Anterior Cerebral Artery Territory Research Articles

The interpositional bypass with a parietal branch of superficial temporal artery graft for symptomatic atherosclerotic anterior cerebral artery stenosis or occlusion.

For nonmoyamoya patients with anterior cerebral artery (ACA) stenosis or occlusion, whether direct revascularization of the ACA territory can prevent stroke is still unclear. The objective of this study was to investigate the efficacy and safety of a parietal branch of superficial temporal artery-interposed superficial temporal artery-to-ACA bypass (PISAB) for preventing stroke in patients with symptomatic atherosclerotic ACA stenosis or occlusion (SAASO). We retrospectively analyzed the data from patients with SAASO who had undergone PISAB in our center between April 2016 and November 2021. The rates of patency, satisfaction (revascularization grades A and B) of bypass, perioperative complications, recurrence of ischemic stroke, changes in bypass flow, and improvements in cerebral blood perfusion were analyzed. A total of 19 SAASO patients were involved in this study. Sixteen out of 19 (84.2%) patients were free from any cerebral ischemic events after surgery. Only 3 patients (15.8%) had recurrent stroke postoperatively. Two (10.5%) surgery-related complications occurred, including hyperperfusion syndrome and minor stroke. No skin ischemic complications occurred. The average follow-up period was 50.6 ± 18.3 months. The flow rate of the bypass was significantly increased half a year after surgery (56.2 ± 8.0 mL/min vs. 44.3 ± 5.3 mL/min, p < 0.001). The ratio of ipsilateral/contralateral mean transit time in the superior frontal gyrus was decreased significantly after bypass (1.08 ± 0.07 vs. 1.23 ± 0.05, p < 0.001) and continued to decrease 6 months after surgery (1.05 ± 0.04 vs. 1.08 ± 0.07, p = 0.002). The patency rate of PISAB was 94.7% (18/19) 2 years after surgery. The satisfaction rate of bypass was 89.5% (17/19). The results of this study indicate that PISAB, as a safe superficial bypass, can effectively reduce the risk of stroke in SAASO patients. More precise conclusions will require randomized control studies.

Case report: Three characteristics of tyrosine kinase inhibitor-associated cerebrovascular stenosis. High threshold for infarction, atypical infarct area, and vascular recoverability under the use of ponatinib

While tyrosine kinase inhibitors (TKI)-associated cerebral vascular stenosis (CVS) exhibit distinct mechanisms compared to conventional stroke in basic research, the clinical strategy remains nearly the same other than TKI-switching. We present the case of a 22-year-old female with chronic myeloid leukemia without stroke risk factors, who developed ponatinib-associated CVS. Three potential characteristics of TKI-associated CVS were identified: a heightened threshold for infarction, an atypical infarct area, and vascular recoverability. Specifically, brain computed tomography remained normal despite 20 h of severe hemiplegia. The ischemic distribution was confined in gray matter and the anterior cerebral artery territory on magnetic resonance imaging, despite severe stenosis of the internal carotid artery. Ischemic changes resolved within 10 days and arterial stenosis improved after ponatinib withdrawal. These unique features, distinct from typical stroke, could lead to misdiagnosis as non-organic neurological disorders or other conditions in ponatinib-treated patients.

Moyamoya Syndrome in a Child with Beta-Thalassemia Trait: A Case Report with Review of Literature

Background: The association of moyamoya angiopathy with hematological conditions such as sickle cell anemia and beta-thalassemia major or intermedia is well-known, but moyamoya syndrome (MMS) associated with thalassemia trait is hardly reported. We report such a rare association. Clinical Description: A 7-year-old boy presented with right-sided monoparesis with right-sided focal seizures, along with right-sided upper motor neuron type facial nerve palsy. He had a history of recurrent transient episodes of limb weakness, which were unevaluated. Examination revealed pallor and mild splenomegaly. Management and Outcome: Routine investigations revealed microcytic hypochromic anemia with normal serum iron levels. High-performance liquid chromatography was suggestive of beta-thalassemia trait. Contrast-enhanced computerized tomography of the head showed infarction in the territory of the left anterior cerebral artery (ACA) and middle cerebral artery (MCA). Magnetic resonance angiography revealed significantly attenuated bilateral internal carotid arteries in the supraclinoid region with attenuated bilateral ACA and bilateral MCA along with collateral formation suggestive of moyamoya angiopathy. The final diagnosis of MMS secondary to beta-thalassemia trait was made. The child improved with aspirin and supportive management. Conclusion: MMS can be rarely associated with the beta-thalassemia trait. Such an underlying, unsuspected heterozygous beta-thalassemia (trait) may be diagnosed only after the identification of moyamoya disease following a stroke.

