Magnetic resonance angiographic evaluation of circle of Willis: A morphologic study in a tertiary hospital set up

Anatomical variations in the circle of Willis on magnetic resonance angiography in a south Trinidad population

Objectives

This article seeks to determine the prevalence of a complete circle of Willis (CoW) and its common morphological variations in a south Trinidad population, while also investigating the influence of gender, age, and ethnicity on CoW morphology.

Methods

A prospective, descriptive, cross-sectional study was done on the magnetic resonance images for consecutive patients who had a brain MRI/magnetic resonance angiography at a tertiary health institution in south Trinidad between October 2019 and September 2020. Patients with significant cerebrovascular disease and/or a history of prior neurosurgical intervention were excluded.

Results

A complete CoW was seen in 24.3%, with more complete circles observed in younger participants (≤45 years) and Afro-Trinidadians. No gender predilection for a complete CoW was demonstrated. The most common variations in the anterior and posterior parts of the circle were a hypoplastic anterior communicating artery (8.6%, n = 13) and bilateral aplastic posterior communicating arteries (18.4%, n = 28), respectively.

Conclusions

Significant variations exist in the CoW of a south Trinidad population with a frequency of complete in 24.3%, and more complete circles in younger patients and Afro-Trinidadians. Gender did not influence CoW morphology.

Advances in knowledge

Structural abnormalities in the CoW may be linked to future incidence of cerebrovascular diseases and should therefore be communicated to the referring physician in the written radiology report. Knowledge of variant anatomy and its frequency for a particular populations is also required by neurosurgeons and neuro-interventional radiologists to help with preprocedural planning and to minimize complications.

Evaluation of Circle of Willis variants using magnetic resonance angiography

The Circle of Willis (COW) is an important collateral pathway to protect the persistence of cerebral blood perfusion. This study aims to investigate the morphological variants of this significant vascular structure with a large study population. 867 patients who had undergone MR angiography (MRA) evaluation were enrolled in this study. The MRA images of these patients obtained by the three-dimensional time-of-flight technique were re-interpreted to measure the vessel diameters of all components of the COW and classify the COW variations. In addition, correlations of the vessel calibers and the integrity of the COW with gender and age groups were presented. There was female dominance in the study population, and the mean age was 48. Type A was the most common variation in anterior (75.78%) and posterior (53.98%) circulation. Types G and H were the other common variation in the anterior circulation, and types E and D were the second and third common variations in the posterior COW, respectively. Smaller calibration for both ICAs, both P1s and BA were observed in females compared with the male group. Diameters of the BA, and both P1 segments were lower, and the left PCom diameter was significantly higher in the patients with a complete circle. There was a significant sex and age difference regarding the distribution of the complete, partially complete, and incomplete circle groups. The significant differences in the vessel calibers of specific components of the COW for complete, partial, and incomplete circulations revealed by this study should be explained with further research. In addition, meta-analyses with other studies in the literature might be a guide to understanding the morphological alterations of the COW and their relationships with a complete and non-complete circle.

Demographic age-related variation in Circle of Willis completeness assessed by digital subtraction angiography

OBJECTIVE:

Incomplete circle of Willis (CoW) configuration is an important risk factor for cerebrovascular pathology, namely aneurysm formation and ischemic stroke. This study was performed to characterize CoW variation using digital subtraction angiography and to identify demographic and physiologic features that may influence the risk of having an incomplete CoW configuration.

MATERIALS AND METHODS:

A retrospective review of 274 patients who underwent cerebral angiography by a single surgeon for any indication was conducted. Each CoW branch was graded as normal, hypoplastic, or aplastic. Univariate and multivariate regression analyses were conducted to assess the impact of age, gender, race, and certain comorbidities on CoW configuration.

RESULTS:

A complete CoW was identified in 37.23% of patients. In univariate analysis, patients <40 years old were more likely to have a complete CoW (odds ratio [OR]: 4.973, 95% confidence interval [CI]: 2.610–9.476, P < 0.001) as were patients <70 years old (OR: 2.849, 95% CI: 1.131–7.194, P < 0.05). Univariate analysis on demographic factors and comorbidities revealed CoW completeness to decrease with hypertension (OR: 0.575, 95% CI: 0.347–0.951, P = 0.031) and diabetes mellitus (OR: 0.368, 95% CI: 0.180–0.754, P = 0.006). Multivariable logistic regression analysis used to assess the impact of age on CoW completeness showed age to be an independent predictor of complete CoW, with an inverse correlation between increasing age and CoW completeness (OR: 0.955, 95% CI: 0.937–0.973, P < 0.001) after controlling for potential confounders including hypertension and diabetes mellitus.

CONCLUSIONS:

CoW configuration shows considerable variation with age; however, further investigation is required to elucidate the full impact of other demographic and vascular risk factors on CoW anatomy.

Anatomical variants of circle of Willis

Introduction: The circle of Willis is the major source of collateral blood flow between the carotid and vertebrobasilar system. Its potential depends on the presence and size of arteries that vary greatly among normal individuals and therefore their adequate observation by a radiologist is necessary. Aim: Determine the type of the circle of Willis and their frequency. Determine the type, frequency and localization of anatomical variants of arteries, as well as their average diameter. Compare these variables according to the age and gender of the examinees. Material and methods: A retrospective study was performed at the Center for Radiology of the Clinical Center Nis during 2017. All subjects underwent CT or MR angiography according to a standard endocranial protocol. The anterior and posterior parts of the circle were specially observed, with an emphasis on the presence or absence of anatomical variants of the arteries, with the measurement of their diameter. The obtained data were classified into variants of the front or rear part of the ring as well as the type of ring according to integrity. The frequency of these variables and their comparison by sex and age were measured. Results: The research included 92 examinees. According to the configuration of the Willis arterial ring, the adult type was the most often represented (71.7%). The most common type in terms of integrity was partially complete. The most common anatomical variants obtained in our work was aplasia of AcoA (27.2%) and aplasia of one or both PCoA (21%). PcoA hypoplasia was occured in women with a frequency of 13.5% while in men it was not present. Conclusion: Adequate understanding of the morphology of the circle of Willis by radiological methods is a good guide for neurosurgical and radiological intervention procedures. In this way, potentially significant neurological complications and the risk of morbidity and mortality could be reduced.

