Anterior Circulation Arteries Research Articles

Reconstructive Endovascular Treatment of Compensative-Flow-Related Posterior Circulation Aneurysms With Anterior Circulation Artery Occlusion.

The aim of this study was to delineate the reconstructive endovascular treatment and periprocedural management of compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion. A total of 87 patients were enrolled in this retrospective double-center cohort study from May 2011 to November 2023. The baseline demographics, aneurysm characteristics, etiology and status of anterior circulation artery occlusion, treatment modalities, anesthesia management, complications, and clinical and angiographic outcomes of the patients were retrospectively analyzed in this study. Atherosclerosis and moyamoya disease were found to be the two main etiologies of anterior circulation artery occlusion. The mean American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scores were significantly higher in patients with posterior communicating artery trunk collaterals than those with posterior cerebral artery pial collaterals (P < .05). Treatment strategies included stent-assisted coiling (55, 63.2%), standard coiling (22, 25.3%), and flow diversion or flow diversion-assisted coiling (8, 9.2%). The overall rate of procedure-related ischemic and hemorrhagic complications (10.3%) was considered acceptable. The ischemic complication was significantly associated with a >20% drop in mean arterial pressure (P < .05) during the procedure. Finally, 86.2% of all patients showed a modified Rankin Scale score of 0 to 2 at the final clinical follow-up. Our study indicates that reconstructive endovascular treatments are feasible and effective strategies for compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion. However, these treatments are associated with a risk of periprocedural ischemic complications, which can be reduced by collateral arterial assessment, appropriate periprocedural anesthesia management, and antiplatelet treatment.

Intracranial vasculopathy: an important organ damage in young adult patients with late-onset Pompe disease

BackgroundLate-onset Pompe disease (LOPD) is mainly characterized by progressive limb-girdle muscle weakness and respiratory impairment, whereas stroke and cerebrovascular abnormalities have been insufficiently studied in LOPD. This study aimed to evaluate the frequency and pattern of intracranial artery and brain parenchyma abnormalities in LOPD patients.ResultsNeuroimaging data from 30 Chinese adult LOPD patients were collected from our center. Seven patients (7/30) had acute cerebral infarction or hemorrhage. Brain magnetic resonance angiography (MRA) or computed tomography angiography (CTA) revealed artery abnormalities in 23 patients (23/30). Dilative arteriopathy was found in 19 patients (19/30), with vertebrobasilar dolichoectasia found in 17 patients and dilatation of the anterior circulation arteries found in 8 patients. The maximum diameter of the basilar artery was correlated with disease duration (p < 0.05). In addition, aneurysms (7/30) and fenestrations (3/30) were discovered. There were 14 patients with arterial stenosis (14/30), and both anterior and posterior circulation involvement occurred in 9 patients (9/14). Stenosis and dilative arteriopathy simultaneously occurred in 10 patients (10/30). White matter hyperintensities were present in 13 patients (13/28). Microbleeds, predominantly located in the cerebellum and brainstem, were detected in 7 patients (7/22) via susceptibility-weighted imaging.ConclusionsIntracranial vasculopathy involving both large arteries and small vessels is an important organ damage in LOPD patients. LOPD should be considered a key differential diagnosis in young adults with cryptogenic stroke, and a series of imaging evaluations of the brain and intracranial blood vessels is recommended as a routine workup in adult LOPD patients.

Correlations between intravascular pressure gradients and cerebral blood flow in patients with symptomatic, medically refractory, anterior circulation artery stenosis: an exploratory study

BackgroundFractional flow reserve is widely used in coronary disease management, with a threshold of 0.80. However, similar thresholds are unclear in functional assessment of intracranial atherosclerotic stenosis (ICAS).ObjectiveTo investigate the...

Differences and Correlations of Morphological and Hemodynamic Parameters between Anterior Circulation Bifurcation and Side-wall Aneurysms.

