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Hamada Y, Matsuoka H, Sato S, Kawabata Y, Iwamoto K, Ikeda M, Sato T, Takaguchi G, Takashima H. Combining the deployment of only the distal basket segment of the EMBOTRAP III and an aspiration catheter for M2 occlusions: the ONE-SEG technique. Front Neurol 2024; 15:1424030. [PMID: 39258155 PMCID: PMC11383764 DOI: 10.3389/fneur.2024.1424030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 08/14/2024] [Indexed: 09/12/2024] Open
Abstract
Background Endovascular therapy (EVT) for distal medium vessel occlusions requires prioritizing effectiveness and safety. We developed a technique combining the deployment of only the distal basket segment of the EMBOTRAP III and an aspiration catheter (AC) for M2 occlusions, called the "ONE-SEG technique," and evaluated its clinical and technical impacts. Methods This was a retrospective review of 30 consecutive patients with M2 segment middle cerebral artery occlusion treated using the ONE-SEG technique. This method involves deploying the EMBOTRAP III through a microcatheter in only one segment and guiding the AC to the M2 origin or distal M1. The rates of final-pass expanded thrombolysis in cerebral infarction (eTICI) scores of 2c/3 or 2b/2c/3, safety (symptomatic intracranial hemorrhage [sICH]), and clinical outcomes (modified Rankin Scale [mRS] score 0-2, 0-3 at 90 days, and mortality at 90 days) were evaluated. Results Of the 30 cases, 36.7% were female, and the mean age was 75.6 ± 11.0 years. The ONE-SEG technique was used for 17 cases (56.7%, median NIHSS 10 [5-15.5]) with primary M2 occlusion and 13 cases (43.3%, median NIHSS 20 [14-22.5]) with secondary M2 occlusion after proximal thrombus removal. The successful final reperfusion rate (eTICI 2b/2c/3) was 90% overall (27/30 cases). One case (3.3%) developed sICH with secondary M2 occlusion. At 3 months, mRS scores 0-2 were seen in 64.7% of patients with primary M2 occlusion (11/17 cases) and in 23.1% (3/13 cases) with secondary M2 occlusion. Conclusion EVT using the ONE-SEG technique appears to be safe and effective for M2 occlusion.
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Affiliation(s)
- Yuki Hamada
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Hideki Matsuoka
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Shinsuke Sato
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Yutaro Kawabata
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Kana Iwamoto
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Mei Ikeda
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Takeo Sato
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Go Takaguchi
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Saal-Zapata G, Walker M, Cervantes-Medina R, Rodríguez-Varela R. Three-Dimensional Morphometric Analysis of Anterior Cerebral Circulation Aneurysms. Int J Angiol 2024; 33:22-28. [PMID: 38352634 PMCID: PMC10861294 DOI: 10.1055/s-0043-1774740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
This article assesses the association between anterior circulation morphometry and the presence of intracranial aneurysm using three-dimensional rotational angiography (3DRA). A retrospective analysis at a Peruvian academic medical center between December 2018 and February 2020 identified 206 patients with unruptured intracranial aneurysms and matched controls who underwent 3DRA. Angiographic images were obtained per standard of care, and measurements of the vasculature were performed using 3DRA vascular automated software. A total of 163 aneurysms and 43 control angiograms were evaluated. Women represented 82.5% of the cases and the mean age was 55.9 years (standard deviation ± 14.2). In multivariate analysis, five specific features were found to be statistically significant predictors for presence of an anterior circulation aneurysm: female sex (odds ratio [OR] = 2.71; p = 0.048), C-shape of the middle cerebral artery (MCA) (OR = 2.73; p = 0.018), distal internal carotid artery (ICA) diameter (OR = 3.42; p = 0.012), ICA bifurcation angle (OR = 1.02; p = 0.036), and length of the carotid siphon (OR = 1.08; p = 0.047). Features detected on 3DRA suggest morphological characteristics of the ICA and MCA may be predictive for intracranial aneurysm. Our findings build from prior reports by demonstrating five specific patient and imaging features associated with anterior circulation aneurysms. While 3DRA is the standard of care in many settings, medical centers with resource limitations may not have access to this technique. The demographic and morphological features identified in our study may have correlates that if detected on contrast computed tomography or magnetic resonance imaging studies, may be used to help screen for a higher level of care in select patients.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Perú
| | - Melanie Walker
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rosa Cervantes-Medina
- Department of Radiology, Interventional Radiology Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Perú
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Perú
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Ay M, Ogul H, Kantarci M. Anomalous origin of the temporopolar artery from the internal carotid artery and aneurysms at the temporopolar and internal carotid arteries: a very rare case report. Surg Radiol Anat 2023; 45:1301-1304. [PMID: 37572148 DOI: 10.1007/s00276-023-03225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/29/2023] [Indexed: 08/14/2023]
Abstract
The temporopolar artery (TPA) originates directly from the sphenoidal segment of the middle cerebral artery (MCA). Its originating from the M1 segment of the MCA as a branch of the anterior temporal artery is not uncommon. However, internal carotid artery origination is a very rare variation of the TPA. Here, we report a very rare case of the variant origin of the TPA and the presence of saccular aneurysm at this origin.
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Affiliation(s)
- Mutlu Ay
- Department of Radiology, Medical Faculty, Erzincan Binali Yildirim University, Erzincan, Turkey
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Hayri Ogul
- Department of Radiology, Medical Faculty, Duzce University, Duzce, Turkey.
| | - Mecit Kantarci
- Department of Radiology, Medical Faculty, Erzincan Binali Yildirim University, Erzincan, Turkey
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
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4
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Xia J, Gao H, Zhang K, Gao B, Li T, Wang Z. Effects of endovascular recanalization on symptomatic non-acute occlusion of intracranial arteries. Sci Rep 2023; 13:4550. [PMID: 36941301 PMCID: PMC10027893 DOI: 10.1038/s41598-023-31313-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023] Open
Abstract
To investigate the effect and safety of recanalization surgery for non-acute occlusion of large intracranial arteries and factors affecting clincial outcomes. Patients with non-acute occlusion of internal carotid artery (ICA), middle cerebral artery (MCA), and vertebrobasilar artery (VBA) treated with recanalization were retrospectively enrolled. The clinical and angiographic data were analyzed. 177 patients were enrolled, including 67 patients with intracranial ICA occlusion, 52 with MCA occlusion, and 58 with VBA occlusion. Successful recanalization was achieved in 152 (85.9%) patients. Complications occurred in 15 patients (8.5%). Followed up for 3-7 months, the 90 day mRS was significantly improved compared with that before the procedure. Among 152 patients with successful recanalization, eight patients experienced reocclusion (5.3%), and 11 patients experienced restenosis (7.2%). Successful recanalization was significantly (P < 0.05) associated with occlusion duration, calcification or angulation of the occluded segment. Complications were significantly (P < 0.05) associated with location of occlusion, hyperlipidemia, and patients' height. Restentosis or reocclusion at follow-up was significantly (P < 0.05) associated with complications and mRS at 90 days. The significant (P < 0.05) independent risk factors were angulation and calcification for successful recanalization, hyperlipidemia for complications, and mRS at 90 days for restenosis or reocclusion at follow-up. Recanalization surgery may be a safe and effective approach for patients with non-acute symptomatic occlusion of large intracranial arteries, and factors significantly independently associated with successful recanalization, periprocedural complications and restenosis or reocclusion after surgery have been identified for future reference to improve clinical outcomes.
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Affiliation(s)
- Jinchao Xia
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Huili Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Kun Zhang
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Bulang Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Tianxiao Li
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Ziliang Wang
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China.
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5
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Tsuji K, Nakamura S, Aoki T, Nozaki K. The cerebral artery in cynomolgus monkeys (Macaca fascicularis). Exp Anim 2022; 71:391-398. [PMID: 35444076 PMCID: PMC9388346 DOI: 10.1538/expanim.22-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cerebral artery structure has not been extensively studied in primates. The aim of this study was to examine the cerebrovascular anatomy of cynomolgus monkeys (Macaca fascicularis), which are one of the most commonly used primates in medical research on human diseases, such as cerebral infarction and subarachnoid hemorrhage. In this study, we investigated the anatomy and diameter of cerebral arteries from 48 cynomolgus monkey brain specimens. We found three anatomical differences in the vascular structure of this species compared to that in humans. First, the distal anterior cerebral artery is single. Second, the pattern in which both the anterior inferior cerebellar artery and posterior inferior cerebellar artery branch from the basilar artery is the most common. Third, the basilar artery has the largest diameter among the major arteries. We expect that this anatomical information will aid in furthering research on cerebrovascular disease using cynomolgus monkeys.
