Anterior Cerebral Circulation Research Articles

Differences in internal carotid artery tortuosity in ruptured and unruptured anterior circulation aneurysms. A matched case-control study

ObjectiveTortuosity of the internal carotid artery is believed to contribute to the formation of intracranial aneurysms, although there is scant literature on its role as a risk factor for rupture specifically. Therefore, this study investigated the influence of cervical internal carotid artery (cICA) tortuosity on rupture of aneurysms of the anterior cerebral circulation. MethodsAngiographic imaging studies from patients who underwent endovascular embolisation for anterior circulation aneurysms at a tertiary centre were identified. 83 patients with a history of aneurysmal rupture and subarachnoid haemorrhage (SAH group) were matched for age, aneurysm location and size, history of subarachnoid haemorrhage and hypertension to 83 subjects with unruptured aneurysms (control group). cICA tortuosity was assessed utilising subjective (kinks, loops or coils) and objective (tortuosity index) parameters. ResultsSubjective cICA tortuosity was identified in 33.7% and 56.6% of patients in the SAH and control groups respectively (OR 0.39 [95% CI 0.21–0.75]). Objective cICA tortuosity was present in 35.7% and 46.8% of SAH and control patients (OR 0.63 [95% CI 0.32–1.27]). OR values are suggestive of cICA tortuosity as a negative predictor of aneurysmal rupture, with more predictive power attributed to the subjective assessment, despite the limited statistical significance of the objective results. ConclusionsThis study demonstrated an increased presence of cICA tortuosity in unruptured aneurysms compared to ruptured aneurysms, suggesting it is unlikely to represent a risk factor for rupture. Further research in the form of longitudinal observational studies of untreated aneurysms would aid in investigating cICA tortuosity as a protective factor.

Prevalence and Distribution of Intracranial Vessel Occlusion on Angiography and Its Association with Functional Outcome in Patients with Atrial Fibrillation Presenting with Ischemic Stroke.

To determine the prevalence and distribution of intracranial vessel occlusion identified on computed tomography (CT) or magnet resonance (MR) angiography and to explore its association with functional outcome in patients with atrial fibrillation (AF) and ischemic stroke. Multicenter cohort study enrolling consecutive patients with AF with imaging-confirmed ischemic stroke who underwent CT- or MR-angiography on admission (2014-2022). Multivariable regression was used to explore the association between intracranial vessel occlusion and poor functional outcome (modified Rankin Scale score 3-6) at 90 days. The analysis included 10,164 patients (median age 81.5 years, 47.8% female, median National Institutes of Health Stroke Scale score on admission 6; 14.7% on a vitamin K antagonist [VKA], 27.5% on a direct oral anticoagulant [DOAC], 57.8% not receiving oral anticoagulation). Angiography showed intracranial vessel occlusion in 5,190 patients (51.1%), affecting the anterior cerebral circulation in 87.4%. Overall, 29.2% and 29.4% of patients received thrombolysis and mechanical thrombectomy, respectively. The proportion of patients with poor functional outcome at 90 days was 60.6% and 42.7% in those with and without vessel occlusion, respectively. In multivariable analyses, vessel occlusion was associated with poor functional outcome (adjusted odds ratio [aOR]: 1.95, 95% confidence interval [CI]: 1.71-2.22) with consistent results in subgroups according to oral anticoagulation use (VKA, aOR: 1.98, 95% CI: 1.40-2.80; DOAC, aOR: 2.35, 95% CI: 1.83-3.03; none, aOR: 1.76, 95% CI: 1.49-2.09). Intracranial vessel occlusion is common in patients with AF with ischemic stroke, mainly affects the anterior circulation and is associated with poor functional outcome. ANN NEUROL 2024.

