Artery Perforator Research Articles

4: Four-flap Breast Reconstruction: Assessing Breast-q And Donor Site Morbidity In Bilateral Stacked Autologous Breast Reconstruction

Purpose:Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Four-flap reconstruction patients are a unique population in which to compare donor site morbidity of the two most commonly used free flaps in breast reconstruction (DIEP and PAP). Our aim was to characterize the donor site morbidity and overall patient outcomes of four-flap breast reconstruction patients.Methods:Retrospective chart review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between 2014-2019 at a single academic medical center. Inpatient surgical site pain location and pain scores by Numeric Pain Rating Scale (NPRS) were recorded during the immediate post-operative admission. All patients were contacted to complete the BREAST-Q reconstructive module and the Lower Extremity Functional Scale (LEFS). Four-flap BREAST-Q scores were compared to bilateral DIEP and to bilateral PAP patients as reference populations.Results:A total of 63 patients undergoing four-flap breast reconstruction were identified. BREAST-Q (n=38) scores demonstrated mean Satisfaction With Breasts of 66.1+/-32.2, Psychosocial Well-Being 70.8+/-34.3, Sexual Well-Being 44.5+/-36.5, Physical Well-Being Chest 72.8+/-32.5, and Physical Well-Being Abdomen 63.6+/-34.9. In comparison to bilateral DIEP (n=180), and bilateral PAP reconstruction patients (n=43), four-flap BREAST-Q scores were similar. No difference in BREAST-Q scores remained after matching four-flap patients to bilateral DIEP patients by Age, Race, BMI, Zip Code, and radiation history. With regard to donor site morbidity, mean instances of donor site pain location recorded at the abdomen (9.72, 95%CI[7.78-11.66]) were significantly higher than the thigh (2.82, 95%CI[1.63-4.00]) during the post-operative admission (p=<0.0001). Mean pain scores by NPRS were similar between abdomen, thigh, and breast surgical sites. Subjective survey data revealed more donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier post-operative care for the DIEP donor site. Further, a majority of patients felt the thighs were aesthetically improved post-operatively (54.29%). Long term survey outcomes from the LEFS (n=35) demonstrated a mean score of 92.4% (SD 10.9). The majority of women would make the same decision for four flap breast reconstruction (81.82%).Conclusion:This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. Patients undergoing four-flap breast reconstruction have more immediate donor site pain at the abdomen than the thigh, but more thigh pain after discharge home once ambulating. BREAST-Q scores in four-flap patients demonstrate overall high patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. In patients who require increased flap volume for body appropriate breast reconstruction, four-flap reconstruction is comparable to bilateral DIEP and bilateral PAP by BREAST-Q scores.

A Case Report of Classical eight-and-a-Half Syndrome and Etiology Analysis

Eight-and-a-half syndrome is one-and-a-half syndrome plus ipsilateral seventh (facial) cranial nerve palsy, which was first reported by Eggenberger in 1998. This syndrome is caused by a lesion (most often vascular or demyelinating) in the dorsal tegmentum of the caudal pons. It involves the para pontine reticular formation and the medial longitudinal fasciculus, as well as the nucleus and the fasciculus of the facial nerve. We describe a case of a 56-year-old man presented with eight-and-a-half syndrome. We also discuss the vascular pathology and etiology of this syndrome through the literature review. Most eight-and-a-half syndrome cases are caused by occlusions of the perforating branches of the pons. The pathology can be transparent lipid-like changes at the perforator arteries. It can also be thrombosis at the orifice of the main or perforator arteries. BAH could be a very important factor in perforator artery infarction at the pontine. The etiology is closely related to hyperglycemia. An effective intervention is to avoid bad habits and control the hyperglycemia.

Investigation of flow velocity in recipient perforator artery for a reliable indicator for the flap transfer with perforator to perforator anastomosis.

