Bilateral Posterior Cerebral Artery Research Articles

A bilateral fetal origin of the posterior cerebral artery coexisting with an absent A1 segment of the anterior cerebral artery.

The cerebral arterial circle variants are well-described due to their clinical significance for neurosurgeons and neuroradiologists. This magnetic resonance angiography (MRA) report describes the unusual coexistence of three cerebral variants incidentally identifiedin a 44-year-old female patient. The right-sided first segment (A1) of the anterior cerebral artery (ACA) was absent, and both the posterior cerebral arteries (PCAs) originated from the internal carotid arteries (ICAs). Thus, the unilateral A1 segment absence coexisted with a bilateral PCA of fetal origin. These variants' coexistence significantly disrupts the patient's primary collateral pathway. The clinical significance and consequences of such variants after stroke or transient ischemic attack cannot be overstated, underscoring the importance of the current imaging findings in understanding and managing these conditions.

Macrovascular blood flow and microvascular cerebrovascular reactivity are regionally coupled in adolescence.

Cerebrovascular imaging assessments are particularly challenging in adolescent cohorts, where not all modalities are appropriate, and rapid brain maturation alters hemodynamics at both macro- and microvascular scales. In a preliminary sample of healthy adolescents (n = 12, 8-25 years), we investigated relationships between 4D flow MRI-derived blood velocity and blood flow in bilateral anterior, middle, and posterior cerebral arteries and BOLD cerebrovascular reactivity (CVR) in associated vascular territories. As hypothesized, higher velocities in large arteries are associated with an earlier response to a vasodilatory stimulus (cerebrovascular reactivity delay) in the downstream territory. Higher blood flow through these arteries is associated with a larger BOLD response to a vasodilatory stimulus (cerebrovascular reactivity amplitude) in the associated territory. These trends are consistent in a case study of adult moyamoya disease. In our small adolescent cohort, macrovascular-microvascular relationships for velocity/delay and flow/CVR change with age, though underlying mechanisms are unclear. Our work emphasizes the need to better characterize this key stage of human brain development, when cerebrovascular hemodynamics are changing, and standard imaging methods offer limited insight into these processes. We provide important normative data for future comparisons in pathology, where combining macro- and microvascular assessments may better help us prevent, stratify, and treat cerebrovascular disease.

An Interventional Quandary—Clipping vs Coiling vs STA-MCA Bypass in a Ruptured Basilar Tip Aneurysm with Bilateral ICA Stenosis: A Rare Case Report and a Comprehensive Review

Our primary goal is to report a detailed case outlining the clinical and radiological characteristics of an extremely rare condition: bilateral internal carotid artery (ICA) stenosis with ruptured basilar tip aneurysm, and bilateral posterior cerebral arteries (PCAs) arising from the sac, treatment options, as well as its outcome. We searched the PUBMED database from 1980 to 2023 for similar case reports. Among seven similar cases found, two were conservatively managed, focusing on reducing intracranial pressure (ICP). One out of two survived, while one ended in fatality. In the other five cases, interventions (endovascular in four/STA-MCA (superficial temporal artery–middle cerebral artery) bypass in one) were pursued, resulting in significant recovery and discharge. Dealing with such complex cases with uncommon pathoanatomy poses treatment challenges due to their hemodynamics and the risk of collateral flow cessation despite multiple available treatment options.

Macrovascular blood flow and microvascular cerebrovascular reactivity are regionally coupled in adolescence.

Cerebrovascular imaging assessments are particularly challenging in adolescent cohorts, where not all modalities are appropriate, and rapid brain maturation alters hemodynamics at both macro- and microvascular scales. In a preliminary sample of healthy adolescents (n=12, 8-25 years), we investigated relationships between 4D flow MRI-derived blood velocity and blood flow in bilateral anterior, middle, and posterior cerebral arteries and BOLD cerebrovascular reactivity in associated vascular territories. As hypothesized, higher velocities in large arteries are associated with an earlier response to a vasodilatory stimulus (cerebrovascular reactivity delay) in the downstream territory. Higher blood flow through these arteries is associated with a larger BOLD response to a vasodilatory stimulus (cerebrovascular reactivity amplitude) in the associated territory. These trends are consistent in a case study of adult moyamoya disease. In our small adolescent cohort, macrovascular-microvascular relationships for velocity/delay and flow/CVR change with age, though underlying mechanisms are unclear. Our work emphasizes the need to better characterize this key stage of human brain development, when cerebrovascular hemodynamics are changing, and standard imaging methods offer limited insight into these processes. We provide important normative data for future comparisons in pathology, where combining macro- and microvascular assessments may better help us prevent, stratify, and treat cerebrovascular disease.

