P2 Segment Research Articles

Unilateral double fenestration of the same posterior cerebral artery at P1 segment: first cadaveric case report and literature review.

Arterial fenestration involves an artery emerging from the same embryological origin, with its lumen divided into two channels that subsequently rejoin. This kind of vascular variant has consequences, such as focal defects in the histologic layers of the arteries, hemodynamic stress, and challenges for endovascular procedures in the management of vascular pathologies. The main objective of this work is to present a rare vascular variant, a double fenestration of the same P1 segment of a cadaveric specimen, and a literature review of these kind of vascular variants. A cadaveric study was performed in which 20 central nervous system specimens, from patients without neurological pathology obtained as a donation from the National Institute of Legal Medicine and Forensic Sciences, were dissected for educational and research purposes. In one specimen it was found a double fenestration of the right P1 segment, associated with a single fenestration of the right superior cerebellar artery. Few cases of posterior circulation fenestration, beyond the vertebrobasilar trunk are reported in the literature, with limited understanding of the potential hemodynamic consequences thereof. In all the literature available, only eight cadaveric cases of P1 segment fenestration are documented, often linked with other central nervous system vascular abnormalities such as aneurysms or duplications. There is a single report of unilateral double P1 segment fenestration in a living patient. To our knowledge, this is the second case reported in the literature on this specific anatomical anomaly, and the first such report in a cadaver.

Microsurgical Anatomy of the Lateral Posterior Choroidal Artery and Its Thalamic Branches

Only a few articles have been published about the lateral posterior choroidal artery (LPChA), and yet none of them contains data regarding the thalamic branches. The LPChA and its twigs of the 26 cerebral hemispheres were injected with a mixture of a 10% Indian ink and gelatin. Following fixation in a 10% formaldehyde solution, the vessels were micro dissected under the stereoscopic microscope. In addition, serial cerebral angiograms of the 168 patients were examined. The LPChA, which was commonly singular or double and averaged 0.68 mm in diameter, most often originated from the P2 and P3 segments (76%) of the posterior cerebral artery (PCA). It always gave off the choroidal, pulvinar and typical thalamic branches, occasionally the parahippocampal (4%), hippocampal (8%), peduncular (8%), tegmental (12%), pretectal (4%), lateral geniculate (40%) and medial geniculate twigs (16%), and the forniceal, subependymal (100%), stria terminalis (32%), and caudate twigs (28%). The pulvinar and thalamic branches averaged almost 4 in number and 0.27 mm in diameter. They most often supplied the pulvinar nuclei, and occasionally portions of the mediodorsal, lateral dorsal, lateral posterior, ventral lateral, and the ventral posterior thalamic nuclei. Among the 168 serial cerebral angiograms, one presented the arteriovenous malformation of the LPChA, but no one showed an aneurysm. This is the first description of the LPChA thalamic branches to date. Their microanatomic features are important for understanding the neurologic symptoms following vessels occlusion, for precise radiologic diagnoses, and for safe neurosurgical and endovascular interventions.

Measurement of transcranial Doppler insonation angles from three-dimensional reconstructions of CT angiography scans.

Blood velocities measured by Transcranial Doppler (TCD) are dependent on the angle between the incident ultrasound beam and the direction of blood flow (known as the Doppler angle). However, when TCD examinations are performed without imaging the Doppler angle for each vessel segment is not known. We have measured Doppler angles in the basal cerebral arteries examined with TCD using three-dimensional (3D) vessel models generated from computed tomography angiography (CTA) scans. This approach produces angle statistics that are not accessible during non-imaging TCD studies. We created 3D models of the basal cerebral arteries for 24 vasospasm patients. Standard acoustic windows were mapped to the specific anatomy of each patient. Virtual ultrasound transmit beams were generated that originated from the acoustic window and intersected the centerline of each arterial segment. Doppler angle measurements were calculated and compiled for each vessel segment. Doppler angles were smallest for the middle cerebral artery M1 segment (median 24.6°) and ophthalmic artery (median 25.0°), and largest for the anterior cerebral artery A2 segment (median 76.4°) and posterior cerebral artery P2 segment (median 75.8°). The ophthalmic artery had the highest proportion of Doppler angles that were less than 60° (99%) while the anterior cerebral artery A2 segment had the lowest proportion of Doppler angles that were less than 60° (10%). These angle measurements indicate the expected deviation between measured and true velocities in the cerebral arteries, highlighting specific segments that may be prone to underestimation of velocity.

