Bilateral Anterior Cerebral Artery Research Articles

Exploring the relationship between embolic acute stroke distribution and supra-aortic vessel patency: key findings from an in vitro model study

BackgroundWe investigated differences in intracranial embolus distribution through communicating arteries in relation to supra-aortic vessel (SAV) patency.MethodsFor this experimental analysis, we created a silicone model of the extracranial and intracranial...

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

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

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

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

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series.

Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

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

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

FRI318 A Case Of Mixed Growth Hormone And Prolactin-secreting Giant Pituitary Macroadenoma

Abstract Disclosure: A. Khan: None. I. Alpertunga: None. V. Kantorovich: None. Introduction Co-secretion of prolactin (PRL) and growth hormone (GH) from a single pituitary adenoma is an established entity in the medical literature and present in about 5% of the cases. Guidelines recommend to obtain an insulin-like growth factor-1 (IGF-1) in patients with prolactinoma at the time of initial diagnosis. Our case describes the management of a giant pituitary macroadenoma co-secreting PRL and GH. Case A 20-year-old male with history significant for schizophrenia presented with visual disturbances and discharge from his left nipple. His prolactin level (PRL) was noted to be elevated at 12,396 (4.0-15.2) ng/ml on work-up during recent prior investigation. On physical exam, he had bilateral temporal visual field deficit as well as dysfunction in upward gaze of left eye. Head imaging showed a 7.5 x 6.2 x 5 cm associated with remodeling of the sella turcica and expanding into the suprasellar space and significant mass-effect on the adjacent frontal lobes bilaterally, mild mass-effect on the adjacent optic chiasm with significant surrounding vasogenic edema and compressing the bilateral anterior cerebral arteries. Patient was started on low dose cabergoline in caution of prevention of possibility of rapid response-related significant volume contraction of the tumor with possibility of reactive edema. The dose of cabergoline was rapidly titrated up to 3 mg bi-weekly with minimal prolactin fluctuation of PRL between 12,000 and 16,000 ng/ml. Because of mild atypical acromegalic facial features, patient had GH axis assessment. IGF-1 level came back elevated at 529 (83-456) ng/ml with a high IGF Binding Protein- 3 of 8.9 (2.9-7.2) mg/l. He was started on octreotide titrated up to a dose of 150 mcg three times daily. Repeat MRI brain did not show tumor shrinkage. Subsequently, patient underwent bifrontal craniotomy for resection/debulking of parasellar tumor. PRL dropped to 931 ng/ml immediately after surgery. At the time of writing, pathology of the tumor and repeat IGF-1 level is pending. Patient was monitored closely in the ICU with a steroid taper postoperatively. Discussion Dopamine agonists are the first-line therapy for medical treatment of hyperprolactinemia but can also suppress GH and IGF-1 levels. However, in acromegaly, cabergoline is utilized mostly for small adenomas with mild elevation of IGF-1. In our case, we decided to use a combination of cabergoline and somatostatin receptor analog, octreotide. However, given the giant adenoma with very high PRL and IGF-1 levels, patient showed a poor response to medical therapy, and given the impending threat to patient’s vision, he underwent surgical debulking. Our case highlights the management of a giant, mixed hormone-secreting pituitary adenoma. Presentation: Friday, June 16, 2023

VERTIGO AND DIZZINESS IN ANTERIOR CIRCULATION CEREBROVASCULAR DISEASE : SYSTEMATIC REVIEW

Introduction: Recurrent spontaneous vertigo/dizziness episodes may manifest as fleeting occurrences. It is uncommon for vascular vertigo to cause an isolated positional vestibular condition, also known as recurrent positional vertigo or disorientation. The anteriormost boundary of the structure is the solitary anterior communicating artery (ACom), which connects the ring to the bilateral anterior cerebral arteries (ACA).
 The aim: This article explore about vertigo and dizziness in anterior circulation cerebrovascular disease.
 Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2013 and 2023 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done.
 Result: In the PubMed database, the results of our search brought up 12 articles, whereas the results of our search on SagePub brought up 6 articles. The results of the search conducted for the last year of 2013 yielded a total 7 articles for PubMed and 2 articles for SagePub. In the end, we compiled a total of five papers, 4 of which came from PubMed and one of which came from SagePub. We included three research that met the criteria.
 Conclusion: Previous research has linked the findings of vertigo with disturbances in the cerebral arteries, especially when accompanied by complaints of hearing loss, balance disturbances, and limb weakness.