Predicting Acute Mountain Sickness Using Regional Sea-Level Cerebral Blood Flow

Objective To investigate the role of sea-level cerebral blood flow (CBF) in predicting acute mountain sickness (AMS) using three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL).Methods Forty-eight healthy volunteers reached an altitude of 3,650 m by air after undergoing a head magnetic resonance imaging (MRI) including 3D-pCASL at sea level. The CBF values of the bilateral anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) territories and the laterality index (LI) of CBF were compared between the AMS and non-AMS groups. Statistical analyses were performed to determine the relationship between CBF and AMS, and the predictive performance was assessed using receiver operating characteristic (ROC) curves.Results The mean cortical CBF in women (81.65 ± 2.69 mL/100 g/min) was higher than that in men (74.35 ± 2.12 mL/100 g/min) (P < 0.05). In men, the cortical CBF values in the bilateral ACA, PCA, PICA, and right MCA were higher in patients with AMS than in those without. Cortical CBF in the right PCA best predicted AMS (AUC = 0.818). In women, the LI of CBF in the ACA was different between the AMS and non-AMS groups and predicted AMS with an AUC of 0.753.Conclusion Although the mechanism and prediction of AMS are quite complicated, higher cortical CBF at sea level, especially the CBF of the posterior circulatory system, may be used for prediction in male volunteers using non-invasive 3D-pCASL.

Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke.

Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.

“Worse than hell”: Complex Neuraxial Lesions Resulting in Tetraplegia and Blindness after Polytrauma - Case presentation

Background. Lesions of the vertebral artery (VA) may develop spontaneously or as a result of severe traumatic cervico-cephalic injuries. Most frequent VA injuries (VAI) result from blunt trauma to the spine or may be due to penetrating lesions. VAI plays a significant role in the broader context of cervical spine trauma by providing insights into the vascular aspects of spinal cord injury (SCI). Upper cervical spine fractures and accompanying subluxation, as well as transverse process fractures extending into the artery bone foramen, are associated with an elevated risk of VAI. Clinical case. A 63-year-old female patient with flaccid C4 AIS-A quadriplegia (global motor score 3/100), vertebral myelopathy, neurogenic bladder, sacral pressure sore, and blindness was transferred from the spinal neurosurgical department. The patient fell from the same level and suffered a mild brain concussion and, apparently, a minor cervical SCI on October 1, 2022. She was asymptomatic, then quickly became tetraplegic, and then blindness added on in a few days. She was operated on on October 7, 2022, for a C6 vertebral body fracture and a C5-6 dislocation. The surgical protocol consisted of anterior spinal cord decompression, dislocation reduction, and mixed anterior fusion with bone grafts and fixation screws. Following the traumatic event, a bilateral posterior cerebral artery (PCA) stroke subsequently produced blindness and partial optic atrophy in both eyes. Serial clinical and imaging examinations confirmed the diagnosis: a subacute bilateral occipital stroke and a chronic lacunar lesion in the right thalamus associated with a severe spinal cord lesion. Anticoagulation has partially improved the neurological outcomes of stroke in the PCA territory. Ethical considerations. The patient's next of kin has given written consent to the case study and to use the radiological images related to the case for academic purposes. The personal identity data was anonymized. The presentation of this clinical case has the approval of the ethics commission of TEHBA (no. 40205/01.09.2023). Discussion. The clinical example is notable for the concurrent development of two severely devastating neurological syndromes, quadriplegia, and blindness, which occurred after an initially minor cervical trauma and progressed gradually over a few days. VA lesions after cervical trauma are considered rare, and the diagnosis is difficult because the vast majority of individuals do not exhibit cerebral neurological symptoms (due to the collateral compensatory blood supply from the circle of Willis). Most of the patients with bilateral or dominant VA occlusions are symptomatic, with rapid (and possibly fatal) ischemic damage to the encephalon, cerebellum, or brainstem. The detection and tracking of evolutionary tendencies required a series of clinical tests, including fundoscopy, and imaging procedures, including native CT, MRI, and MR angiography scans of the brain and spine. Conclusions. Although VAI is a rare complication, in every polytrauma patient with head and neck trauma, VA damage should be suspected. Careful clinical and imaging monitoring through detailed serial imaging procedures must be performed for every person with severe cranio-cervical trauma. The clinical example emphasizes the importance of the interprofessional team's participation in the patient's care.