In flap transfer with perforator to perforator anastomosis (FTPPA), encountering poor pulsation and blood flow in a recipient perforator intraoperatively often makes FTPPA impossible. This study sought to identify color and spectral Doppler ultrasonography (CSDUS) parameters that can aid reliable preoperative selection of a recipient perforator artery. The study enrolled 38 patients with lower extremity lymphedema who underwent vascularized lymphatic tissue transfer with perforator to perforator anastomosis for physiological lymphatic flow reconstruction. In all cases, three candidate recipient perforators were searched in each lower extremities, and vessel diameter and peak systolic flow velocity (PSFV) were measured. The inclusion criteria for candidates were a vessel diameter of >0.5 mm and a PSFV of >10cm/s. These measures were compared with intraoperative findings, diameters and if there was pulsation and visible spurting evident. A total of 114 candidates were selected, and 52 of the candidates were dissected until suitable perforators were found. PSFV (cm/s) on CSDUS was ≥20.0 in 32 perforators (84.2%) and was 15.0-19.9 in 6 perforators (15.8%) in the group with pulsation and visible spurting evident, and 15.0-19.9 in one perforator (7.1%) and ≤ 14.9 in 13 perforators (92.9%) in the group without pulsation and visible spurting evident. There was a statistically significant correlation between preoperative PSFV and intraoperative pulsation and visible spurting evident after dissection (P=0.021 × 10-3 ). The flap survival rate was 92.1%. PSFV is an important preoperative determinant of the suitability of a recipient perforator artery for FTPPA.

A Practical Tip for Intraoperative Perforator Vessel Selection

In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (&lt;0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.

Management tactics in patients with chronic cerebral ischemia during COVID-19 pandemic

The article describes the current state of evidence of hypertension and diabetes mellitus roles in the pathophysiology of chronic cerebral ischemia (CCI). CCI is mediated by cerebral microangiopathy, which develops due to vascular remodeling, increased arterial stiffness, endothelial dysfunction, impaired cerebrovascular reactivity, and neuroinflammation. All those mechanisms lead to white matter lesions and cognitive impairment. Arteriolosclerosis is the primary morphological process that damages perforating arteries and arterioles. COVID-19 pandemic can modify CCI progression due to similar pathophysiology. In particular, COVID-19-associated coagulopathy can lead to silent lacunar infarctions and lacunar stroke development. Treatment features of patients with CCI during the COVID-19 pandemic are reviewed. It is concluded that special attention in this group of patients should be paid to primary and secondary cardiovascular prevention issues, an essential element of which is the use of dipyridamole since it has a pleiotropic effect.

Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series.

Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.

Paradoxical paramagnetic calcifications in the globus pallidus: An ex vivo MR investigation and histological validation study.

MR images based on phase contrast images have gained clinical interest as an in vivo tool for assessing anatomical and histological findings. The globus pallidus is an area of major iron metabolism and storage in the brain tissue. Calcium, another important metal in the body, is frequently deposited in the globus pallidus as well. Recently, we observed dense paramagnetic deposition with paradoxical calcifications in the globus pallidus and putamen. In this work, we explore detailed MR findings on these structures, and the histological source of the related findings using ex vivo CT and MR images. Ex vivo MR was obtained with a maximum 100 μm3 isotropic resolution using a 15.2 T MR system. 3D gradient echo images and quantitative susceptibility mapping were used because of their good sensitivity to metallic deposition, high signal-to-noise ratio, and excellent contrast to iron and calcium. We found dense paramagnetic deposition along the perforating arteries in the globus pallidus. This paramagnetic deposition was hyperdense on ex vivo CT scans. Histological studies confirmed this finding, and simultaneous deposition of iron and calcium, although more iron dominant, was observed along the vessel walls of the globus pallidus. This was an exclusive finding for the penetrating arteries of the globus pallidus. Thus, our results suggest that several strong and paradoxical paramagnetic sources at the globus pallidus can be associated with vascular degeneration.

Failure modes and effects analysis of mechanical thrombectomy for stroke discovered in human brains.

