Anterior Cerebral Artery Territory Research Articles

3D GRASE pulsed arterial spin labeling at multiple inflow times in patients with long arterial transit times: comparison with dynamic susceptibility-weighted contrast-enhanced MRI at 3 Tesla.

Pulsed arterial spin labeling (PASL) at multiple inflow times (multi-TIs) is advantageous for the measurement of brain perfusion in patients with long arterial transit times (ATTs) as in steno-occlusive disease, because bolus-arrival-time can be measured and blood flow measurements can be corrected accordingly. Owing to its increased signal-to-noise ratio, a combination with a three-dimensional gradient and spin echo (GRASE) readout allows acquiring a sufficient number of multi-TIs within a clinically feasible acquisition time of 5 minutes. We compared this technique with the clinical standard dynamic susceptibility-weighted contrast-enhanced imaging-magnetic resonance imaging in patients with unilateral stenosis >70% of the internal carotid or middle cerebral artery (MCA) at 3 Tesla. We performed qualitative (assessment by three expert raters) and quantitative (region of interest (ROI)/volume of interest (VOI) based) comparisons. In 43 patients, multi-TI PASL-GRASE showed perfusion alterations with moderate accuracy in the qualitative analysis. Quantitatively, moderate correlation coefficients were found for the MCA territory (ROI based: r=0.52, VOI based: r=0.48). In the anterior cerebral artery (ACA) territory, a readout related right-sided susceptibility artifact impaired correlation (ROI based: r=0.29, VOI based: r=0.34). Arterial transit delay artifacts were found only in 12% of patients. In conclusion, multi-TI PASL-GRASE can correct for arterial transit delay in patients with long ATTs. These results are promising for the transfer of ASL to the clinical practice.

Exploring the Value of Using Color-Coded Quantitative DSA Evaluation on Bilateral Common Carotid Arteries in Predicting the Reliability of Intra-Ascending Aorta Flat Detector CT-CBV Maps.

Cerebral blood volume, acquired with flat panel detector CT by injecting contrast medium into the ascending aorta, enabled real-time acquisition of brain functional information with remarkable reduction of contrast medium usage comparing to an intravenous injection approach. However, individual vasculature and flow variations cause inhomogeneous contrast medium distribution and unexpected asymmetric perfusion for certain patients even without cerebral circulatory disorders. This work aimed at testing the feasibility of using color-coded quantitative DSA to predict the reliability of flat panel detector CT-based CBV maps by injecting contrast medium into the ascending aorta by exploring the correlation between measurements of color-coded quantitative DSA and the symmetry of CBV maps. For 12 patients without perfusion-related cerebral abnormities, color-coded quantitative DSA at the aortic arch and flat panel detector CT-based CBV maps by injecting contrast medium into the ascending aorta were acquired. In color-coded quantitative DSA, ROIs were defined on the bilateral common carotid arteries. Time-density curves were extracted, and area under the curve values were calculated. To evaluate brain perfusion symmetry, we defined ROIs on the anterior and middle cerebral artery territories in CBV maps, and quantitative CBV values were extracted. Eight patients demonstrated good perfusion symmetry with relative CBV of 0.96 ± 0.06, and their relative area under the curve was found to be 0.99 ± 0.02. For the other 4 patients, CBV from the left hemisphere was significantly lower than that from the right with relative CBV of 0.81 ± 0.09. This asymmetric perfusion was confirmed by the color-coded quantitative DSA with relative area under the curve values of 0.79 ± 0.03. This preliminary study showed good correlation between relative area under the curve from color-coded quantitative DSA and relative CBV from CBV maps. Color-coded quantitative DSA potentially helped sort out patients whose vascular anatomy could support reliable CBV acquisitions of flat detector CT by injecting contrast medium into the ascending aorta.