The objective of this research was to explore the difference and correlation of the morphological and hemodynamic features between sidewall and bifurcation aneurysms in anterior circulation arteries, utilizing computational fluid dynamics as a tool for analysis. In line with the designated inclusion criteria, this study covered 160 aneurysms identified in 131 patients who received treatment at Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, China, from January 2021 to September 2022. Utilizing follow-up digital subtraction angiography (DSA) data, these cases were classified into two distinct groups: the sidewall aneurysm group and the bifurcation aneurysm group. Morphological and hemodynamic parameters in the immediate preoperative period were meticulously calculated and examined in both groups using a three-dimensional DSA reconstruction model. No significant differences were found in the morphological or hemodynamic parameters of bifurcation aneurysms at varied locations within the anterior circulation. However, pronounced differences were identified between sidewall and bifurcation aneurysms in terms of morphological parameters such as the diameter of the parent vessel (Dvessel), inflow angle (θF), and size ratio (SR), as well as the hemodynamic parameter of inflow concentration index (ICI) (P<0.001). Notably, only the SR exhibited a significant correlation with multiple hemodynamic parameters (P<0.001), while the ICI was closely related to several morphological parameters (R>0.5, P<0.001). The significant differences in certain morphological and hemodynamic parameters between sidewall and bifurcation aneurysms emphasize the importance to contemplate variances in threshold values for these parameters when evaluating the risk of rupture in anterior circulation aneurysms. Whether it is a bifurcation or sidewall aneurysm, these disparities should be considered. The morphological parameter SR has the potential to be a valuable clinical tool for promptly distinguishing the distinct rupture risks associated with sidewall and bifurcation aneurysms.

Microsurgical excision of intracranial arteriovenous malformation

Objectives: Brain Arteriovenous malformations are high-flow cerebrovascular lesions with dysplastic vascular nidus, fed by arteries and drained by veins without intervening capillaries. Prevalence is 0.2% and is an important cause of intracerebral haemorrhage in about 38% of young adults. The objective of this study is to analyze surgically managed Intracranial AV malformations with respect to their demographic features, varied clinical presentations, imaging features Spetzler Martin grading and outcome. Methods: A study of 48 patients with Intracranial Arteriovenous malformations who underwent microsurgical excision at the Institute of Neurosurgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai over a period of 5 years from July 2018 to June 2022 and extracted their data including demographic characteristics, clinical presentations, Spetzler-Martin (SM) grades, complications and outcome were assessed. Results: Of the 48 patients treated with microsurgery, the most common 51% belongs to the age group between 21 to 40years, left-sided is slightly more common with headache major symptom, involving Parietooccipital lobe 33% commonly, 28 (62.2%) patients initially presented with haemorrhage. Anterior circulation artery feeders was common 68.8% and mostly drainage involving superficial venous drainage system. Based on the Spetzler-Martin (SM) grading system, the patients were graded as follows: 6(13 %) Grade I, 10(21%) Grade II, 25(52%) Grade III, 3 (6%) Grade IV and 4(8%) Grade V. Overall, 35(73%) patients had a favorable outcome, most commonly seen in Grade I, II and Grade III. Almost complete obliteration of the AVMs were achieved in all favorable outcome cases. Conclusion: Microsurgical excision is the gold standard treatment of choice for low grade AVMs and certain high-grade AVMs with increased risk of rupture. The Spetzler-Martin grading system is a simple and effective method to estimate the risk of surgery and to evaluate the prognosis. Proper patient selection combined with appropriate preoperative evaluation, meticulous surgical technique and postoperative care all lead to reduced mortality and morbidity.

Abstract 139: Regional Disparities in Mechanical Thrombectomy Utilization for Treatment of Acute Ischemic Stroke in the United States

Background: A current national priority is to understand geographic disparities in mechanical thrombectomy (MT) provision for patients with acute ischemic stroke (AIS). We examine variation in rates of MT by geographic region and urban-rural areas to identify utilization disparities across the United States. Methods: The state-specific annual incidence of AIS in 2019 was determined using data from the Global Burden of Disease Collaborative Network. We determined the number of patients who were admitted with AIS due to thrombosis or embolism of anterior circulation arteries and those who received MT in a particular region/state based on the State Inpatient Database of NIS. The National Inpatient Sample data were used to create national weighted estimates of the size of subject populations, age at admission, length of stay, and discharge status. Results: In the United States, approximately 28,165 MT were performed in 2019, representing 4% of the AIS population. In large central metropolitan areas, the proportion of thrombectomies performed to the AIS patient population was significantly higher than the national estimate (4.34%, P &lt; 0.001); small metropolitan areas and rural settings (micropolitan and noncore) had significantly lower proportions of MT-treated patients with 3.2% and 2.9%, respectively (P &lt; 0.001), when compared with the national estimate. West region had significantly higher proportions of MT-treated patients with 4.3%, compared with the national estimate (P &lt; 0.001), whereas South region had significantly lower proportions with 3.8% (P &lt; 0.001). Conclusions: We found prominent regional disparities in the utilization rates of MT in acute ischemic stroke patients in the United States, which may have implications for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities.

