber tracts from infarction. This may occur as a consequence of the posterior location of M1 fiber tracts and the evolving topography of ACA stroke due to the compensatory capacity of leptomeningeal anastomoses.

Unilateral agenesis of the internal carotid artery (ICA) is a rare anatomical variant. We identified a case of unilateral ICA agenesis with interparaclinoid and contralateral carotid-ACA anastomoses. A 65-year-old female with a long history of depressive episodes underwent MR imaging including MR angiography at National Hospital Organization Kyushu Medical Center. MR imaging was performed using a 3.0-T MR scanner to rule out vascular Parkinsonism, although drug-induced Parkinsonism was suspected from her medical history. The proximal left ICA was not visible on MR angiography, and an anterior communicating artery (ACoA) aneurysm was identified. The left middle cerebral artery was supplied from the right ICA via an interparaclinoid anastomosis. This interparaclinoid anastomosis showed no communication with the basilar, posterior communicating, or posterior cerebral arteries. A communicating artery connecting the interparaclinoid anastomosis and anterior cerebral artery (ACA) branched off from the presumed transition point between the interparaclinoid anastomosis and left ICA. Both right and left ophthalmic arteries (OAs) originated from the clinoid segment of the ICA. The communicating artery connecting the interparaclinoid anastomosis and ACA arose proximal to the left OA, and the communicating artery was identified as the carotid-ACA anastomosis. Neuroradiologists, physicians, and neurosurgeons need to be aware of this extremely unusual anatomical variant to determine appropriate treatment strategies in cases of aneurysmal growth or anterior cranial base surgery.

Background. Despite the achievements of neonatology, severe asphyxia at birth and hypoxic-ischemic encephalopathy in full-term infants are still associated with high lethality, long-term neurological morbidity and disability. In the algorithm for the ma­nagement of children with hypoxic-ischemic encephalopathy, it is important to use methods of additional examinations, including ultrasound examination of the brain (neurosonography), its potential for the early evaluation of the severity of the brain tissue injury using therapeutic hypothermia. Thus, the aim of the research was to determine the effect of therapeutic hypothermia on the severity of neurosonographic signs of destructive hypoxic-ischemic brain injury in full-term newborns. Materials and methods. Data were analyzed for 50 full-term neonates with severe asphyxiation and signs of destructive hypoxic-ischemic brain injury. The first group (hypothermia group 1) included 12 newborn infants who were treated with hypothermia in 2014–2016. The second group (hypothermia group 2) — 14 children with severe asphyxiation who were treated with hypothermia in 2011–2013. The third group (group of normothermia) consisted of 24 full-term babies born in 2009–2010, with no therapeutic hypothermia. Results. The share of the most severe destructive brain injuries (diffuse ischemic lesions) was 33.3 % in the first group, 35.7 % in the second group and 45.8 % in the third group. Significant differences between groups in terms of the frequency of diffuse ischemic brain injures were not found. In general, in the structure of destructive hypoxic-ischemic brain injuries in newborns after hypothermia, diffuse ischemic lesions were detected in 34.6 % of cases (non-significant differences with the group of normothermia, p = 0.385 according to Fisher’s criterion calculations). When studying the indicators of cerebral blood flow, reliable differences were found for the index of resistance of the anterior cerebral artery on the third day of life (0.53 ± 0.05 for normothermia group and 0.65 ± 0.04 for hypothermia group). Conclusions. Despite the reduction in the proportion of the most severe diffuse ischemic brain injuries among the total number of diagnosed destructive hypoxic-ischemic lesions during the introduction of hypothermia, the statistical analysis did not reveal any significant differences between the groups. After all, the development of diffuse ischemic brain injuries, first of all, is due to primary asphyxia lesions that lead to global deaths of neurons, or by these injuries, the phase of the therapeutic window in which ended up at the time of birth. But significant differences in the parameters of cerebral hemodynamics prove the fact that the potential of therapeutic hypothermia for the prevention of secondary reperfusion injury remains in these cases.

Objectives Distal anterior cerebral artery (DACA) aneurysms are a subset of aneurysms located in the anterior circulation but away from the circle of Willis. We analyze the clinical presentation and outcomes of two treatment groups—surgical and endovascular—for DACA aneurysms managed by a dual-trained neurosurgeon. Material and Methods A retrospective evaluation of radiological and operative/interventional data of 34 patients with 35 DACA aneurysms over a 12-year period was analyzed. Twenty-seven patients underwent surgery, whereas seven underwent endovascular coiling of the aneurysms. Modified Fisher grade and World Federation of Neurosurgical Societies scale (WFNS) were used to note the subarachnoid hemorrhage (SAH) severity. Statistical Analysis Categorical data were presented as frequency and percentage, while noncategorical data were represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using Chi-square test, and p Results Of 34 patients, 33 presented with a bleed and 23.5% patients were noted to have another aneurysm in addition to the DACA aneurysm. Patients who underwent clipping for another aneurysm along with the DACA aneurysm in a single surgical exercise had a poor outcome compared with those who underwent surgery for the lone DACA aneurysm (7 vs. 20, p = 0.015). Most patients in both surgical (70.37%) and endovascular (85.71%) groups had good outcome (mRS ≤ 2). Conclusions A good outcome can be achieved with either surgery or endovascular coiling in the management of DACA aneurysms. In patients with multiple aneurysms, SAH with aneurysmal rupture of DACA should be managed first; the other unruptured aneurysm may be operated after an interval to avoid morbidity.