Proportion of Variant Anatomy of the Circle of Willis and Association with Vascular Anomalies on Cerebral CT Angiography

Background and Purpose

There is a wide variation in the anatomy of the CW in different individuals and population groups. The purpose of this study was to determine the proportion of variant anatomy of the circle of Willis (CW) and associated anomalies in patients with suspected cerebrovascular disease referred for cerebral computed tomography angiography (CTA) in two tertiary hospitals in Kenya.

Methodology

This was a cross-sectional descriptive study conducted on 94 patients referred for cerebral CTA at the Kenyatta and Nairobi hospitals from August 2017 to February 2018. MIP and 3D reformatted images were analyzed by two senior radiologists to determine the final configuration of the CW and presence of vascular pathology. Vessels with diameters <0.8 mm were considered to be absent or hypoplastic. Chen et al. classification was used to determine the final configuration of CW.

Results

Complete CW was seen in 37.2% (37.7% vs. 36.6% in males and females, respectively, p=0.909). Type A variant was the commonest anterior variant at 78.7%. Type E variant was the dominant posterior variant at 41.5%. Fetal PCA was demonstrated in 25.5%, unilateral > bilateral fetal PCA. Aneurysms were seen in 24.5% of patients. ACoA aneurysms were commonest at 43.6%. AVMs were seen in 8.5% of patients. Azygous ACA, fenestration, and duplication of vessels and persistent TA were not demonstrated. There is no significant association between aneurysms/AVMs and CW configuration.

Conclusion

The findings in this study demonstrate slight differences in the CW configuration. A higher proportion of complete anterior CW was seen in female patients. Type A anterior and type E posterior circulation variants were the commonest in both males and females. No significant association was demonstrated between CW configuration and occurrence of aneurysms/AVMs in this study. Various methods of classification of CW configuration have been proposed with no standardized method to date, thus the need for consensus building between neuroanatomists, neurologists, neurosurgeons, and neuroradiologists for ease of comparison between similar future studies on the CW.

Genetic and Environmental Contributions to Variation in the Posterior Communicating Collaterals of the Circle of Willis

Variation in blood flow mediated by the posterior communicating collateral arteries (PComs) contributes to variation in the severity of tissue injury in obstructive disease. Evidence in animals and humans indicates that differences in the extent of PComs, i.e., their anatomic lumen diameter and whether they are present bilaterally, unilaterally, or absent, are a major factor. These differences arise during development since they are present at birth. However, the causal mechanisms are unknown. We used angiography after maximal dilation to examine involvement of genetic, environmental, and stochastic factors. The extent of PComs varied widely among seven genetically diverse strains of mice. Like pial collaterals in the microcirculation, aging and hypertension reduced PCom diameter, while in contrast, obesity, hyperlipidemia, metabolic syndrome, and diabetes mellitus had no effect. Naturally occurring intrauterine growth restriction had no effect on extent of PCom or pial collaterals in the adult. The number and diameter of PComs evidenced much larger apparent stochastic-dependent variation than pial collaterals. In addition, both PComs underwent flow-mediated outward remodeling after unilateral permanent MCA occlusion that varied with genetic background and was greater on the ipsilesional side. These findings indicate that variation in the number and diameter of PCom collateral arteries arises from stochastic factors and naturally occurring genetic variants that differ from those that cause variation in pial collateral arterioles. Environmental factors also contribute: aging and hypertension reduce PCom diameter. Our results suggest possible sources of variation of PComs in humans and provide information relevant when studying mouse models of occlusive cerebrovascular disease.

Spatially extended versus frontal cerebral near-infrared spectroscopy during cardiac surgery: a case series identifying potential advantages

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.

Association between patency of the circle of Willis and diabetes mellitus in patients with cerebral ischaemic stroke

Objective To examine patency of the cerebral anterior and posterior communicating arteries in patients with ischaemic stroke with or without diabetes mellitus. Methods This retrospective study included patients with acute ischaemic stroke treated between July 2011 and May 2016. Cerebral infarction was evaluated by magnetic resonance imaging. Anterior and posterior communicating-artery patency was determined using magnetic resonance angiography. Vessels were defined as patent or occluded. Results Out of 1 406 patients, incidence of vertebral basilar artery brain infarction and posterior cerebral artery brain infarction were significantly higher in patients with diabetes versus those without diabetes (35.5% versus 22.3% and 11.7% versus 6.8%, respectively). Among patients with posterior cerebral artery brain infarction, anterior and posterior communicating-artery patency rates were higher in patients with diabetes versus those without diabetes (66.7 versus 23.5% and 33.3% versus 5.9% [bilateral], respectively). Among patients with vertebral basilar artery infarction and posterior cerebral artery P1 segment infarction, patency rate of the anterior communicating artery was higher in patients with diabetes versus those without diabetes (55.7% versus 45.9%). Conclusion Among patients with ischaemic stroke, patency rate of the circle of Willis may be higher in patients with diabetes than those without diabetes.