Simultaneous beating-heart mitral valve replacement and aortic repair following Bentall procedure via double right mini-thoracotomies: a case report

BackgroundRedo mitral valve surgery by re-sternotomy approach has challenges such as bleeding and organ injury due to adhesion dissection, sternal bone infection, and poor field of view of mitral valve. On the other hand, redo mitral valve surgery via a right mini-thoracotomy approach appears to address these challenges. We successfully performed a double right mini-thoracotomies approach for mitral valve replacement and pseudoaneurysm repair under the beating-heart condition. Herein, we report the effectiveness and the safety of this technique and detailed procedure.Case presentation.The patient is a 71-year-old man with a history of Bentall procedure using a mechanical valve at another hospital 30 years ago. He developed acute heart failure due to severe mitral valve regurgitation. After medication, he was referred to our department for the purpose of surgery for mitral valve regurgitation. Preoperative transesophageal echocardiography showed extensive degenerative change of the both leaflets and chordae tendineae rupture at the P3 segment. Both left atrium and ventricle dilated, and left ventricle contractility reduced. Aortic mechanical valve had no problem. In addition, preoperative contrast enhanced computed tomography revealed a pseudoaneurysm at the distal anastomotic site of Bentall procedure. We performed mitral valve replacement by mechanical valve and repair of distal anastomotic cite under beating heart condition, utilizing a double right mini-thoracotomies approach for mitral valve and ascending aortic pseudoaneurysm respectively. The postoperative course was uneventful, the patient was discharged without complications.ConclusionThe right mini-thoracotomies approach efficiently accessed mitral valve and ascending aorta in reoperations, reducing the adhesion dissection risks and ensuring clear exposure. Moreover, concomitant use of beating-heart technique minimized adhesion dissection for aortic cross-clamp, preserved cardiac function.

Micro to macro scale anatomical analysis of the human hippocampal arteries with synchrotron hierarchical phase-contrast tomography.

To date, no non-invasive imaging modality has been employed to profile the structural intricacies of the hippocampal arterial microvasculature in humans. We hypothesised that synchrotron-based imaging of the human hippocampus would enable precise characterisation of the arterial microvasculature. Two preserved human brains from, a 69-year-old female and a 63-year-old male body donors were imaged using hierarchical phase-contrast tomography (HiP-CT) with synchrotron radiation at multiple voxel resolutions from 25.08μm down to 2.45μm. Subsequent manual and semi-automatic artery segmentation were performed followed by morphometric analyses. These data were compared to published data from alternative methodologies. HiP-CT made it possible to segment in context the arterial architecture of the human hippocampus. Our analysis identified anterior, medial and posterior hippocampal arteries arising from the P2 segment of the posterior cerebral artery on the image slices. We mapped arterial branches with external diameters greater than 50 μm in the hippocampal region. We visualised vascular asymmetry and quantified arterial structures with diameters as small as 7 μm. Through the application of HiP-CT, we have provided the first imaging visualisation and quantification of the arterial system of the human hippocampus at high resolution in the context of whole brain imaging. Our results bridge the gap between anatomical and histological scales.

Rapid growth of calcified amorphous tumor with mitral annulus calcification: a case report

BackgroundCalcified amorphous tumor (CAT) of the heart is a rare, non-neoplastic cardiac mass with mitral valves and annuli being the most common sites. The presence of mitral annular calcification (MAC) is associated with an increased risk of stroke or other systemic embolisms. Here, we report a case of CAT showing rapid growth with MAC and investigate the link between the two.Case presentationA 71-year-old man presented at our hospital with dyspnea and had been undergoing hemodialysis for 26 years for chronic glomerulonephritis. Transthoracic echocardiography (TTE) revealed moderate mitral stenosis with bulky MAC. Two months later, the patient developed progressive dyspnea, and follow-up TTE revealed a highly mobile mass (8 × 5 mm) attached to the left ventricular (LV) side of the posterior MAC. He underwent surgery because of congestive heart failure and a high risk of embolization. Surgical inspection revealed that the tumor was attached beneath the P3 segment of the mitral valve on the LV side and was removed. When removing the MAC, toothpaste-like contents drained from the encapsulated mass inside the MAC at the P3 segment, where the tumor was located. After reconstructing the posterior mitral annulus defect with a bovine pericardial patch, mitral valve replacement with a mechanical prosthesis, a maze procedure, and left appendage closure were performed. Histopathological examination revealed that the excised tumor contained fibrin and calcium deposits. The mass was diagnosed as a CAT.ConclusionsCAT may be one of the causes of stroke induced by MAC. Routine follow-up echocardiography should be recommended for patients with MAC, especially those undergoing hemodialysis.