OBJECTIVE Isolated anterior cerebral artery (ACA) territory ischemia in pediatric moyamoya disease (MMD) is rare but has been increasingly recognized, particularly in children manifesting progression of disease in a delayed fashion after middle cerebral artery revascularization surgery. Surgical treatment is complicated by limited graft choices, with the small number of case series largely focused on complex, higher-risk operations (omental flap transfers, large interhemispheric rotational grafts); direct bypass (often untenable in children due to vessel size); or, alternatively, the technically simpler method of multiple burr holes (of limited efficacy outside of infants). Faced with the problem of a growing cohort of pediatric patients with MMD that could benefit from anterior cerebral revascularization, the authors sought to develop a solution that was specifically designed for children and that would be lower risk than the more complex approaches adapted from adult populations but more effective than simple burr holes. In this study, the authors aimed to describe the long-term clinical and radiographic outcomes of a novel approach of pial pericranial dural (PiPeD) revascularization, building on the principles of pial synangiosis but unique in using the pericranium and the dura mater as the primary vascular supply, and employing a larger craniotomy with arachnoid dissection to provide robust full-territory revascularization in all ages with reduced risk relative to more complex procedures. METHODS The medical records of all pediatric patients with MMD who presented at a single center between July 2009 and August 2019 were retrospectively reviewed to identify patients with MMD with anterior cerebral territory ischemia. Clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic follow-up data were collected and analyzed. RESULTS A total of 25 operations (5.6% of total procedures) were performed in 21 patients (mean age 9.4 years [range 1–16.5 years]; 12 female and 9 male). Almost one-third of the patients had syndromic associations, with no familial cases. Complications included 1 patient (4.7%) with a superficial infection, with no postoperative strokes, hemorrhage, seizures, or deaths. Long-term follow-up was available in 18 of 21 patients (mean 24.9 months [range 4–60 months]). Radiographic engraftment was present in 90.9% (20/22 hemispheres), and no new strokes were evident on MRI on long-term follow-up, despite radiographic progression of the disease. CONCLUSIONS The use of the pericranium and the dura mater for indirect revascularization provided robust vascularized graft with great flexibility in location and high potential for engraftment, which may obviate more complex and higher-risk operations for ACA territory ischemia. Long-term follow-up demonstrated that PiPeD revascularization conferred durable, long-term radiographic and clinical protection from stroke in pediatric patients with MMD. Based on the results of the current study, the PiPeD technique can be considered an additional tool to the armamentarium of indirect revascularization procedures in select pediatric patients with MMD.

Background and Purpose: The circle of Willis (CoW) and leptomeningeal anastomoses play an important role in transforming infarct topography following middle cerebral artery occlusion. Their role in infarct topography following anterior cerebral artery occlusion is not well understood. The aim of this study was to evaluate the role of the CoW and leptomeningeal anastomoses in modifying regional variation in infarct topography following occlusion of the anterior cerebral artery and its branches. Methods: Perfusion and magnetic resonance imaging of patients with anterior cerebral artery stroke and evidence of vessel occlusion were segmented and manually registered to standard brain template for voxel-wise comparison. Next, a computer model of the cerebral arteries was formulated as network of nodes connected by cylindrical pipes. The experiments included occlusion of successive branches of the anterior cerebral artery while the configurations of the CoW were varied. Results: Forty-seven patients with a median age of 77.5 years (interquartile range, 68.0–84.5 years) were studied. The regions with the highest probabilities of infarction were the superior frontal gyrus (probability =0.26) and anterior cingulate gyrus (probability =0.24). The regions around the posterior cingulate gyrus (probability =0.08), paracentral lobule (probability =0.05), precuneus and superior parietal lobule (probability =0.03) had a low probability of infarction. Following occlusions distal to the anterior communicating artery, the computer model demonstrated an increase in flow (>30%) in neighboring cortical arteries with leptomeningeal anastomoses. Conclusions: Traditionally the CoW has been regarded as the primary collateral system. However, our computer model shows that the CoW is only helpful in redirecting flow following proximal vessel occlusions (pre-anterior communicating artery). More important are leptomeningeal anastomoses, which play an essential role in distal vessel occlusions, influencing motor outcome by modifying the posterolateral extent of infarct topography.