The impact of increased cardiac output induced by dobutamine on cerebral blood flow based on MRI 3D-pcASL technology

Objective: To investigate the effect of increased cardiac output induced by dobutamine on cerebral blood flow (CBF) in healthy volunteers using magnetic resonance 3D-pseudo-continuous arterial spin labeling technology. Methods: A prospective study was conducted on 48 healthy volunteers recruited by handy sampling from June 2021 to January 2022. Physiological parameters before (at rest state) and after (under stress state) dobutamine-induced increase in cardiac output were analyzed. Quantitative CBF maps were generated by using arterial spin labeling difference imaging and proton density weighted reference image processing, and CBF changes under the rest and stress states were compared. Multivariable logistic regression model was used to analyze factors associated with reduced CBF. Results: A total of 48 subjects were included, with an age [M (Q1, Q3)] of 25.0 (24.0, 28.0) years, including 43 men and 5 women. Compared with the rest state, the CBF in the anterior cerebral artery [(36.2±6.9) vs (34.5±6.5) ml·(100 g)-1·min-1, P=0.006] and the middle cerebral artery perfusion area [(35.8±6.5) vs (34.1±6.4) ml·(100 g)-1·min-1, P=0.006] decreased under the stress state, however there was no statistically significant change in CBF in the posterior cerebral artery and the vertebral-basilar artery perfusion area (all P>0.05). Logistic regression analysis showed that the decrease in CBF in the anterior cerebral artery and middle cerebral artery supply regions during the stress state were correlated with an increase in diastolic blood pressure [OR (95%CI): 0.887 (0.796-0.989) and 0.895 (0.805-0.994), both P<0.05]. Conclusions: Dobutamine-induced increase in cardiac output leads to a decrease in CBF in anterior cerebral circulation but has no effect on posterior circulation. The increase in diastolic blood pressure is associated with decreased CBF under the stress state. Changes in CBF should be considered in the context of increased cardiac output.

The Association Between the Location of Subarachnoid Hemorrhage and the Occurrence of Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis.

Takotsubo cardiomyopathy (TCM) is a syndrome characterized by transient regional cardiac dysfunction of the left ventricle. The goal of this review is to better understand the relationship between the anatomic locations of subarachnoid hemorrhages (SAHs) and the development of TCM as identified through a review of cohort studies. From inception to December 2023, we systematically explored major electronic medical information sources to identify cases of TCM that developed after SAHs. The six selected studies included in the meta-analysis suggest a modest but statistically significant increase in the odds of the events in the posterior circulation group compared to the anterior circulation group, with a combined odds ratio (OR) estimate of around 1.45-1.46. The fixed effect model gives an overall OR of 1.45 with a 95% confidence interval (CI) of 1.01 to 2.10, z = 2.01, p = 0.0442, while the random effects model yields a slightly higher OR of 1.46 with the same 95% CI, z = 2.03, p = 0.0425. There is a tendency for SAH occurrence in the posterior cerebral circulation to cause SAH-related TCM more frequently than in the anterior cerebral circulation.

Endovascular thrombectomy versus medical management on outcomes with infarct volumes more than 70 mL.

Endovascular thrombectomy (EVT) in patients with large infarct volume remains controversial. The aim of this study is to compare clinical outcomes between EVT and medical management in acute large vessel occlusion with infarct volumes larger than 70 mL on diffusion-weighted magnetic resonance imaging (DWI). A prospective observational cohort study was conducted, including patients with anterior cerebral circulation occlusion due to ischemic stroke with infarct volumes larger than 70 mL within 24 h of onset between July 2018 and June 2023. Eligible patients were divided into two groups: the EVT group and the medical management (non-EVT) group. The main outcomes were functional independence and mortality at 90 days. To assess clinical endpoints, we selected variables including age, NIHSS score, infarct volume, and occlusion location for 1:1 propensity score (PS) matching and PS adjustment using inverse probability of treatment weighting (IPTW). Among the 131 identified patients (mean [SD] age, 69.9 [13.7] years; 58 female), the median infarct volume was 123.6 mL. Of these patients, 75 (57.3%) underwent EVT. After PS adjustment, EVT was not associated with functional independence (10.9% vs. 10.9%; p = 1.000) or mortality (43.5% vs. 47.8%; p = 0.675). Additionally, after PS adjustment using IPTW, EVT was also not associated with a functional independence (15.8% vs. 13.7%; p = 0.767) or mortality (46.8% vs. 44.0%; p = 0.762). This study provides real-world evidence regarding infarct volumes larger than 70 mL, indicating that EVT does not provide benefits compared to medical management alone when considering age, NIHSS score, infarct volume, and occlusion location.