Abstract 089: A Case of Complicated Dissection: Vertebral Artery Sacrifice for Recurrent Stroke Prevention

Introduction Posterior circulation strokes account for 20% of ischemic strokes (1). Optimal management for posterior circulation strokes has been studied less than for anterior circulation strokes (2). Endovascular parent vessel sacrifice is an established technique used to treat vascular pathologies. There is limited evidence for parent artery sacrifice for recurrent strokes and there is no current guideline for standard of care. Methods '‐ Results 51‐year‐old gentleman with history of tobacco use presented with left homonymous hemianopsia, onset 1.5 hours prior to arrival. CT brain showed no bleed and patient received IV tissue‐plasminogen activator (tPA). CT angiography (CTA) demonstrated occlusion of the right posterior cerebral artery (PCA) and dissection of the left vertebral artery (V2 segment) with distal reconstitution. He underwent emergent thrombectomy for right P2 thrombus with complete reperfusion TICI 3 (Thrombolysis in Cerebral Infarction Score). Less than 24 hours later, he developed a right homonymous hemianopsia, and was found to have a new occlusion of the left P1 segment of the left PCA. Emergent thrombectomy was performed with complete reperfusion (TICI3). MRI brain demonstrated bilateral PCA territory infarcts. Within 12 hours of the second thrombectomy, his neurological exam deteriorated, and interval imaging revealed a basilar trunk thrombus, for which he underwent a successful endovascular thrombectomy complete reperfusion (TICI3). His antiplatelet regimen was optimized with Aspirin. Heparin was considered as treatment but was not provided because of the hemorrhagic conversion of his ischemic strokes. Given the persistent recurrence of thromboemboli in the posterior circulation despite being on optimal medical management, and evidence of hemorrhagic conversion, a decision was made to perform endovascular coil embolization of the left vertebral artery V2 segment at the site of dissection. Angiographic imaging demonstrated antegrade blood flow through the dissection as the source of recurrent embolic strokes. Six Stryker Target coils were deployed spanning the region of dissection within the left V2 segment via a right radial access with the guide catheter in the right vertebral artery. Post coil embolization angiographic runs demonstrated complete occlusion of the left vertebral V2 segment at the region of dissection which was confirmed via a left vertebral injection from a left femoral arterial access. There was preservation of ascending cervical collaterals beyond the dissection with patency of the contralateral vertebral artery supplying the intracranial circulation. Following embolization, repeat imaging showed no new infarcts and no new or worsening hemorrhage. He was continued on Aspirin monotherapy. It is notable that though his neurological exam deteriorated during each recurrent thromboembolic event, his neurologic exam at the time of discharge significantly improved with NIHSS of 3. He is currently being followed at our neuroscience institute. Conclusion Cervical arterial dissections pose increased risk for ischemic strokes (3). Vertebral artery dissection accounts for approximately 2%, of which, 10‐25% occur in middle‐aged and younger patients (4). This is a case of a young patient that exemplifies a successful role for vertebral artery sacrifice with coil embolization to prevent recurrent thromboembolic posterior circulation strokes. However controlled studies are needed for safety and efficacy of these interventions.

Medial-type persistent trigeminal artery and ipsilateral posterior communicating artery supplying bilateral posterior cerebral arteries combined with an aberrant right subclavian artery and bicarotid trunk.

To describe a case of a medial-type persistent trigeminal artery (PTA) associated with multiple arterial variations. A 34-year-old woman with multiple sclerosis underwent cranial magnetic resonance (MR) angiography from the aortic arch to the neck region and intracranial region for the evaluation of an unruptured cerebral aneurysm that was previously detected on MR imaging. The MR machine was a 3-T scanner. There was an aberrant right subclavian artery and bicarotid trunk, medial-type left PTA and ipsilateral posterior communicating artery (PCoA) supplying bilateral posterior cerebral arteries (PCAs). The unruptured aneurysm was located at the paraclinoid segment of the left internal carotid artery and was treated successfully by coil embolization via a transfemoral approach. Only 10% of PTAs are classified as the medial type. The association with extremely large ipsilateral PCoA, which supplies the bilateral PCAs, has not been previously reported. Aberrant right subclavian arteries are common and are frequently associated with a bicarotid trunk. Before catheterization of the cerebral arteries, the aortic arch and its branches must be evaluated by MR angiography or computed tomography angiography to prevent catheterization failure via the right transradial approach.