Anterior cerebral artery blood velocity and vascular conductance index along with prefrontal oxygenated-hemoglobin concentration all increased at the onset of finger tapping, peaking immediately after tapping onset, as long as tapping was arbitrarily started. Positive cross correlation and linear regression between the increases in ACABV and prefrontal Oxy-Hb were significant in 67%–75% of subjects. Active vasodilatation of the ACA vascular bed occurs with arbitrary tapping onset and contributes to increased ACABV and prefrontal oxygenation.

Background: The anterior cerebral artery (ACA) supplies many eloquent areas and can have anatomical variations making ACA strokes clinically and radiologically challenging. This study looks at the clinical and radiological features of isolated acute ACA strokes from a stroke centre in Oman. Methods: A retrospective study conducted over a 2 year period on ACA strokes presenting within 12 hours of symptom onset. TOAST classification was used for aetiology. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) were used to assess stroke severity. Fischer’s classification was used for assessing the arterial segments with CT angiogram. Heidelberg Bleeding Classification was used for haemorrhagic conversion. Results: Isolated ACA strokes constituted 25/1180 (2.1 %) of ischemic strokes. Males 15/25 (60%) Mean age was 68.4 years (Range 42 -97 years). Twenty eight percent of patients had earlier strokes. Hemiparesis (68%) was the commonest clinical presentation. Twenty percent had only lower limb weakness. Hypertension 22/25 (88%) followed by diabetes mellitus 12/25 (48%) was the commonest risk factor. The mean NIHSS was 9 (range 3 to 13). In 36% of patients there was progression of stroke. Plain CT Picked the infarct only in 6/24 (25%). Left side involvement in 18/25 (72%) Artery of Hubner was involved in 6/25 (24%); 44% had an embolic aetiology. There was no mortality and at discharge, 11/25 (44%) had mRS3 or less. Conclusions: In acute ACA infarcts a CT scan can miss the diagnosis in 74%. An embolic aetiology has to be considered in any Isolated ACA stroke and the outcome appears to be good.

Intracranial aneurysm (IA) rupture in pediatric patients is a rare but fatal condition. Although risk factors for aneurysm rupture in adults have been well documented, they remain unknown in pediatric patients. Data for 94 pediatric patients with IAs were retrospectively analyzed. The patients were divided into ruptured and unruptured groups. Risk factors for aneurysm rupture were analyzed through univariable and multiple logistic regression analyses. Typical patients with risk factors were described. Univariable analyses showed that the unruptured group had significantly higher percentages of giant aneurysms (43.2% vs 12.3%, P = 0.002), wide-neck aneurysms (67.6% vs 29.8%, P = 0.001), and aneurysms located in the internal carotid artery (40.5% vs 3.5%, P

To observe the clinical efficacy of acupuncture plus MOTOmed intelligent motor training in treating children with spastic cerebral palsy, and analyze the effects on lower limb motor function, intelligence development level, immune function and cerebral hemodynamics. A total of 42 children with spastic cerebral palsy were selected as the observation objects, and enrolled into the observation group. Another 42 cases treated in the same period were selected as the control group. Both groups received MOTOmed intelligent motor training, and the observation group was given additional acupuncture therapy, and the control group was given additional conventional rehabilitation treatment. After 2 consecutive treatment courses, the psychomotor development index (PDI) and mental development index (MDI) of Children’s Developmental Center of China (CDCC) scale, the scores of gross motor function measure (GMFM) scale and modified Ashworth scale (MAS), and the changes in CD3+, CD4+, CD8+ and CD4+/CD8+ were observed. The peak systolic velocity (PSV) and mean flow velocity (MFV) of the anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) were observed and measured. The clinical efficacy was evaluated. Compared with the same group before treatment, the scores of GMFM, PDI and MDI, levels of CD3+, CD4+ and CD4+/CD8+, PSV and MFV levels of ACA, MCA and PCA in both groups were significantly increased after treatment (all P 0.05). After treatment, the total effective rate of lower limb spasm in the observation group was 90.5%, significantly higher than 71.4% in the control group (P 0.05). Acupuncture plus MOTOmed intelligent motor training has a better clinical efficacy than conventional rehabilitation plus MOTOmed intelligent motor training in treating children with spastic cerebral palsy, and is also superior in improving lower limb motor function and the level of intellectual development. And the mechanism may be related to the improvement of cerebral hemodynamics.