Predictions for functional outcome and mortality in acute ischaemic stroke following successful endovascular thrombectomy

BackgroundAccurate outcome predictions for patients who had ischaemic stroke with successful reperfusion after endovascular thrombectomy (EVT) may improve patient treatment and care. Our study developed prediction models for key clinical...

Efficacy and safety of mechanical thrombectomy in the posterior cerebral circulation—a single center study

Mechanical thrombectomy (MT) is the current standard treatment for strokes in the anterior cerebral circulation (AMT) and has recently been proven to be beneficial in the posterior circulation strokes (PMT). Our study aims to evaluate parameters for favorable outcomes in PMT-patients and to compare the clinical characteristics of individuals who received AMT and PMT. For this purpose, we confronted AMT and PMT-receipients and performed a multivariate regression analysis to assess the influence of factors on favorable outcomes in the study group and in the AMT and PMT subgroups. When analysing 623 MT-patients, those who received PMT had significantly lower admission National Institutes of Health Stroke Scale (NIHSS) scores (9 vs. 13; p < 0.001) and 24 h post-MT (7 vs. 12; p = 0.006). Key parameters influencing the favorable outcomes of PMT at discharge and at 90th day include: NIHSS scores (OR: 0.865, 95% CI: 0.813–0.893, and OR: 0.900, 95% CI: 0.861–0.925), MT time (OR: 0.993, 95% CI: 0.987–0.998 and OR: 0.993, 95% CI: 0.990–0.997), and leukocytosis (OR: 0.961, 95% CI: 0.928–0.988 and OR: 0.974, 95% CI: 0.957–0.998). Different clinical profiles exist between AMT and PMT-recipients, with the neurological status post-MT being decisive for the prognosis. Several factors play an important role in predicting outcome, especially in the PMT group.

Microsurgical treatment of ruptured intracranial aneurysms: An Ethiopian experience

IntroductionIn this ambispective cohort study, the authors share their experience with surgical outcomes of intracranial aneurysms in a resource-limited setting. MethodsThe study spans a 10-year period (January 2010 to December 2022) at Myungsung Christian Medical Center (MCM) in Addis Ababa, Ethiopia. Patient data, aneurysm characteristics, preoperative, intraoperative, and postoperative factors, along with patient outcomes, were collected using a structured questionnaire. Data analysis employed SPSS version 25, utilizing descriptive statistics and Multivariable logistic regression to identify independent predictors of outcomes. The primary outcome measure was the Glasgow Outcome Scale (GOS) at discharge. ResultsThe study included 71 patients with ruptured intracranial aneurysms, with 63 aneurysms clipped in 62 patients. No sex predilection was observed. Aneurysms were predominantly in the anterior cerebral circulation (98.6%), with 60.6% in the anterior communicating artery. Aneurysm size was less than 10 mm in 75.76% of cases. Favorable outcomes were achieved in 83.9% of patients, while 16.10% had unfavorable outcomes. Unfavorable outcomes correlated with a worsening neurological grade assessed by the Glasgow Coma Scale (GCS). The occurrence of delayed vasospasm and hemiparesis showed strong predictive value. ConclusionThe study demonstrated acceptable mortality and favorable outcomes. Patient outcomes in ruptured cerebral aneurysms were primarily influenced by non-modifiable factors, such as GCS on admission and neurological deficit. GCS exhibited a superior predictive value for outcomes compared to commonly used WFNS and Hunt–Hess scales in patients with intracranial aneurysms.