Utilizing the supreme anterior connecting artery in embolization of a parietal lobe arteriovenous malformation.

The supreme anterior connecting artery (SAConnA) is an exceedingly rare anatomical variant. This artery may interconnect bilateral anterior cerebral arteries (ACAs), yet its existence and clinical implications are scarcely discussed in the literature. A 60-year-old man with no significant past medical or family history presented to our emergency department. He exhibited right homonymous hemianopsia and Gerstmann's syndrome. Cranial computed tomography indicated a left parietal lobar hemorrhage, and digital subtraction angiography revealed a flow-related aneurysm in the anterior communicating artery, with the arteriovenous malformation (AVM) receiving blood supply from the anterior, middle, and posterior cerebral arteries. Notably, the angiography also disclosed the presence of a SAConnA. We adopted a treatment approach of staged embolizations followed by resection. During the second session, the SAConnA was utilized for the embolization of feeding arteries within the ACA system. This case demonstrates that SAConnA can be associated with AVMs and can serve as an access route during AVM embolization. SAConnA may be a remnant artery interconnecting bilateral ACAs formed during early embryogenesis.

Evaluation of single-delay arterial spin labeling-based spatial coefficient of variation and histogram-based parameters in relation to cerebrovascular reserve in patients with Moyamoya disease.

Single-delay Arterial Spin Labeling (ASL)-based spatial coefficient of variation (CoVCBF) has been suggested as a measure of hemodynamic disturbance in patients with cerebrovascular diseases. However, spatial CoVCBF and other histogram-based parameters such as skewness and kurtosis and the volume of the arterial transit time artefact (ATAvol), has not been evaluated in patients with MMD nor against cerebrovascular reserve (CVR). The aim of this study was to assess whether any associations between spatial CoVCBF, skewness, kurtosis, and ATAvol are present and to analyze any potential associations with CVR, derived from single-delay ASL in patients with MMD. Fifteen MMD patients were included before or after revascularization surgery. Cerebral blood flow (CBF) maps were acquired using pseudo-continuous ASL before, and 5, 15, and 25 min after an intravenous acetazolamide injection. CVRmax was defined as the highest percentual increase in CBF at any of the three post-injection time points. A vascular territory template was spatially normalized to each patient, including the bilateral anterior, middle, and posterior cerebral arteries. All affected anterior and middle cerebral artery regions and all unaffected posterior cerebral artery regions were included, based on Suzuki grading by digital subtraction angiography. Significant differences between affected and unaffected regions were found for CBF, CVRmax, and ATAvol. No association was found between CVRmax and any other parameter. High correlations were found between spatial CoVCBF, skewness and ATAvol. Spatial CoVCBF derived from single-delay ASL does not correlate with CVR in patients with MMD. Moreover, skewness and kurtosis did not provide additional information of clinical value.

Comparison of arterial spin labeling perfusion with dynamic susceptibility contrast perfusion in Moyamoya disease.