Abstract TMP12: Large Vessel Vasculopathy is Associated With Oxygen Metabolic Stress in Children and Young Adults With Sickle Cell Disease

Background: Large-vessel vasculopathy (LVV), such as moyamoya syndrome, increases stroke risk with sickle cell disease (SCD). We hypothesized that tissue-based cerebral blood flow (CBF) and oxygen extraction fraction (OEF), as indicators of hemodynamic and metabolic stress, would differ in hemispheres with vs. without LVV. Methods: Patients underwent serial brain MRI and time-of-flight MRA to quantify voxel-wise CBF, OEF, and infarcts. LVV was defined as 75-99% stenosis of a major anterior circulation artery. Hemispheres with large vessel occlusion or revascularization surgery were excluded. Infarcted voxels were removed. Mean hemispheric (hemi-) CBF, OEF of the anterior circulation were extracted based on a vascular territory template. Hemi- OEF was normalized to whole brain OEF (nOEF). Hemi- cerebral metabolic rate of oxygen utilization (CMRO 2 ) was calculated from arterial oxygen content, hemi- CBF, and hemi- OEF. Mann-Whitney U was used to compare hemispheres with vs. without LVV. Effects of age, hemoglobin, and repeated MRIs were adjusted for in linear mixed model. Results: Of 158 patients, 221 MRI and MRAs were performed. At baseline, LVV occurred in 5% of hemispheres. Median infarct volume was larger in hemispheres with vs. without LVV (6.5 vs. 0.04 mL, p &lt;0.001). In baseline univariate analysis, hemispheres with LVV had lower CBF (25.8 vs 31.3 mL/100g/min, p =0.04), non-significantly higher nOEF (0.99 vs. 0.96, p =0.067), and lower CMRO 2 (8.1 vs. 12.4 mL/100g/min, p =0.002) vs. without LVV. In mixed model, with all MRIs included, LVV was independently associated with nOEF (β = 0.03, p =0.04) and showed a trend for association with CBF (β = -5.4, p =0.09) and CMRO 2 (β = -35.2, p =0.08). Discussion: In SCD, hemispheric OEF was increased as a compensatory response to flow-limiting stenosis, yet may be inadequate to prevent infarction as CMRO 2 decreased. Hemispheric OEF, as an indicator of increased stroke risk, may guide medical management and surgical intervention.

Mixed reality compared to the traditional ex cathedra format for neuroanatomy learning: the value of a three-dimensional virtual environment to better understand the real world.

Neuroanatomy comprehension is a keystone of understanding intracranial surgeries. Traditionally taught to students during ex cathedra courses, neuroanatomy is described as complex. Mixed reality (MxR) opens new perspectives in the learning process. This study aims to compare MxR-based courses with traditional ex cathedra lectures for neuroanatomy education. Two lectures describing the neuroanatomy of the anterior circulation arteries ("Vascular Lecture" [VS]) and important white matter fiber tracts ("White Fibers Lecture" [WF]) were designed and delivered in ex cathedra and MxR-based formats with the same audio content. Ninety-one medical students were randomly assigned to group A (ex cathedra WF/MxR VS) or group B (MxR WF/ex cathedra VS). The MxR content was delivered via MxR goggles. Prior to each lecture, students took a 10-item multiple choice question (MCQ) pretest. After the lectures, students took a 20-item MCQ posttest (75% neuroanatomy, 25% clinical correlation). The pretest scores showed no statistical difference between groups. Median posttest scores increased by 14.3% after using the MxR-based format compared to the ex cathedra format (16.00 [13.0, 18.0] vs 14.0 [11.0, 17.0], respectively, p < 0.01). Regarding the VS, students scored 21.7% better using the MxR format compared to the ex cathedra format (14.0 [12.0, 16.0] vs 11.5 [10.0, 14.0], p < 0.001). Concerning the WF, the median score using MxR was 18.0 (17.0, 19.0), and the median score using the ex cathedra format was 17.0 (16.0, 18.0; p < 0.01). Students showed high motivation to learn neuroanatomy in the future using MxR (74%) rather than ex cathedra format (25%; p < 0.001). Mild discomfort using the MxR goggles was reported by 48.3% of participants. Most participants (95.5%) preferred the MxR-based teaching. Students acquired a better knowledge of the anatomy of the anterior circulation arteries and white fiber tracts using MxR-based teaching as compared to the standard ex cathedra format. The perception of lecture quality and learning motivation was better using MxR-based teaching despite some mild discomfort. The development of MxR-based solutions is promising to improve neuroanatomy education.