Rare complication characterized by late-onset transient neurological symptoms without hyperperfusion after carotid artery stenting: A report of three cases

We experienced a rare complication after carotid artery stenting (CAS) characterized by transient neurological symptoms with no evidence of distal emboli or hyperperfusion. Using neuroimaging, we investigated the pathogenesis of the complication that occurred after CAS in three patients who developed neurological symptoms over a period of ten hours after CAS and improved within two days. None of the three patients showed signs of fresh infarctions on diffusion-weighted imaging or hyperperfusion on single-photon emission computed tomography. However, high signal intensity was observed in the leptomeningeal zone of the cerebral hemisphere on the stent side in all three patients and in the leptomeningeal zone of the contralateral anterior cerebral artery territory in one patient. These areas were assessed using fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging without gadolinium administration. The high signal intensity in the leptomeningeal zone disappeared as the symptoms improved. Based on the transient nature of the neurological disorders and the normalization of FLAIR imaging findings in these patients, the pathogenesis of this complication might have been vasogenic edema due to vasoparalysis of the local vessels caused by the hemodynamic changes occurring after CAS.

Zigzag skin incision effectively camouflages the scar and alopecia for moyamoya disease: technical note.

Moyamoya disease is commonly diagnosed in children, and requires various vascular reconstruction to improve symptoms. Therefore, scar widening and hair loss after craniotomy, which sometimes occurs in this disease, are serious problems for patients. A variety of plastic surgical techniques in scalp have been reported to minimize the scar widening and hair loss. However, any neurosurgical reports describing this purpose have never been published for moyamoya disease. The objective of this study was to investigate whether these plastic surgical techniques could be applied to bypass surgery without any compromise of vascular reconstruction for moyamoya disease. We performed direct and indirect vascular reconstruction in six hemispheres of moyamoya disease patients not only in the middle cerebral artery territory but also in the anterior cerebral artery territory. The scalp incision was designed not parallel to the hair stream, and the bevelled incision was conducted not to jeopardize the hair follicles. The scar and hair loss were effectively camouflaged throughout the postoperative period in all cases. This study demonstrates that our design of scalp incision achieve effective vascular reconstruction and obscure the scar and hair loss.

Right-side propensity of cardiogenic emboli in acute ischemic stroke with atrial fibrillation

Objectives. We attempted to determine the propensity for sidedness of cardiogenic emboli associated with atrial fibrillation (AF) by comparing the sides on which microembolic signals (MES) were detected via transcranial Doppler (TCD) monitoring and the location of infarcts on magnetic resonance imaging. Design. Patients with AF on Holter monitoring and MES on TCD monitoring were selected from an ischemic stroke registry. Patients with prosthetic valves or cerebral/carotid artery stenosis were excluded. Results. By TCD monitoring of 30 patients, 78 MES were detected: 47 on the right and 31 on the left side (60.3% vs. 39.7%, p < 0.01, chi-square test). Among 21 patients who had middle or anterior cerebral artery (MCA/ACA) territory infarcts, 16 had right-side-dominant infarcts and 5 patients had left-side-dominant infarcts (76.2% vs. 23.8%, p < 0.01, chi-square test). The median infarct volume on the right side was 16.2 (3.18–75.4) ml, while that of left side was 1.2 (0.25–5.05) ml (p < 0.01, Mann–Whitney U test). Conclusion. This study demonstrated the existence of a right-side propensity of cardiogenic emboli and the larger infarct volume of right-side MCA/ACA stroke in patients with AF. These results can be attributed to anatomical differences between the innominate and the left common carotid artery.

Magnetic resonance angiographic investigation of azygous alias monkey type anterior cerebral artery – Incidence and clinical significance

IntroductionAzygous anterior cerebral artery (ACA) is one of the extremely rare variant occuring in the A2 segment of ACA, where the bilateral A1 segments unite together to form a single midline trunk. This trunk supplies both ACA territories. It has been also referred to as the unpaired pericallosal stem artery, unpaired anterior cerebral artery, common anterior cerebral trunk and azygos pericallosal artery. Method1.5 T (GE OPTIMA MR 360) was used for obtaining the angiographs, 114 MRA were reviewed, 90 male and 24 female, aged between 20 and 75 years. ResultThe Azygous type anterior cerebral artery was present in (3.5%), in (1.75%) a long trunk depicting the classical Azygous anterior cerebral artery was present, while in (1.75%) a short median stem was present. DiscussionThis type of presentation is a risk factor for development of aneurysm in distal part of ACA due to alteration of hemodynamics, sometimes this variation may be associated with vascular or nonvascular neurological anomalies like arteriovenous malformations, defects of septum pellucidm, Holoprosencephaly, meningomyelocele.