The study aimed to describe a case of a 7-year-old Caucasian girl who developed isolated chorea in her right upper and lower extremities progressively increasing over 2 years. This study is a case report and conducted at tertiary care center. A 7-year-old Caucasian girl who gradually developed worsening choreiform movements in her right upper and lower extremities over the course of 2 years until medical attention was sought. Literature review of children presenting with chorea as the only manifestation in moyamoya disease. A 7-year-old right-handed Caucasian girl presented with progressively worsening choreiform movements in her right upper and lower extremities affecting her fine motor skills and gait impairment There was no weakness, hyperreflexia, or spasticity on her neurological exam. Neuroimaging studies showed “ivy sign,” asymmetric prominence of vessels within the subarachnoid spaces overlying the left cerebral hemisphere with corresponding serpiginous T2 fluid-attenuated inversion recovery abnormality, but no parenchymal volume loss or diffusion restriction. Magnetic resonance angiography showed focal moderate-to-severe stenosis at the junction of the paraophthalmic and supraclinoid segments of the left internal carotid artery, with poststenotic dilatation. Angiography demonstrated focal stenosis involving the ophthalmic segment of the left internal carotid artery with 50% stenosis. There was compensation through a medium sized left posterior communicating artery as well as posterior cerebral artery to middle cerebral artery and anterior cerebral artery collateralization. Brain single-photon emission computerized tomography scan showed no evidence of perfusion defects in the cerebral hemispheres, basal ganglia, or thalami. She underwent successful revascularization procedure (left pial synangiosis) with resolution of her choreiform movements and normalization of her gait. Our case demonstrates that moyamoya disease should be suspected when evaluating a child with hemichorea and describes resolution of symptoms after revascularization surgery. Neuroimaging and vascular studies should be obtained in children with unilateral movement disorder.

Middle cerebral artery (MCA) is the largest and most complex arterial system of the brain. Variations of the aortic arch branches are due to alteration in the development of specific branchial arch arteries during the embryonic period. Knowledge of these variations is important during aortic instrumentation, thoracic, and neck surgeries. The anatomy of the anterior cerebral artery branches and the anterior communicating artery complex needs to be investigated individually to minimise neurovascular morbidity before iatrogenic procedures. The study aimed to study the variations in the microsurgical anatomy of the MCA in our population and compare the variables and discuss their importance with anatomic and surgical considerations. Specimens were collected from the embalmed cadavers and the post-mortem bodies in the department of forensic medicine of Thanjavur Medical College. The different variables regarding the MCA in our population were analysed and compared with the studies in the Western population and other Indian studies. The mean length of the MCA in this study was 12.8 mm with a standard error of 3.79 mm. The outer diameter of the M1 segment was with a mean length of 3.75mm. In 69.2% middle, Cerebral Artery shows bifurcation and in 20%, it shows trifurcation and in 10.8%, it shows ramification types of branching patterns. The 39.1% cases show Temporo polar, 21.7% orbitofrontal, 9.1% anterior temporal, 6.6% prefrontal, and 4.1% middle temporal branches. Our results also reveal that the origin of the lenticulostriate branch in the middle cerebral artery was 85.85% from the trunk and 14.2% from division, respectively. MCA branching pattern is slightly higher in trifurcation pattern as compared to bifurcation and ramification. Thorough knowledge of the microvascular anatomy and the myriads of variations is essential for the operating surgeon to choose the ideal technique to avoid any catastrophe during and after surgery and give the best possible functional outcome.

OBJECTIVES Anterior communicating artery (ACoA) aneurysm is one of the most common intracranial aneurysms, and it is also the aneurysm with the highest rupture rate. With the improvement of endoscopic techniques, it is possible to use an endoscopic endonasal approach (EEA) to clip ACoA aneurysms. For further analysis of the EEA for clipping ACoA aneurysms, we used cadaver heads and three-dimensional (3D)-printed models to finish the anatomical study, and we finally selected 1 clinical case to complete the clipping through the EEA. MATERIALS AND METHODS We first collected 3 cadaver heads to simulate the EEA. Then, the imaging data of 29 real cases of ACoA aneurysm were collected, and the model of an aneurysm was prepared by 3D printing technology; then, the EEA was used to simulate the clipping of the aneurysm model. Finally, a clinical case with 2 ACoA aneurysms was selected to adopt the EEA for clipping. RESULTS Both the cadaver head and 3D-printed aneurysm model could simulate aneurysm clipping with the EEA. The clinical case of the selected ACoA aneurysm can successfully complete the clipping through the EEA. CONCLUSIONS 3D-printed models are a good method to study the anatomical characteristics of a surgical approach. For specially selected ACoA aneurysms, the EEA is relatively simple method that can be used to clip the aneurysm successfully. The EEA for clipping ACoA aneurysms is a useful complement to the current traditional craniotomy approaches and endovascular embolization.

Background Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. Methods This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0–2. Results A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. Conclusions Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.