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Affiliation(s)
- Keiichi Tsuji
- Department of Neurosurgery, Shiga University of Medical Science
| | - Shinichiro Nakamura
- Laboratory of Laboratory Animal Science, Azabu University.,Research Center for Animal Life Science, Shiga University of Medical Science
| | - Tomohiro Aoki
- Department of Molecular Pharmacology, Research Institute, National Cerebral and Cardiovascular Center
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science
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6
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Żytkowski A, Clarke E, Olszewska A, Mazurek A, Dubrowski A, Radek M. Early bifurcation of the middle cerebral artery – A case report with commentaries on the clinical significance. TRANSLATIONAL RESEARCH IN ANATOMY 2022. [DOI: 10.1016/j.tria.2022.100161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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7
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Kashani N, Cimflova P, Ospel JM, Singh N, Almekhlafi MA, Rempel J, Fiehler J, Chen M, Sakai N, Agid R, Heran M, Kappelhof M, Goyal M. Endovascular Device Choice and Tools for Recanalization of Medium Vessel Occlusions: Insights From the MeVO FRONTIERS International Survey. Front Neurol 2021; 12:735899. [PMID: 34603187 PMCID: PMC8480153 DOI: 10.3389/fneur.2021.735899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs. Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression. Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07–1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53–3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16–14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01–4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26–8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11–10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38–3.24; and RR 0.49, 95% CI 0.34–0.70, respectively) compared to the United States and Canada. Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.
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Affiliation(s)
- Nima Kashani
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Petra Cimflova
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada.,Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Johanna M Ospel
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Nishita Singh
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Jeremy Rempel
- Department of Diagnostic Imaging, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Chen
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ronit Agid
- Department of Neuroradiology, Toronto Western Hospital, Toronto, ON, Canada
| | - Manraj Heran
- Department of Neuroradiology, Vancouver General Hospital, Toronto, ON, Canada
| | - Manon Kappelhof
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
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8
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Sato K, Hijikata Y, Omura N, Miki T, Kakita H, Yoshida T, Shimizu F. Usefulness of three-dimensional fast imaging employing steady-state acquisition MRI of large vessel occlusion for detecting occluded middle cerebral artery and internal carotid artery before acute mechanical thrombectomy. J Cerebrovasc Endovasc Neurosurg 2021; 23:201-209. [PMID: 34332521 PMCID: PMC8497723 DOI: 10.7461/jcen.2021.e2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/22/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Acute mechanical thrombectomy (AMT) in patients with acute ischemic stroke from large vessel occlusion (LVO) is performed without directly identifying the occluded vessels. In this study, we evaluated whether 1.5 T magnetic resonance imaging (MRI) with 3D-fast imaging employing steady-state acquisition (FIESTA) could visualize the occluded intracranial middle cerebral artery (MCA) and internal carotid artery (ICA) before AMT. Methods This retrospective study included 21 consecutive patients who underwent time-of-flight magnetic resonance angiography (TOF MRA) and 3D-FIESTA MRI immediately before AMT. The patients also underwent TOF MRA after AMT and achieved TICI 2b or 3 by AMT at our hospital between February 2018 and April 2019. When LVO in the anterior circulation was detected by TOF MRA, 3D-FIESTA MRI was additionally performed. Then, the occluded intracranial MCA and ICA, including their branches, were constructed on the workstation with volume rendering. The obtained images were fused with the TOF MRA images to create combined 3D images. Results The length and top-to-bottom distance of the affected M1 segment (calculated by the ipsilateral-to-contralateral ratio) were 1.29 and 1.17, respectively, on 3D-FIESTA MRI before AMT and 1.34 and 1.24, respectively, on TOF MRA after AMT. We assessed the number of M2 segments branching from the affected M1/M2 junction and visualized the affected anterior temporal artery. The 3D-FIESTA MRI before AMT and TOF MRA after AMT were consistent in all patients, except for two who moved vigorously during imaging. Conclusions Images acquired by 1.5T 3D-FIESTA MRI can visualize to predict the existing path of the occluded MCA and ICA before AMT in patients with LVO of the anterior circulation.
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Affiliation(s)
- Kimitoshi Sato
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Yasukazu Hijikata
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Naoki Omura
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Takanori Miki
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Hiroto Kakita
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Takashi Yoshida
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Fuminori Shimizu
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
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Yoshimoto T, Tanaka K, Koge J, Shiozawa M, Yamagami H, Inoue M, Kamogawa N, Satow T, Kataoka H, Toyoda K, Ihara M, Koga M. Blind Exchange With Mini-Pinning Technique Using the Tron Stent Retriever for Middle Cerebral Artery M2 Occlusion Thrombectomy in Acute Ischemic Stroke. Front Neurol 2021; 12:667835. [PMID: 34093417 PMCID: PMC8172139 DOI: 10.3389/fneur.2021.667835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: The usefulness of the blind exchange with mini-pinning (BEMP) technique has recently been reported for mechanical thrombectomy in patients with stroke owing to medium vessel occlusion (MeVO). The Tron stent retriever can be delivered and deployed through a 0.0165-inch microcatheter. This retriever has potential as an effective and safe treatment for acute ischemic stroke (AIS) due to occlusion of the M2 segment of the middle cerebral artery (MCA). Here, we report the outcomes of the BEMP technique using Tron stent retrievers for M2 occlusion thrombectomy. Methods: Consecutive patients with AIS owing to M2 occlusion who underwent the BEMP technique using 2 × 15-mm or 4 × 20-mm Tron stent retrievers were included. The technique involves deploying a Tron stent retriever through a 0.0165-inch microcatheter, followed by microcatheter removal and blind navigation of a 3MAX or 4MAX aspiration catheter over the bare Tron delivery wire until the aspiration catheter reaches the clot. A Tron stent retriever is inserted into the aspiration catheter like a cork and subsequently pulled as a unit. We assessed procedural outcomes [first-pass expanded thrombolysis in cerebral infarction (eTICI) score 2c/3 and 2b/2c/3], safety outcomes [symptomatic intracranial hemorrhage (sICH)], and clinical outcomes (good outcome rate defined as modified Rankin Scale score 0–2 at 90 days and mortality at 90 days). Results: Eighteen M2 vessels were treated in 15 patients (six female, median age: 80 years, and median National Institutes of Health Stroke Scale score: 18). The BEMP technique was performed successfully in all cases. Whether to use a 3MAX or 4MAX catheter was determined by considering one of the following target vessels: dominant, non-dominant, or co-dominant M2 (3MAX, n = 9; 4MAX, n = 9). The first-pass eTICI 2c/3 and 2b/2c/3 rates were 47 (7/15) and 60% (9/15), respectively; sICH was not observed. Seven patients (47%) achieved good outcomes, and one patient (7%) died within 90 days. Conclusions: The Tron stent retriever was safely and effectively used in the BEMP technique for acute MCA M2 occlusion and can be combined with a 0.0165-inch microcatheter, which may be useful for treating MeVO, in general.
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Affiliation(s)
- Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naruhiko Kamogawa
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Karadag A, Bozkurt B, Yagmurlu K, Ozcan AI, Moen S, Grande AW. Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study. ORL J Otorhinolaryngol Relat Spec 2021; 83:187-195. [PMID: 33721866 DOI: 10.1159/000514177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441-56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms. METHODS The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera. RESULTS The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk. CONCLUSIONS The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.
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Affiliation(s)
- Ali Karadag
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey,
| | - Baran Bozkurt
- Department of Neurosurgery, Acibadem University, Istanbul, Turkey
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Sean Moen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
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11
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Temporal Artery and Temporal Region Supplied by the Middle Cerebral Artery: An Anatomical Study. J Craniofac Surg 2021; 32:2873-2877. [PMID: 33710055 DOI: 10.1097/scs.0000000000007612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT This study was conducted to describe in detail the branching patterns of cortical branches from the middle cerebral artery supplying the feeding of the temporal region, to define the arterial structure of temporal artery (TA) and to determine the effect of this arterial supply to the temporal region. The arteries of brains (n = 22; 44 hemispheres) were prepared for dissection after filling them with colored latex. TA was defined, and its classification was described, specifying its relationship with other cortical branches. A new classification was defined related to TA terminology. TA was found in 95% of cadavers, and it originated as an early branch in 75% and from the inferior trunk in 24% of cadavers. TA was classified as Type 0: No TA, Type I: single branch providing two cortical branches, Type II: single branch providing three or more cortical branches and Type III: double TA. Type I-TA (45%) was the most common, and Type II-TA arterial diameter was significantly larger than that of other types. All cadavers showed the cortical branches of temporal region from middle cerebral artery, anterior TA , middle TA, posterior TA and temporooccipital artery, except temporopolar artery (81%). Temporopolar artery, anterior TA, and middle TA primarily originated from TA, an early branch, but posterior TA and temporooccipital artery primarily originated from the inferior trunk. Detailed knowledge about cortical branches together with TA and also this region's blood supply would enable increased prediction of complications, especially in cases with these region-related pathologies, and would make interventions safer.
