Infundibular Widening Research Articles

Management of Fallot's Uncorrected Tetralogy in Adulthood: A Narrative Review.

The majority of cyanotic congenital cardiac defects are caused by the tetralogy of Fallot. Some symptoms include a biventricular connection of the aortic root, right ventricular hypertrophy, blockage of the right ventricular outflow tract, and a ventricular septal defect. Our understanding of tetralogy of Fallot (TOF) has significantly advanced since it was first described in 1888, and early diagnosis has led to improved surgical management and increased life expectancy. Adults with unrepaired and repaired TOF present with a range of late complications, including heart failure, the need for re-interventions, and late arrhythmias. Right ventricular (RV) failure, often caused by chronic pulmonary regurgitation, is a significant cause of heart failure in patients with TOF. Current treatment options are limited, and mainstay surgical procedures such as pulmonary-valve replacement (PVR), trans-annular repair (TAR), or infundibular widening repair have not shown a significant reduction in preventing right ventricular (RV) failure or death. Here, we explain the mechanisms of RV failure in ToF, chronic pulmonary regurgitation, heart failure, and secondary polycythemia. HF management in untreated adults is discussed. The progression of the disease, as well as complications, are also discussed. The treatment plan and the need to investigate the best management approach for this unsolved problem are included. This review aims to fill the knowledge gaps and supply valuable information regarding mechanisms of RV failure, chronic pulmonary regurgitation, and secondary polycythemia. To summarize, a new combat strategy must be found to battle RVF, and a more profound vision of these mechanisms is required. If it is not corrected, it will be one of the future research lines that will contribute to designing more efficacious treatment techniques for adults with TOF.

A Systematic Review and Case Illustrations of Misdiagnosing Intracranial Aneurysms.

Modern neuroimaging methods do not completely rule out false diagnoses of intracranial aneurysms which can lead to an unwarranted operation associated with risks of complications.However,surgical interventions for falsely diagnosed aneurysms are quite rare. The purpose of this study is to demonstrate two clinical cases of false-positive aneurysms and a systematic review of the literature dedicated to the incidence and etiology of false-positive aneurysms, identifying risk factors associated with false-positive aneurysms. A literature search in two databases (PubMed and Web of Science) using keywords "mimicking an intracranial aneurysm", "presenting as an intracranial aneurysm", "false positive intracranial aneurysms", and "neurosurgery" was conducted. A total of 243 papers were found in the initial search in two databases. Sixteen papers (including 20 patients) were included in the final analysis. There were 10 women and 10 men. The most common location of false-positive aneurysms was the bifurcation of the middle cerebral artery (MCA). In the posterior circulation, false-positive aneurysms were identified either on the basilar artery, or at the vertebro-basilar junction. The main causes of false intracranial aneurysm diagnosis included artery occlusion with vascular stump formation, infundibular widening, fenestration, arterial dissection, contrast extravasation, and venous varix.In conclusion, summarizing the results of our analysis, we can say that surgical interventions for false-positive aneurysms are an underestimated problem in vascular neurosurgery. Despite extremely rare published clinical observations, the actual frequency of erroneous surgical interventions for false-positive aneurysms is unknown.

Infundibular Widening of Angiographically Invisible Duplicate Anterior Choroidal Artery Mimicking Typical Anterior Choroidal Artery Aneurysm

A diagnosis of an intracranial aneurysm depends on the angiographic configuration and should be cautiously differentiated from aneurysm mimics. In cases of duplicate anterior choroidal arteries (AChAs), infundibular widening of the distal minor AChA can be an aneurysm mimic. If the minor AChA with a smaller diameter is obscured angiographically due to poor contrast filling, an associated infundibular widening beside the proximal large AChA can misinterpreted as a typical AChA aneurysm in angiograms. The authors report on two such cases of duplicate AChAs with infundibular widening presenting like a typical AChA aneurysm in angiograms. Surgical exploration revealed a perforating artery emitting from the dome of the saccular lesion, confirming infundibular widening of a duplicate AChA. No reparative procedure was applied to the infundibular widening in a 48-year-old man, while two vascular outpouchings from the infundibular widening were clipped preserving the duplicate AChA in a 55-year-old woman.