Purpose: The purpose of this study was to evaluate the prevalence and risk factors of unruptured intracranial aneurysms (UIAs), which can help establish guidelines of treatment for asymptomatic Korean adults using 3T magnetic resonance angiography (MRA).Materials and Methods: Our Institutional Review Board approved this retrospective study, and informed consent was waived. All patients consisted of healthy individuals who underwent brain MRA using 3T magnetic resonance imaging between January 2011 and December 2012 as part of a routine health examination. Patient data and follow-up results were obtained from medical records.Results: A total of 2,118 individuals (mean age=53.9±9.6 years, male:female=1,188:930) who had undergone brain MRA were enrolled in the study. UIAs were found in 80 patients with 105 UIAs (3.77%). Female predominance (55% in UIA versus 43.47% in non-UIA, P=0.0416) and hypertension were more common in the UIA group (43.75% vs. 28.8%, P=0.004, respectively). The mean size of the aneurysms was 3.10±1.62 mm, and they were all saccular in shape and asymptomatic. The UIAs were most common in the internal carotid artery (59.1%), internal carotid-posterior communicating artery (15.2%), middle cerebral artery (9.5%), anterior communicating artery (8.6%), anterior cerebral artery (4.8%), and vertebral artery (2.9%). Twenty-eight of 80 patients (35%) had multiple aneurysms. The incidence of UIAs increased significantly with age (P=0.014).Conclusion: In single center experience, we demonstrated the characteristics and prevalence of UIAs in asymptomatic adults, which may help establish guidelines or therapeutic standards for UIAs.

BACKGROUND AND PURPOSE The aim of this study was to investigate the relationship between arterial morphological parameters and the rupture risk of anterior communicating artery (AComA) aneurysms. METHODS A hospital database was retrospectively reviewed to identify patients with AComA aneurysms. Morphologic parameters were evaluated on the 3-dimensional computed tomography angiograms. The patients were divided into two groups as ruptured and unruptured. Patient age, sex, morphological parameters such as aneurysm height and weight, neck diameter, aspect ratio (AR), size ratio (SR), bifurcation angle, aneurysm shape, and diameters of the artery were statistically compared between two groups. RESULTS Ninety-five AComA aneurysms were analyzed in this study (60 ruptured and 35 unruptured). The aneurysm neck size (p = .005) and the diameter of the A1 segment of the ipsilateral anterior cerebral artery (i-A1) were smaller in the ruptured group than in the unruptured group (p = .001), but AR (p = .001) was higher. The number of patients with irregular shape aneurysm were higher in the ruptured group (p = .006). There was no significant difference between the two groups in terms of age, sex, aneurysm height and weight, bifurcation angle, and SR. Univariate logistic regression analysis showed that i-A1 segment diameter (odds ratio [OR]: -2.070, confidence interval [CI]: 0.030-0.531, p = .005), aneurysm neck diameter (OR: -0.409, CI: 0.491-0.899, p = .008), irregular shape (OR: 1.197, CI: 1.382-7.929, p = .007), and AR (OR: 0.880, CI: 1.315-4.417, p = .004) were significantly correlated with ruptured status. Multivariate regression analysis demonstrated that aneurysm neck diameter (OR: -0.457, CI: 0.410-0.977, p = .039) was the only independent variable for rupture. CONCLUSION AComA aneurysm rupture is more likely to occur in aneurysms with smaller i-A1 segment diameter, smaller aneurysm neck diameter, irregular aneurysm shape, and higher AR. Aneurysm neck diameter may be a more important determinant for rupture prediction.

Endovascular treatment of fenestration-related aneurysms (FAs) is prone to technical challenges, given the inherent complexities. Herein, we have analyzed FAs in terms of angioarchitectural characteristics and outcomes achieved through endovascular intervention. Data accrued prospectively between January 2002 and July 2020 were productive of 105 FAs in 103 patients, each classifiable by the nature of incorporated vasculature as proximal portion, fenestrated limb, or distal end. Our investigation focused on clinical and morphological outcomes, with emphasis on technical aspects of treatment. The FAs selected for study originated primarily in anterior communicating artery (AcomA: 88/105, 83.8%), followed by basilar (7/105, 6.7%), anterior cerebral (4/105, 3.8%), and internal carotid (3/105, 2.8%) arteries. In nearly all locations, proximally situated aneurysms (43/105, 41%) were more frequent than aneurysms arising at distal ends (3/105, 2.8%), but the majority of AcomA lesions involved fenestrated segments (58/88, 65.9%); and most fenestrated channels (90/105, 85.7%) were asymmetric in size. Orifices of smaller fenestrated limbs were intentionally compromised during coil embolization in 23 aneurysms (21.9%), achieving complete (n = 19) or incomplete (n = 4) compromise, without resultant symptomatic ischemia. Saccular occlusion proved satisfactory in 77 lesions (73.3%). In follow-up monitoring of 100 patients for a mean period of 35.3 ± 26.5 months, 17 instances of recanalization (17.0%) occurred (minor, 9; major, 8). There was no recanalization of aneurysms with compromised limbs. Coil embolization of FAs is safe and effective, enabling tailored procedures that accommodate aberrant angioanatomic configurations. Compromise of a single limb during coiling also appears safe, conferring long-term protection from recanalization.