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Kitazawa K, Ito Y, Koyama M, Ohara H, Minagawa M. Thrombectomy for Small-Artery Occlusions with the Small-Diameter Stent Retriever, Tron Fx 2 mm × 15 mm: A Case Series. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:332-338. [PMID: 37501907 PMCID: PMC10370981 DOI: 10.5797/jnet.oa.2020-0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/11/2020] [Indexed: 07/29/2023]
Abstract
Objective The safety and efficacy of thrombectomy for small-artery occlusions is still controversial. In April 2019, Tron Fx, a stent retriever with an expansion diameter of 2 mm, became reimbursed by health insurance in Japan. We report on cases of thrombectomy for small-artery occlusions performed using this device in seven patients. Methods The subjects were seven patients who underwent thrombectomy between July 2019 and June 2020 using Tron Fx with 2 mm in diameter. We analyzed clinical results including recanalization and complications. Results The mean age of the seven patients was 80.1 years, and the subjects included six men. The sites of occlusion were the middle cerebral artery M2 (n = 4), M4 (n = 1), anterior cerebral artery A2 (n = 1), and A3 (n = 1). One of the seven patients had an M2 occlusion that was formed during coil embolization for a ruptured cerebral aneurysm. In five cases, four cases were of primary occlusion and one case was of emboli into a new territory, treating with only Tron Fx 2 mm resulted in thrombolysis in cerebral infarction (TICI) 2b-3 in four cases. There was one case of grade 0, which was M4 occlusion. Finally, TICI 2b-3 were achieved in six of seven cases. No symptomatic intracranial hemorrhage occurred. Symptoms improved in five of six patients, excluding a vascular occlusion that occurred during surgery. Conclusion Tron Fx with 2 mm diameter can be used safely for small-artery occlusion. The introduction of Tron Fx with 2 mm diameter may contribute to expand indications for thrombectomy for small-artery occlusions.
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Affiliation(s)
- Keiko Kitazawa
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Niigata, Japan
| | - Yasushi Ito
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Niigata, Japan
| | - Miyako Koyama
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Niigata, Japan
| | - Hiroshi Ohara
- Department of Neurology, Shinrakuen Hospital, Niigata, Niigata, Japan
| | - Makoto Minagawa
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Niigata, Japan
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Clinical Trial of the New Stent Retriever Tron FX for both Proximal and Distal Intracranial Large Vessel Occlusions. J Stroke Cerebrovasc Dis 2021; 30:105585. [PMID: 33412401 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/25/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In all of randomized controlled trials of mechanical thrombectomy, the target vessels were proximal. Herein we report a clinical trial of the Tron FX stent retriever, including the smallest size of 2/15 mm for distal intracranial large vessel occlusion (LVO). OBJECTIVE Eligible patients presented within 8 h of onset with proximal or distal LVOs, and the Tron FX 4/20 mm or 2/15 mm were used as the first-line device. METHODS The primary endpoints were rate of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2a-3 immediately after using Tron FX only, and mortality rate 90 d. We compared the outcomes between sizes 4/20 and 2/15 mm. RESULTS The clinical trial was conducted in 50 cases, of which 44% presented with distal LVO and 15 cases were treated using only Tron FX 2/15 mm. The overall rate of mTICI grade 2a-3 was 80.0% (75.8% with Tron FX 4/20 mm, and 86.7% with 2/15 mm), and a 90-day modified Rankin Scale ≤ 2 or improvement of National Institute of Health Stroke Scale after thrombectomy ≥ 10 was achieved in 66.7% of cases (61.3% with Tron FX 4/20 mm, and 80.0% with 2/15 mm). The overall 90-day mortality rate was 8.0%, and symptomatic intracranial hemorrhage within 24 h occurred in 2.0% of cases. CONCLUSION In this clinical trial using the Tron FX, which included the size of 2/15 mm for distal LVO, its efficacy was similar and its safety was superior compared with previous studies.
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Lutz Y, Meiner T, Krames L, Cattaneo G, Meckel S, Dossel O, Loewe A. Selective Brain Hypothermia for Ischemic MCA-M1 Stroke: Influence of Cerebral Arterial Circulation in a 3D Brain Temperature Model. IEEE Trans Biomed Eng 2020; 68:404-415. [PMID: 32746020 DOI: 10.1109/tbme.2020.3000521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acute ischemic stroke is a major health problem with a high mortality rate and a high risk for permanent disabilities. Selective brain hypothermia has the neuroprotective potential to possibly lower cerebral harm. A recently developed catheter system enables to combine endovascular blood cooling and thrombectomy using the same endovascular access. By using the penumbral perfusion via leptomeningeal collaterals, the catheter aims at enabling a cold reperfusion, which mitigates the risk of a reperfusion injury. However, cerebral circulation is highly patient-specific and can vary greatly. Since direct measurement of remaining perfusion and temperature decrease induced by the catheter is not possible without additional harm to the patient, computational modeling provides an alternative to gain knowledge about resulting cerebral temperature decrease. In this work, we present a brain temperature model with a realistic division into gray and white matter and consideration of spatially resolved perfusion. Furthermore, it includes detailed anatomy of cerebral circulation with possibility of personalizing on base of real patient anatomy. For evaluation of catheter performance in terms of cold reperfusion and to analyze its general performance, we calculated the decrease in brain temperature in case of a large vessel occlusion in the middle cerebral artery (MCA) for different scenarios of cerebral arterial anatomy. Congenital arterial variations in the circle of Willis had a distinct influence on the cooling effect and the resulting spatial temperature distribution before vessel recanalization. Independent of the branching configurations, the model predicted a cold reperfusion due to a strong temperature decrease after recanalization (1.4-2.2 °C after 25 min of cooling, recanalization after 20 min of cooling). Our model illustrates the effectiveness of endovascular cooling in combination with mechanical thrombectomy and its results serve as an adequate substitute for temperature measurement in a clinical setting in the absence of direct intraparenchymal temperature probes.
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Matsubara R, Bivard A, Parsons M, Sakashita N. Automatic whole brain vascular territory mapping. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:1080-1083. [PMID: 33018173 DOI: 10.1109/embc44109.2020.9175261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Cerebral vascular territories are related to the clinical progression and outcome of ischemic stroke. The vascular territory map (VTM) helps to understand stroke pathophysiology and potentially the clinical prognosis. A VTM can be generated from the bolus arrival time map. However, previous methods require initial seed points to be chosen manually, and the region inferior to the circle of Willis is not included. In this paper, we propose a method to automatically generate a map of the whole cerebral vascular territory from CT perfusion imaging. We applied the proposed method to 19 cases of ischemic stroke to generate VTM for each case.Clinical Relevance- The proposed map may improve the interpretation of the physiological status of collateral flow for ischemic stroke, and aid in treatment decision making.
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Khatri R, Qureshi MA, Chaudhry MRA, Maud A, Vellipuram AR, Cruz-Flores S, Rodriguez GJ. The Angiographic Anatomy of the Sphenoidal Segment of the Middle Cerebral Artery and Its Relevance in Mechanical Thrombectomy. INTERVENTIONAL NEUROLOGY 2020; 8:231-241. [PMID: 32508905 DOI: 10.1159/000502545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
Abstract
Objective The middle cerebral artery (MCA) is the most commonly treated artery in mechanical thrombectomy stroke trials; however, there is no pragmatic agreement about the segmental anatomy and nomenclature utilized. It results in significant clinical-radiological dissociation and introduces bias in research trials. The purpose of the study is to review and compare angiographic anatomy with microsurgical anatomy literature of the MCA with emphasis on the discrepancy. Methodology Consecutive cerebral angiograms between January 2011 and March 2014 were retrospectively reviewed by endovascular surgical neuroradiologists. Information about the anatomy of the sphenoidal segment of the MCA classified as classic and non-classic pattern, the lenticulostriate artery takeoff pattern, and the course angulation of the sphenoidal segment were studied. Results A total of 500 patients, 886 cerebral angiograms, were reviewed. We found the classic pattern of the main trunk MCA bifurcation and a straight angulation course in less than half of the cases. The lenticulostriate arteries arose not only from the main trunk but also from its divisions in more than half of the cases. Conclusion It is important to corroborate our findings and to develop a pragmatic classification to accurately assess MCA occlusions from the radiological and clinical perspective.
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Affiliation(s)
- Rakesh Khatri
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | | | - Alberto Maud
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | - Gustavo Jose Rodriguez
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
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Shapiro M, Raz E, Nossek E, Chancellor B, Ishida K, Nelson PK. Neuroanatomy of the middle cerebral artery: implications for thrombectomy. J Neurointerv Surg 2020; 12:768-773. [PMID: 32107286 DOI: 10.1136/neurintsurg-2019-015782] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/27/2020] [Indexed: 11/04/2022]
Abstract
Our perspective on anatomy frequently depends on how this anatomy is utilized in clinical practice, and by which methods knowledge is acquired. The thrombectomy revolution, of which the middle cerebral artery (MCA) is the most common target, is an example of a clinical paradigm shift with a unique perspective on cerebrovascular anatomy. This article reviews important features of MCA anatomy in the context of thrombectomy. Recognizing that variation, frequently explained by evolutionary concepts, is the rule when it comes to branching pattern, vessel morphology, territory, or collateral potential is key to successful thrombectomy strategy.