Anatomical differences of the vertebrobasilar artery between normal subjects and patients with cerebral infarction.

Previous studies have reported various anatomical differences in the cerebral artery between healthy subjects and patients with posterior circulation cerebral infarction. In particular, basilar artery angulation has been associated with posterior circulation cerebral infarction. We compared anatomical variations and the degree of anterior and lateral vertebrobasilar artery angulation and deviation to compare the incidence of cerebral infarction of healthy subjects and patients with posterior circulation cerebral infarction. We compared basilar artery anatomy using brain magnetic resonance angiography in 97 patients who underwent brain magnetic resonance angiography during health checkups at our hospital and in 92 patients diagnosed with posterior circulation cerebral infarction between 2012 and 2022. Anatomical variations, including fetal-type posterior cerebral artery, hypoplastic P1 segment, vertebrobasilar dolichoectasia, and dominant vertebral artery, as well as the degree of anterior and lateral deviation and angulation, were evaluated. Correlations between these variations and the occurrence of cerebral infarction were analyzed. The prevalence of hypoplastic P1 was significantly differences in patients with posterior circulation cerebral infarction (odds ratio: 5.655). Furthermore, patients with posterior circulation cerebral infarction exhibited more acute anterior and lateral angulation, as well as lateral deviation. Hypoplastic P1 and more acute anterior or lateral angulation of the vertebrobasilar artery are associated with increased frequency of cerebral infarction.

Ultrasound-Assisted Sagittal View for Retrograde Puncture of the P2 Segment of Popliteal Artery for Recanalization of Femoropopliteal Lesions

To assess the safety and efficacy of ultrasound-assisted sagittal view for retrograde puncture of the P2 segment of popliteal artery (PA) for treating femoropopliteal lesions. A retrospective study was conducted on consecutive patients who underwent retrograde puncture of the PA for the recanalization of femoropopliteal lesions. A retrograde access was made to either the P2 or P3 segment of the PA in 23 cases. In 10 cases (8 men; mean age 68±9years), ultrasound-guided retrograde PA (P2 segment) puncture using the long-axis in-the-plane approach was performed, and in 13 cases (11 men; mean age 69±5years), angiography-guided retrograde PA (P3 segment) puncture was performed. Clinical data was compared preintraoperatively and postoperatively in the 2 groups. All occluded lesions were successfully recanalized via dual channel intervention. Puncture success were 100% (10/10) in the P2 group compared with 92.3% (12/13) in the P3 group (P>0.05). The mean puncture time in the P2 group was significantly shorter when compared to the P3 group (4.70±0.95mins vs 11.33±6.37mins; P<0.05). There was no difference in mean hemostasis time between the 2 groups (6.11±2.20mins vs 8.46±3.76mins; P>0.05). There were no in-hospital deaths in all patients. The occurrence of puncture-related complications in the P2 group was 10% compared with 15% in the P3 group (P>0.05). A low-flow arteriovenous fistula was observed in one case in the P3 group. None of the patients reported any access-related complication at a mean follow-up of 11.3±5.5months. Ultrasound-assisted sagittal view for retrograde puncture of the P2 segment of PA is at least as safe as angiography-guided retrograde puncture of the P3 segment for femoropopliteal lesions. Furthermore, this technique appears to be more suitable for patients with tandem iliofemoral artery occlusion, as it allows for the creation of a retrograde access.

Rare simultaneous fetal posterior cerebral artery and conventional posterior cerebral artery duplication in a patient with a ruptured posterior communicating artery aneurysm: illustrative case.