This magnetic resonance imaging study examined the most frequent anatomical variants of the anterior communicating artery (ACoA) complex of the cerebral arterial circle, and aimed to determine whether they were associated with ACoA complex aneurysm. The study enrolled 669 patients. Using three-dimensional time-of-flight magnetic resonance angiography, 617 patients were classified into the following groups based on the anatomical variation in the ACoA complex: no ACoA complex anomaly; ACoA complex aneurysm; and vascular anomaly distant from the cerebral arterial circle. Of the 617 classified subjects, the classical anatomical description applied to 48.73% in the no ACoA complex anomaly group and 37.5% in the ACoA complex aneurysm group. One variant (left anterior cerebral artery segment A1 hypoplasia) was significantly more frequent in the ACoA complex aneurysm group. There was no sex difference in the prevalence of any variant. Anatomical variants of the ACoA complex of the cerebral arterial circle were found in almost half of the subjects. One variant seemed to be associated with a higher likelihood of an aneurysm, but causality could not be inferred.

Introduction. Conventionally, hemodynamic significance of carotid stenosis is characterized with an increased peak systolic velocity up to 230 cm/s, which corresponds to 70 % carotid stenosis. This does not take into account changes of cerebral hemodynamics or collateral circulation, which can be determined by assessment of blood flow distribution in precerebral arteries. Aim – to evaluate blood flow redistribution in precerebral arteries in patients with critical carotid stenosis. Materials and methods. 40 patients (aged 49–80 y. o.) with critical carotid stenosis were studied (13 patients had 70–79 % stenosis, 11 patients – 80–89 %, and 16 patients – 90–99 % stenosis). Flow velocity index in precerebral arteries was determined with duplex scanning (Vivid e, USA), whereas linear blood flow velocity in intracranial arteries – with transcranial Doppler (MultiDop X, Germany). Results. In 60 % of patients, flow velocity index in ipsilateral carotid artery was reliably decreased (pConclusion. Thus, critical degree of carotid stenosis does not always indicate its hemodynamic significance. Flow velocity index distribution in precerebral arteries can be used as an additional criterion for assessing hemodynamic significance of carotid stenosis and, along with other indicators, should be taken into account when choosing treatment modality.

ObjectiveTo test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke–International Stroke Thrombectomy Register (SITS-ISTR).MethodsWe identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0–2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS–Monitoring Study. We performed propensity score–matched (PSM) and multivariable logistic regression analyses.ResultsOf 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT–treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT–treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%,p< 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%,p= 0.035). SICH rates (3.5% vs 3.0%,p= 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.ConclusionPretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication.Classification of EvidenceThis study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.

Moyamoya disease (MMD) is an idiopathic progressive steno-occlusive disease in the internal carotid artery (ICA) bifurcation. In rare circumstances, transdural anastomotic aneurysm (TAA) could develop during the progression of MMD. We present an illustrative case of TAA in association with MMD. To further explore this rare entity, a comprehensive literature review was also conducted. Our illustrative patient experienced spontaneous remission of the aneurysm during follow-up. By literature review, 12 patients with 13 TAAs, including our case, were identified. The patients aged from 10 to 74 years (46.3 ± 17.4). Eleven (92%) of the patients presented with intracranial hemorrhage, and 1 TAA (8%) was incidentally found. The responsible transdural collaterals were from the middle meningeal artery, occipital artery, internal maxillary artery, and ophthalmic artery in 8 (66.7%), 2 (16.7%), 1 (8%), and 2 (17%) patients, respectively. The anastomosed cerebral arteries were middle cerebral artery, anterior cerebral artery, posterior cerebral artery, and ICA in 5 (42%), 3 (25%), 3 (25%), and 1 (8%) patient, respectively. Eight (67%) patients underwent open surgeries. Two (17%) patients underwent transarterial embolization (TAE) only. Two (17%) patients experienced spontaneous remission of the aneurysm. Seven (58%) patients died or had neurologic deficits. TAAs rarely occur in the progression of MMD, which often presents with intracranial bleeding. Invasive management through open surgery or endovascular treatment is warranted to prevent catastrophic rebleeding. As some individuals might experience spontaneous aneurysm remission, conservative treatment and close imaging follow-up could be considered as an alternative when invasive treatment is risky.

Mechanical thrombectomy (MT) is an effective treatment in patients with acute ischemic stroke (AIS) due to emergent large-vessel occlusion in the anterior circulation. Occlusion of the anterior cerebral artery (ACA) affects up to 15% of these patients. Here we report a case of an elderly patient with an successful MT of an embolic A2-segment occlussion with the anatomic variation of a triplication. Triplication of ACA is a rare anatomical variation, and the occlusion could have been easily overlooked in case of not performing the CT-perfusion (CTP) sequences. As anatomical variations of the circle of Willis are present in most subjects, CTA alone might be limited in the acute setting, particularly for young residents performing the first view on call. This case highlights the importance of including CTP in the initial CT-diagnostic algorithm in AIS patients who are basically eligible for recanalization therapies, irrespective of inconspicuous initial findings in CTA.