319 A Case Series of Direct Multi-territory Cerebral Revascularizations Using a Three-Vessel Anastomosis

INTRODUCTION: The ability to perform simultaneous, multi-territory cerebral bypass using a single interposition graft has significant utility for the revascularization of multiple cerebral territories that would otherwise require multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. METHODS: Peri-operative data and outcomes were collected retrospectively for patients undergoing multi-territory cerebral revascularization using a three-vessel anastomosis over a 4-year period (2019-2023). RESULTS: Five patients underwent triple vessel bypass (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery (MCA) aneurysms (one ruptured) were treated multi-territory external carotid artery (ECA)-M2-M2 revascularization using a saphenous vein interposition graft, followed by either proximal ligation or partial/complete aneurysm clip trapping. Two patients with predominately bilateral anterior cerebral artery (ACA) territory moyamoya disease were treated with proximal superficial temporal artery (STA)-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap (RAFF) graft. Bypass patency was 100% and zero patients experienced surgery-related ischemia. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for a post-operative hematoma and RAFF debridement that did not affect bypass patency or neurologic outcome. Median Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores on discharge were 4 (range 3-5) and 2 (range 0-5), respectively. GOS and mRS scores were stable or improved on follow up in 4/5 patients; one patient died from medical complications of their original stroke. CONCLUSIONS: In experienced hands, three-vessel anastomosis can be a viable option for the safe, simultaneous revascularization of multiple ACA and MCA territories.

Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Unilateral Moyamoya Disease Using Quantitative Magnetic Resonance Angiography.

Moyamoya disease (MMD) is a chronic steno-occlusive disease of the intracranial circulation that depends on neoangiogenesis of collateral vessels to maintain cerebral perfusion and is primarily managed with cerebral revascularization surgery. A quantitative assessment of preoperative and postoperative collateral flow using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA) was used to illustrate the impact of revascularization on cerebral flow distribution. A retrospective review of patients with unilateral MMD who underwent direct, indirect, or combined direct/indirect cerebral revascularization surgery was conducted between 2011 and 2020. Using NOVA, flow was measured at the anterior cerebral artery (ACA), ACA distal to the anterior communicating artery (A2), middle cerebral artery (MCA), posterior cerebral artery (PCA), and PCA distal to the posterior communicating artery (P2). Pial flow (A2 + P2) and collateral flow (ipsilateral [A2 + P2])-(contralateral [A2 + P2]) were measured and compared before and after revascularization surgery. Total hemispheric flow (MCA + A2 + P2) with the addition of the bypass graft flow postoperatively was likewise measured. Thirty-four patients with unilateral MMD underwent cerebral revascularization. Median collateral flow significantly decreased from 68 to 39.5 mL/min (P = .007) after bypass. Hemispheres with maintained measurable bypass signal on postoperative NOVA demonstrated significant reduction in median collateral flow after bypass (P = .002). Median total hemispheric flow significantly increased from 227 mL/min to 247 mL/min (P = .007) after bypass. Only one patient suffered an ipsilateral ischemic stroke, and no patients suffered a hemorrhage during follow-up. NOVA measurements demonstrate a reduction in pial collateral flow and an increase in total hemispheric flow after bypass for MMD, likely representing a decrease in leptomeningeal collateral stress on the distal ACA and PCA territories. Further studies with these measures in larger cohorts may elucidate a role for NOVA in predicting the risk of ischemic and hemorrhagic events in MMD.