The fetal-type posterior cerebral artery (PCA) is defined as a variant anatomy in which the posterior communicating artery (PCOM) is larger than the hypoplastic or aplastic P1 segment of the PCA. The authors present the novel case of a patient with a duplicated right PCA in parallel with fetal-type and conventional PCAs supplying adjacent components of the PCA cerebral territory. A 59-year-old woman presented with a modified Fisher Scale score 4 subarachnoid hemorrhage. A right irregular PCOM aneurysm that measured 9.5 mm × 4.5 mm × 4.5 mm arose from the base of a variant branch supplying a portion of the PCA, rather than a conventional PCOM, and was found on digital subtraction angiography. Following endovascular coil embolization, the patient was discharged home. The fetal-type variant has implications for thromboembolic events. If an embolism occludes the anterior circulation in a patient with a fetal-type PCA, it may result in an infarct in the PCA territory. Awareness of cerebral arterial anatomy, including an atypical collateral supply, informs a treating team's latitude in tolerance of which sites must be preserved and which can be safely sacrificed. https://thejns.org/doi/10.3171/CASE23735.

Outcome of CAS under flow reversal and analysis for the intraprocedural flow of internal carotid artery

ObjectiveCarotid artery stenting (CAS) under flow reversal with dual protection using a proximal balloon and distal filter has been an established procedure for internal carotid artery (ICA) stenosis. This study investigates the effect of external carotid artery (ECA) occlusion on outcomes of CAS and ICA flow under flow reversal. MethodsWe reviewed 231 cases of CAS under flow reversal with ECA occlusion and 32 without. In the last 14 of 32 cases, the flow in the ICA under flow reversal was analyzed by ultrasound. The collateral index, which was defined as the total value of the maximum diameters of the ipsilateral anterior cerebral artery at the A1 segment and the anterior communicating artery, as well as those of the ipsilateral posterior cerebral artery at the P1 segment and the ipsilateral posterior communicating artery, and the maximum diameter of the ipsilateral ECA were correlated with the flow direction in the ICA. ResultsThere was no significant difference in the outcome of CAS between the groups with or without ECA occlusion. Among the 14 cases without ECA occlusion, antegrade flow in the ICA was observed in 6 cases (42.9 %). The group with the antegrade flow in the ICA exhibited a significantly lower collateral index (5.08±0.33 vs 6.71±0.28, p=0.01) and a significantly larger ECA diameter (4.66±0.51 mm vs 3.21±1.24 mm, p=0.01) than the group with the stagnant or retrograde flow in the ICA. ConclusionsThe outcomes of CAS under flow reversal were acceptable even without ECA occlusion. The ECA occlusion may not be necessary for CAS under dual protection; however, distal filter protection should be used even under flow reversal.

Evaluating the Prevalence and Clinical Significance of Fetal Posterior Cerebral Artery Variants via Magnetic Resonance Imaging: Insights From a Tertiary Healthcare Facility in Tamil Nadu.

Introduction The prevalence and clinical significance of fetal posterior cerebral artery (FPCA) variants are studied using magnetic resonance imaging (MRI) at Saveetha Medical College. This research focuses on the fetal origin of the posterior cerebral artery (PCA), a condition where the posterior communicating artery (PComA) is larger than the P1 segment of the PCA, affecting cerebral hemodynamics and associated with various cerebrovascular pathologies. Materials and methods This retrospective analysis employed MRI records from the Department of Radio Diagnosis at Saveetha Medical College, conducted between January 2013 and December2023. The study included patients undergoing MRI for various neurological indications, with specific imaging protocols including T1- and T2-weighted sequences, diffusion-weighted imaging, and magnetic resonance angiography (MRA). Results The study confirmed a prevalence rate of FPCA variants within the expected range of 20%-30%. MRI findings were systematically analyzed by experienced radiologists to assess the presence and characteristics of FPCA variants. The relationship between these variants and clinical symptoms was explored, revealing significant correlations that emphasize the variants' impact on patient outcomes, particularly in the context of cerebrovascular events. Conclusion The study underlines the importance of recognizing FPCA variants due to their significant implications in neurovascular health and cerebrovascular accident (CVA) outcomes. These variants alter cerebral hemodynamics and can complicate neurosurgical and diagnostic procedures. Therefore, personalized treatment and management strategies are crucial for optimizing patient care.