Background Intracranial aneurysms may be misdiagnosed with other vascular lesions such as vascular loops, infundibulum, or the stump of an occluded artery (very rare and reported compromising only the middle cerebral artery and the posterior circulation territory). Our aim was to describe a unique case of occlusion of an anterior cerebral artery mimicking a cerebral aneurysm in a probable moyamoya disease patient, and to highlight its clinical presentation, diagnosis, and management, and to perform an extensive literature review. Case A 67-year-old man suffering from recurrent dizziness for 3 months. Previous medical history was unremarkable. Brain magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) demonstrated occlusion of the right middle cerebral artery (MCA) associated with a “probable moyamoya disease” and an aneurysm-like shadow protruding lesion at the anterior communicating artery (AcomA). Perfusion images showed ischemia along the right temporo-occipital lobe. Due to MCA occlusion with perfusion deficits and unspecific symptoms, we offered a right side encephalo-duro-myo-synangiosis (EDMS) and clipping of the AcomA aneurysm in one session. Intraoperatively, there was no evidence of the AcomA aneurysm; instead, this finding corresponded to the stump of the occluded right anterior cerebral artery (A1 segment). This segment appeared to be of yellowish color due to atherosclerosis and lacked blood flow. The patient underwent as previously planned a right side EDMS and the perioperative course was uneventful without the presence of additional ischemic attacks. Conclusion Arterial branch occlusions can sometimes present atypical angiographic characteristics that can mimic a saccular intracranial aneurysm. It is relevant to consider this radiographic differential diagnosis, especially when aneurysm treatment is planned.

Intracranial aneurysms (IAs) are localized dilations of the cerebral vasculature, representing the leading cause for non-traumatic subarachnoid hemorrhage and an important source of morbidity and mortality. Despite it being a frequent pathology and most often diagnosed incidentally, IAs in infants are a very rare occurrence, and the ruptured variant is exceptional. A 4-month-old boy with a negative family history was brought to our department because of several episodes of incoercible vomiting and fever. Upon examination, the child was somnolent, without any noticeable deficit. Transfontanellar ultrasonography and CT angiography revealed a ruptured aneurysm of the anterior communicating artery (AComA), whereas the pre-clipping MRI showed thin, almost angiographically invisible anterior cerebral arteries (ACAs) on both sides due to vasospasm. We intervened surgically by placing an external ventricular shunt in an emergency setting, followed by clipping of the IA in a delayed manner. The child was discharged a month after admission with no deficit, despite the paradoxical aspect of the ACA. Ruptured IAs can be safely treated via microsurgery, even in infants. However, this requires a great amount of experience and surgical expertise. Furthermore, the lack of proper management would most likely result in a severe deficit in the long term. Lastly, the lack of visibility of the ACA on angiographic studies may not have neurological consequences if they occur in this age group.

Background: Every year, more than 795,000 people in the United States have a stroke, and each year about 140,000 Americans die from strokes. Although there is abundant information on the epidemiology, risk factors, pathophysiology, and many clinical features of strokes, there is a lack of specific numerical quantitation on the neuroanatomical distribution of strokes. Methods: This retrospective study utilized de-identified reports of radiologic imaging to determine the neurovascular anatomical location of acute ischemic cerebral infarcts in a 637-bed regional hospital in a rural area during the one-year interval from October 1, 2018 through September 30, 2019. Results: During the one-year study period, there were 418 acute ischemic strokes, and 54.6% (228/418) were in the territory of a single large vessel. Of the single large vessel strokes, 62.3% (142/228) were in a middle cerebral artery (MCA) territory, 12.1% (29/228) in a posterior cerebral artery (PCA) territory, 8.8% (20/228) in a basilar artery distribution, 7.5% (17/228) in a posterior inferior cerebellar artery (PICA) distribution, 6.6% (15/228) in an anterior cerebral artery (ACA) distribution, 1.8% (4/228) in a superior cerebellar artery (SCA) distribution, and 0.4% (1/228) in an anterior inferior cerebellar artery (AICA) territory. Internal capsule lacunar strokes accounted for 17.7% (74/418) of the total, brainstem lacunar strokes for 8.1% (34/418) and thalamic lacunar strokes for 5% (21/418) of the infarctions. Watershed infarctions accounted for 2.9% (12/418) of the strokes, 9 in the MCA/PCA watershed area and 3 in the MCA/ACA watershed area. Conclusions: This pilot study illustrates a methodology for collecting data to substitute specific numerical quantitation for vague generalities about the neuroanatomical distribution of strokes. Such quantification can enable evidence-based data-driven improvements in the care of stroke patients.