WITHDRAWN: Cerebral Arterial Infundibula Are Preaneurysmal Lesions Caused by Direct Flow Impact

To investigate whether arterial infundibular widening is a preaneurysmal lesion or not. Two hundred and nine patients with cerebral angiography were enrolled. The morphology, size and location of infundibula and cerebral aneurysms were studied in two-dimensional angiography and three-dimensional software space. Computational fluid dynamics (CFD) analysis was performed. 234 infundibula and 129 infundibulum-like aneurysms (IFAs) were detected. In two-dimensional space, the typical morphology of an infundibulum was a symmetric dilatation at the arterial branch origin with a small vessel branch emanating from the tip and a wide base connecting the parent artery. In three-dimensional space, the infundibulum was dissymmetric with always one side longer than the other side. Furthermore, the infundibulum tilted upstream rather than downstream, with the longer side located downstream and the shorter side upstream in all cases. All the 129 IFAs occurred on the distal wall of the vessel branch origin, and no IFAs grew from the proximal wall of the branch origin. The possible development process of an infundibulum to an IFA was described in four development stages. The CFD analysis revealed that these lesions were associated with direct flow impingement in all cases. All the hemodynamic parameters on the distal wall of infundibula and IFAs were significantly (P<0.0001 or P<0.05) decreased compared with on the distal wall after virtual lesion removal. The infundibulum is a preaneurysmal lesion associated with high total pressure and high wall shear stress resulted from direct flow impingement and will progress to an aneurysm with time.

Cardiac Magnetic Resonance in long term follow-up of Tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most frequent cyanotic congenital heart disease. Pulmonary regurgitation (PR) and right ventricle (RV) enlargement and dysfunction are the most common long-term complications. Cardiac magnetic resonance (CMR) is the gold standard for RV evaluation. To analyze CMR results in the follow-up of TOF patients. All CMR performed between 2007 and 2012 in TOF patients with transannular patch (TAP) repair or infundibular widening, and without pulmonary valve replacement (PVR) were included. Pulmonary regurgitant fraction (PRF), ventricular end-diastolic (EDV) and end-systolic volume (ESV), and ejection fraction (EF) were examined. 122 CMR were performed in 114 patients. Average age at CMR was 15.4±7.4 years. 53.3% of them presented severe PR (> 40%). RVEDV was 157.3 ± 38.6 ml/m2, RVESV was 85.3 ± 27 ml/m2 and RVEF was 46.4 ± 7.1%. RVEDV was > 150 ml/ m2 in 48.4% and > 170 ml/m2 in 32.8% of patients. Patients with TAP showed larger RV volumes compared with those with infundibular widening. RVEDV > 170 ml/m2 showed worse RVEF that those with lower RVEDV (47.9 ± 7% vs 43.2 ± 6.4%, p < 0.01). Almost half of the pa tients showed significant RV enlargement, demonstrating that the indication of CMR is late in their follow-up. TAP was associated with higher RVEDV and RVESV, but no worse RVEF.

Fenestrations and Various Duplications of the Posterior Communicating Artery in the Prenatal and Postnatal Periods

The 2 paired arteries-the posterior communicating arteries (PCoAs) and the precommunicating parts of the posterior cerebral arteries-form the so-called posterior segment of the cerebral arterial circle on the base of the brain. A number of (ab)normal morphologic features were described in the literature (e.g., unusual kinking, or extreme elongations, hypoplasia, duplications, fenestrations, the infundibular widening, or aplasia of the PCoA in the prenatal and/or postnatal periods). The aim of this study was to analyze an incidence of various fenestrations and duplications of the PCoA, and describe their general features and their association with other vascular abnormalities. The research was performed on the brains of 200 human fetuses and 377 adult cadavers of both genders and different ages using microdissection and macrodissection methods. There were 0.34% cases with PCoA fenestrations and 3.12% cases with various PCoA duplications. Their morphologic features were described and compared with the similar PCoA abnormalities recorded in the scientific literature. There was no association between the PCoA and either duplication or aneurysm in adult cases. After thorough examination, the fenestrations and duplications of the PCoA are distinguished as 2 special forms of vascular abnormalities, and the PCoA duplications are characterized as partial and total. Furthermore, whereas the low incidence of a fenestration of the PCoA suggests it to be a sufficiently rare phenomenon, the duplications of the PCoA trunk are fairly frequent, especially concerning its terminal segment.