Abstract TP212: 2b or Not 2b? TICI 2b Reperfusion Score in Endovascular Thrombectomy for Acute Ischemic Stroke Carries a Poor Functional Outcome

Background: Endovascular thrombectomy (EVT) for treatment of acute ischemic stroke (AIS) in the proximal cerebrovasculature has, since its inception, become part of the standard of care when addressing AIS. Overall, one in six individuals treated has improved neurologic and functional outcomes. Reperfusion following thrombectomy in the anterior cerebral circulation has long been graded by the modified Thrombolysis in Cerebral Infarction (mTICI) scale-and the score of mTICI (2b, or, “partial filling of more than 50% of the affected vascular territory” is considered the benchmark for “good” outcomes in EVT. It remains unclear whether this score at time of reperfusion reliably predicts a sustained improvement in neurologic or functional outcome. Method: This is a retrospective review of all anterior AIS patients with large vessel occlusion (LVO) at Barrow Neurological Institute between 01/01/2018 and 12/31/2022 who underwent EVT with mTICI 2b or greater. The study was approved by the local IRB. Demographic data of patients between the ages of 18 and 95 who had AIS with LVO in the anterior Circle of Willis or its supplying vessels were collected. Other variables collected and analyzed include mTICI score, and modified Rankin Score (mRS) at discharge and 90 days. The TICI grade was obtained via digital cerebral angiography post EVT. Descriptive statistics was used to examine the differences of mRS scores at 90 days. Results: Of 81 cases reviewed, 52 (65%) had a TICI 2b score and their average mRS was 3.7, 20 (25%) had a TICI 2c and their average mRS was 3.6, and 4 (5%) had a TICI 3 with mRS 3 at discharge. At 90 days, the average mRS for TICI 2b patients was 3.2, for TICI 2c patients 2.9 and for TICI 3 patients 2.3. No difference in the rate of intracerebral hemorrhage (ICH) following reperfusion between the TICI 2 and 3 groups (17%). Conclusion: Our results demonstrated that patients with a mTICI of 2b had a higher mean mRS at discharge and minimal improvement of mRS at 90 days compared against patients with a mTICI of 2c or 3 (average change in score was -0.6, -0.7 and -1.3 in the TICI 2b, 2c and 3 groups respectively). Therefore, a reperfusion score of mTICI 2b may not be sufficient to indicate a high probability of a good functional outcome. With EVT, reaching a TICI 3 should be attempted.

Clinical features and prognostic factors of patients with cancer-associated stroke.

Cerebrovascular diseases in cancer patients significantly aggravate their condition and prognosis; therefore, prompt and accurate diagnosis and treatment are important. The purpose of this study was to investigate patient demographics, laboratory data, brain magnetic resonance imaging (MRI) findings, and prognosis among patients with stroke and cancer, especially cancer-associated ischemic stroke (CAIS). We performed a retrospective, single-center study. We enrolled consecutive patients who had acute stroke and were admitted to our hospital between January 2011 and December 2021. We collected general demographic characteristics, cancer histopathological type, laboratory data, brain MRI findings, and prognosis data. Among 2040 patients with acute stroke, a total of 160 patients (7.8%) had active cancer. The types of strokes were cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack in 124, 25, 5, and 6 patients, respectively. Among the patients with ischemic stroke, there were 69 cases of CAIS. Pancreas and adenocarcinoma were the most frequent types of primary tumor and histopathology. Patients with adenocarcinoma and those with cerebral infarctions in both bilateral anterior and posterior cerebral circulation areas showed higher D-dimer levels. Pancreatic cancer and high plasma D-dimer levels were associated with poor survival rate. CAIS was seen more frequently in patients with pancreatic cancer and adenocarcinoma. Pancreatic cancer and high plasma D-dimer levels were potential factors of poor prognosis in patients with CAIS.

Possible association between β-blocker use and a risk of intracranial aneurysm rupture.