A case report of reversible cerebral vasoconstriction syndrome with thunderclap headache significantly exacerbated in the supine position and alleviated in the standing position

BackgroundReversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden onset thunderclap headache and multiple segmental reversible cerebral vasoconstrictions that improve within 3 months. The postpartum period is a well-known precipitating factor for the onset of RCVS. Cerebral venous thrombosis (CVT) causes thunderclap headaches in the postpartum period. While headache in CVT is sometimes exacerbated in the supine position, the severity of the headache in RCVS is usually independent of body position. In this study, we report a case of RCVS with thunderclap headache exacerbated in the supine position, and headache attacks that resolved quickly in the standing position during the postpartum period.Case presentationA 33-year-old woman presented with a sudden increase in blood pressure and thunderclap headache on the fifth postpartum day (day 1: the first sick day). The headache was severe and pulsatile, with onset in the supine position in bed, and peaked at approximately 10 s. It was accompanied by nausea and chills but there were no scintillating scotomas or ophthalmic symptoms. The headache resolved in the standing or sitting position but was exacerbated and became unbearable within a few seconds when the patient was in the supine position. Therefore, she was unable to lie supine at night. Computed tomography angiography (CTA) of the head on day 2 and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) on day 3 showed no abnormalities. However, considering the possibility of RCVS, verapamil was initiated on day 3. The headache resolved the following day. MRA of the head on day 10 revealed diffuse and segmental stenoses in the bilateral middle and posterior cerebral arteries and basilar artery. Therefore, the patient was diagnosed with RCVS. The headache gradually resolved and disappeared completely on day 42. Cerebral vasoconstriction was also improved on MRA on day 43.ConclusionsThis postpartum RCVS case was notable for the exacerbation of headaches in the supine position. For the diagnosis of thunderclap headache in the postpartum period, RCVS should be considered in addition to CVT when the patient presents with a headache that is exacerbated in the supine position.

Dide Botcazo Syndrome: An Atypical and Rare Presentation of Stroke

Dide-Botcazo syndrome is a very rare condition resulting from bilateral posterior cerebral infarction. The clinical presentation is atypical of cerebral infarction and is characterized by the association of cortical blindness and anosognosia associated with amnesia and topographical disorientation. We report the clinical case of a 65-year-old man consulting for confusion associated with amnesia, cortical blindness and right hemiparesis evolving for one week. The CT scan showed hypodensity in the territory of the bilateral posterior cerebral arteries. The scan also ruled out malformations such as aneurysms or cerebral masses, as well as hemorrhagic stroke. The patient was treated with antiplatelet drugs and early rehabilitation. Progression was marked by partial improvement in motor disorders and confusion. Cortical blindness and anosognosia were permanent.

Hemodynamic outcomes of stenting for vertebrobasilar insufficiency in patients with a low flow state.

The Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study determined patients with low flow in their vertebrobasilar (VB) system are at increased risk of recurrent stroke. Endovascular interventions such as angioplasty and stenting are reserved for patients with refractory symptoms; however, few series to date have demonstrated either hemodynamic or clinical outcomes in this high-risk patient group. We present our combined institutional series of patients with symptomatic VB atherosclerotic disease and low-flow state who underwent angioplasty and stenting. Retrospective chart review of patients undergoing angioplasty and stenting for symptomatic VB atherosclerotic disease at two institutions was performed. Clinical and radiographical outcomes were collected including flow rates using quantitative MRA (QMRA) pre- and post-stenting. Seventeen patients underwent angioplasty and stenting for symptomatic VB atherosclerotic disease and met VERiTAS low-flow state criteria. There were four cases (23.5%) of periprocedural stroke, two of which were minor and transient. The stent was placed intracranially in 82.4% of patients. Basilar and bilateral posterior cerebral artery (PCA) flows significantly improved post-stenting (p < 0.05) and normalized based upon VERiTAS criteria in all patients. Fourteen patients had delayed QMRA at mean follow-up 20 months demonstrating appropriate patency and flow post-stenting. Two patients (10%) had recurrent stroke, one from medication nonadherence and in-stent thrombosis, and the other from a procedural dissection that subsequently became symptomatic. Our series demonstrates angioplasty and stenting significantly improve intracranial flow over long-term. Angioplasty and stenting may improve the natural history of low-flow VB atherosclerotic disease.