Brain volume measured by synthetic magnetic resonance imaging in adult moyamoya disease correlates with cerebral blood flow and brain function

Moyamoya disease (MMD) is characterized by progressive arterial occlusion, causing chronic hemodynamic impairment, which can reduce brain volume. A novel quantitative technique, synthetic magnetic resonance imaging (SyMRI), can evaluate brain volume. This study aimed to investigate whether brain volume measured with SyMRI correlated with cerebral blood flow (CBF) and brain function in adult MMD. In this retrospective study, 18 adult patients with MMD were included. CBF was measured using iodine-123-N-isopropyl-p-iodoamphetamine single photon emission computed tomography. Cerebrovascular reactivity (CVR) to acetazolamide challenge was also evaluated. Brain function was measured using the Wechsler Adult Intelligence Scales (WAIS)-III/IV and the WAIS-R tests. Gray matter (GM), white matter, and myelin-correlated volumes were evaluated in six areas. Resting CBF was positively correlated with GM fractions in the right anterior cerebral arterial and right middle cerebral arterial (MCA) territories. CVR was positively correlated with GM fraction in the right posterior cerebral arterial (PCA) territory. Full-Scale Intelligence Quotient and Verbal Comprehension Index scores were marginally positively correlated with GM fractions in the left PCA territory. Processing Speed Index score was marginally positively correlated with GM fraction in the right MCA territory. The SyMRI-measured territorial GM fraction correlated with CBF and brain function in patients with MMD.

Abstract TP40: Identification of Domain-Specific Cognitive Phenotypes of Post Stroke Vascular Contributions to Cognitive Impairment and Dementia

Introduction: Vascular contributions to cognitive impairment and dementia (VCID) are variably expressed following stroke. The purpose of this investigation is to identify the domain-specific cognitive phenotypes of VCID in the acute and sub-acute post-stroke interval measured using the Mark VCID battery. Methods: Mark VCID neurocognitive test battery was administered to 33 patients with incident ischemic stroke in the left (n=15), right (n=17), and bilateral (n=1) hemispheres including the anterior and middle cerebral artery territory, and 39 age and sex matched healthy controls (HC). Participants ranged in age from 42 to 88 years (Patient M=65.64 yrs, Control M=64.97 yrs). Patient group consisted of 17 males and 22 females, and the control group had 20 males and 13 females. Mean post stroke interval was 8 weeks (Range: 2.5 to 19 weeks). The test battery assessed: language (naming, fluency), perception (facial recognition, spatial orientation), psychomotor speed (digit symbol substitution), memory (word list, story recall), and attention (trails, number span). Normative test scores were converted to z-scores for assessment of between group differences using independent t-tests. Results: Patients with stroke performed significantly worse (p&lt;0.05) than HCs on measures of language (semantic and phonemic fluency), perception (facial recognition and spatial orientation), and psychomotor speed (symbol digit modalities test) (Figure 1). There were no significant group differences in the scores of memory (Hopkins Verbal Learning, Craft Story) and attention tracking (Oral Trails A, Number Span). Conclusion: Cognitive abnormalities in these acute stoke patients represent impairments in diverse dominant (language) and non-dominant (perceptual/spatial) hemisphere cortical and subcortical (psychomotor speed) abilities. At the group level, the findings suggest a phenotype of VCID in patients with acute middle and anterior cerebral artery ischemic stroke.

Assessment of Collateral Flow in Patients with Carotid Stenosis Using Random Vessel-Encoded Arterial Spin-Labeling: Comparison with Digital Subtraction Angiography.

Collateral circulation plays an important role in steno-occlusive internal carotid artery disease (ICAD) to reduce the risk of stroke. We aimed to investigate the utility of planning-free random vessel-encoded arterial spin-labeling (rVE-ASL) in assessing collateral flows in patients with ICAD. Forty patients with ICAD were prospectively recruited. The presence and extent of collateral flow were assessed and compared between rVE-ASL and DSA by using Contingency (C) and Cramer V (V) coefficients. The differences in flow territory alterations stratified by stenosis ratio and symptoms, respectively, were compared between symptomatic (n = 19) and asymptomatic (n = 21) patients by using the Fisher exact test. Good agreement was observed between rVE-ASL and DSA in assessing collateral flow (C = 0.762, V = 0.833, both P < .001). Patients with ICA stenosis of ≥90% were more likely to have flow alterations (P < .001). Symptomatic patients showed a higher prevalence of flow alterations in the territory of the MCA on the same side of ICAD (63.2%), compared with asymptomatic patients (23.8%, P = .012), while the flow alterations in the territory of anterior cerebral artery did not differ (P = .442). The collateral flow to MCA territory was developed primarily from the contralateral internal carotid artery (70.6%) and vertebrobasilar artery to a lesser extent (47.1%). rVE-ASL provides comparable information with DSA on the assessment of collateral flow. The flow alterations in the MCA territory may be attributed to symptomatic ICAD.