Aneurysmal subarachnoid hemorrhage is a devastating type of stroke, associated with high mortality and morbidity. One of modifiable risk factors of aneurysm rupture is hypertension, however, it is still not clear whether any particular antihypertensive drugs play a significant role in the prevention of aneurysm rupture. We decided to investigate whether there is any association between acetylsalicylic acid, α-blockers, β‑blockers, angiotensin‑converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, statins, and anticoagulants and a risk of intracranial aneurysm rupture. We retrospectively analyzed 334 patients with ruptured and unruptured intracranial aneurysm. Based on logistic regression models, we obtained unadjusted and adjusted odds ratios (ORs) of subarachnoid hemorrhage associated with the use of vasoactive medications and with indices of tortuosity. We found that β‑blocker intake was significantly related to higher tortuosity of the cerebral arteries. Also, the intake of β‑blockers (OR, 0.41; 95% CI, 0.21-0.77; P = 0.01) and statins (OR, 0.23; 95% CI, 0.05-0.68; P = 0.01) significantly decreased the risk of aneurysm rupture, a result driven by a decreased rupture risk of anterior circulation aneurysms. No such association was found for the posterior part of the cerebral circulation. Aneurysm located in the anterior cerebral circulation might be less likely to rupture if patients receive β‑blockers or statins.

Osteovascular Conflicts in the Neck Region and Cerebrovascular Events: Illustrative Cases and Literature Review.

Literature Review. Abnormal bone structures in the neck can cause headache, neck pain, and difficulty swallowing, but also cerebrovascular events. We introduce the term "osteovascular conflicts" to describe this phenomenon. The objective of this study was to conduct a literature review of such conflicts involving the anterior and posterior cerebral circulation. Furthermore, we aimed at presenting additional illustrative cases from our institution both for increasing awareness for unusual osteovascular conflicts, and for assessing the practice and care of such patients. We focused on osteovascular conflicts in the neck leading to cerebrovascular events related to an abnormal bone structure causing arterial or venous compression, dissection, and/or occlusion. We excluded pure vascular forms without cerebrovascular repercussions. Our PubMed/MEDLINE search for articles published in any language and for which an English abstract was available (from 1966 to 2022) included Eagle's neurovascular, bow hunter's syndrome, and golfer's stroke, excluding trauma-induced artery dissections or compressions and those concerning systemic bone disorders. We also provided illustrative cases collected by the authors. All studies were either case reports or small case series. We found 82 cases of Eagle's neurovascular, 258 of bow hunter's syndrome, and 17 golfer's stroke cases. Mean ages were 52, 48, and 47years, respectively. Male predominance was evident: 81% for Eagle's, 74% for bow hunter's, and 93% for golfer's. Osteovascular conflicts are rare but important causes of cerebrovascular events and often go unrecognised. A greater awareness of cerebrovascular symptoms related to these conflicts can facilitate early diagnosis and treatment.

Predictive value of the anterior communicating artery (ACoA) complex variations for the incidence and rupture of ACoA aneurysms

BackgroundIncrease pressure on arteries branching points and curves (hyperdynamic theory) is the most popular theory to explain the aneurysms formation that augmented by the observation of high incidence of anomalies (either A1 aplasia or hypoplasia) and the anterior communicating artery (ACoA) aneurysms. It still underestimated the correlation between these anatomical anomalies and aneurysm occurrence and its rupture. We aim to estimate the incidence and type of anatomical anomalies of the anterior cerebral circulation, including the A2 segment in patients with ACoA aneurysms and their predictive value for aneurysm occurrence and rupture parallel to the risk of hypertension. Also, we study the impact of these anomalies on the configuration of the aneurysm, including the neck and size.ResultsA1 hypoplasia and aplasia were significantly higher in AcoA aneurysms group than in the control group (P < 0.001 and 0.002, respectively). These anomalies have no significant statistical difference between rupture and unruptured ACoA aneurysms. A2 anomalies were insignificantly different between both groups.ConclusionCongenital anomalies in the A1 segment (hypoplasia and aplasia) have a significant predictive value for AcoA aneurysms formation, with no predictive value for the aneurysm rupture. Concomitantly, A2 anomalies have no significant risk for AcoA aneurysms formation and rupture.

Short-term efficacy of stenting as a rescue therapy for acute atherosclerotic occlusion in anterior cerebral circulation.