The posterior communicating artery: morphometric study in 3D angio-computed tomography reconstruction. The proof of the mathematical definition of the hypoplasia.

The aim of this study was to investigate the morphometry of the posterior communicating artery (PCoA), on the basis of angio-computed tomography (CT), and to give proof of the mathematical definition of the term "hypopal sia of the PCoA". One hundred 3-dimensional (3D) angio-CT images, performed in adult patients with bilateral reconstruction of the PCoA (200 results) were used tocalculate the morphometry of the vessel. The average length of the vessel on the right side was 14.48 ± 3.47 mm, andon the left side 14.98 ± 4.77 mm (in women 14.75 mm, in men 14.70 mm). The mean of the diameter at the "proximal" point (the junction with P1) on the right side was 1.49 ± 0.51 mm, and on the left 1.46 ± 0.47 mm (in women 1.44 mm and in men 1.51 mm). The mean of the diameter in the "distal" part (the connection with ICA) on the right side was 1.4 ± 0.49 mm, and on the left 1.37 ± 0.41 mm (in women 1.38 mm, and in men 1.39 mm). No statistical correlation between the length and the diameter of the PCoA in relation to the sex and side was shown. On the basis of our measurements, we defined the hypoplasia of the artery as the estimated value less than the average diameter minus the standard deviation. The percentage distribution was as follows: the left artery 15.5%, the right artery 24%, women 11.5%, and the men 9%. Similarly to the above parameters, we have not found any statistical differences. The presence of the foetal origin was noted in 25% of the radiological examinations. The infundibular widening was visualised in 11.5% of cases of 3D reconstructions. The agenesis of PCoA was found in 9% (never bilaterally), and in 1 case the unilateral duplication of the artery was observed. No statistical differences between those parameters in relation to sex and the examined side were revealed. Morphological calculation of the PCoA on the basis of angio-CT from adult patients did not show any statistical differences depending on sex or the investigated side. The presented method of the calculations proved to be useful for the mathematical definition of the term "hypoplasia of the PCoA".

Infundibular widening mimicking anterior communicating artery aneurysm

Because infundibular widening most commonly appears at the origins of the posterior communicating artery and anterior choroidal artery from the internal carotid artery, its occurrence in association with the anterior communicating artery (ACoA) or the A1-A2 junction can be misinterpreted as an ACoA aneurysm on angiograms. The authors report on 2 such cases; one in a 73-year-old woman with infundibular widening of the recurrent artery of Heubner, and the other in a 44-year-old woman with infundibular widening of a perforating vessel from the ACoA. The correct diagnosis was established based on surgical exploration. In addition, grayscale modification of 3D reconstruction images of preoperative digital subtraction angiography revealed the cases of the recurrent artery of Heubner and perforating artery of the ACoA arising from the apex of the infundibular widening.

Evolution from an Infundibulum of the Posterior Communicating Artery to a Saccular Aneurysm

An infrequent case of a de novo aneurysm formation originating from an infundibulum at the origin of the posterior communicating artery (PcomA) is presented. The aneurysm developed within 7 years in a patient who initially presented with subarachnoid hemorrhage (SAH) from a saccular aneurysm of the vertebral artery. A 43-year-old female patient was admitted to our hospital on 16th June 2000 after an acute onset of massive occipital headache. A computed tomography (CT) scan showed a subarachnoid hemorrhage (SAH) around the brainstem and 4-vessel angiography revealed an aneurysm originating from the V4 segment of the right vertebral artery (VA) as the cause of the SAH. A small aneurysm at the basilar artery (BA)/superior cerebellar artery (SCA) bifurcation was also found. Injection of the left internal carotid artery (ICA) showed a diffuse enlargement at the origin of the left PcomA, which at this time was considered to be a so-called infundibulum. The VA aneurysm was treated by coil occlusion. Follow-up digital subtraction angiography (DSA) in 2005 showed a de novo aneurysm formation at the VA junction, again treated by coil occlusion. The PcomA infundibulum at the left ICA was not examined. Follow-up angiography performed in 2007 revealed a saccular de novo aneurysm of the left ICA arising from the origin of the left PcomA with a maximum diameter of 12 mm. Coil occlusion of the PcomA aneurysm was subsequently carried out. Infundibular widening of cerebral arteries can develop into true aneurysms. Mid-term and long-term follow-up MRI (e.g., in yearly intervals) is advised for infundibula with a diameter of 3 mm or more. In patients with other aneurysm(s), with a documented de novo aneurysm formation or with a familial occurrence of aneurysms, the risk of evolution of an infundibulum to a saccular aneurysm may be increased and follow-up should be even more stringent.