Agreement between CT-Angiography and Digital Subtraction Angiography in Predicting Angiographic Vasospasm in Patients with Subarachnoid Hemorrhage.

Background/Objectives: Digital subtraction angiography (DSA) is the gold standard in the diagnosis of cerebral vasospasm, frequently observed after subarachnoid hemorrhage (SAH). However, less-invasive methods, such as computed tomography angiography (CTA), may be equally accurate. To further clarify comparability, this study evaluated the reliability of CTA in detecting cerebral vasospasm. Methods: This retrospective study included 51 patients with SAH who underwent both CTA and DSA within 24 h. The smallest diameter of the proximal cerebral arterial segments was measured in both modalities at admission and during the vasospasm period. The mean difference in diameter, the intraclass correlation coefficient (ICC) of CTA and DSA, the difference in grade of vasospasm and sensitivity, the specificity and the positive predictive value (PPV) for CTA were calculated. Results: A total of 872 arterial segments were investigated. At time of admission, arterial diameters were significantly smaller on CTA compared to DSA in all segments (-0.26 ± 0.12 mm; p < 0.05). At time of suspected vasospasm (day 9 ± 5), these differences remained significant only for the M1 segment (-0.18 ± 0.37 mm, p = 0.02), the P1 segment (-0.13 ± 0.24 mm, p = 0.04) and the basilar artery (-0.20 ± 0.37 mm, p = 0.0.04). The ICC between CTA and DSA was good (0.5-0.8). The sensitivity of CTA for predicting angiographic vasospasm was 99%, the specificity was 50% and the PPV was 92%. Conclusions: Arterial diameters measured on CTA may underestimate the arterial caliber observed in DSA; however, these absolute differences were minor. Importantly, vessel diameter alone does not fully reflect malperfusion, requiring additional imaging techniques such as CT perfusion.

GmMYB183, a R2R3-MYB Transcription Factor in Tamba Black Soybean (Glycine max. cv. Tamba), Conferred Aluminum Tolerance in Arabidopsis and Soybean.

Aluminum (Al) toxicity is one of the environmental stress factors that affects crop growth, development, and productivity. MYB transcription factors play crucial roles in responding to biotic or abiotic stresses. However, the roles of MYB transcription factors in Al tolerance have not been clearly elucidated. Here, we found that GmMYB183, a gene encoding a R2R3 MYB transcription factor, is involved in Al tolerance. Subcellular localization studies revealed that GmMYB183 protein is located in the nucleus, cytoplasm and cell membrane. Overexpression of GmMYB183 in Arabidopsis and soybean hairy roots enhanced plant tolerance towards Al stress compared to the wild type, with higher citrate secretion and less Al accumulation. Furthermore, we showed that GmMYB183 binds the GmMATE75 gene promoter encoding for a plasma-membrane-localized citrate transporter. Through a dual-luciferase reporter system and yeast one hybrid, the GmMYB183 protein was shown to directly activate the transcription of GmMATE75. Furthermore, the expression of GmMATE75 may depend on phosphorylation of Ser36 residues in GmMYB183 and two MYB sites in P3 segment of the GmMATE75 promoter. In conclusion, GmMYB183 conferred Al tolerance by promoting the secretion of citrate, which provides a scientific basis for further elucidating the mechanism of plant Al resistance.

Stop Ischemic Event to the Brain: Screening Risk Factors of Cerebrovascular Stenosis in Coronary Artery Disease Patients.

In this study, we investigated the difference in risk factors between the 2 diseases, aiming to further clarify who needs to do ischemic cerebrovascular disease (ICVD)-related screening among coronary artery disease (CAD) patients. Clinical data of 326 patients with first-episode CAD from June 1, 2017, to July 31, 2020, in the Chinese PLA General Hospital were retrospectively reviewed. Outcomes, including clinical features and laboratory examination, were taken. Features related to ICVD including the extension of intracranial arterial (internal carotid artery intracranial segment, middle cerebral artery M1 segment, anterior cerebral A1 segment, vertebrobasilar artery intracranial segment, posterior cerebral artery P1 segment) and carotid arterial (internal carotid artery extracranial segment, common carotid artery, subclavian artery) stenosis were detected. Risk factors for the occurrence of ICVD in patients with CAD were analyzed. Among patients with the onset of CAD, in comparison of the nonstenosis and stenosis of intracranial artery subgroups, there were statistical differences in the onset age, hypertension, and duration of hypertension as well as the biochemical indicators, including high-density lipoprotein and glycosylated hemoglobin. In addition, statistical differences were detected in the onset age as well as the biochemical indicators, including glycosylated hemoglobin and blood glucose serum protein, along with the difference in the degree of cardiovascular stenosis. The onset age of CAD was shown to serve as a vital risk factor for ICVD. The primary prevention of ICVD in patients with CAD should lay more emphasis on the management of hypertension and diabetes.