Safety and effectiveness of emergency stenting for acute anterior circulation large artery disease

Objective: To explore the safety and effectiveness of early stent implantation in patients with acute anterior circulation large artery disease. Methods: Patients were recruited from the RESCUE-RE study (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization). Patients who were diagnosed with acute ischemic stroke within 24 hours of onset and given endovascular treatment after consultation from July 2018 to May 2019 from 18 sub-centers nationwide were retrospectively enrolled. According to whether the stents were placed during the operation, the patients were divided into two groups: stenting group and non-stenting group. The baseline between the two groups was matched by propensity score. The matching variables included age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, baseline Glasgow Coma Scale (GCS) score, history of stroke, smoking and onset to hospital time. The primary clinical outcome was 90-day good neurological outcome [defined as modified Rankin score (mRS) 0-2]. Secondary outcomes include 90-day mortality, 24-hour re-occlusion of the responsible artery, and symptomatic intracranial hemorrhage. The differences in clinical endpoints between the two groups were compared. Result: A total of 899 patients with acute anterior circulation artery stenosis or occlusion were included in the study, with a mean age of(66±12)years,and 532(59.18%) were male. There were 193 patients in the stenting group and 706 patients in the non-stenting group. After the baseline data between the two groups were matched by propensity score, 169 patients were enrolled in each of two groups respectively. After matching, the proportion of patients in the stenting group with etiological diagnosis of large atherosclerosis [82.53% (137/166) vs 55.69% (93/167)] and the proportion of patients with previous history of hypertension [63.31% (107/169) vs 47.93% (81/169)] in the stenting group were higher than those in the non-stenting group (both P<0.05). While the proportion of patients in the non-stenting group with cardiogenic embolism [37.73%(63/167) vs 11.45%(19/166)]and the proportion of patients with atrial fibrillation [18.93% (32/169) vs 10.65%(18/169)]was higher(all P<0.05). In the stenting group, the time from onset to recanalization was longer[519 (408, 620)min vs 469 (365, 690)min], and the proportion of general anesthesia [50.89% (86/169) vs 35.50% (60/169)] was higher in the stenting group(both P<0.05). In addition, in the stenting group, the proportion of patients receiving mechanical thrombectomy[67.46% (114/169) vs 88.76% (150/169)] and arterial thrombolysis [2.37% (4/169) vs 18.93% (32/169)] was lower than non-stenting group during the operation, while the proportion of patients receiving balloon dilation [53.85% (91/169) vs 13.61% (23/169)]was higher(both P<0.05). The proportion of patients in stent group receiving antiplatelet drugs before operation was higher [13.46% (21/169) vs 8.70% (14/169)](both P<0.05). In terms of clinical outcome, compared with the non-stenting group, the proportion of patients in the stenting group with good neurological function in 90 days was lower [44.79% (73/169) vs 56.36% (93/169)], and the proportion of death at 90 days was higher[15.98% (27/169) vs 8.88% (15/169)] (both P<0.05). There was no significant difference between the two groups in 24-hour re-occlusion[8.88% (15/169) vs 9.47% (16/169)] and symptomatic intracranial hemorrhage[5.92% (10/169) vs 4.76% (8/169)](both P>0.05). Conclusion: For patients with acute anterior circulation artery disease, early stent therapy may increase the proportion of patients with adverse neurological outcomes.

Association of intracranial atherosclerosis with cerebral small vessel disease in a community-based population.