Central retinal artery occlusion with concomitant ipsilateral cerebral infarction after cosmetic facial injections

We report 2 cases of central retinal artery occlusion with concomitant ipsilateral cerebral infarction after cosmetic facial injections and a literature review. The 2 patients were two healthy women, in which cosmetic facial injections with autologous fat and filler were performed, respectively. The patients had no light perception at the final visit and their conditions led to memory retrieval disturbance in case 1 and right arm weakness, dysarthria, facial palsy, and ophthalmoplegia in case 2. Neuroimaging showed multifocal small infarctions in the ipsilateral frontal lobe with occlusion of the ophthalmic artery in case 1 and multiple infarctions in the ipsilateral anterior and middle cerebral artery territories with subsequent hemorrhagic transformation in case 2. Poor visual prognosis and neurological complications can occur in healthy adults undergoing cosmetic facial injection, and all patients should be informed of this risk before the procedure.

Territorial location of cerebral infarcts on imaging in patients with first ever stroke with diabetes

Aims: The study was aimed to evaluate vascular territories of infarcts involved in patients with stroke for the first time with diabetes on CT and/ or MRI of brain. Methodology: This cross sectional descriptive study was carried on a total of 100 adult patients with first ever stroke consecutively reported in the Department of Neurology, BIRDEM General Hospital, Dhaka, over a period of six months. Results: The mean age was 61.45 years and majority (35%) belongs to age group of 50-59. Ten (10%) subjects had age above 80 years. Male were 68% and 32% were female. Majority (89%) of the subjects had hemiplegia following acute stroke. Aphasia (71%), headache (39%), convulsion (23%), vomiting (18%) and cranial nerve palsy (17%) were also found. Additional preexisting risk factors were hypertension (72%), dyslipidaemia (59%), smoking (56%) and alcohol abuse (2%). Among the study subjects the diabetic complications were peripheral vascular disease (4% ), neuropathy (8%), nephropathy( 9%)and retinopathy(25%). CT scan and/ or MRI brain showed parietal lobe lesion in 57% cases. Majority (76%) had infarcts in middle cerebral artery territory. Involvement of anterior and posterior cerebral artery territory was found in 7% and 5% subjects respectively. Vertebro-basilar arterial system involvement was observed in 6% cases. 4% subjects had involvement of both middle and posterior cerebral arteries. Both anterior and posterior arterial territory infarcts were found in 2% cases. Conclusions: In conclusion most of the diabetic subjects with first ever ischemic stroke had involvement of middle cerebral artery. DOI: http://dx.doi.org/10.3329/bccj.v2i1.19951 Bangladesh Crit Care J March 2014; 2 (1): 16-20

Influences of reconstruction and attenuation correction in brain SPECT images obtained by the hybrid SPECT/CT device: evaluation with a 3-dimensional brain phantom.

The aim of this study was to evaluate the influences of reconstruction and attenuation correction on the differences in the radioactivity distributions in (123)I brain SPECT obtained by the hybrid SPECT/CT device. We used the 3-dimensional (3D) brain phantom, which imitates the precise structure of gray matter, white matter and bone regions. It was filled with (123)I solution (20.1 kBq/mL) in the gray matter region and with K2HPO4 in the bone region. The SPECT/CT data were acquired by the hybrid SPECT/CT device. SPECT images were reconstructed by using filtered back projection with uniform attenuation correction (FBP-uAC), 3D ordered-subsets expectation-maximization with uniform AC (3D-OSEM-uAC) and 3D OSEM with CT-based non-uniform AC (3D-OSEM-CTAC). We evaluated the differences in the radioactivity distributions among these reconstruction methods using a 3D digital phantom, which was developed from CT images of the 3D brain phantom, as a reference. The normalized mean square error (NMSE) and regional radioactivity were calculated to evaluate the similarity of SPECT images to the 3D digital phantom. The NMSE values were 0.0811 in FBP-uAC, 0.0914 in 3D-OSEM-uAC and 0.0766 in 3D-OSEM-CTAC. The regional radioactivity of FBP-uAC was 11.5% lower in the middle cerebral artery territory, and that of 3D-OSEM-uAC was 5.8% higher in the anterior cerebral artery territory, compared with the digital phantom. On the other hand, that of 3D-OSEM-CTAC was 1.8% lower in all brain areas. By using the hybrid SPECT/CT device, the brain SPECT reconstructed by 3D-OSEM with CT attenuation correction can provide an accurate assessment of the distribution of brain radioactivity.