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Affiliation(s)
- Maksim Shapiro
- Radiology and Neurology, New York University Langone Medical Center, New York, New York, USA
| | - Eytan Raz
- Radiology, NYU Langone Medical Center, New York, New York, USA
| | - Erez Nossek
- Neurosurgery, NYU School of Medicine, New York, New York, USA
| | - Breehan Chancellor
- Radiology and Neurology, New York University Langone Medical Center, New York, New York, USA
| | - Koto Ishida
- Neurology, New York University Langone Medical Center, New York, New York, USA
| | - Peter Kim Nelson
- Radiology and Neurology, New York University Langone Medical Center, New York, New York, USA
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Lutz Y, Daschner R, Krames L, Loewe A, Dossel O, Cattaneo G. Estimating Local Therapeutic Hypothermia in Case of Ischemic Stroke Using a 1D Hemodynamics Model and an Energetic Temperature Model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:3983-3986. [PMID: 31946744 DOI: 10.1109/embc.2019.8856447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In Western countries, stroke is the third-most widespread cause of death. 80% of all strokes are ischemic and show a mortality rate of about 25%. Furthermore, 35-55% of affected patients retain a permanent disability. Therapeutic hypothermia (TH) could decrease inflammatory processes and the stroke-induced cerebral damage. Currently, the standard technique to induce TH is cooling of the whole body, which can cause several side effects. A novel cooling sheath uses intra-carotid blood cooling to induce local TH. Unfortunately, the control of the temporal and spatial cerebral temperature course requires invasive temperature measurements. Computational modeling could be used to predict the resulting temperature courses instead. In this work, a detailed 1D hemodynamics model of the cerebral arterial system was coupled with an energetic temperature model. For physiological conditions, 50% and 100% M1-stenoses, the temperatures in the supply area of the middle cerebral artery (MCA) and of the systemic body was analyzed. A 2K temperature decrease was reached within 10min of cooling for physiological conditions and 50% stenosis. For 100% stenosis, a significant lower cooling effect was observed, resulting in a maximum cerebral temperature decrease of 0.7K after 30min of cooling. A significant influence of collateral flow rates on the cooling effect was observed. However, regardless of the stenosis degree, the temperature decrease was strongest within the first 20min of cooling, which demonstrates the fast and effective impact of intra-carotid blood cooling.
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Pant M, Pant J, Pandey SK, Shukla RC. Study of pattern of origin of central branches of middle cerebral artery by using 64-slice computed tomography angiography. NATIONAL JOURNAL OF CLINICAL ANATOMY 2020. [DOI: 10.4103/njca.njca_3_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Fauzi AA, Aji YK, Suroto NS. Neuroangiography patterns of the middle cerebral artery: Study of 554 cerebral angiography results. J Clin Neurosci 2019; 68:62-68. [DOI: 10.1016/j.jocn.2019.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/30/2019] [Accepted: 07/16/2019] [Indexed: 11/27/2022]
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Modeling of the Human Cerebral Collateral Circulation: Evaluation of the Impact on the Cerebral Perfusion in Case of Ischemic Stroke. CURRENT DIRECTIONS IN BIOMEDICAL ENGINEERING 2019. [DOI: 10.1515/cdbme-2019-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Stroke is the third-most cause of death in developed countries. A new promising treatment method in case of an ischemic stroke is selective intracarotid blood cooling combined with mechanical artery recanalization. However, the control of the treatment requires invasive or MRI-assisted measurement of cerebral temperature. An auspicious alternative is the use of computational modeling. In this work, we extended an existing 1D hemodynamics model including the characteristics of the anterior, middle and posterior cerebral artery. Furthermore, seven ipsilateral anastomoses were additionally integrated for each hemisphere. A potential stenosis was placed into the M1 segment of the middle cerebral artery, due to the highest risk of occlusion there. The extended model was evaluated for various degrees of collateralization (“poor”, “partial” and “good”) and degrees of stenosis (0%, 50%, 75% and 99.9%). Moreover, cerebral autoregulation was considered in the model. The higher the degree of collateralization and the degree of stenosis, the higher was the blood flow through the collaterals. Hence, a patient with a good collateralization could compensate a higher degree of occlusion and potentially has a better outcome after an ischemic stroke. For a 99.9% stenosis, an increased summed mean blood flow through the collaterals of +97.7% was predicted in case of good collateralization. Consequently, the blood supply via the terminal branches of the middle cerebral artery could be compensated up to 44.4% to the physiological blood flow. In combination with a temperature model, our model of the cerebral collateral circulation can be used for tailored temperature prediction for patients to be treated with selective therapeutic hypothermia.
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Acute basilar thrombosis: Recanalization following intravenous thrombolysis is dependent on thrombus length. PLoS One 2018; 13:e0193051. [PMID: 29466399 PMCID: PMC5821367 DOI: 10.1371/journal.pone.0193051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 02/02/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction We investigated whether thrombus length measured in Computed Tomography Angiography (CTA) is predictive of the success rate of intravenous thrombolysis (IVT) in acute basilar occlusion and whether recanalization can be achieved by additional mechanical endovascular thrombectomy. Methods In 51 patients with acute basilar thrombosis thrombus length was measured on CTA images before intravenous thrombolysis (IVT) with rt-PA was started. After 114 minutes on average success of IVT was evaluated either by CTA or DSA. Patients with persistent basilar occlusion and no major brainstem infarction on CT underwent endovascular recanalization. Results 87% of patients had no recanalization of basilar artery after IVT alone. The average thrombus length was 15 mm in patients with persistent basilar occlusion after IVT and 7 mm in patients with recanalization after IVT. Thrombi longer than 13 mm did not resolve after IVT alone and 80% of thrombi shorter than 13 mm did not resolve either. 41 patients were transferred to endovascular recanalization; endovascular therapy was performed successfully in 90% (37 / 41). Conclusions Recanalization rates in acute basilar occlusion after IVT alone are low and dependent on thrombus length. Additional mechanical endovascular thrombectomy showed to be a very successful recanalization therapy.
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Rai AT, Domico JR, Buseman C, Tarabishy AR, Fulks D, Lucke-Wold N, Boo S, Carpenter JS. A population-based incidence of M2 strokes indicates potential expansion of large vessel occlusions amenable to endovascular therapy. J Neurointerv Surg 2017; 10:510-515. [PMID: 28963363 PMCID: PMC5969390 DOI: 10.1136/neurintsurg-2017-013371] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 11/04/2022]
Abstract
Background M2 occlusions may result in poor outcomes and potentially benefit from endovascular therapy. Data on the rate of M2 strokes is lacking. Methodology Patients with acute ischemic stroke discharged over a period of 3 years from a tertiary level hospital in the ‘stroke belt’ were evaluated for M2 occlusions on baseline vascular imaging. Regional and national incidence was calculated from discharge and multicounty data. Results There were 2739 ICD-9 based AIS discharges. M2 occlusions in 116 (4%, 95% CI 3.5% to 5%) patients constituted the second most common occlusion site. The median National Institute of Health Stroke Scale (NIHSS) score was 12 (IQR 5–18). Good outcomes were observed in 43% (95% CI 34% to 53%), poor outcomes in 57% (95% CI 47% to 66%), and death occurred in 27% (95% CI 19% to 37%) of patients. Receiver operating characteristics curves showed the NIHSS to be predictive of outcomes (area under the curve 0.829, 95% CI 0.745 to 0.913, p<0.0001). An NIHSS score ≥9 was the optimal cut-off point for predicting poor outcomes (sensitivity 85.7%, specificity 67.4%). 71 (61%) patients had an NIHSS score ≥9 and 45 (39%) an NIHSS score <9. The rate of good-outcome was 22.6% for NIHSS score ≥9 versus 78.4% for NIHSSscore <9 (OR=0.08, 95% CI 0.03 to 0.21, p<0.0001). Mortality was 42% for NIHSS score ≥9 versus 2.7% for NIHSS score <9 (OR=26, 95% CI 3.3 to 202, p<0.0001). Infarct volume was 57 (±55.7) cm3 for NIHSS score ≥9 versus 30 (±34)cm3 for NIHSS score <9 (p=0.003). IV recombinant tissue plasminogen activator (rtPA) administered in 28 (24%) patients did not affect outcomes. The rate of M2 occlusions was 7 (95% CI 5 to 9)/100 000 people/year (3%, 95% CI 2% to 4%), giving an incidence of 21 176 (95% CI 15 282 to 29 247)/year. Combined with M1, internal carotid artery terminus and basilar artery, this yields a ‘large vessel occlusion (LVO)+M2’ rate of 31 (95% CI 26 to 35)/100 000 people/year and a national incidence of 99 227 (95% CI 84 004 to 112 005) LVO+M2 strokes/year. Conclusion M2 occlusions can present with serious neurological deficits and cause significant morbidity and mortality. Patients with M2 occlusions and higher baseline deficits (NIHSS score ≥9) may benefit from endovascular therapy, thus potentially expanding the category of acute ischemic strokes amenable to intervention.