Intellectual function and memory in children with moyamoya disease: relationship between Wechsler Intelligence Scale and Benton Visual Retention Test scores and regional cerebral blood flow.

Intellectual function declines in about 30% of children with moyamoya disease (MMD). Memory function underpins higher order brain function, but the relationship between intellectual function and memory in pediatric MMD patients has not been well studied. This study aimed to investigate correlations between scores on the Wechsler Intelligence Scale for Children (WISC) and the Benton Visual Retention Test (BVRT), a visual memory test that can be administered to children, in children with MMD. Relationships between intellectual function or memory and regional cerebral blood flow (rCBF) have also not been well clarified in pediatric MMD patients. The authors also investigated associations between WISC or BVRT scores and rCBF in various brain regions. WISC and BVRT scores and rCBF were assessed in 17 children with ischemic-onset MMD before revascularization. Single-photon emission CT with 123I-iodoamphetamine was used to measure rCBF. Relationships between WISC and BVRT scores were evaluated using Spearman's correlation coefficient and multivariate linear regression analysis. Cutoff values were identified for BVRT scores. Sensitivity and specificity were calculated to predict full-scale intelligence quotient (FSIQ) > 85 or ≤ 85. Associations between rCBF and WISC or BVRT scores were evaluated using linear regression analysis. BVRT scores were significantly correlated with FSIQ and scores on the Working Memory Index (WMI), Processing Speed Index, and Verbal Comprehension Index (VCI)/Verbal Intelligence Quotient (VIQ) of WISC. Multivariate linear regression revealed that number correct score and number of errors score of BVRT were associated with FSIQ. As cutoff values, a number correct score of 5 and a number of errors score of 8 offered the most reliable predictors of FSIQ > 85 and ≤ 85, respectively. FSIQ correlated positively with rCBF in the right and left hemispheres, right and left ganglia, right and left thalamus, right and left cerebellum, right middle cerebral artery (MCA) territory, pons, and vermis. WMI score was positively associated with rCBF in the right hemisphere, right anterior cerebral artery territory, right MCA territory, right basal ganglia, right and left thalamus, right and left cerebellum, pons, and vermis. BVRT score correlated well with WISC index scores, suggesting that BVRT may be helpful in screening for intellectual impairments in children with MMD. In the MCA territory, basal ganglia, thalamus, cerebellum, pons, and vermis, rCBF associated well with WISC index scores, suggesting that reduced rCBF in relevant brain regions may influence intellectual function.

Study of Cerebral Hemispheric Lateralization in Stroke and the Arterial Territories Involved in High-risk Patients

Introduction: According to WHO, Stroke is the 2nd leading cause of death and disability after Ischemic heart disease. Prevalence rate of stroke in India varies from 44.45 to 150 per lakh population. Studies have reported a higher frequency of stroke of the left hemisphere. The artery reported to be the most affected is Left Middle Cerebral artery(MCA) followed by Right Middle Cerebral artery. The aim of this study is to determine the side of cerebral hemisphere most affected by stroke and the arterial territories involved in high-risk patients aged above 35 years presenting to the tertiary healthcare centre, as well as to study the sex predilection of stroke. Materials and Methods: A cross-sectional prospective study of 50 high risk stroke patients with Diabetes Mellitus(DM) and /or Hypertension(HTN) presenting to General medicine OPD of a tertiary healthcare centre were investigated with CT/MRI for the side of the cerebral hemisphere affected and the arterial territories involved. The data was tabulated over the course of three months and statistical analysis was carried out. Results: The left cerebral hemisphere was affected in 50%, right in 40% and bilateral involvement was found in 10% patients. Slight predilection of stroke towards the left was seen, however it was not found to be statistically significant (P-value= 0.249). MCA territory was involved in 66% of the patients, Posterior Cerebral Artery(PCA) territory in 8%, Vertebrobasilar Artery(VB) territory in 8%, Anterior Cerebral Artery(ACA) territory in 6% and MCA+ACA in 4%, MCA+VB in 2% and MCA-PCA watershed in 6% patients. Conclusions: We found a slight predilection of stroke towards the left, which was however, not found to be statistically significant. We also found that Middle Cerebral Artery(MCA) territory is the most commonly involved in stroke.