Fusiform Dilatation of the Outer Contour of a Dissected Anterior Cerebral Artery Revealed by Magnetic Resonance Cisternography in a Patient with Simultaneous Cerebral Infarction and Subarachnoid Hemorrhage

A 46-year-old man presented with right hemiparesis. Cranial magnetic resonance (MR) imaging revealed both an acute cerebral infarction in the territory of the left anterior cerebral artery (ACA) and a thin subarachnoid hemorrhage in the left superior frontal sulcus. MR angiography revealed stenosis at the A2 segment of the left ACA. MR cisternography was, therefore, performed on day 12 after admission using sagittal, 3-dimensional, heavily T2-weighted images. Fusiform dilatation of the outer contour was confirmed by MR cisternography at the region of narrowing identified by MR angiography. This case indicates that the combination of MR cisternography and angiography can be useful for detecting ACA dissection.

Cerebral infarction caused by pituitary apoplexy: case report and review of literature

Pituitary apoplexy followed by cerebral infarction is rare. In this report, we present a 42-year-old man who had been diagnosed of pituitary adenoma presented with a sudden onset of unconsciousness, left hemiplegia and right ptosis. Investigations revealed the development of pituitary apoplexy. The extension of tumor mass compressed the supraclinoid portion of the right internal carotid artery, resulting in the cerebral infarction in the right anterior and middle cerebral artery territory. Left anterior cerebral artery territory infarction was also found, which could be caused by vasospasm provoked by pituitary apoplexy. The patient underwent decompression surgery via transsphenoidal approach after four weeks' conservative treatment, and pathological examination revealed hemorrhage and necrosis of the pituitary adenoma. His symptoms improved within five months' follow-up. Since pituitary apoplexy producing cerebral infarction is rare, clinicians should be alert to that possibility, and delayed transsphenoidal surgery following conservative management with steroids is the appropriate management of such an occurrence.

Akinetic Mutism Following Bilateral Anterior Cerebral Artery Territory Infarction Due to Aneurysm: A Case Report

Bilateral anterior cerebral artery (ACA) territory infarction is rare localization in stroke which should always prompt a search for an anterior communicating artery (ACoA) aneurysm. The common neurological manifestations are contralateral weakness predominate in the lower extremity, behaviour disturbance, motor inertia, muteness, incontinence, grasp reflex, diffuse rigidity, akinetic mutism. We describe a 38-year-old woman presented with a left sided hemiparesia and decrease of speech for last days. She was a smoker and morbide obese. She had no any diagnosed disease. Her neurological examination had weakness of left extremities affected leg more than the arm and akinetic mutism like as no spontaneously speech and move and grasp reflex. CT showed bilateral ACA infarction which included cingulate gyrus, the right side more than left and subarachnoid hemorrhage in the interhemispheric fissure. MRI angiography showed the appearance of AcoA aneurysm. We report a patient with bilateral infarction in the ACA which a rare localization and clinicians must be alert to exist AcoA aneurysm which may bleed, different symptoms and signs like as akinetic mutism, primitive reflexes.

Efficacy of Superficial Temporal Artery-Middle Cerebral Artery Double Anastomoses in a Patient with Rapidly Progressive Moyamoya Disease: Case Report