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Affiliation(s)
- Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Jennifer R Domico
- Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Chelsea Buseman
- Department of Enterprise Analytics, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Abdul R Tarabishy
- Department of Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| | - Daniel Fulks
- Department of Medicine, The University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Noelle Lucke-Wold
- Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - SoHyun Boo
- Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Jeffrey S Carpenter
- Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
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Hakim A, Gralla J, Rozeik C, Mordasini P, Leidolt L, Piechowiak E, Ozdoba C, El-Koussy M. Anomalies and Normal Variants of the Cerebral Arterial Supply: A Comprehensive Pictorial Review with a Proposed Workflow for Classification and Significance. J Neuroimaging 2017; 28:14-35. [PMID: 28945289 DOI: 10.1111/jon.12475] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022] Open
Abstract
Cerebral arteries may exhibit a wide range of variation from normal anatomy, which can be incidentally discovered during imaging. Knowledge of such variants is crucial to differentiate them from pathologies, to understand the etiology of certain pathologies directly related to a vascular variant, and to depict the changes in collateral circulation in patients with certain variants. Detection of particular variants may lead to the discovery of other nonvascular or vascular anomalies, especially aneurysms, and may also affect planning of endovascular or neurosurgical interventions. In this review, we summarize the variants and anomalies of cerebral arteries seen on cross-sectional imaging classified by a morphological approach and categorize their significance from a clinical perspective. This structured review is intended to serve as a guide for daily use in clinical practice.
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Affiliation(s)
- Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Rozeik
- Radiology Department, Lörrach District Hospital, Lörrach, Germany
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Lars Leidolt
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Eike Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Ozdoba
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Yaşargil MG, Krisht AF, Türe U, Al-Mefty O, Yaşargil DC. Microsurgery of Insular Gliomas: Part I—Surgical Anatomy of the Sylvian Cistern. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/01.cne.0000522111.96155.e8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tayebi Meybodi A, Lawton MT, Griswold D, Mokhtari P, Payman A, Benet A. The anterior temporal artery: an underutilized but robust donor for revascularization of the distal middle cerebral artery. J Neurosurg 2016; 127:740-747. [PMID: 27834592 DOI: 10.3171/2016.8.jns161225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anterior temporal artery (ATA) supplies an area of the brain that, if sacrificed, does not cause a noticeable loss of function. Therefore, the ATA may be used as a donor in intracranial-intracranial (IC-IC) bypass procedures. The capacities of the ATA as a donor have not been studied previously. In this study, the authors assessed the feasibility of using the ATA as a donor for revascularization of different segments of the distal middle cerebral artery (MCA). METHODS The ATA was studied in 15 cadaveric specimens (8 heads, excluding 1 side). First, the cisternal segment of the artery was untethered from arachnoid adhesions and small branches feeding the anterior temporal lobe and insular cortex, to evaluate its capacity for a side-to-side bypass to insular, opercular, and cortical segments of the MCA. Any branch entering the anterior perforated substance was preserved. Then, the ATA was cut at the opercular-cortical junction and the capacity for an end-to-side bypass was assessed. RESULTS From a total of 17 ATAs, 4 (23.5%) arose as an early MCA branch. The anterior insular zone and the frontal parasylvian cortical arteries were the best targets (in terms of mobility and caliber match) for a side-to-side bypass. Most of the insula was accessible for end-to-side bypass, but anterior zones of the insula were more accessible than posterior zones. End-to-side bypass was feasible for most recipient cortical arteries along the opercula, except for posterior temporal and parietal regions. Early ATAs reached significantly farther on the insular MCA recipients than non-early ATAs for both side-to-side and end-to-side bypasses. CONCLUSIONS The ATA is a robust arterial donor for IC-IC bypass procedures, including side-to-side and end-to-side techniques. The evidence provided in this work supports the use of the ATA as a donor for distal MCA revascularization in well-selected patients.
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Affiliation(s)
- Ali Tayebi Meybodi
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Michael T Lawton
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Dylan Griswold
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Pooneh Mokhtari
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Andre Payman
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Arnau Benet
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
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Mercier P, Brassier G, Cronier P, Fournier D, Reignier B, Velut S, Pillet J. Microsurgical Anatomy of the Perforating Arteries of the Anterior Part of the Circle of Willis. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/19714009930060s310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - S. Velut
- Laboratoire d'Anatomie, Faculté de Médecine; Tours
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Janssen H, Killer-Oberpfalzer M, Patzig M, Buchholz G, Lutz J. Ultra-distal access of the M1 segment with the 5 Fr Navien distal access catheter in acute (anterior circulation) stroke: is it safe and efficient? J Neurointerv Surg 2016; 9:650-653. [PMID: 27342761 DOI: 10.1136/neurintsurg-2016-012370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/30/2016] [Accepted: 06/01/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND AIM The importance of mechanical thrombectomy in acute stroke treatment has grown over recent years. Mechanical thrombectomy comprises many different techniques. Technical improvements in the catheter material have led to the development of large-bore distal access catheters which can enter tortuous intracranial vessels. This has promising applications for endovascular stroke treatment. This study evaluated the safety and success rate of ultra-distal access of the middle cerebral artery (MCA) M1 segment with the 5 Fr Navien 58 distal access catheter in the treatment of acute stroke in combination with stent retrievers. METHODS We retrospectively analyzed 81 patients with an acute stroke of the anterior circulation in whom ultra-distal access to the M1 segment was carried out using the Navien 58 catheter with an anchoring technique with a stent retriever for mechanical thrombectomy. Technical complications, success rates of catheter placement, success rates of thrombectomy using the modified Thrombolysis In Cerebral Infarction (mTICI) score, and the procedure times were evaluated. RESULTS Ultra-distal access with the Navien 58 was successful in 75% (61/81) of cases. Recanalization success with a mTICI score of 2b and better was achieved in 83% overall (67/81), in 90% (55/61) of cases with successful ultra-distal access and in 60% (12/20) of cases without ultra-distal access. No severe adverse effects such as dissections or perforations occurred as a result of the ultra-distal catheter placement in the M1 segment. In 4% (3/81) of the cases a reversible MCA vasospasm occurred. CONCLUSIONS Ultra-distal placement of the Navien 58 distal access catheter into the M1 segment in acute anterior circulation stroke can be achieved consistently, is safe in practice, and results in good recanalization success rates.
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Affiliation(s)
- H Janssen
- Department of Neuroradiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - M Killer-Oberpfalzer
- Department of Neurology/Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Germany
| | - M Patzig
- Department of Neuroradiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - G Buchholz
- Department of Neurology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - J Lutz
- Department of Neuroradiology, Ludwig-Maximilians-University Hospital, Munich, Germany
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Cilliers K, Page BJ. Detailed description of the anterior cerebral artery anomalies observed in a cadaver population. Ann Anat 2016; 208:1-8. [PMID: 27237980 DOI: 10.1016/j.aanat.2016.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
Anomalies of the anterior cerebral artery (ACA) include the median ACA (MedACA), bihemispheric ACA (BihemACA) and the azygos ACA. Knowledge of these anomalies can be crucial to clinicians and neurosurgeons, especially during surgeries involving the interhemispheric region and in the interpretation of the clinical signs of a stroke. Since few reports exist on the origin, area supplied, diameter and length of the ACA anomalies, the aim of this study is to give a detailed description on the anatomy of the ACA anomalies. The ACAs of 60 brains were injected with a colored silicone. When an anomaly was observed, a detailed illustration of the course and pattern of the ACA and cortical branches were made. The origins and the areas supplied by the anomalous arteries were noted. The external diameter was measured using a digital micrometer and the length was measured using string and a ruler. There were seven cases (11.7%) of a MedACA and 12 cases (20.0%) of a BihemACA. The MedACA originated mostly from the anterior communicating artery, and from the A2 segment in one case. The MedACA was bilateral in four cases and unilateral in three cases. Excluding Cases 5 and 9, the BihemACA cases can be divided into two groups; one branch to the left hemisphere (n=3), and one branch to the right hemisphere (n=7). The average diameter of both the BihemACA and MedACA was 1.8mm. Studies rarely provide additional information on these anomalies. Therefore, the present study elaborated on the origin, diameter, length and the area supplied by these anomalies. The definitions are described in the literature, although additional criteria were still lacking and this was provided in the present study. Since information on these aspects of the ACA anomalies is scarce, future research should give detailed descriptions on the ACA anomalies.
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Affiliation(s)
- K Cilliers
- Anatomy and Histology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - B J Page
- Anatomy and Histology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
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Djulejić V, Marinković S, Georgievski B, Stijak L, Aksić M, Puškaš L, Milić I. Clinical significance of blood supply to the internal capsule and basal ganglia. J Clin Neurosci 2016; 25:19-26. [DOI: 10.1016/j.jocn.2015.04.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/18/2015] [Indexed: 11/29/2022]
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Delion M, Mercier P, Brassier G. Arteries and Veins of the Sylvian Fissure and Insula: Microsurgical Anatomy. Adv Tech Stand Neurosurg 2016:185-216. [PMID: 26508410 DOI: 10.1007/978-3-319-21359-0_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present a vascular anatomical study of the arteries and veins of the sylvian fissure and insula.A good knowledge of the sylvian fissure, the insula, and their vascular relationship would seem mandatory before performing surgery in this area, whatever the type of surgery (aneurysms, arteriovenous malformations, insular tumors).We start with the sylvian fissure and insula morphology, followed by the MCA description and its perforators, with special attention paid to the insular perforators. We demonstrate that the long insular perforators penetrating in the superior part of the posterior short gyrus and long gyri vascularize, respectively, the corticonuclear and corticospinal fasciculi. We particularly insist too on three anatomical constants regarding the vascularization of the insula, already described in the literature: The superior periinsular sulcus is the only sulcus on the lateral surface of the brain without an artery along its axis; the superior branch of the MCA supplies the anterior insular pole and both the anterior and middle short gyri in 100 % of cases; in at least 90 % of cases, the artery that supplied the central insular sulcus continued on to become the central artery.We end with the anatomical study of the veins and cisterns.