The study aimed to explore the efficacy and safety of the Neuroform EZ stent in treating acute anterior circulation large artery occlusion. The clinical data of 42 consecutive patients with acute anterior circulation large atherosclerotic occlusion who were treated with the Neuroform EZ stent from January 2018 to August 2019 in our stroke care center, including baseline characteristics, images, therapeutic condition, and follow-up data were retrospectively analyzed. There were 42 mechanical thrombectomy (MT) failure cases of intracranial atherosclerotic stenosis with rescue Neuroform EZ stent implantation, of which 78.6% (33/42) had a good prognosis and 88.1% (37/42) showed no re-stenosis at follow-up. The average time from puncture to recanalization is 79.50 ± 14.19 min. The successful rate of intraoperative stent release is 97.6%, while there is one case of stent displacement, three cases of thrombus escape, and six cases of hemorrhage. Rescue therapy of the Neuroform EZ stent for acute anterior circulation large atherosclerotic occlusion can archive good short-term imaging and clinical results, while long-term follow-up is still needed to verify.

Effect of thin-split encephalomyosynangiosis on transient neurological events in revascularization surgery for pediatric patients with moyamoya disease.

Transient neurological events (TNEs) are among the most important events after revascularization surgery in pediatric patients with moyamoya disease (MMD). Although hemodynamic changes and crying are representative factors of TNEs, brain compression by encephalomyosynangiosis (EMS) is another important cause of TNEs. Therefore, the authors assumed that making the EMS as thin as possible reduces the frequency of TNEs. However, thin-split EMS can lead to insufficient development of collateral vessels. This study aimed to evaluate the effects of thin-split EMS in combined revascularization surgery on postoperative outcomes in pediatric patients with MMD. The authors retrospectively included 56 consecutive combined revascularization surgeries in the anterior cerebral circulation in pediatric patients with MMD. These surgeries were classified into the former group and thin-split EMS group. The temporal muscle was halved in the former EMS group and split as thinly as possible in the thin-split EMS group. The authors performed between-group comparisons of postoperative stroke events and TNEs during the acute period and the development of collateral flow and stroke events during the chronic period. Former and thin-split EMS procedures were performed in 37 and 19 patients, respectively. TNEs without crying or hemodynamic changes were observed significantly less frequently in the thin-split EMS group than in the former EMS group (0 [0.0%] in the thin-split EMS group vs 9 [24.3%] in the former EMS group, p = 0.021). There were no significant between-group differences in the development of indirect bypass during the chronic period (good: 34 [91.9%] and poor: 3 [8.1%] in the former EMS group vs good: 16 [84.2%] and poor: 3 [15.8%] in the thin-split EMS group; p = 0.397). Additionally, there were no significant between-group differences in the incidence of chronic clinical events, including death or stroke. Thin-split EMS can reduce TNEs that do not accompany crying or hemodynamic changes. Furthermore, the procedure has sufficient prevention effects against stroke events during the chronic postoperative period in pediatric patients with MMD.

The effect of distal aspiration catheter position on collateral flow in mechanical thrombectomy - an in vitro study.

Endovascular mechanical thrombectomy for ischaemic stroke is one of the most effective treatments. Despite the devices and techniques that have been developed, thrombi are not always successfully retrieved. The incidence of futile reperfusion after successful clot retrieval also remains a major concern. We hypothesise that simply placing an aspiration catheter in the system compromises collateral flow which may have an impact on functional outcomes. An in vitro study was conducted using a physical pulsatile flow model designed in glass to mimic the anterior cerebral circulation with middle cerebral artery M1 segment occlusion. A 5Fr aspiration catheter was positioned at the supra-clinoid internal carotid (SC-ICA), carotid terminus (T-ICA) and M1. For each catheter position, the flow rate through the model's anterior cerebral (ACA) and posterior communicating (PCOM) arteries was measured (no aspiration applied). Our results showed significant mean percentage flow reductions in the ACA and PCOM with the catheter positioned at the SC-ICA (PCOM 59.14% ± 0.93, ACA 59.52% ± 0.82, p < 0.001), T-ICA (PCOM 81.54% ± 0.55, ACA 85.65% ± 1.54) and M1 (PCOM 75.79% ± 0.98, ACA 84.20% ± 0.43) (Mann-Whitney U Test, p < 0.001). These results indicate a significant reduction in collateral flow following the insertion of a wide bore catheter in an in vitro model. In a clinical setting, this could have an impact on patient outcome, particularly in prolonged procedures and those requiring several passes to achieve recanalisation.