Background and purpose Bilateral carotid artery occlusion (CAO) is a rare condition and the collateral circulation is more complicated than in unilateral CAO. The circle of Willis (CoW) is the most important collateral circulation compensation pathway in CAO. However, the specific role of CoW in the collateral circulation compensation pathway of CAO has not been fully elucidated. The purpose of this study is to investigate the role of CoW in the collateral circulation compensation pathway of CAO. Materials and methods Clinical, imaging, and hemodynamic data of 30 patients with bilateral CAO were collected to analyze the collateral blood flow compensation pathway and its characteristics, and to examine the correlation between the structure of the CoW and the collateral circulation of bilateral CAO. Results This paper summarized 30 patients with bilateral CAO. There were 0 cases of the CoW complete type, 18 cases of the partially complete type (60%), and 12 cases of the incomplete type (40%). For the partially complete type cases, there were 14 complete anterior circulation cases (46.7%). The collateral circulation collateral circulation pathway included 14 cases with anterior communicating artery(ACoA), 7 cases with posterior cerebral artery (PCA)-middle cerebral artery (MCA) leptomeningeal anastomosis (LMA), 5 cases with ophthalmic artery(OA), 3 cases with lateral posterior communicating artery(PCoA), 1 case with internal carotid artery (ICA) stealing, 1 case with new Moyamoya vessels, and 4 cases of other types. There were four cases (13.3%) with complete posterior circulation, including four cases with bilateral PCoA, three cases with PCA-MCA LMA, and two cases with OA. There were 12 cases (40%) with incomplete CoW, including 8 cases with PCA-MCA LMA, 3 cases with lateral PCoA, 1 case with anterior cerebral artery (ACA)-MCA LMA, 4 cases with OA, and 1 other case. Conclusion The collateral circulation pathway differs among patients with different CoW structure types. When the CoW is partially complete, it mainly provides blood flow compensation to the ischemic area through primary collateral circulation. When the CoW is incomplete, it mainly provides blood flow compensation to the ischemic area through secondary collateral circulation.

Inadequate cerebral perfusion is a risk factor for cerebral ischemia in patients with large artery steno-occlusion. We investigated whether prefrontal oxyhemoglobin oscillation (ΔHbO2, 0.6–2 Hz) was associated with decreased vascular reserve in patients with steno-occlusion in the large anterior circulation arteries. Thirty-six patients with steno-occlusion in the anterior circulation arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery) were included and compared to thirty-six control subjects. Patients were categorized into two groups (deteriorated vascular reserve vs. preserved vascular reserve) based on the results of Diamox single- photon emission computed tomography imaging. HbO2 data were collected using functional near-infrared spectroscopy. The slope of ΔHbO2 and the ipsilateral/contralateral slope ratio of ΔHbO2 were analyzed. Among the included patients (n = 36), 25 (69.4%) had deteriorated vascular reserve. Patients with deteriorated vascular reserve had a significantly higher average slope of ΔHbO2 on the ipsilateral side (5.01 ± 2.14) and a higher ipsilateral/contralateral ratio (1.44 ± 0.62) compared to those with preserved vascular reserve (3.17 ± 1.36, P = 0.014; 0.93 ± 0.33, P = 0.016, respectively) or the controls (3.82 ± 1.69, P = 0.019; 0.94 ± 0.29, P = 0.001). The ipsilateral/contralateral ΔHbO2 ratio could be used as a surrogate for vascular reserve in patients with severe steno-occlusion in the anterior circulation arteries.

Pericallosal artery aneurysms differ from other cerebral aneurysms for the difficulty in establishing proximal vascular control during surgical clipping. A frontomedial craniotomy with combined pterional and interhemispheric approach allows obtaining a better proximal control. We present our surgical technique to achieve a proximal vessel control in pericallosal artery aneurysm clipping using a combined pterional and interhemispheric approach through frontomedial craniotomy. This surgical technique is illustrated by an intraoperative video. Proximal control for pericallosal artery aneurysm clipping can be challenging. In selected cases, a single craniotomy allows performing two approaches and obtaining a safer proximal control for surgical clipping.

Purpose: Red blood cell distribution width (RDW) evaluates the variation (size heterogeneity) in red blood cells. Elevated RDW has been identified as a predictor of poor functional outcomes for acute ischemic stroke. The association between elevated RDW level and poor functional outcome in stroke patients undergoing mechanical thrombectomy has not been reported before. This study aims to investigate this relationship.Materials and Methods: This was a multicenter retrospective study involving the prospectively and consecutively collected data of 205 adult stroke patients who underwent mechanical thrombectomy for anterior circulation large vessel occlusion (middle cerebral artery M1, anterior cerebral artery A1, tandem ICA-MCA, carotid T) between July 2017 and December 2019. RDW cut off levels were accepted as >16%. The effect of elevated RDW on poor functional outcome (modified Rankin scale 3–6) was investigated using bivariate and multivariate regression analysis.Results: Elevated RDW was significantly associated with poor functional outcome in bivariate and multivariate analysis (odds ratio [OR] for RDW >16%, 2.078; 95% confidence interval [95% CI], 1.083–3.966; P=0.027 and OR for RDW >16%, 2.873; 95% CI, 1.342–6.151; P=0.007; respectively).Conclusion: These findings suggest that elevated RDW may be an independent predictor of poor functional outcomes in ischemic stroke patients undergoing mechanical thrombectomy.