Moyamoya disease (MMD) leads to frequent ischemic/hemorrhagic manifestations. Our aim was to compare findings of arterial spin labeling (ASL) with dynamic susceptibility contrast (DSC) perfusion in patients of MMD. Patients diagnosed as MMD underwent magnetic resonance imaging with ASL and DSC perfusion sequences. Perfusion in bilateral anterior cerebral artery and middle cerebral artery territories at two levels (level of thalami and centrum semiovale) was graded as normal (score 1), or reduced (score 2) on DSC and ASL cerebral blood flow (CBF) maps by comparison with normal cerebellar perfusion. Time to peak (TTP) maps of DSC perfusion were also qualitatively scored as normal (score 1), or increased (score 2) similarly. Correlation between scores of ASL, CBF, DSC, CBF, and DSC, TTP maps was assessed by using Spearman's rank correlation. Among the 34 patients, we did not find any significant correlation between the ASL CBF maps and DSC CBF maps (r = -0.028, P = 0.878), mean matching index 0.39 ± 0.31, whereas significant correlation was noted between the ASL CBF maps and DSC TTP maps (r = 0.58, P = 0.0003), mean matching index 0.79 ± 0.26. ASL CBF underestimated the perfusion compared to DSC perfusion. ASL perfusion CBF maps do not match the DSC perfusion CBF maps and rather match the TTP maps of DSC perfusion. This is explained by inherent problems in estimation of CBF in these techniques because of delay in arrival of label (in ASL perfusion) or contrast bolus (in DSC perfusion) due to the presence of stenotic lesions.

IMAGING OF THE ANTERIOR COMMUNICATING ARTERY: NORMAL AND ABNORMAL FINDINGS RELATED TO ANEURYSM

The anterior communicating artery (AComA) is a critical component of the Circle of Willis, serving as a vital conduit that connects the bilateral anterior cerebral arteries. This study aims to provide a comprehensive overview of the imaging characteristics of the AComA, encompassing both normal variations and abnormal findings associated with aneurysm development. Utilizing advanced imaging techniques, a thorough analysis of the AComA complex was conducted in a cohort of subjects. Normal anatomical variants were meticulously documented, highlighting variations in length, diameter, and branching patterns. Abnormal findings indicative of potential aneurysm markers was carefully assessed, encompassing variations in morphology, hemodynamic flow patterns, and wall integrity. Special attention was given to elucidate the factors contributing to aneurysm initiation within the AComA complex. The clinical significance of distinguishing between normal anatomical variations and potential pathological findings was underscored, emphasizing the critical importance of early detection and intervention to mitigate the risks associated with aneurysm rupture. The findings of this study contribute valuable insights to the field of neurovascular diagnostics and therapeutic strategies. By enhancing our understanding of the AComA and its role in aneurysm development, this research aims to empower clinicians with the knowledge needed for informed decision-making and proactive management. Ultimately, the comprehensive examination of AComA imaging, encompassing both normal and abnormal variants, holds the potential to drive advancements in cerebrovascular care and improve patient outcomes.

Ruptured ACoM aneurysm with anomalous origin of bilateral ACA from the cavernous segment: Case report and literature review

Abstract Anterior communicating artery (ACoM) and anterior cerebral artery (ACA) are the most common locations of anomalous variations and aneurysm formation. Infraoptic origin of ACA is an extremely rare anatomical variant. This case report illustrates an extremely rare anatomical variation of bilateral infraoptic origin of ACA with ruptured ACoM aneurysmal subarachnoid hemorrhage. The authors detail this case in the light of the available literature and operative nuance in its management. For the treatment of a complex situation, accurate understanding of the anatomic variations, intraoperative three-dimensional orientation, proper imaging study, and extremely careful technique are essential.

BILATERAL ANTERIOR CEREBRAL ARTERY INFARCT – A RARE CASE.

Stroke is prevalent across patient populations and is the fifth commonest cause of death if considered separately from other cardiovascular diseases, thus accounting for significant morbidity and mortality. Infarcts involving the territory of the anterior cerebral artery (ACA) are uncommon due to significant collateral blood supply from anterior communicating artery. Infarction of the ACA territory accounts for only 0.3% to 4.4% of cerebral infarctions reported. Bilateral ACA infarction is even rarer. (1,2) We would like to present a case of 60 years old male who has presented to us with bilateral ACA infarct.