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.

Anatomical differences of intracranial arteries according to sex: a systematic review and meta-analysis

Background and PurposeIntracranial aneurysms are more common in women than in men. Some anatomical variants of the circle of Willis (CoW) are associated with a higher risk of developing intracranial aneurysms. We hypothesized that variations of the CoW are sex dependent which may partly explain why intracranial aneurysms are more common in women. We systematically reviewed and meta-analyzed the literature to compare the presence of anatomical variations of the CoW between women and men in the general population. Material and MethodsA systematic search in Pubmed and EMBASE using predefined criteria, following the PRISMA guidelines was performed. The presence of different CoW anatomical variants and a complete CoW was compared between women and men using an inverse variance weighted random effects meta-analysis to calculate relative risks (RR) with 95% confidence intervals (95% CIs). ResultsFourteen studies were included reporting on 5478 healthy participants (2511 women, 2967 men). Bilateral fetal type posterior cerebral arteries (RR 2.79; 95%CI 1.65–4.72, I2=0%), and a complete CoW (RR 1.24, 95%CI 1.13–1.36; I2=0%) were more prevalent in women than in men. The variants absence or hypoplasia of one of the anterior cerebral arteries (RR 0.58, 95%CI 0.38–0.88, I2=57%) and hypoplasia or absence of both posterior communicating arteries (RR 0.79, 95%CI 0.71–0.87, I2=0%) were more prevalent in men. ConclusionsSeveral anatomical variations of the CoW are sex dependent, with some variants being more common in women while others in men. Future research should assess how these sex-specific CoW variants relate to the sex-specific occurrence of intracranial aneurysms.

Childhood posterior circulation arterial ischemic stroke – An unusual case with a possible COVID-19-related arteriopathy

Viral infections are known to increase predilection to stroke and coronavirus disease 2019 (COVID-19) has proven these concerns true. We are presenting the case of a 6-year-old previously normal male child diagnosed with posterior circulation stroke who had all etiological workups negative except for the COVID antibody. Imaging showed thrombi over the V3 segment of the vertebral artery at C1–C2 level causing near complete occlusion, with embolic infarct in the bilateral posterior inferior cerebellar artery, bilateral posterior cerebral artery, bilateral anterior inferior cerebellar artery, and the left superior cerebellar artery. The child was managed with methylprednisolone, anticoagulation, and supportive care and was able to restore near-normal neurological status within months. This case is unique in terms of the involvement of posterior circulation which is rare in the pediatric population. A possibility of inflammation-related arteriopathy secondary to infection should be considered in the etiological workup of stroke. Anti-inflammatory measures to control cytokine storm along with supportive care will ensure a good outcome.

Efficacy of Prolonged Impella 5.5 Support as Bridge to Heart Transplantation: Current Concepts and Future Direction.

To the Editor: Zaky et al.1 recently published an interesting article titled, “Impella 5.5 Support beyond 50 Days as Bridge to Heart Transplant in End-Stage Heart Failure Patients” that demonstrated efficacy of the Impella 5.5 regarding its ability to provide adequate prolonged hemodynamic support and maintain durability in four cases. The four patients presented in cardiogenic shock with a history of heart failure with or without chronic kidney disease. Due to contraindications to left ventricular assist device use, they received Impella 5.5 support for a mean duration of 70 days (range 54–83). All patients were able to ambulate by day 6, with the only device malfunction being loss of placement signal in one patient and the only complication being bilateral posterior cerebral artery infarcts of unknown cause in another patient. All four patients had devices with intact pump function on explantation and underwent successful heart transplantation. The authors note only one other report in the literature of prolonged Impella 5.5 support as bridge to heart transplantation and no reports in the existing literature of malfunctions or complications in patients with prolonged use (>50 days). Adding on to their discussion of the relevant literature, we wanted to note our published experience with a patient on prolonged Impella support beyond 50 days.2 The patient was a 51-year-old male with decompensated heart failure, chronic kidney disease, and cirrhosis who was sequentially supported with axillary intra-aortic balloon pump, Impella 5.5, and venoarterial extracorporeal membrane oxygenation (V-A ECMO) prior to triple organ, heart-liver-kidney transplantation. The patient was supported on Impella 5.5 for 79 days, comparable to the mean duration of support in the case series published by Zaky et al.1 Total length of temporary mechanical circulatory support (MCS) was 95 days prior to successful transplantation. During the period of Impella support in our patient, he had an episode of heparin-induced thrombocytopenia (HIT) at 30 days treated with argatroban and, subsequently, sepsis at 78 days, prompting Impella explant and initiation of V-A ECMO. Studies have evaluated the risk of these patterns of complications in patients supported with Impella and have shown an association between Impella support and HIT and sepsis.3–5 Our case report corroborates the findings of the reported case series.1 While our collective findings do demonstrate the efficacy of Impella 5.5 support for prolonged temporary MCS as a bridge to heart transplantation beyond the duration of less than or equal to 14 days as approved by the Food and Drug Administration, rates of complications during prolonged support have not been fully delineated. These potential complications do appear to be significant; however, they have not affected survival to transplantation based on our single-center experience. Multicenter, longitudinal studies are warranted to examine the risk and significance of complications of prolonged Impella support before prolonged use of this device becomes an established and widely applied bridging strategy.