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Affiliation(s)
- Matthieu Delion
- Department of Neurosurgery, Angers Teaching Hospital, Angers, 49933, France.
- Anatomy Laboratory, Medical Faculty, rue haute de Reculée, Angers, 49045, France.
| | - Philippe Mercier
- Department of Neurosurgery, Angers Teaching Hospital, Angers, 49933, France
- Anatomy Laboratory, Medical Faculty, rue haute de Reculée, Angers, 49045, France
| | - Gilles Brassier
- Department of Neurosurgery, Rennes Teaching Hospital, Rennes, 35033, France
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Unfused or twig-like middle cerebral artery. Eur J Radiol 2015; 84:2013-8. [DOI: 10.1016/j.ejrad.2015.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/10/2015] [Accepted: 06/15/2015] [Indexed: 11/23/2022]
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Djulejić V, Marinković S, Milić V, Georgievski B, Rašić M, Aksić M, Puškaš L. Common features of the cerebral perforating arteries and their clinical significance. Acta Neurochir (Wien) 2015; 157:743-54; discussion 754. [PMID: 25772345 DOI: 10.1007/s00701-015-2378-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/19/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The perforating vessels supply very important regions of the brain stem and diencephalon, as well as the basal ganglia and internal capsule. Some of their micro-anatomical characteristics are still not well known. The aim of this study was to examine and evaluate the features of all the perforating vessels. METHODS The arteries of 24-32 cerebral hemispheres, diencephalons and halves of the brain stem were injected with India ink mixture or methylmethacrylate, and microdissection was performed or the vascular casts were produced and examined under the sterescopic microscope. RESULTS It was noticed that the perforators ranged from 0 to 14 in number, with the smallest mean value (1.1) for the diencephalic perforators and the largest one (8.1) for the lenticulostriate arteries. The smallest mean diameter (175 μm) was found in the group of the perforators of the anterior communicating artery, whereas the largest one is related to the Heubner's artery (668 μm), the diencephalic thalamoperforating vessels (562 μm), the premamillary vessel (489 μm) and the lenticulostriate arteries (469 μm). The perforators most frequently originated from the pial branches of the basilar artery (91.7 %) and of the posterior cerebral artery (59.4 %). The common stems were most often formed by the perforators of the basilar (79.2 %), posterior cerebral (75.0 %) and middle cerebral arteries (40.6 %). Some perforators arose close to or from the terminal divisions, the branching sites or the junctions of the parent arteries, where the saccular aneurysms most often develop. The anastomoses among the perforators were present in a range from 6.3 % to 53.2 %. CONCLUSIONS The micro-anatomical data obtained may be useful for neurosurgeons when operating at the base of the brain, as well as for a neurological and radiological evaluation of the perforators in the occlusive cerebrovascular disease, or in the cases of an aneurysm, arteriovenous malformation (AVM) or tumour presence.
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Affiliation(s)
- Vuk Djulejić
- Institute of Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotić 4/2, 11000,, Belgrade, Serbia
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Abstract
OBJECTIVE The objective of this work was to explore the feasibility of bypass between the maxillary artery (MA) and proximity of middle cerebral artery (MCA). METHODS Ten fixed and perfused adult cadaver heads were dissected bilaterally, 20 sides in total. The superficial temporal artery and its 2 branches were dissected, and outer diameters were measured. The MA and its branch were exposed as well as deep temporal artery; outer diameter of MA was measured. The lengths between the external carotid artery, internal carotid artery, maxillary artery, and proximal middle cerebral artery were measured. Ten healthy adults as targets (20 sides), inner diameter and blood flow dynamic parameters of the common carotid artery, external carotid artery, internal carotid artery, maxillary artery, superficial temporal artery, and its 2 branches were done with ultrasound examination. RESULTS The mean outer diameter of MA (2.60 ± 0.20 mm) was larger than that of the temporal artery trunk (1.70 ± 0.30 mm). The mean lengths of graft vessels between the internal carotid artery, external carotid artery, and the bifurcation section of MCA (171.00 ± 2.70 and 162.40 ± 2.60 mm) were longer than the mean lengths of graft vessels between MA and MCA bifurcation section (61.70 ± 1.50 mm). In adults, the mean blood flow of the second part of MA (62.70 ± 13.30 mL/min) was more than that of the 2 branches of the superficial temporal artery (15.90 ± 3.70 mL/min and 17.70 ± 4.10 ml/min). CONCLUSION Bypass between the maxillary artery and proximity of middle cerebral artery is feasible. It is a kind of effective high flow bypass with which the graft vessel is shorter and straighter than the bypass between internal carotid artery or external carotid artery and proximity of middle cerebral artery.
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van Doormaal TP, Sluijs JH, Vink A, Tulleken CA, van der Zwan A. Comparing five simple vascular storage protocols. J Surg Res 2014; 192:200-5. [DOI: 10.1016/j.jss.2014.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/19/2014] [Accepted: 05/01/2014] [Indexed: 11/26/2022]
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Delion M, Mercier P. Microanatomical study of the insular perforating arteries. Acta Neurochir (Wien) 2014; 156:1991-7; discussion 1997-8. [PMID: 24986536 DOI: 10.1007/s00701-014-2167-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/19/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The insular perforating arteries originate from the middle cerebral artery. They have only been very partially described up to now. In the literature, they come from the M2 segment and three types are listed: the short, medium and long perforators. The first two types supply the claustrum as well as the external and extreme capsules. OBJECTIVE We describe the anatomy of long perforating insular arteries and their arterial contribution to the main white matter bundles of the oval center of Vieussens. MATERIALS AND METHOD Twenty adult cadaveric hemispheres were studied after perfusion of the arteries and veins with colored latex. The arteries were dissected and photographed under an operating microscope. RESULTS The long insular perforating arteries come from the M2 segment or from the junction of the M2 and M3 segments and sometimes from the M3 segment. They often perforate the insular cortex on the top of the posterior short insular gyrus and the insular long gyri, or in the superior peri-insular sulcus, before coming together in the oval center. At this level, they give arterial contribution to the main white matter bundles such as corticospinal and corticonuclear tracts for motricity, and the arcuate fasciculus and the occipitofrontal tract for language in the dominant hemisphere. CONCLUSION These perforating arteries have to be carefully respected during insular surgery to avoid neurologic weakness.
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Affiliation(s)
- Matthieu Delion
- Department of Neurosurgery, Angers Teaching Hospital, 49933, Angers, France,
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Zaidat OO, Castonguay AC, Teleb MS, Asif K, Gheith A, Southwood C, Pollock G, Lynch JR. Middle Cerebral Artery Aneurysm Endovascular and Surgical Therapies. Neurosurg Clin N Am 2014; 25:455-69. [DOI: 10.1016/j.nec.2014.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Farnoush A, Avolio A, Qian Y. Effect of bifurcation angle configuration and ratio of daughter diameters on hemodynamics of bifurcation aneurysms. AJNR Am J Neuroradiol 2013; 34:391-6. [PMID: 22859285 DOI: 10.3174/ajnr.a3222] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE EL associated with ruptured aneurysms is higher than that for unruptured aneurysms. In this study, the effect of arterial morphologic variation of bifurcation aneurysms on EL was investigated in idealized models of middle cerebral artery aneurysms. MATERIALS AND METHODS Bifurcation angle configuration and DA ratio were evaluated in 6 idealized numeric models. Type A and B bifurcation models were defined with symmetric and asymmetric bifurcation angles of 136°, and 57° and 79°, respectively. Three models with DA ratios of 1, 1.3, and 2 were constructed for each type. EL was calculated as the energy difference between aneurysm inflow and outflow at the aneurysm neck. Three growth paths (R1, R2, and R3) were proposed. RESULTS The highest EL and influx occurred in bifurcations with DA ratios of 1 for both types A and B. As the DA ratio increases, flow distribution between branches becomes more asymmetric, resulting in a reduction of EL and intra-aneurysmal flow. No strong relation was found between bifurcation angle configuration, inflow flux, and EL. EL decreased with an increase in the AR and DA ratio and increased with an increase in the AR and reduction of DA ratio. CONCLUSIONS EL determined in idealized models is less dependent on bifurcation angle configuration than on DA ratio, and the stability of the aneurysm strongly depends on variation of the daughter artery morphology after aneurysm growth.