Case Report: Hyperprolactinemia In Suprasellar Meningioma

Introduction: Hyperprolactinemia is a condition in which abnormally elevated prolactin levels (normal prolactin levels are 10-28 g/L) is a common endocrine disorder. Establishing the diagnosis and etiology of hyperprolactinemia should include a thorough medical history and the use of drugs, physical examination, laboratory tests, analysis of the pituitary, and sella turcica features. Pituitary tumor imaging analysis using MRI remains the method of choice. The main goals of managing hyperprolactinemia are restoring and maintaining fertility function and preventing osteoporosis. The choice of treatment depends on the underlying etiology. Case Presentation: A 33-year-old woman complained that her right side of vision could not function properly, and her left side of vision began to blur, which started four years ago with irregular menstrual disorders, and milk came out of her breasts. On breast examination, Tanner 5 was found with galactorrhea and pubic hair Tanner stage 3. On Laboratory examination found FSH (5.50 mIU/mL), LH (1.7 mIU/mL) and prolactin (1125 IU/mL). The MRI examination showed an extra-axial solid mass, broad-based on the planum sphenoidal to the dorsum sellae, suggesting a meningioma; with compression of the optic chiasm, middle cerebral artery, and bilateral anterior cerebral arteries, size 3.1 x 2.8 x 2.3 cm. Conclusion: Hyperprolactinemia with meningiomas is a unique case. First-line therapy for prolactinomas is dopamine agonist administration and, in this case, is followed by surgery, which showed significant results.

Stenosis of Azygos Anterior Cerebral Artery Results in Bilateral Anterior Cerebral Artery Strokes.

HomeStrokeVol. 53, No. 10Stenosis of Azygos Anterior Cerebral Artery Results in Bilateral Anterior Cerebral Artery Strokes Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBStenosis of Azygos Anterior Cerebral Artery Results in Bilateral Anterior Cerebral Artery Strokes Diana Yang, Brian Behdad Miremadi, Anton Mlikotic and Kassi Kronfeld Diana YangDiana Yang Correspondence to: Diana Yang, DO, Harbor-UCLA Medical Center, 1000 W. Carson St, Building N-25, Torrance, CA 90502. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6695-1771 Department of Neurology (D.Y., B.B.M., K.K.), Harbor-UCLA Medical Center, Torrance, CA. Search for more papers by this author , Brian Behdad MiremadiBrian Behdad Miremadi Department of Neurology (D.Y., B.B.M., K.K.), Harbor-UCLA Medical Center, Torrance, CA. Search for more papers by this author , Anton MlikoticAnton Mlikotic Department of Radiology (A.M.), Harbor-UCLA Medical Center, Torrance, CA. Search for more papers by this author and Kassi KronfeldKassi Kronfeld Department of Neurology (D.Y., B.B.M., K.K.), Harbor-UCLA Medical Center, Torrance, CA. Search for more papers by this author Originally published15 Jul 2022https://doi.org/10.1161/STROKEAHA.122.040216Stroke. 2022;53:e448–e449Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 15, 2022: Ahead of Print KEY POINTAlthough much rarer than unilateral extremity weakness, bilateral lower extremity weakness may still result from a stroke—specifically due to vascular compromise of an azygos anterior cerebral artery.A 55-year-old female presented with 1 week of acute onset bilateral lower extremity weakness and reduced speech output. Examination was notable for spastic paralysis of lower extremities, trace weakness in bilateral shoulder abduction, and abulia. Magnetic resonance imaging revealed bilateral anterior cerebral artery (ACA) territory strokes. Computed tomography angiography demonstrated absence of the anterior communicating artery, a hypoplastic right ACA precommunicating segment (A1), azygos continuation of a dominant left ACA, and focal stenosis in the lone A2 segment.ACA territory infarcts only account for 1.8% of cerebral infarcts, and bilateral ACA infarcts are even less common.1 Azygos ACA is a rare circle of Willis variant (0.3%–2% of the population) notable for an absent anterior communicating artery and one ACA postcommunicating segment (A2) feeding both ACA territories.2 Despite the initial difficult localization, bilateral lower extremity weakness may still result from a stroke, specifically due to vascular compromise of an azygos ACA (Figure).Download figureDownload PowerPointFigure. Brain magnetic resonance imaging and head computed tomography angiography. Bilateral anterior cerebral artery (ACA) territory diffusion restriction on magnetic resonance imaging diffusion-weighted imaging (DWI) sequence (A) with corresponding hyperintensity on fluid-attenuated inversion recovery (FLAIR) sequence (B). Three-dimensional computed tomography angiography (C and D) demonstrates 2 anatomic variants: hypoplastic right A1 segment (short arrow) with dominant left ACA and an absent anterior communicating artery. There is significant focal stenosis in the A2 segment (long arrows).Article InformationSources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page e449.Correspondence to: Diana Yang, DO, Harbor-UCLA Medical Center, 1000 W. Carson St, Building N-25, Torrance, CA 90502. Email [email protected]lacounty.gov