Long-term prognostic value of [15O]H2O PET imaging in patients suspected for cerebral hemodynamic insufficiency

ObjectivesQuantitative regional cerebral perfusion (rCBF) measurements using [15O]H2O PET with arterial cannulation and acetazolamide (ACZ) challenge have been reserved to identify high-risk patients that are candidates for by-pass operation. We aimed to assess the prognostic value of various parameters in quantitative [15O]H2O PET measurements in patients not subsequently undergoing surgery. MethodsWe identified 32 eligible patients who underwent [15O]H2O brain PET imaging for suspicion of hemodynamic insufficiency between 2009 and 2020. Cerebrovascular events were defined as new ischemic lesions on MRI, stroke, transient ischemic attack, vascular dementia. Follow-up period was 91 months (range: 26-146). rCBF before (rCBFbase) and after (rCBFacz) ACZ challenge and the relative increase (CVR), were examined in the anterior (ACA), middle (MCA), and posterior (PCA) cerebral artery territories of the affected hemisphere, and the most recent MRI scans were scored for infarcts and white matter lesions. ResultsReceiver operating characteristic (ROC) curve analysis showed higher prognostic accuracy for rCBFacz(AUC:0.82) compared to CVR (AUC:0.72) and rCBFbase (AUC:0.77). ROC AUC, optimal thresholds (and corresponding sensitivity/specificity/accuracy) for rCBFacz after ACZ in individual territories were 0.79 and 37.8 mL 100g−1 min−1 (0.81/0.63/0.72) for the ACA, 0.84 and 32 mL 100g−1 min−1 (0.81/0.75/0.78) for the MCA, and 0.70 and 43.9 ml/(mL 100g−1 min−1 (0.81/0.43/0,62) for the PCA. Kaplan Meier survival curve showed longer event-free survival in patients with rCBFacz below cut-off (p=0.007). In multivariate analysis rCBFacz remained a significant predictor when correcting for age. ConclusionQuantitative rCBF measurements after ACZ challenge with [15O]H2O PET provided high prognostic value for future cerebrovascular events.

Abstract 117: Digitally Subtracted Angiogram &amp; Biopsy Negative Recurrent Spontaneous Bilateral Anterior Cerebral Artery Territory Intracranial Hemorrhage

Introduction Up to 18% of spontaneous intracerebral hemorrhages are cryptogenic despite a thorough workup, usually noted in a lobar location. Although undetected on DSA, a significant proportion of these represent ruptured micro‐AVM/AVF or cavernous malformations that ultimately are amenable to surgical resection if detected on biopsy. However, occult cerebral amyloid angiopathy can also present similarly, and their management is markedly different. Methods We present a case of recurrent bilateral medial frontal hemorrhage in a patient without known cerebrovascular disease that evaded diagnosis despite hematologic evaluation, MRI, CTA, two DSAs, three clot evacuations with pathology, and brain biopsy. Results The patient is a 60‐year‐old previously healthy woman who presented with sudden onset right hemiparesis and speech arrest. CT revealed a left parasagittal hemorrhage. She was brought to the OR for clot evacuation. Pathology from the clot revealed blood vessels of multiple sizes consistent with meningeal vessels or underlying AVM/AVF. A 6‐vessel cerebral angiogram as unremarkable. The patient’s inpatient course was complicated by new onset Afib with RVR and asymptomatic DVT with PE, however no etiology of coagulopathy was detected. MRI brain showed no evidence of cerebral microbleed or other underlying pathology, noting only DWI + FLAIR hyperintensity in the left ACA territory. The patient was diagnosed with ACA territory stroke complicated by PH2‐type hemorrhagic conversion. She was initially placed on IV Heparin, before transition to apixaban uneventfully. She continued to recover in the hospital and was eventually discharged to rehab. She re‐presented 1 month later with worsening behavioral arrest and right hemiparesis. CT head revealed recurrence of left parasagittal ICH. She underwent clot evacuation in the OR again and repeat pathology was unrevealing. A repeat MRI showed only the evident bleed and a subtle hyperintensity in the right occipital cortex suspicious for an interval subacute occipital lobe stroke with laminar necrosis, ostensibly from Afib. She improved clinically and was discharged to rehab with a diagnosis of recurrent hemorrhage attributed to anticoagulant use and recent stroke. She was discharged this time on no anticoagulant or antiplatelets. She re‐presented 1 month later with sudden onset speech arrest, but now with left hemiparesis. CT revealed a right parasagittal hemorrhage. She was brought to the OR for emergent clot evacuation and parenchymal biopsy – which was initially normal. A repeat 6‐vessel DSA was again unremarkable as was repeat brain MRI. The patient’s parenchymal biopsy was sent for specific congo‐red and immunohistochemistry for beta‐amyloid. IHC revealed beta‐amyloid plaques in the parenchyma and vessel walls, confirming a diagnosis of CAA. Conclusion Apparently cryptogenic lobar hemorrhage may be caused by both occult micro‐AVM/fistula and CAA. As in this case, when a patient experiences recurrent DSA negative lobar hemorrhages, biopsy should be pursued. This case was particularly challenging given the anatomical plausibility of parasagittal AVM/fistula given its midline location and venous drainage, considering the patient’s evident predisposition to systemic venous thrombosis hemorrhagic venous infarction mimicking lobar ICH is also possible. We present this case to raise awareness of the potential need for early biopsy, especially in patients who may also require anticoagulation or antiplatelet medications.