Moyamoya disease can be associated with a rapidly progressive course in young patients. This report describes a patient with moyamoya disease who experienced rapid disease progression, resulting in cerebral infarction and a wide area of diminished cerebral perfusion. Double superficial temporal artery (STA)-middle cerebral artery (MCA) anastomoses were utilized to immediately increase cerebral perfusion in the affected area. This case involved a 5-year-old girl who had been diagnosed with moyamoya disease and had undergone STA-MCA anastomosis with indirect bypass in the right hemisphere at the age of 3. At the time of presentation, magnetic resonance (MR) imaging showed cerebral infarction at the left frontal lobe, and MR angiography showed rapidly progressive narrowing of the left MCA that had not been present 3 months prior. N-isopropyl-p-[I123] iodoamphetamine single-photon emission computed tomography (IMP-SPECT) showed markedly decreased uptake in the left hemisphere. She underwent emergent STA-MCA double anastomoses with indirect bypass on the left side. IMP-SPECT showed marked increase in uptake in the left hemisphere. The anterior cerebral artery (ACA) territory adjacent to the cerebral infarction also showed increased uptake on the SPECT. Postoperatively, there were no clinical or radiographic indications of ischemic or hemorrhagic complications. Double anastomoses are effective in quickly and significantly increasing blood flow. The postoperative course in this case was uneventful. Double anastomoses are a surgical option for patients with moyamoya disease who show rapid disease progression, even in those in the acute phase of cerebral infarction.

Combined Bypass Technique for Contemporary Revascularization of Unilateral MCA and Bilateral Frontal Territories in Moyamoya Vasculopathy.

Moyamoya vasculopathy (MMV) leads to chronic hypoperfusion predominantly in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) territories. Most revascularization techniques focus on revascularization of the MCA territory. Augmentation of blood flow in the frontal area is important for neurocognition and lower extremity function. In this article we describe a new combined (direct and indirect) one-stage bypass technique consisting of a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with encephalo-duro-synangiosis (EDS) for unilateral MCA revascularization, along with an encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal blood flow augmentation. The strength of this technique is the revascularization of three vascular territories during a single surgical intervention: the MCA unilaterally; and the frontal territories bilaterally. Bifrontal EDPS may also be considered as a supplementary independent procedure for patients who previously underwent revascularization treatment in the MCA territory, but develop symptoms due to frontal hypoperfusion.

前大脳動脈領域に骨膜と浅側頭動脈を用いた小児もやもや病に対する複合的血行再建術の有用性と問題点

前大脳動脈領域に骨膜と浅側頭動脈を用いた小児もやもや病に対する複合的血行再建術の有用性と問題点

Risk factors and consequences of unexpected trapping for ruptured anterior communicating artery aneurysms.

Background:While clipping cerebral aneurysms at the neck is optimal, in some cases this is not possible and other strategies are necessary. The purpose of this study was to describe the incidence, risk factors, and outcomes for inability to clip reconstruct ruptured anterior communicating artery (ACoA) aneurysms.Methods:Of the 70 cases of ruptured ACoA aneurysms between January 2006 and December 2013, our institutional experience revealed four cases of small ACoA aneurysms that had been considered clippable prior to operation but required trapping. When a unilateral A2 segment of anterior cerebral artery (ACA) was compromised by trapping, revascularization was performed by bypass surgery. Clinical presentation, angiographic characteristics, operative approach, intraoperative findings, and treatment outcomes were assessed.Results:Very small aneurysm under 3 mm was a risk factor for unexpected trapping. The reason for unexpected trapping was laceration of the aneurysmal neck in two cases, and lack of clippaple component due to disintegration of entire aneurysmal wall at the time of rupture in the others. Aneurysms with bilateral A1 were treated with sole trapping through pterional approach in two cases. The other two cases had hypoplastic unilateral A1 segment of ACA and were treated with combination of aneurysm trapping and revascularization of A2 segment of ACA through interhemispheric approach. No patients had new cerebral infarctions of cortical ACA territory from surgery. Cognitive dysfunction was observed in three cases, but all patients became independent at 12-month follow up.Conclusions:Unexpected trapping was performed when ruptured ACoA aneurysms were unclippable. Trapping with or without bypass can result in reasonable outcomes, with acceptable risk of cognitive dysfunction.