Bilateral Cerebral Infarctions Secondary to Unilateral ICA Stenosis

A 76-year-old diabetic man presented to us with complaints of sudden-onset right-sided weakness for the last 4 days. On evaluation, he was found to have right hemiparesis (Modified Medical Research Council grade 4-/5) along with left leg weakness (4+/5). Neuroimaging revealed acute infarcts in the right anterior cerebral artery (ACA) territory and left cerebral external watershed territory. Magnetic resonance (MR) angiogram of the brain showed a hypoplastic right A1-ACA with bilateral A2-ACA arising from the left A1-ACA (bi-hemispheric A1-ACA). MR angiogram of the neck revealed significant left internal carotid artery (ICA) origin stenosis. It was concluded that the origin of right A2-ACA from left ACA was the probable because of right ACA infarcts, along with left cerebral watershed infarcts (embolic phenomenon). This represents a very important variation, as in these cases, even a unilateral ICA stenosis can lead to bilateral ACA stroke and thus necessitates urgent revascularization.

Comparison of the clinical value of transcranial Doppler ultrasound and computed tomography angiography for diagnosing ischemic cerebrovascular disease.

ObjectiveTo compare the clinical value of transcranial Doppler (TCD) ultrasound and computed tomography angiography (CTA) for diagnosing ischemic cerebrovascular disease.MethodsA retrospective clinical study was conducted in 142 patients with ischemic cerebrovascular disease who were initially diagnosed by digital subtraction angiography. Under the single-blind condition, the patients were diagnosed by using TCD ultrasound and CTA independently. The accuracy of these two methods was compared.ResultsThe accuracy of diagnosing bilateral middle cerebral artery, bilateral vertebral artery and bilateral internal carotid artery lesions with a TCD examination was significantly higher than that with a CTA examination. There were no significant differences in the accuracy of diagnosing bilateral anterior cerebral artery, bilateral posterior cerebral artery or basilar artery lesions between TCD ultrasound and CTA. The accuracy of diagnosing all cerebral arterial ischemic lesions was significantly higher with a TCD examination (87.39%) than with a CTA examination (69.75%). The accuracy of diagnosing all cerebral arteries that cause ischemic encephalopathy (cerebrovascular + cervical blood vessels) was significantly higher with a TCD examination (88.03%) than with a CTA examination (69.01%).ConclusionsTCD ultrasound has several advantages over CTA. Therefore, TCD ultrasound is better for diagnosing ischemic encephalopathy than CTA.

Sensorineural hearing loss due to delayed cerebral ischemia in bilateral auditory cortices following aneurysmal subarachnoid hemorrhage: illustrative case.

BACKGROUNDRecognizing rare signs of delayed cerebral ischemia (DCI) is crucial to caring for patients with subarachnoid hemorrhage. The authors presented a case of central hearing loss that occurred during the clinical course of a patient treated for aneurysmal subarachnoid hemorrhage.OBSERVATIONSThe patient had a ruptured right posterior communicating artery aneurysm successfully treated with coil embolization but later developed severe vasospasm and DCI. She developed bilateral hearing loss, and imaging revealed DCI to the left temporal lobe and the right auditory cortex. Computed tomography angiography and digital subtraction angiography demonstrated severe vasospasm of bilateral internal carotid arteries, bilateral middle cerebral arteries, and bilateral anterior cerebral arteries. One month after hospitalization, the patient had recovered fully neurologically intact except for persistent hearing loss.LESSONSThis case serves to teach important neuroanatomical features and discuss the unique pathophysiology of DCI affecting the auditory cortex.