The purpose of this study was to explore the relationship between intracranial atherosclerosis and cerebral small vessel disease (CSVD). Community-dwelling residents of Lishui, China in the PRECISE (Polyvascular Evaluation for Cognitive Impairment and Vascular Events) study were involved. Intracranial atherosclerosis was grouped by the severity of intracranial artery plaques with stenosis and burden. Four imaging markers including lacunes, white matter hyperintensity (WMH), cerebral microbleeds (CMBs), and perivascular spaces (PVS) as well as the CSVD burden scores were assessed. Logistic regression or ordinal logistic regression models with odds ratio (OR) or common OR (cOR) were used to estimate the relationship between intracranial atherosclerosis and CSVD markers and burdens. The mean age was 61.20 ± 6.68 years, and 1424 (46.52%) were men among 3061 participants included at baseline. Intracranial atherosclerotic burden was associated with the severity of the lacunes (OR = 4.18, 95% confidence interval [CI] = 1.83-9.58), modified WMH burden (cOR = 1.94, 95% CI = 1.01-3.71), presence of CMBs (OR = 2.28, 95% CI = 1.05-4.94), and CMB burden (OR = 2.23, 95% CI = 1.03-4.80). However, it was not associated with the WMH burden and PVS. Intracranial atherosclerotic burden was associated with CSVD burden (Wardlaw: cOR = 2.73, 95% CI = 1.48-5.05; Rothwell: cOR = 2.70, 95% CI = 1.47-4.95). The association between intracranial atherosclerosis and CSVD was obvious in participants with both anterior and posterior circulation artery stenosis. Based on a Chinese community population, there may be an association between intracranial atherosclerosis and CSVD, but its mechanism in relation to vascular risk factors still needs to be clarified.

Fetal posterior cerebral artery in pediatric and adult moyamoya disease: A single-center experience of 480 patients

PurposeIn past pediatric and adult cohort studies of moyamoya disease, the fetal posterior cerebral artery has received less attention. Its relationship with the clinical manifestations and collateral circulation of moyamoya disease or ipsilateral cerebral hemispheres remains unclear. MethodWe summarize the clinical features of patients with and without fetal posterior cerebral artery moyamoya disease from consecutive cases.We explored the relationship between fetal posterior cerebral arteries and collateral circulation in the ipsilateral cerebral hemispheres, as well as differences among different subgroups of patients.According to the morphology, the fetal posterior cerebral artery is divided into complete fetal posterior cerebral artery and partial fetal posterior cerebral artery. Clinical features were classified as: infarction,hemorrhage,and non-stroke in unilateral/bilateral cerebral hemispheres. Collateral circulation is divided into extracranial vascular compensation and leptomeningeal collateral circulation. Digital subtraction angiography and CT/MR were used to evaluate the blood flow status and clinical characteristics of patients with moyamoya disease. ResultA total of 960 cerebral hemispheres from 142 pediatric patients and 338 adult patients were included in the study. A total of 273 (56.9%) patients had 399 cerebral hemispheres (41.6%) with fetal posterior cerebral arteries. Adults with fetal posterior cerebral arteries had lower rates of infarction (24.6%vs37.3%, P =0.005) and were less likely to have bilateral stroke (8.4%vs11.5%, P =0.038). Cerebral hemispheres with fetal posterior cerebral artery were more likely to have anterior cerebral artery and middle cerebral artery stenosis and less likely to have occlusion (P =0.002, 0.001), and less likely to involve the posterior circulation (P < 0.001). The cerebral hemispheres of the fetal posterior cerebral artery had higher leptomeningeal collateral circulation scores. There are significant differences in extracranial vascular compensation between cerebral hemispheres with and without fetal posterior cerebral artery. Adult patients with fetal posterior cerebral artery were more advanced in Suzuki stage (P =0.017). ConclusionsOur results suggest that fetal posterior cerebral artery is associated with infarct manifestations in pediatric and adult moyamoya disease. In the cerebral hemispheres, the fetal posterior cerebral artery is associated with ipsilateral hemispheric anterior and posterior circulation artery injury, extracranial vascular compensation, leptomeningeal collateral circulation compensation, and infarction. Adult patients with fetal posterior cerebral artery were more advanced in Suzuki stage.