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Affiliation(s)
- A Farnoush
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
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Djulejić V, Marinković S, Maliković A, Jovanović I, Djordjević D, Ćetković M, Todorović V, Milisavljević M. Morphometric analysis, region of supply and microanatomy of the lenticulostriate arteries and their clinical significance. J Clin Neurosci 2012; 19:1416-21. [DOI: 10.1016/j.jocn.2011.10.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/29/2011] [Indexed: 11/30/2022]
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Hainsworth AH, Brittain JF, Khatun H. Pre-clinical models of human cerebral small vessel disease: utility for clinical application. J Neurol Sci 2012; 322:237-40. [PMID: 22698483 DOI: 10.1016/j.jns.2012.05.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/18/2012] [Accepted: 05/23/2012] [Indexed: 12/11/2022]
Abstract
Small vessel disease (SVD) is a frequent cause of vascular cognitive impairment (VCI), encompassing vascular dementia. SVD is characterised by vasculopathy in deep penetrating arteries, diffuse white matter lesions (seen radiologically as leukoaraiosis) and focal, lacunar infarcts. Risk factors are age and hypertension but the pathogenic mechanism is unknown. Recent systematic reviews assessed experimental models of SVD or VCI. Chronically hypertensive animals (e.g. stroke-prone spontaneously hypertensive rats) display some features of SVD vasculopathy, such as vessel wall thickening. White matter lesions are seen in chronic hypoperfusion states (e.g. carotid occlusion/stenosis models). Small focal infarcts are induced by targeted ischemic challenge (surgical occlusion of a small artery, or stereotaxic endothelin-1 injection). Some degree of cognitive impairment is detectable in most cerebrovascular models, probably reflecting the broad neuroanatomical mapping of cognitive function. Important confounds to be considered in animal models of VCI are somatosensory impairment and hippocampal damage. Advances in clinical understanding will come from targeting specific questions on some aspect of SVD (e.g. vasculopathy, white matter damage) to the appropriate model in vivo. In vivo models of SVD are likely to benefit experimental studies of pathological processes, interactions with other brain disease states (such as Alzheimer disease), and therapeutic strategies.
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Affiliation(s)
- Atticus H Hainsworth
- Stroke & Dementia Research Centre, St George's University of London, London, United Kingdom.
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Farnoush A, Qian Y, Avolio A. Effect of inflow on computational fluid dynamic simulation of cerebral bifurcation aneurysms. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2011:1025-8. [PMID: 22254487 DOI: 10.1109/iembs.2011.6090238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Morphological characteristics associated with cerebral aneurysm formation can be used to assess aneurysm rupture. This study investigated hemodynamic effects resulting from change in the parent artery diameter of bifurcation type aneurysm. Computational fluid dynamic (CFD) analysis was performed on middle cerebral artery (MCA) models with various parent artery diameters. Calculations were performed with steady flow rate (125 ± 12.5 ml/min) at the parent artery inlet. Energy loss (EL) was calculated from pressure and kinetic energy obtained from flow velocity. The results indicate that the high wall shear stress (WSS) and EL occurs in model with the smallest parent vessel compared to the other models for all three inflows. Results also showed that 10% variation of inflow results in average of 23 ± 2.9% changes in WSS and 25.5 ± 0.5% changes in energy loss. These results demonstrated that for CFD analysis of MCA bifurcation type aneurysm, upstream parent vessel and inflow evaluation for individual patient is essential.
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Affiliation(s)
- A Farnoush
- Australia School of Advanced Medicine, Macquarie University.
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Kahilogullari G, Ugur HC, Comert A, Tekdemir I, Kanpolat Y. The branching pattern of the middle cerebral artery: is the intermediate trunk real or not? An anatomical study correlating with simple angiography. J Neurosurg 2012; 116:1024-34. [PMID: 22360571 DOI: 10.3171/2012.1.jns111013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The branching structure of the middle cerebral artery (MCA) remains a debated issue. In this study the authors aimed to describe this branching structure in detail. METHODS Twenty-seven fresh, human brains (54 hemispheres) obtained from routine autopsies were used. The cerebral arteries were first filled with colored latex and contrast agent, followed by fixation with formaldehyde. All dissections were done under a microscope. During examination, the trunk structures of the MCA and their relations with cortical branches were demonstrated. Lateral radiographs of the same hemispheres were then obtained and comparisons were made. Angles between the MCA trunks were measured on 3D CT cerebral angiography images in 25 patients (50 hemispheres), and their correlations with the angles obtained in the cadaver brains were evaluated. RESULTS A new classification was made in relation to the terminology of the intermediate trunk, which is still a subject of debate. The intermediate trunk was present in 61% of cadavers and originated from a superior trunk in 55% and from an inferior trunk in 45%. Cortical branches supplying the motor cortex (precentral, central, and postcentral arteries) significantly originated from the intermediate trunk, and the diameter of the intermediate trunk significantly increased when it originated from the superior trunk. In measurements of the angles between the superior and intermediate trunks, it was found that the intermediate trunk had significant dominance in supplying the motor cortex as the angle increased. The intermediate trunk was classified into 3 types based on the angle values and the distance to the bifurcation point as Group A (pseudotrifurcation type), Group B (proximal type), and Group C (distal type). Group A trunks were seemingly closer to the trifurcation structure that has been reported on in the literature and was seen in 15%. Group B trunks were the most common type (55%), and Group C trunks were characterized as the farthest from the bifurcation point. Group C trunks also had the smallest diameter and fewest cortical branches. Similarities were found between the angles in cadaver specimens and on 3D CT cerebral angiography images. Beyond the separation point of the MCA, trunk structures always included the superior trunk and inferior trunk, and sometimes the intermediate trunk. CONCLUSIONS Interrelations of these vascular structures and their influences on the cortical branches originating from them are clinically important. The information presented in this study will ensure reliable diagnostic approaches and safer surgical interventions, particularly with MCA selective angiography.
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Affiliation(s)
- Gokmen Kahilogullari
- Department of Neurosurgery, Ankara University, Faculty of Medicine, Ankara, Turkey
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Farnoush A, Qian Y, Takao H, Murayama Y, Avolio A. Effect of saccular aneurysm and parent artery morphology on hemodynamics of cerebral bifurcation aneurysms. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2012:6677-6680. [PMID: 23367461 DOI: 10.1109/embc.2012.6347526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Morphological descriptors of aneurysms have been used to assess aneurysm rupture. This study investigated the relation between the morphological parameters and the flow related parameter of energy loss (EL). Four size indices and one shape index were assessed in idealized middle cerebral artery models with various aneurysm morphologies. Four patient-specific aneurysms (2 ruptured, 2 unruptured) were virtually manipulated by removing the aneurysms from their parent arteries and merging them with the idealized bifurcation models. EL was calculated from the energy difference between inflow and outflow. The results indicate that among size indices, EL is mostly dependent on bottleneck factor and less dependent on the aspect ratio. Results also showed that there is a direct relationship between nonsphericity index (NSI) and EL in manipulated models. No specific correlation was found between EL and NSI in patient-specific models.
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Affiliation(s)
- A Farnoush
- Australian School of Advanced Medicine, Macquarie University, Australia.
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Seifert T, Secher NH. Sympathetic influence on cerebral blood flow and metabolism during exercise in humans. Prog Neurobiol 2011; 95:406-26. [PMID: 21963551 DOI: 10.1016/j.pneurobio.2011.09.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/13/2011] [Accepted: 09/19/2011] [Indexed: 11/26/2022]
Abstract
This review focuses on the possibility that autonomic activity influences cerebral blood flow (CBF) and metabolism during exercise in humans. Apart from cerebral autoregulation, the arterial carbon dioxide tension, and neuronal activation, it may be that the autonomic nervous system influences CBF as evidenced by pharmacological manipulation of adrenergic and cholinergic receptors. Cholinergic blockade by glycopyrrolate blocks the exercise-induced increase in the transcranial Doppler determined mean flow velocity (MCA Vmean). Conversely, alpha-adrenergic activation increases that expression of cerebral perfusion and reduces the near-infrared determined cerebral oxygenation at rest, but not during exercise associated with an increased cerebral metabolic rate for oxygen (CMRO(2)), suggesting competition between CMRO(2) and sympathetic control of CBF. CMRO(2) does not change during even intense handgrip, but increases during cycling exercise. The increase in CMRO(2) is unaffected by beta-adrenergic blockade even though CBF is reduced suggesting that cerebral oxygenation becomes critical and a limited cerebral mitochondrial oxygen tension may induce fatigue. Also, sympathetic activity may drive cerebral non-oxidative carbohydrate uptake during exercise. Adrenaline appears to accelerate cerebral glycolysis through a beta2-adrenergic receptor mechanism since noradrenaline is without such an effect. In addition, the exercise-induced cerebral non-oxidative carbohydrate uptake is blocked by combined beta 1/2-adrenergic blockade, but not by beta1-adrenergic blockade. Furthermore, endurance training appears to lower the cerebral non-oxidative carbohydrate uptake and preserve cerebral oxygenation during submaximal exercise. This is possibly related to an attenuated catecholamine response. Finally, exercise promotes brain health as evidenced by increased release of brain-derived neurotrophic factor (BDNF) from the brain.
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Affiliation(s)
- Thomas Seifert
- Department of Anaesthesia and The Copenhagen Muscle Research Centre, Rigshospitalet 2041, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark.