Association between symptomatic intracranial atherosclerotic disease and the integrity of the circle of Willis

The relationship between the severity of intracranial atherosclerotic disease and the circle of Willis integrity is unclear. In this brief report, we investigate the associations between symptomatic intracranial atherosclerotic disease and the integrity of the circle of Willis. Patients with symptomatic intracranial atherosclerosis were enrolled and underwent intracranial artery magnetic resonance vessel wall imaging and time-of-flight angiography. The presence or absence of an intracranial atherosclerotic plaque and its maximum wall thickness and stenosis were evaluated. The presence or absence of the A1 segment of the bilateral anterior cerebral arteries (from the internal carotid artery to the anterior communicating artery segment is called anterior cerebral artery A1 segment), and anterior communicating artery, the P1 segment of the bilateral posterior cerebral arteries (The P1 segment of the posterior cerebral artery is a horizontally outward segment), and bilateral posterior communicating arteries were determined. The associations of the intracranial plaque features with the integrity of the circle of Willis were analyzed. Of the 110 recruited subjects (57.2 ± 11.1 years; 65% males), 51 had intracranial plaques, and 44 had stenosis. In patients with bilateral A1 and P1 segments (n = 85), intracranial stenosis was more severe in patients with an anterior communicating artery than those without an anterior communicating artery (19.7% ± 21.7% vs. 1.4% ± 3.3%, p = 0.046). In patients with bilateral A1 and P1 segments and an anterior communicating artery (n = 79), intracranial stenosis was more severe in patients with posterior communicating arteries than those without posterior communicating arteries (27.9% ± 23.7% vs. 13.5% ± 17.9%, p = 0.007). The odds ratio of intracranial stenosis was 1.214 (95% confidence interval (CI), 1.054-1.398; p = 0.007) in discriminating for the presence of posterior communicating arteries in patients with bilateral A1 and P1 segments and an anterior communicating artery after adjusting for confounding factors. The severity of intracranial atherosclerosis was independently associated with the presence of posterior communicating arteries in patients with a complete anterior part of the circle of Willis.

Relationship of Pressure Reactivity Index and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage.

Patients with aneurysmal subarachnoid hemorrhage (SAH) continue to have poor functional outcome due to the occurrence of delayed cerebral ischemia (DCI). Although vasospasm represents the primary therapeutic target for mitigating DCI, DCI occurs through multifocal etiologies that involve impaired cerebral autoregulation. Worse pressure reactivity index (PRx) values, which consists of a moving correlation coefficient between intracranial pressures and mean arterial pressures, have been shown to be associated with DCI in non-randomized clinical trials. We discuss two patients that presented with high-grade SAH and comatose exams. Patient one was a 34-year-old male diagnosed with SAH from a ruptured right middle cerebral artery aneurysm. He had intact PRx values (Mean: -0.07 during hospital days 9-19), while having severe, refractory vasospasm. At the conclusion of his hospitalization, he was functionally independent, had negligible DCI, and was successfully discharged home. Patient two was a 78-year-old female diagnosed with SAH from a ruptured anterior communicating artery aneurysm. She had an improving PRx ranging from -0.1 to 0.1 early in her hospitalization. However, upon developing severe vasospasm, her PRx increased to 0.6 (overall PRx from hospital days 4-16 was 0.3), and she suffered from extensive DCI in bilateral middle cerebral and anterior cerebral artery distributions that ultimately resulted in malignant cerebral edema and brain death. Cerebral autoregulation as measured by PRx may represent a viable target for neuroprognostication by evaluating DCI risk in patients with SAH who develop severe or refractory vasospasm. Further studies evaluating the role of cerebral autoregulation, PRx, and its pathophysiological role in DCI are warranted.