The role of leptomeningeal collaterals in redistributing blood flow during stroke.

Leptomeningeal collaterals (LMCs) connect the main cerebral arteries and provide alternative pathways for blood flow during ischaemic stroke. This is beneficial for reducing infarct size and reperfusion success after treatment. However, a better understanding of how LMCs affect blood flow distribution is indispensable to improve therapeutic strategies. Here, we present a novel in silico approach that incorporates case-specific in vivo data into a computational model to simulate blood flow in large semi-realistic microvascular networks from two different mouse strains, characterised by having many and almost no LMCs between middle and anterior cerebral artery (MCA, ACA) territories. This framework is unique because our simulations are directly aligned with in vivo data. Moreover, it allows us to analyse perfusion characteristics quantitatively across all vessel types and for networks with no, few and many LMCs. We show that the occlusion of the MCA directly caused a redistribution of blood that was characterised by increased flow in LMCs. Interestingly, the improved perfusion of MCA-sided microvessels after dilating LMCs came at the cost of a reduced blood supply in other brain areas. This effect was enhanced in regions close to the watershed line and when the number of LMCs was increased. Additional dilations of surface and penetrating arteries after stroke improved perfusion across the entire vasculature and partially recovered flow in the obstructed region, especially in networks with many LMCs, which further underlines the role of LMCs during stroke.

Heritability of cerebral blood flow in adolescent and young adult twins: an arterial spin labeling perfusion imaging study.

Blood perfusion is a fundamental physiological property of all organs and is closely linked to brain metabolism. Genetic factors were reported to have important influences on cerebral blood flow. However, the profile of genetic contributions to cerebral blood flow in adolescents or young adults was underexplored. In this study, we recruited a sample of 65 pairs of same-sex adolescent or young adult twins undergoing resting arterial spin labeling imaging to conduct heritability analyses. Our findings indicate that genetic factors modestly affect cerebral blood flow in adolescents or young adults in the territories of left anterior cerebral artery and right posterior cerebral artery, with the primary contribution being to the frontal regions, cingulate gyrus, and striatum, suggesting a profile of genetic contributions to specific brain regions. Notably, the regions in the left hemisphere demonstrate the highest heritability in most regions examined. These results expand our knowledge of the genetic basis of cerebral blood flow in the developing brain and emphasize the importance of regional analysis in understanding the heritability of cerebral blood flow. Such insights may contribute to our understanding of the underlying genetic mechanism of brain functions and altered cerebral blood flow observed in youths with brain disorders.

Delayed intraoperative rupture of clipped aneurysm during the awaking from anaesthesia

Introduction. Intraoperative rupture (IOR) of an aneurysm is a frightful complication that causes significant morbidity and mortality worldwide. IOR can be attributed to various parameters, including hypertension, increased intracranial pressure (ICP), fragility of the vessels, and inadequate anaesthesia. IOR due to insufficient anaesthesia is scarcely reported in the literature. Here, we describe a re-ruptured anterior communicating artery (ACoA) after incomplete clipping of the neck during craniotomy closure due to unintended early wake-up from anaesthesia with a discussion about the management. Case description. A 38-year-old male suddenly developed a severe headache, a brief loss of consciousness, and vomiting. Computed tomography (CT) scan showed a subarachnoid haemorrhage in the basal cistern. CT angiography showed a bilobed right ACoA aneurysm with a wide neck and Murphy's teat. The patient was considered for surgery. Clipping of the aneurysm neck was done through two curved clips. During craniotomy closure, the patient started coughing and gagging then a huge IOR was encountered. These events can be mainly attributed to unintended inadequate anaesthesia, particularly muscle relaxants. The bleeding ceased after two suction catheters were inserted, temporary clips were applied, and the readjustment of permanent clips. After surgery, the patient showed a left-sided weakness. His postoperative CT scan showed a right distal anterior cerebral artery (ACA) territory infarction. The weakness improved in the follow-up period. Conclusion. Delayed IOR due to early awaking from anaesthesia should be considered a potential source of complications and bad outcomes in aneurysm surgery.