Effects of superficial temporal artery to middle cerebral artery bypass on postoperative infarction rates among young children (≤ 5 years old) with moyamoya disease

Revascularization surgery for young children with moyamoya disease (MMD) is challenging. Although indirect revascularization is preferred because of the technical difficulty in direct anastomosis, higher risks of postoperative infarction remain a problem. We aimed to investigate the effect of superficial temporal artery to middle cerebral artery (STA-MCA) bypass on postoperative outcomes during the acute postoperative period in young children ≤ 5years old with MMD. This retrospective study included consecutive young children with MMD who underwent surgical revascularization of the anterior cerebral circulation. Groups were determined according to the procedures performed, namely, the combined (STA-MCA bypass with indirect revascularization) and the indirect revascularization groups. The incidences of radiological or symptomatic infarction, transient neurological events, and new neurological deficits that remained at discharge were compared between groups. Of 38 surgical procedures, there were 23 combined and 15 indirect revascularizations. The median age of the patients was 3.0years, which was significantly different between groups (P < .01). When comparing the postoperative outcomes between groups, the incidences of radiological and symptomatic infarction and new neurological deficits that remained at discharge were significantly lower in the combined revascularization group (P < .05). Logistic regression analysis adjusted for potential confounders found that surgical modality was a statistically significant independent risk factor associated with radiological and symptomatic infarctions (indirect/combined, odds ratio: 10.2; 95% confidence interval: 1.30-79.7; P < .05). STA-MCA bypass combined with indirect revascularization can reduce the incidence of postoperative infarction in young children with MMD and might lead to better neurological outcomes.

Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis

BackgroundThe supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms. MethodsWe searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches. ResultsFourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms. ConclusionThe meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

DEEP MOVEMENT: Deep learning of movie files for management of endovascular thrombectomy

ObjectivesTreatment and outcomes of acute stroke have been revolutionised by mechanical thrombectomy. Deep learning has shown great promise in diagnostics but applications in video and interventional radiology lag behind. We aimed to develop a model that takes as input digital subtraction angiography (DSA) videos and classifies the video according to (1) the presence of large vessel occlusion (LVO), (2) the location of the occlusion, and (3) the efficacy of reperfusion.MethodsAll patients who underwent DSA for anterior circulation acute ischaemic stroke between 2012 and 2019 were included. Consecutive normal studies were included to balance classes. An external validation (EV) dataset was collected from another institution. The trained model was also used on DSA videos post mechanical thrombectomy to assess thrombectomy efficacy.ResultsIn total, 1024 videos comprising 287 patients were included (44 for EV). Occlusion identification was achieved with 100% sensitivity and 91.67% specificity (EV 91.30% and 81.82%). Accuracy of location classification was 71% for ICA, 84% for M1, and 78% for M2 occlusions (EV 73, 25, and 50%). For post-thrombectomy DSA (n = 194), the model identified successful reperfusion with 100%, 88%, and 35% for ICA, M1, and M2 occlusion (EV 89, 88, and 60%). The model could also perform classification of post-intervention videos as mTICI < 3 with an AUC of 0.71.ConclusionsOur model can successfully identify normal DSA studies from those with LVO and classify thrombectomy outcome and solve a clinical radiology problem with two temporal elements (dynamic video and pre and post intervention).Key Points• DEEP MOVEMENT represents a novel application of a model applied to acute stroke imaging to handle two types of temporal complexity, dynamic video and pre and post intervention.• The model takes as an input digital subtraction angiograms of the anterior cerebral circulation and classifies according to (1) the presence or absence of large vessel occlusion, (2) the location of the occlusion, and (3) the efficacy of thrombectomy.• Potential clinical utility lies in providing decision support via rapid interpretation (pre thrombectomy) and automated objective gradation of thrombectomy outcomes (post thrombectomy).

A challenging case of recurrent and progressive fusiform anterior circulation intracranial aneurysms: illustrative case.

Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters. Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above. This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.