A unilateral partial duplication of a fetal variant posterior cerebral artery associated with anomalous origin of duplicated superior cerebellar artery: a case report.

Variations at the junction of embryonic internal carotid and vertebrobasilar systems are rare and associated with a high incidence of stroke. During cadaver dissection, we demonstrated for the first time a case of hypoplastic right vertebral artery associated with partial duplication of the distal part of the right P1 segment of a partial fetal posterior cerebral artery (FPCA) and bilateral duplication of superior cerebellar arteries (SCAs), of which, the upper right SCA originated from PCA. We hypothesize that the poor development of the right half of the vertebrobasilar system caused the persistence of FPCA with anomalous origin of the right upper SCA as well as partial duplication of P1 segment of PCA as a remnant of the weak anastomosis between the embryonic right PCA and the basilar system. Such complex variations provide a huge challenge in their diagnosis and in choosing the suitable treatment modality for the stroke.

Super-selective injection of propofol into the intracranial arteries enables Patient's self-evaluation of expected neurological deficit

IntroductionIt is hard to realize the extent of the expected postoperative neurological deficit for patients themselves. The provision of appropriate information can contribute not only to examining surgical indications but also to filling the gap between patient and expert expectations. We hypothesized that propofol infusion into the intracranial arteries (ssWada) could induce focal neurological symptoms with preserved wakefulness, enabling the patients to evaluate the postsurgical risk subjectively. MethodsPresurgical evaluation using ssWada was performed in 28 patients with drug-resistant epilepsy. Based on anatomical knowledge, propofol was super-selectively infused into the intracranial arteries including the M1, M2, and M3 segments of the middle cerebral artery (MCA), A2 segment of the anterior cerebral artery, and P2 segment of the posterior cerebral artery to evaluate the neurological and cognitive symptoms. We retrospectively analyzed a total of 107 infusion trials, including their target vessels, and elicited symptoms of motor weakness, sensory disturbance, language, unilateral hemispatial neglect (UHN), and hemianopsia. We evaluated preserved wakefulness which enabled subjective evaluations of the symptoms and comparison of the subjective experience to the objective findings, besides adverse effects during the procedure. ResultsPreserved wakefulness was found in 97.2% of all trials. Changes in neurological symptoms were positively evaluated for motor weakness in 51.4%, sensory disturbance in 5.6%, language in 48.6%, UHN in 22.4%, and hemianopsia in 32.7%. Six trials elicited seizures. Multivariate analysis showed significant correlations between symptom and infusion site of language and left side, language and MCA branches, motor weakness and A2 or M2 superior division, and hemianopsia and P2. Transient adverse effect was observed in 8 cases with 12 infusion trials (11.2 %). ConclusionThe ssWada could elicit focal neurological symptoms with preserved wakefulness. The methodology enables specific evaluation of risk for cortical resection and subjective evaluation of the expected outcome by the patients.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

An unusual presentation of subacute Haemophilus parainfluenzae endocarditis in a low-risk woman treated by minimally invasive mitral valve repair: a case report