Abstract Number ‐ 11: Automated Measurement Of Vascular Tortuosity: Association With Baseline Clinical Characteristics And Impact On Mechanical Thrombectomy

Introduction Vascular tortuosity is considered one of the main hurdles that may negatively impact mechanical thrombectomy in stroke treatment, delaying catheter access to the occluded vessel. Automatic characterization of anatomical vascular features may help in the planification of endovascular interventions. We developed a fully automatic algorithm for vascular tortuosity measurement and explored the association of several anatomical features with baseline characteristics and procedural outcomes. Methods An automatic software integrating segmentation, centerline extraction and vessel labelling, was used to extract features directly from computed tomography angiograms (CTA) of stroke patients undergoing transfemoral endovascular treatment.Mean vessel diameter and tortuosity index (TI) of the carotid arteries and brachiocephalic trunk were used as relevant tortuosity indicators. Patients were compared according to six different clinical conditions(gender, hypertension, dyslipidemia, diabetes, obesity and atrial fibrillation). Tortuosity values were also correlated with age.Patients with an anterior circulation stroke were further classified according to four procedural measures:time from groin puncture to first angiographic run, time to first retrieval attempt, time to revascularization. Results A sample of 558 patients with acute ischemic stroke who underwent mechanical thrombectomy at our medical center were included in this study. Forty patients (7.2%) were discarded due to sub‐optimal segmentation (n = 30) or processing errors (n = 10), leaving a final sample size of N = 518 (51% female, 74.8±12.9 years). Women presented significantly smaller mean diameter for all analyzed vessels (p &lt; 0.01) and an increased TI for both carotid arteries(p &lt; 0.01). Age was significantly correlated with increased TI in all analyzed vessels (0.35£r£0.52;p &lt; 0.01) Patients with hypertension and/or atrial fibrillation displayed significantly higher TI in both carotid arteries (p &lt; 0.01). Additionally, the brachiocephalic trunk was found to be more tortuous in patients with atrial fibrillation (p &lt; 0.01). A higher TI in all ipsilateral carotid segments was associated with higher times to first angiographic run and to final revascularization (p &lt; 0.05). A TI from the ipsilateral carotid segment over 0.28 independently predicted difficult catheter access (time to first angiographic run &gt;40 min, 3.8% of cases) with a sensitivity of 0.92 and a specificity of 0.68. Conclusions An automated software was successfully used to characterize the anatomical vascular features from CTA. Gender, age, hypertension and atrial fibrillation were found to significantly influence vascular tortuosity in anterior circulation arteries. Patients with difficult catheter access and/or delayed revascularization presented higher TI of ipsilateral carotid arteries. Carotid TI emerged as a potential predictor of difficult catheter access.

Abstract Number ‐ 250: Case Series of Moyamoya Patients Diagnosed on Hyperacute Imaging

Introduction Moyamoya disease is the idiopathic bilateral progressive stenosis of the anterior circulation arteries at the skull base, followed by the compensatory formation and proliferation of collateral small vessel arteries typically in the lenticulostriate region. The clinical diagnosis is made by neurovascular imaging with digital subtraction angiography being the gold standard of diagnosis. The term moyamoya syndrome is used when the formation of collateral arteries occur after unilateral vasculopathy or if the progressive stenosis occurs in the setting of known associated conditions such as sickle cell disease or prior cranial radiation treatment. For patients who have undiagnosed moyamoya syndrome, stroke symptoms may be the first presentation of the underlying disease. Methods We present a case series of 15 patients who arrived to our tertiary care hospital from December 2014 to July 2022. Results The majority of the patients were women with the average age of 43 years old. Patients were admitted with NIHSS ranging from 0 to 14, and two patients presented with signs suggestive of MCA syndrome. Including major ischemic stroke risk factors, five patients also had differentials of antiphospholipid antibody syndrome, connective tissue disorder, vasculitis, and congenital rubella as possible underlying conditions promoting the vasculopathy. Morbidity was high for moyamoya patients, with an average modified Rankin scale of 2 at discharge. Eleven patients had unknown moyamoya history at time of arrival and were identified based on hyperacute diagnostic CT angiography during stroke evaluation. Five patients were initially diagnosed as large vessel occlusion on CT angiography. Given the speed at which IV thrombolysis and mechanical thrombectomy decisions are made, patients with moyamoya vasculopathy require rapid and accurate interpretation of CT findings that distinguish them from standard large vessel occlusion patients and prevent the potentially catastrophic consequences of inappropriate treatment. Conclusions The pathophysiology leading to moyamoya disease is not well understood, but the stenosis process of major arteries is thought to be secondary to irregular hyperplasia of the tunica media, followed by compensatory growth of small collateral vessels. This collateralization leads to micro‐aneurysm formation in the small perforator branches. Moyamoya patients are at an increased risk of hemorrhage, representing a contraindication to IV thrombolysis, and, if mechanical thrombectomy is attempted, risk of possible large vessel rupture. In our case series, the 15 patients did not receive IV thrombolysis or mechanical thrombectomy based on appropriate diagnosis of moyamoya vasculopathy at time of emergency CT angiography, subsequently confirmed by elective, catheter cerebral angiography.