Enlargement to a saccular aneurysm and subsequent rupture of infundibular widening of posterior communicating artery

A small dilatation known as infundibular widening (IFw) is frequently seen (7%-25%) on the posterior communicating artery (PComA) at its origin from the internal carotid artery. Development and subsequent rupture of an aneurysm on a previously radiographically demonstrated IFw has rarely been documented. We present two patients who suffered from subarachnoid hemorrhage (SAH). Initial cerebral angiography demonstrated IFw on PComA. They were readmitted to the hospital 9 and 11 years later, after a new SAH. Repeated cerebral angiography revealed an aneurysm arising from the site where the IFw had been seen previously in both cases. The aneurysms were clipped with favorable outcome. This report adds two new cases documenting enlargement of PComAIFw into an aneurysm. Patients with PComAIFw, especially those who have experienced SAH, should be considered for periodic follow-up to rule out the development of an aneurysm over time.

Successful Treatment of a Ruptured Enlarged Infundibular Widening of the Posterior Communicating Artery. Case Report.

A 67-year-old female with a history of hypertension and cerebral infarction presented with subarachnoid hemorrhage (SAH) (Hunt and Kosnik grade 4). Brain computed tomography (CT) revealed a clot dominantly on the right (Fisher's classification Group 4). Cerebral angiography showed funnel-shaped widenings at the origins of the bilateral posterior communicating arteries. The maximum diameter of the widening was greater than 3 mm, so this widening was called an enlarged infundibular widening. Angiography showed a small bulge protruding posterolaterally from the wall of the right enlarged infundibular widening, and the right posterior communicating artery arose from the apex of the enlarged infundibular widening. Based on the findings of the brain CT and cerebral angiography, the diagnosis was SAH due to rupture of the right enlarged infundibular widening. Approximately 12 hours after the onset, the clot was evacuated through the right pterional approach. Bleeding from the small bulge of the right enlarged infundibular widening occurred intraoperatively, so a right-angled ring clip was applied parallel to the right internal carotid artery to obliterate the rupture point. Postoperatively, she was discharged without neurological deficit, and follow-up CT showed no other new infarction. We recommend clipping rather than wrapping or coating for similar cases of ruptured enlarged infundibular widening.

MR Findings of Nasal Cavity Lesions Showing the Infundibular Widening on CT

MR Findings of Nasal Cavity Lesions Showing the Infundibular Widening on CT

Abnormalities of collagen cross-linkage in posterior communicating artery aneurysms: a preliminary study.

The collagen of tissues submitted to mechanical load (i.e. arterial wall) is characterised by the presence of intermolecular covalent cross-links (hydroxylysyl pyridinoline or pyridinoline: PYD; and lysyl-pyridinoline or deoxypyridinoline: DPD) which stabilise the molecular structure. In this preliminary study we look for quantitative or qualitative alterations of collagen cross-linkage in intracranial aneurysms of posterior communicating artery (PCoA) which may be considered a site of elective weakening in the intracranial arterial circulation, being one of the most frequent locations of intracranial aneurysms and of so called "infundibular widening'. We analysed the collagen cross-linkage in 6 autopsy samples of intracranial arterial segments of the Circle of Willis which were removed from patients whose cause of death was other than cerebral hemorrhage, and in 6 samples of intracranial PCoA aneurysms obtained at surgery. The analysis of cross-links showed that there was no significant difference in collagen and cross-link content between autopic and aneurysmatic samples except for PCoA. In autoptic nonaneurysmatic samples of PCoA a lower content of PYD than in internal carotid artery (ICA) and a lower content of DPD than in all other arterial segments has been demonstrated; moreover a lower content of cross-links (DPD + PYD/ Collagen) was evident in nonaneurysmatic PCoA samples when compared to other segments (ICA and Anterior Communicating Artery). On the other hand, the mean content of DPD was significantly lower in PCoA aneurysms than in nonaneurysmatic samples of the artery and moreover, a significantly low content of cross-links (DPD + PYD/Collagen) is overemphasised in PCoA aneurysms, suggesting that the peculiar lower content of DPD in PCoA arteries may be considered the expression of minor resistance of the arterial wall at this site, and may be related to the higher incidence of aneurysms or infundibular widening of this arterial segment.