BackgroundHACEK endocarditis is usually insidious and can often be difficult to diagnose due to the slow-growing nature of the organisms. This report presents our experience in treating a patient with Haemophilus parainfluenzae endocarditis.Case presentationWe describe the case of a previously fit and well 23 year-old woman who presented to her local emergency department with a four-week history of persistent febrile illness. She had associated nausea, vomiting, and lethargy. This was preceded by an episode of mucopurulent rhinorrhoea. She was treated empirically with oral amoxicillin for a putative diagnosis of rhinosinusitis. Initially, her symptoms abated, however, she was readmitted with high fevers and a new pansystolic murmur. Transthoracic echocardiography revealed a large, mobile, echogenic mass, tethered to the posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (MR). On examination, she had multiple non-tender, erythematous macules on the plantar surface of her feet, consistent with Janeway lesions. Two separate blood cultures grew H. parainfluenzae. Infectious diseases recommended a four-week course of intravenous ceftriaxone. Transesophageal echocardiography demonstrated a perforation within the P3 segment of the PMVL. Subsequently, the patient underwent mitral valve repair surgery with an uneventful recovery.ConclusionsOur case highlights the importance of promptly diagnosing HACEK endocarditis. A prolonged course of antibiotic therapy can be lifesaving, and surgery is often necessary to address complications such as perforation within the mitral valve leaflets. In our patient, we were able to perform a sliding P2 leaflet plasty for good quality repair of the mitral valve, through a minimally invasive right anterior thoracotomy.

EnDovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for MedIum distal VeSsel Occlusion sTroke (DISTAL): An international, multicentre, randomized-controlled, two-arm, assessor-blinded trial.

Whether endovascular therapy (EVT) in addition to best medical treatment (BMT) in people with acute ischemic stroke (AIS) due to a medium distal vessel occlusion (MDVO) is beneficial remains unclear. To determine if people experiencing an AIS due to an isolated MDVO (defined as the co- or non-dominant M2 segment, the M3 or M4 segment of the middle cerebral artery, the A1, A2, or A3 segment of the anterior cerebral artery or the P1, P2 or P3 segment of the posterior cerebral artery) will have superior outcome if treated with EVT in addition to BMT compared to BMT alone. To randomize 526 participants 1:1 to EVT plus BMT or BMT alone. A multicentre, international, prospective, randomized, open-label, blinded-endpoint (PROBE) superiority trial. The primary efficacy endpoint is the distribution of disability levels on the modified Rankin Scale at 90 days. Secondary clinical efficacy outcomes include normalized change in National Institutes of Health Stroke Scale score from baseline to day 1, cognitive outcome at 90 days, and health-related quality of life at 90 days. Safety outcomes include all serious adverse events, symptomatic intracranial hemorrhage within 24 h, and all-cause mortality up to 90 days. Secondary imaging outcomes include successful reperfusion at end of EVT procedure and recanalization of target artery at 24 h. DISTAL will inform physicians whether EVT in addition to BMT in people with AIS due to a MDVO is more efficacious than BMT alone.

Anatomical Markers Associated With the Presence of Intracranial Aneurysms in Individuals Screened for Aneurysms

Background Hemodynamic stress is linked to the development of intracranial aneurysms (IAs) and may be influenced by anatomic variation of intracranial arteries. We assessed diameters and bifurcation angles of intracranial arteries forming the circle of Willis in a cohort of individuals screened for the presence of IAs. Methods Individuals with and without IAs identified at screening with magnetic resonance angiography were compared. Diameters and bifurcation angles of the following arteries were measured using semiautomatic methods: A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery, P1 segments of the posterior cerebral artery, posterior communicating artery (Pcom), internal carotid artery, vertebral artery, and basilar artery. We employed univariate general linear models to assess group differences. This included subgroup comparisons between individuals with IAs at specific locations and matched controls, and comparisons on group level between individuals with and without IAs, corrected for age and sex. Results In 94 of the 1049 individuals (9.0%) included, IAs were detected. Individuals with middle cerebral artery IAs had wider ipsilateral M2–M2 bifurcation angles compared with controls (121±25° versus 97±19°; P &lt;0.01). Individuals with anterior communicating artery IAs showed smaller angles for the A1–A2 bifurcation (106±16° versus 120±17°; P = 0.02), while those with Pcom IAs had wider Pcom–C7 bifurcation angles (147±14° versus 127±17°; P = 0.02) and smaller diameters below the ipsilateral internal carotid artery top (2.86±0.36 mm versus 3.10±0.33 mm; P = 0.03) compared with controls. Conclusion We found associations between wider M2–M2 bifurcation angles or narrower A1–A2 bifurcation angles and IA presence, consistent with prior literature. Moreover, we uncovered previously unexplored associations, including wider Pcom–C7 bifurcation angles and smaller internal carotid artery diameters in individuals with Pcom IAs. Future research should explore the potential of these markers in predicting IAs in at‐risk populations during follow‐up screenings.