Longitudinal real world correlation study of blood pressure and novel features of cerebral magnetic resonance angiography by artificial intelligence analysis on elderly cognitive impairment.

This study aims to investigate novel clinical risk factors for cognitive impairment (CI) in elderly. A total of 3221 patients (259 patients with CI and 2,962 subjects without CI) were recruited into this nested case-control study who underwent cerebral magnetic resonance angiography (MRA) from 2007 to 2021. All of the clinical data with MRA imaging were recorded followed by standardization processing blindly. The maximum stenosis score of the posterior circulatory artery, including the basilar artery, and bilateral posterior cerebral artery (PCA), was calculated by the cerebral MRA automatic quantitative analysis method. Logistic regression (LR) analysis was used to evaluate the relationship between risk factors and CI. Four machine learning approaches, including LR, decision tree (DT), random forest (RF), and support vector machine (SVM), employing 5-fold cross-validation were used to establish CI predictive models. After matching with age and gender, 208 CI patients and 208 control subjects were finalized the follow-up (3.46 ± 3.19 years) with mean age at 84.47 ± 6.50 years old. Pulse pressure (PP) in first tertile (<58 mmHg) (OR 0.588, 95% confidence interval (CI): 0.362-0.955) was associated with a decreased risk for CI, and ≥50% stenosis of the left PCA (OR 2.854, 95% CI: 1.387-5.872) was associated with an increased risk for CI after adjusting for body mass index, myocardial infarction, and stroke history. Based on the means of various blood pressure (BP) parameters, the performance of the LR, DT, RF and SVM models accurately predicted CI (AUC 0.740, 0.786, 0.762, and 0.753, respectively) after adding the stenosis score of posterior circulatory artery. Elderly with low pulse differential pressure may have lower risk for cognitive impairment. The hybrid model combined with the stenosis score of posterior circulatory artery, clinical indicators, and the means of various BP parameters can effectively predict the risk of CI in elderly individuals.

Application of the Intracranial Arterial Pulsatility Index for Determination of Prognosis after Lacunar Infarct.

We aimed to investigate the usefulness of intracranial arterial pulsatility index to assess the prognosis of lacunar infarcts. Forty-nine patients with confirmed acute lacunar infarct were enrolled in the study. A transcranial color-coded sonography was performed to assess the pulsatility index of bilateral middle cerebral, posterior cerebral, vertebral, and proximal internal carotid arteries. Patients' clinical status was assessed using a modified Rankin scale. Spearman correlation was used for reporting the relation between quantitative data. Statistical significance was defined as a two-tail p-value of less than 0.05. The mean age ± standard deviation was 64.1 ± 9.07 years old, and 57.1% of the patients were male. Upon discharge, only 8.2% of the patients were ranked as 0 on the modified Rankin scale; however, after a 6-month follow-up period, this number increased to 49%. There were no significant differences between the left and right pulsatility index measurements in any of the assessed arteries. Patients with vertebral artery pulsatility indexes >1 on their primary assessment had significantly worse outcomes during the first, third, and sixth months follow-up (all r > 0.3, p-values < 0.01). Pulsatility indexes from other arteries did not predict the prognosis. Sonography-assisted assessment of the vertebral artery blood flow during the early stage of lacunar infarct provides a reliable reference for prognosis estimation.

Delayed-Onset Thalamic Dazzle and Homonymous Hemianopic Scotoma Following Bilateral Posterior Cerebral Artery Infarction.

Delayed-Onset Thalamic Dazzle and Homonymous Hemianopic Scotoma Following Bilateral Posterior Cerebral Artery Infarction.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.