Bilateral Anterior Cerebral Artery Territory Infarction Due to Subarachnoid Hemorrhage: Two Case Reports

Bilateral Anterior Cerebral Artery Territory Infarction Due to Subarachnoid Hemorrhage: Two Case Reports

Quantitative Cerebral Perfusion Imaging in Children and Young Adults with Moyamoya Disease: Comparison of Arterial Spin-Labeling-MRI and H2[15O]-PET

Cerebral perfusion assessment is important in the preoperative evaluation and postoperative follow-up of patients with Moyamoya disease. The objective of this study was to evaluate the correlation of quantitative CBF measurements performed with arterial spin-labeling-MR imaging and H2[(15)O]-PET in children and young adults with Moyamoya disease. Thirteen children and young adults (8 female patients; age, 9.7 ± 7.1 years; range, 1-23 years) with Moyamoya disease underwent cerebral perfusion imaging with H2[(15)O]-PET (Discovery STE PET/CT, 3D Fourier rebinning filtered back-projection, 128 × 128 × 47 matrix, 2.34 × 2.34 × 3.27 mm(3) voxel spacing) and arterial spin-labeling (3T scanner, 3D pulsed continuous arterial spin-labeling sequence, 32 axial sections, TR = 5.5 seconds, TE = 25 ms, FOV = 24 cm, 128 × 128 matrix, 1.875 × 1.875 × 5 mm(3) voxel spacing) within less than 2 weeks of each other. Perfusion of left and right anterior cerebral artery, MCA, and posterior cerebral artery territories was qualitatively assessed for arterial spin-labeling-MR imaging and H2[(15)O]-PET by 2 independent readers by use of a 3-point-Likert scale. Quantitative correlation of relative CBF with cerebellar normalization between arterial spin-labeling-MR imaging and H2[(15)O]-PET was evaluated in a volume-based approach for each vascular territory after 3D image coregistration. Interreader agreement was good (κ = 0.67-0.69), and strong and significant correlations were found between arterial spin-labeling-MR imaging and H2[(15)O]-PET for both qualitative perfusion scoring (ρ = 0.77; P < .001) and quantitative perfusion assessment of relative CBF with cerebellar normalization (r = 0.67, P < .001). In children and young adults with Moyamoya disease, quantitative evaluation of CBF is possible with the use of arterial spin-labeling-MR imaging without ionizing radiation or contrast injection with a good correlation to H2[(15)O]-PET after cerebellar normalization.

Central Nervous System vasculitis associated with Hepatitis C virus infection: A brain MRI-supported diagnosis

BackgroundThe Hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, being the Central Nervous System (CNS) rarely involved. Case reportWe report a case of a 54year-old black man with arterial hypertension who presented with progressively worsening headaches, apathy, somnolence and left hemiparesis. Brain MRI showed an acute ischemic lesion in the left anterior cerebral artery (ACA) and an old ischemic infarct in the right ACA territory. Brain MRI with gadolinium revealed mural thickening and contrast enhancement of the A1 and A2 segments of the ACAs, of the middle and distal basilar artery and of the P1 segment of the left posterior cerebral artery, suggesting active vasculitis. Digital angiography confirmed those irregularities and stenosis. Laboratory evaluation revealed ESR (73mm/h), transaminase elevation, elevated HCV viral load genotype 2, positive IGRA, negative cryoglobulins, CSF protein elevation with oligoclonal bands (mirror pattern) and no pleocytosis; investigation excluded other infectious causes. Pegylated interferon alpha-2a and ribavirin, corticotherapy and tuberculosis prophylaxis were started with clinical and imagiological improvement. ConclusionThe typical inflammation signs of the vascular wall demonstrated by the gadolinium-enhanced MRI strengthened the hypothesis of CNS vasculitis. The association with HCV infection is rare but should be investigated once specific therapeutic is required.

Bilirubin labeling of borderzone and anterior cerebral artery territory infarction

A 50-year-old woman developed multiorgan system failure secondary to sepsis. She became obtunded during a period of hypotension, and cranial CT demonstrated diffuse borderzone infarction. Brain autopsy revealed green pigmentation in areas of infarction due to vascular leakage of bilirubin at sites of blood–brain barrier disruption, mapping the borderzone regions and bilateral anterior cerebral artery territories with this endogenous label (total bilirubin at time of death was 24 mg/dL; direct bilirubin 19 mg/dL) (figure). This brain–liver association evokes the first description of pathology in the borderzone regions in 1883 by Samuel-Jean Pozzi,1 who attributed the lesions to cortical “cirrhosis.”