The application of high-resolution vessel wall imaging in the in situ bypass surgeries for complex anterior cerebral artery aneurysms

ObjectiveComplex anterior cerebral artery (ACA) aneurysms are still technically challenging to treat. Bypass surgery is needed to achieve aneurysm obliteration and ACA territory revascularization. Severe atherosclerosis of aneurysm walls can cause clip slippage, intraoperative rupture, postoperative ischemic events. How to assess the atherosclerotic changes in vascular walls by high-resolution vessel wall magnitude resonance imaging (VWI) is the key question in complex ACA aneurysm surgical management. MethodsThis retrospective single-center study included eight patients diagnosed with complex anterior cerebral arteries admitted to our hospital for bypass surgery from January 2019 to April 2022. We discussed the application of VWI in aneurysms treated with in situ bypass and reviewed previous experience of revascularization strategies for complex ACA aneurysms. ResultsIn this study, we treated 8 cases of complex ACA aneurysms (3 communicating aneurysms/5 postcommunicating aneurysms) over the prior one year. In situ side-to-side anastomosis (1 A2-to-A2/6 A3-to-A3) was performed in seven cases, and trapping combined with excision was performed in another case. Following bypass, complete trapping was performed in 4 cases, and proximal clipping was performed in 3 cases. No surgery-related neurological dysfunctions were observed. The final modified Rankin scale was 0 in seven of the eight cases and 2 in one case. ConclusionHigh-resolution VWI, as a favorable preoperative assessment tool, provides insight into patient-specific anatomy and microsurgical options before operations, which can help neurosurgeons develop individualized and valuable surgical plans.

June 2023 Stroke Highlights.

June 2023 Stroke Highlights.

Two‐Piece Craniotomy Is Associated With Improved Postoperative Outcomes of Combined Revascularization in Patients With Moyamoya Disease

Background Revascularization for both anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories in patients with moyamoya disease is often performed in a single operation. The influence of craniotomy type on postoperative outcomes has not been investigated. This study aimed to clarify the effects of craniotomy type on acute postoperative outcomes after combined revascularization by comparing 2‐piece, and large 1‐piece craniotomy approaches. Methods This retrospective study included 337 consecutive combined revascularizations of the ACA and MCA territories in patients with moyamoya disease. Surgeries were classified into 2‐piece and large 1‐piece craniotomy groups. For indirect bypass, the following methods were used: (1) large 1‐piece craniotomy and encephalo‐myo‐galeo‐periosteal‐synangiosis for the MCA and ACA territories; (2) 2‐piece craniotomy and encephalo‐myo‐synangiosis for the MCA territory and encephalo‐periosteal‐synangiosis for the ACA territory. Acute postoperative outcomes were compared between the groups. Results Two‐piece and large 1‐piece craniotomies were performed in 230 and 107 patients, respectively. The incidence of radiological and symptomatic infarction tended to be lower in the 2‐piece craniotomy group than that in the large 1‐piece craniotomy group (3.9% versus 11.2%; P =0.014, and 2.6% versus 6.5%; P =0.12, respectively). Logistic regression adjusted for potential confounders further explained the relationship between craniotomy type and radiological infarction (large 1‐piece/2‐piece craniotomy: odds ratio, 3.1; 95% CI, 1.2–7.6; P =0.015). Conclusion In combined revascularization of the ACA and MCA territories in moyamoya disease, 2‐piece craniotomy may reduce the risk of postoperative cerebral infarction.