Prognosis of ischemic stroke predicted by machine learning based on multi-modal MRI radiomics.

Increased risk of stroke is highly associated with psychiatric disorders. We aimed to conduct the machine learning model based on multi-modal magnetic resonance imaging (MRI) radiomics predicting the prognosis of ischemic stroke. This study retrospectively analyzed 148 patients with acute ischemic stroke due to anterior circulation artery occlusion. Based on the modified Rankin Scale (mRS) score, patients were divided into good (mRS ≤ 2) and poor (mRS > 2) outcome groups. Segmentation of the infarct region was performed by manually outlining a mask of the lesion on diffusion-weighted images (DWI) using MRIcron software. The apparent diffusion coefficient (ADC), fluid decay inversion recoverage (FLAIR), susceptibility weighted imaging (SWI) and T1-weighted (T1w) images were aligned to the DWI images and the radiomic features within the lesion area were extracted for each image modality. The calculations were done using pyradiomics software and a total of 4,744 stroke-related imaging features were automatically calculated. Next, feature selection based on recursive feature elimination was used for each modality and three radiomic features were extracted from each modality plus one feature from the lesion mask, for a total of 16 radiomic features. At last, five machine learning (ML) models were trained and tested to predict stroke prognosis, calculate the received operating characteristic (ROC) curves and other parameters, evaluate the performance of the models and validate their predictive efficacy by five-fold cross-validation. Sixteen radiomic features were selected to construct the ML models for prognostic classification. By five-fold cross-validation, light gradient boosting machine (LightGBM) model-based muti-modal MRI radiomic features performed best in binary prognostic classification with accuracy of 0.831, sensitivity of 0.739, specificity of 0.902, F1-score of 0.788 and an area under the curve (AUC) of 0.902. The ML models based on muti-modal MRI radiomics are of high value for predicting clinical outcomes in acute stroke patients.

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

Long-term changes in cerebral and ocular hemodynamics after carotid endarterectomy in symptomatic patients with unilateral carotid artery stenosis.

The aim of the current study was to describe the alternation pattern of cerebral and ocular blood flow velocities (BFVs) in symptomatic patients with unilateral carotid stenosis after carotid endarterectomy. 20 symptomatic patients underwent carotid endarterectomy for ≥ 50% unilateral carotid stenosis. Cerebral and ocular hemodynamics were evaluated by Transcranial Doppler (TCD) and Color Doppler imaging (CDI), respectively, first preoperatively, then during the following several days after carotid endarterectomy before discharge, and finally two to sixteen months later. Statistically significant improvements in the BFVs were recorded in the ipsilateral anterior cerebral artery (ACA), middle cerebral artery (MCV) and short posterior ciliary artery (SPCA) during the following several days after carotid endarterectomy. Preoperative retrograde flows of the ipsilateral ophthalmic artery (OA) in two patients returned to anterograde direction immediately following carotid endarterectomy. At the follow-up of two to sixteen months, the BFVs of the ipsilateral ACA, MCA and SPCA tended to decline and were no longer statistically significant from the preoperative values. Carotid endarterectomy significantly increased the flow velocities of ipsilateral cerebral anterior circulation and OA branching artery in patients with unilateral carotid stenosis early after surgery. At the long-term follow-up, the flow velocities in the ipsilateral hemisphere had the tendency to reduce and approach the preoperative level.

De novo headache in ischemic stroke patients treated with thrombectomy: a prospective study

Background and aimHeadache attributed to intracranial endovascular procedures is described in the ICHD-3. Our aim was to study the frequency and characteristics of headache specifically related to thrombectomy in patients with ischemic stroke.MethodsProspective evaluation of clinical features of headache after thrombectomy using an ad hoc questionnaire.ResultsOne hundred seventeen patients were included (52.1% females). Most had an anterior circulation artery occlusion (91.5%). 93 (79.5%) received general anaesthesia. 111 (94.9%) required stent retriever, 21 (24.4%) angioplasty and 19 (16.2%) aspiration thrombectomy. 31 (26.5%; 95% CI 18.8–35.5%) had headache related to thrombectomy, and it was associated with a history of primary headache (p = 0.004). No differences about sex, initial NIHSS score, or the type or complexity of the procedure were observed. Headache was usually moderate and oppressive, ipsilateral to the artery occlusion and usually lasted less than 48 hours.ConclusionsAlmost one-third of patients with ischemic stroke who undergo endovascular thrombectomy experience headache in the first 24 hours, occurring more frequently in patients who had a previous history of headaches regardless of the procedure complexity.