Possible Evidence for Homicide in an Egyptian Mummy Head

In the present paper we describe the macroscopic, radiological and histological findings for the head of an adult male Egyptian mummy, who presented with a round to oval defect of the left occipitotemporal bone covered by an almost intact layer of soft tissue and skin. The osseous defect showed infundibular widening into the cranial cavity, such as is seen in cases of depressed fracture due to a massive external force applied by a rather blunt weapon. In addition, the slightly increased thickness of the skull bone indicates that even higher mechanical force was necessary to punch out the defect than in other skulls. Because we assume that the defect occurred intravitally, the unusual constellation of this defect provides some evidence that it had occurred during a violent attack, possibly presenting the palaeopathological remnants of a case of homicide.

内頸動脈後交通動脈分岐部動脈瘤の2型分類とその手術アプローチ

The internal carotid-posterior communicating artery aneurysm is common, and a lot of brief reports have been presented about the classification and surgical approach for this aneurysm. The authors noticed the presence of small redish bulges in this portion, of the artery, which are thought to be the origin of aneurysms. Most of them were observed on the lateral wall of origin of the posterior communicating artery, and others were located on the inferior wall of the internal carotid artery including the infundibular widening of the posterior communicating artery. In this report, judging from these findings, the aneurysms were classified into two types: posterior communicating artery origin type and internal carotid artery origin type. The morphologic charactaristics and basic surgical procedures of these aneurysms were presented in two types respectively.In some subjects, this classification has similarities to former classificstions, but this one is based on a new concept, as mentioned above. Aneurysm surgery based on the concept of this classification shoud be safer and easier to perform.

Anatomical patterns of hypoplastic posterior communicating arteries and their implications for cerebrovascular diseases.

A total of 114 undersized posterior communicating arteries (PCoA-s, external diameter less than 1 mm) and 126 larger ones were investigated histologically. Microscopic examination of hypoplastic PCoA-s revealed five different structural patterns. Two of them showed microscopic appearances characteristic of intracranial arteries seen in adults or newborns without vascular disease. Two other types resembled the histologic picture of Moya Moya disease. The last type was thin-walled and dilated. All PCoA-s larger than 1 mm displayed the adult pattern. The PCoA-s with the Moya Moya-like structure and the thin-walled, dilated pattern contained unusually few reticular fibers. It is supposed that Moya Moya disease may be restricted to the PCoA-s. Further, the types of hypoplastic PCoA-s with reticular fiber deficiency are most probably the source of the so-called unexplained subarachnoid hemorrhage regardless of the presence of infundibular widening. The latter statement stems from the observation that the structure of junctional dilatation does not differ from that of other segments of the artery that exhibit this alteration.

Aneurysm growth and hemodynamic stress

Two cases of intracranial saccular aneurysm related to an arteriovenous malformation (AVM) are illustrated, in which a remarkable growth of the sac over the years was demonstrated angiographically. According to the relevant literature, aneurysm enlargement is correlated to the flow toward the AVM, increasing the intrasaccular turbulence and stress on the wall to which “solitary” aneurysms are usually subjected. The presence of bilateral infundibular widening at the origin of the posterior communicating artery is noted in one of the cases. This finding possibly confirms further the effects of hemodynamic stress.

Angiographic and Histologic Changes in Infundibular Widening of the Posterior Communicating Artery

Angiographic and Histologic Changes in Infundibular Widening of the Posterior Communicating Artery

Infundibular widening of the posterior communicating artery studied by carotid angiography.

(1959). Infundibular widening of the posterior communicating artery studied by Carotid angiography. Acta Radiologica: Vol. 51, No. 6, pp. 415-421.

Infundibular Widening of the Posterior Communicating Artery Studied by Carotid Angiography

Infundibular Widening of the Posterior Communicating Artery Studied by Carotid Angiography