Spontaneous Paradoxical Improvement of Motor Function after a Second Stroke (P2-5.009)

<h3>Objective:</h3> Describe paradoxical improvement of the motor function after a second stroke located in the area of the first stroke. <h3>Background:</h3> Animal studies have shown that humoral factors induced by acute stroke facilitate recovery more if rehabilitation is commenced earlier than later. Moreover, a second stroke may improve recovery from the first stroke. It is unknown if this phenomenon occurs in humans. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> 53-year-old right-handed woman with a history of hypertension and ischemic stroke 2 years before, with residual left hemiplegia, and post-stroke epilepsy presented with acute onset of mild weakness and numbness of the right arm and leg. Neurological examination revealed mild weakness and numbness of the left face, power of 4/5 and 5/5 in the right arm and leg respectively, and 0/5 in the left arm and leg. Sensation to light touch and pin was decreased in the left arm and leg. Vibration was decreased on left and proprioception was impaired distally bilaterally. Reflexes were 1+ at right triceps and biceps, 2+ at right patella, 3+ at left triceps, biceps, patella, and 0 at ankle bilaterally. Next day, she developed dysarthria and the power of right limbs decreased to 2/5. By the third day, dysarthria and right hemiparesis resolved. Additionally, the patient noted spontaneous increased power of the proximal left side to 3/5 in both arm and leg. However, distally, power remained 0/5 in both left arm and leg. MRI demonstrated acute infarction located in the center of a chronic infarct corresponding to the territory of right anterior cerebral artery. CT angiogram showed right anterior cerebral artery occlusion. <h3>Conclusions:</h3> The patient had spontaneous paradoxical improvement of the motor deficit after a second stroke. There is no similar case report in humans. This may confirm the limited window of improved recovery triggered by another stroke. <b>Disclosure:</b> Mr. Li has nothing to disclose. Dr. Bloch has nothing to disclose. Dr. Baek has nothing to disclose. Dr. Sivakumar has nothing to disclose. Dr. Hiana has nothing to disclose. Dr. Marchidann has stock in Eli Lilly. Dr. Marchidann has stock in Pfizer. Dr. Marchidann has stock in Merck. Dr. Marchidann has stock in Illumina. Dr. Marchidann has stock in Aeterna Zentaris. Dr. Marchidann has stock in Abbot. Dr. Marchidann has received publishing royalties from a publication relating to health care. Dr. Marchidann has received publishing royalties from a publication relating to health care.

Iron Deficiency Anemia and Ischemic Stroke in Premenopausal Women (P14-5.022)

<h3>Objective:</h3> We describe three young women with iron deficiency anemia who developed ischemic strokes in the absence of typical risk factors. <h3>Background:</h3> Ischemic stroke is the third leading cause of death in women. Women have unique risk factors for ischemic stroke. Iron deficiency anemia disproportionately affects premenopausal women and has previously been identified to be associated with ischemic stroke. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 39-year old woman with hypertension and menorrhagia presented with left leg weakness and dizziness. Labs revealed a hemoglobin of 5.9g/dL, a unremarkable hypercoagulable work up, transesophageal echo, urine toxicology, rheumatological evaluation, and MRA brain vessel wall imaging. An ultrasound of her uterus revealed a pelvic fibroid measuring 6.5cm and MRI brain revealed a small right anterior cerebral artery territory infarction. A 46-year-old woman with chronic iron deficiency anemia with a hemoglobin of 6.8g/dL who presented with left mild sided weakness and was found to have a right MCA M3 occlusion by CT angiography of the head. She received intravenous tenecteplase and underwent decompressive craniectomy for a right temporal infarct associated with cerebral edema seen on MRI brain. Investigations revealed a normal hemoglobin electrophoresis, urine toxicology, hypercoagulable evaluation, rheumatological evaluation and transesophageal echo. A 43 year old woman presented with diplopia secondary to a vertical gaze palsy. MRI brain revealed an infarct in the left thalamus, cerebral peduncle, and midbrain. Cerebral angiography, transesophageal echocardiogram, urine toxicology, rheumatological evaluation, and hypercoagulable work up were unremarkable. Hemoglobin was 7.2g/dL on presentation and an EGD revealed an antral and duodenal ulcer. All three patients received packed RBC transfusions, iron replacement therapy and discontinuation of aspirin until hemoglobin stabilized. <h3>Conclusions:</h3> Iron deficiency anemia may be an important yet under-recognized risk factor for acute ischemic stroke and should be treated aggressively in premenopausal women. Further studies are warranted. <b>Disclosure:</b> Dr. Imam has nothing to disclose. Dr. Salahuddin has nothing to disclose.