HR-MRI findings of intracranial artery stenosis and distribution of atherosclerotic plaques caused by different etiologies.

To investigate the etiology of intracranial artery stenosis and the distribution characteristics of intracranial artery atherosclerotic stenosis using high-resolution magnetic resonance imaging (HR-MRI). A total of 262 patients with intracranial artery stenosis that underwent HR-MRI from November 2019 to December 2020 were retrospectively enrolled. The etiology of intracranial anterior and posterior circulation artery stenosis was analyzed, and the relationship between the location of plaques and the distribution characteristics of plaques and the occurrence of ischemic stroke was summarized. A total of 276 plaques were identified with HR-MRI. There were 101 cases (36.59%) in the middle cerebral artery (MCA), 14 cases (5.07%) in the posterior cerebral artery (PCA), 90 cases (32.62%) in vertebral artery (VA), and 71 cases (25.72%) in the basilar artery (BA). The infarct rate of ventral and superior wall MCA plaques was higher than that of dorsal and inferior wall (63.33% vs 31.25% P = 0.021) (100.00% vs 50% P = 0.022). MCA with plaques throughout the course had the greatest degree of stenosis (P < 0.001). Sphenoid segment (M1) of MCA was most susceptible (85 cases, 84.16%), MCA plaques were most common in the proximal M1 segment (35 cases, 34.65%), and most BA plaques were found in the distal segment (28 cases, 39.44%). PCA plaques were most frequently involved in traffic anterior segment (P1) (7 cases, 50.00%). HR-MRI could provide accurate imaging reference for clinical evaluation of intracranial arterial stenosis and formulation of treatment plans. The intracranial arterial plates mostly appeared in the middle cerebral artery and vertebral artery. Middle cerebral arteries with atherosclerotic plaques are more likely to narrow.

A comparison between acute large vessel occlusion in the posterior circulation and anterior circulation after endovascular treatment: the ANGEL-ACT registry experience

Background and purposeEndovascular treatment (EVT) has shown an overwhelming benefit for acute anterior circulation artery occlusion (ACO). Whether it can achieve the same outcomes in posterior circulation artery occlusion (PCO)...

High-Resolution Magnetic Resonance Imaging (HR-MRI) Evaluation of the Distribution and Characteristics of Intra-Aneurysm Thrombosis to Improve Clinical Diagnosis of Thrombotic Intracranial Aneurysm.

BackgroundWe aimed to analyze the related factors of intracranial anterior circulation saccular artery thrombosis and its characteristics on high-resolution magnetic resonance imaging (HR-MRI) images to provide a basis for neurosurgeons to select the precise treatment strategy for thrombotic intracranial aneurysms (TIA).Material/MethodsThis retrospective analysis included 136 patients with unruptured intracranial anterior circulation artery aneurysms who underwent HR-MRI. The 136 aneurysms were divided into thrombus (41) and non-thrombus (95) groups. Single factor analysis of morphological and clinical indicators were conducted to select meaningful indicators for logistic regression analysis; the optimal diagnostic threshold was calculated through ROC curve analysis. The location and signal characteristics of thrombi were analyzed to inform clinical treatment.ResultsSingle factor analysis revealed significant differences in patient age, aneurysm size, aneurysm neck, aspect ratio, size ratio, and hyperlipidemia between the 2 groups (P<0.05). Multi-factor regression analysis demonstrated that aneurysm size (OR=2.180) and aspect ratio value (OR=7.495) were correlated with intracranial thrombosis. ROC curve analysis showed that for aneurysms larger than 8 mm, the sensitivity and specificity of TIA prediction were 83% and 93%, respectively. For aneurysms with aspect ratio values greater than 2.5, sensitivity and specificity of TIA predication were 75% and 95%, respectively. The proportion of aneurysm wall enhancement and clinical symptoms in the thrombus group was significantly higher than that in the non-thrombus group.ConclusionsIntracranial unruptured aneurysms with the size larger than 8 mm or with aspect ratio values higher than 2.5 indicated the possible formation of thrombosis in the aneurysm.