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Ogeng'o JA, Njongo W, Hemed E, Obimbo MM, Gimongo J. Branching pattern of middle cerebral artery in an African population. Clin Anat 2011; 24:692-8. [PMID: 21374730 DOI: 10.1002/ca.21147] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/16/2010] [Accepted: 01/17/2011] [Indexed: 11/08/2022]
Abstract
Branching pattern of middle cerebral artery influences frequency of its aneurysms, and is of potential value in their surgical repair and diagnosis of stroke. This pattern shows inter-population variations but there is paucity of data from Africans. This study aimed at describing branching pattern among black Kenyans. Middle cerebral arteries numbering 288 from 144 formalin fixed brains obtained during dissection and autopsy at Department of Human Anatomy, University of Nairobi, Kenya were studied. Origin of the middle cerebral artery was identified at base of brain and its stem followed by gently separating the fronto-parietal and temporal lobes. Pattern of early cortical, lenticulostriate, and terminal branching was recorded and macrographs taken. Results were analyzed using SPSS version 13.0 for windows and presented using macrographs. All the brains had bilateral middle cerebral arteries which were continuations of the internal carotid artery. Variations of the artery observed included duplication (1.7%), early bifurcation (5.2%), and early cortical branching (47%), predominantly temporal (63.9%). Lenticulostriate arteries arose predominantly from the pre-bifurcation segment as single branches (64.6%), and as common trunks (35.4%). Modes of termination were bifurcation (82.3%), trifurcation (10.8%), primary trunks (6.2%), and quadrifurcation (0.7%). Cortical branching pattern of the middle cerebral artery resembles that of Caucasian and Indian populations suggesting equal vulnerability to aneurysms and stroke. Pattern of origin of lenticulostriate arteries, predominantly from the pre-bifurcation segment and higher percentage of common trunks implies that the population is more prone to ischemia after aneurysm repair. Extra diligence during operation on proximal middle cerebral artery is called for.
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Affiliation(s)
- Julius A Ogeng'o
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya.
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Ha SK, Lim DJ, Kang SH, Kim SH, Park JY, Chung YG. Analysis of multiple factors affecting surgical outcomes of proximal middle cerebral artery aneurysms. Clin Neurol Neurosurg 2011; 113:362-7. [PMID: 21216088 DOI: 10.1016/j.clineuro.2010.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 11/29/2010] [Accepted: 12/09/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We analyzed multiple factors including anatomical characteristics that influence the surgical outcomes of proximal middle cerebral artery (M1) aneurysms. METHODS Between January 1999 and February 2007, 189 patients had middle cerebral artery aneurysms and 60 had M1 aneurysms. Eleven patients were excluded from this study. The aneurysms were classified into two groups (superior- and inferior-wall type). Retrospectively, we evaluated characteristics of these patients and investigated factors affecting surgical outcomes. RESULTS Of the 49 patients, 28 had ruptured aneurysms and 43 had aneurysms sized less than 10mm in diameter. There were no giant aneurysms, the incidence of multiple aneurysms was high (22 patients, 45%), and intracerebral hematomas (ICH) were recognized in 13 patients (27%). The superior-wall group included 29 patients (59.2%) and the inferior-wall group had 20 (40.8%). Overall mortality and morbidity rates were 6.1% and 24.5%, respectively. Thirty-four patients (69%) showed good outcomes (GOS 4-5). Eleven and five patients showed unfavorable outcomes from the superior- and inferior-wall group, respectively. Of the four operation-related morbidity patients, three were from the superior-wall and one from the inferior-wall group. There were no statistically significant differences with respect to clinical outcome between the superior- and inferior-wall groups. Patients with poor Hunt-Hess (H-H) grades on admission showed worse outcomes than those with good H-H grades (p=0.002) and those patients without ICH revealed better outcomes than those with ICH (p=0.004). CONCLUSIONS In patients with M1 aneurysms, clinical status on admission and the presence of ICH were significant factors for surgical outcome. Surgical morbidity seems to be related to the direction of the aneurysm. It is critical to save the lenticulostriate arteries and their branches in patients with superior-wall type aneurysms. Thorough preoperative angiographic evaluation, careful brain retraction, and meticulous inspection for hidden small branches are crucial to successful outcomes.
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Affiliation(s)
- Sung-Kon Ha
- Department of Neurosurgery, Korea University Medical Center, Seoul, Republic of Korea
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Zurada A, Gielecki J, Tubbs RS, Loukas M, Maksymowicz W, Cohen-Gadol AA, Michalak M, Chlebiej M, Zurada-Zielińska A. Three-dimensional morphometrical analysis of the M1 segment of the middle cerebral artery: potential clinical and neurosurgical implications. Clin Anat 2010; 24:34-46. [PMID: 20949492 DOI: 10.1002/ca.21051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
With an increase in the understanding of the formation and treatment of cerebral aneurysms and an improvement in imaging technology, actual standardized measurement values for the cerebral arteries are necessary. Therefore, the aim of this study was to provide a detailed assessment of the three-dimension (3D) morphology (vessel's curvature and trajectory) and 3D-morphometry of the M1 segment of the middle cerebral artery using computer tomography angiography (CTA) images. The DICOM files from CTA of 40 male and 75 female individuals with a mean age of 50.1 years were analyzed using an interactive postprocessing 3D volume-rendering algorithm. Specifically, the M1 segment was evaluated. Calculations included the length, internal diameter, volume, deviation (DI) and tortuosity indices (TI). The M1 segment had a mean internal diameter of 2.23 mm and was greater in men. M1 asymmetry was identified in 23.4% of the individuals and was more common in women. The mean length was 15.62 mm and the left M1 segments were a little longer. The mean volume of the M1 segments was 63.92 mm(3) , and this was typically greater in men and on the left sides. The mean TI and DI for the M1 segment were 0.91 and 2.17 mm, respectively. Therefore, the M1 segments are only slightly curved or straight in their course. In addition, the longest vascular M1 segments are more deviated (curved) and more tortuous. Such standardized data as presented herein may be useful in the preprocedural evaluation of patients with intracranial vascular pathology of the M1 segment.
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Affiliation(s)
- Anna Zurada
- Medical Faculty, Department of Anatomy, University of Varmia and Masuria, Olsztyn, Poland.
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Perez J, Machado C, Scherle C, Hierro D. Duplicated middle cerebral artery. BMJ Case Rep 2009; 2009:bcr06.2009.2035. [PMID: 22140405 DOI: 10.1136/bcr.06.2009.2035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion.
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Affiliation(s)
- Jesus Perez
- Hermanos Ameijeiras Hospital, Neurology, San Lazaro 701, Havana, Havana, 10300, Cuba
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Trefilio DE, Borghino VN, Montenegro VA, Aranega CI. Internal capsule: Seth of dissectors for an integral boarding of its fibers. Neurol Res 2009; 31:702-6. [PMID: 19505358 DOI: 10.1179/174313208x322789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Classically, the morphologic study of the internal capsule (IC) is made by two cuts: the coronal of Charcot and the axial of Fleschig. Recent neuroradiologic studies and clinical investigations contribute to the observation in the non-invasive form of this region. OBJECTIVE The present work tries to complement the study of this important anatomical region, demonstrating it in integral and three-dimensional form. For that reason, the channeled soundings and instruments of manicurist and odontology were modified, and were conformed to a Seth of dissectors designed specifically to approach the IC. Each dissector presents particular characteristics, which allows the delicate dissections of the different anatomical structures to be made. MATERIALS AND METHODS Twenty encephala of adult corpses were used for this investigation, fixed with a solution of formol to 10% in distilled water. They were approached at the external face of the cerebral hemisphere at level of the lateral fissure. The middle cerebral artery and the insula lobe were dissected and extirpated using the dissector no. 1, exposing the extreme capsule. The dissector no. 2 was used to dissect the fibers and the extreme capsule was extracted jointly with the claustrum, demonstrating the external capsule. The fibers were dissected using the dissector no. 3, thus exposing the lentiform nucleus. Then, the external face of the nucleus was delimited with the dissector no. 4 and then underwent exeresis, to allow for the entry of the genu of the IC. The genu constituted nervous fibers, laid out vertically and perpendicular to the greater axis the nucleus before mentioned. The fibers were dissected with the dissector no. 5, also appreciating the route of the lenticuloestriadas arteries that irrigate the region in the study. Using the dissector no. 6, nervous fibers of the corona radiata were dissected, as well as the short arciformes fibers and the endings in the cerebral cortex. Lastly, the dissector no. 7 was used to dissect the fibers of the pyramidal route and their route by the cerebral trunk, from above to below. CONCLUSION With the use of the presented instruments, a selective boarding of the IC was obtained, and thanks to the specific characteristics of each dissector, the different anatomical structures related to the IC can be approached with facility. Also, the nervous fibers that compose it can be dissected, which expose the IC in an integral and three-dimensional way.
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Affiliation(s)
- D E Trefilio
- Department of Normal Anatomy, School of Medical Sciences, National University of Córdoba, Córdoba, Argentina
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