Despite advancement of thrombectomy technologies for large-vessel occlusion (LVO) stroke and increased user experience, complete recanalization rates linger around 50%, and one-third of patients who have undergone successful recanalization still experience poor neurological outcomes. To enhance the understanding of the biomechanics and failure modes, the authors conducted an experimental analysis of the interaction of emboli/artery/devices in the first human brain test platform for LVO stroke described to date. In 12 fresh human brains, 105 LVOs were recreated by embolizing engineered emboli analogs and recanalization was attempted using aspiration catheters and/or stent retrievers. The complex mechanical interaction between diverse emboli (elastic, stiff, and fragment prone), arteries (anterior and posterior circulation), and thrombectomy devices were observed, analyzed, and categorized. The authors systematically evaluated the recanalization process through failure modes and effects analysis, and they identified where and how thrombectomy devices fail and the impact of device failure. The first-pass effect (34%), successful (71%), and complete (60%) recanalization rates in this model were consistent with those in the literature. Failure mode analysis of 184 passes with thrombectomy devices revealed the following. 1) Devices loaded the emboli with tensile forces leading to elongation and intravascular fragmentation. 2) In the presence of anterograde flow, small fragments embolize to the microcirculation and large fragments result in recurrent vessel occlusion. 3) Multiple passes are required due to recurrent (15%) and residual (73%) occlusions, or both (12%). 4) Residual emboli remained in small branching and perforating arteries in cases of alleged complete recanalization (28%). 5) Vacuum caused arterial collapse at physiological pressures (27%). 6) Device withdrawal caused arterial traction (41%), and severe traction provoked avulsion of perforating and small branching arteries. Biomechanically superior thrombectomy technologies should prevent unrestrained tensional load on emboli, minimize intraluminal embolus fragmentation and release, improve device/embolus integration, recanalize small branching and perforating arteries, prevent arterial collapse, and minimize traction.

Septal perforating artery originating from the ramus intermedius artery

Septal perforating artery originating from the ramus intermedius artery

Sphygmomanometer-induced hemostasis following iatrogenic guidewire perforation during lower extremity angioplasty.

Iatrogenic guidewire perforation is a well-known complication of lower extremity angioplasty that is often benign or can be easily treated with endovascular techniques. However, perforations that occur in arterial side branches may be more challenging to manage. If bleeding persists, open surgery and fasciotomy may be required to evacuate the resulting hematoma and prevent compartment syndrome. These subsequent procedures increase morbidity and, if the angioplasty was performed in the outpatient setting, necessitate patient transfer to a hospital. To address these challenges, we describe a non-invasive hemostasis technique involving serial sphygmomanometer cuff inflations over the affected site in a series of five patients who experienced this complication at our office. We retrospectively reviewed the medical records of consecutive patients undergoing lower extremity angioplasty that were found to have an arterial guidewire perforation on completion angiogram at our outpatient center between February 2012 and February 2017. Patients found to have iatrogenic guidewire perforations were administered intravenous protamine sulfate and were transferred to the surgical recovery room. Patients received ibuprofen or acetaminophen for pain management. A blood pressure cuff was placed around the site of perforation, and patients received serial cuff inflation cycles with repeated examinations of both limbs until patients reported cessation of pain and there were no signs of a developing hematoma. Patients were observed for two hours before they were discharged home. A follow-up duplex ultrasound examination was completed within one week of the intervention. Over the course of five years, 536 angioplasties were performed at our outpatient office. Five of these patients experienced iatrogenic guidewire perforation (0.93%). Perforations occurred in branches of the anterior or posterior tibial artery. All of these patients were successfully managed with the aforementioned hemostasis technique. None of these patients required transfer to a hospital for further management, and no complications were reported at follow-up. Complications of iatrogenic guidewire perforations in lower extremity arterial side branches can be safely and effectively managed by applying external compression around the affected site with an automatic blood pressure cuff.

Anatomy of the deep circumflex iliac artery perforators and reconstruction of complex mandibular defects with chimeric deep circumflex iliac artery perforator flap

To investigate the anatomy of the perforator vessels of the deep circumflex iliac artery (DCIA) and the techniques for repairing mandibular complex defect using chimeric deep circumflex iliac artery perforator flap (DCIAPF). We analyzed the origin, distribution, number and courses of the perforator vessels of the DCIA, and measured the outside diameters of the vessels at the origin in 6 adult cadaveric specimens (12 sides) with latex perfusion. From July, 2018 to September, 2019, based on the results of anatomical study and imaging findings and using the digital surgical guide plate, we harvested DCIAPF from 4 patients for repairing mandibular body or angle defects and oral soft tissue defects. The perforating vessels of the DCIA included abdominal muscular branches, osteomusculocutaneous branches and terminal musculocutaneous branches. The abdominal muscle branches originated from the DCIA inguinal segment in 4 and from both the inguinal and iliac segments in 2 of the specimens. The osteomusculocutaneous branches all originated from the internal iliac crest in 75% and from both the inguinal and internal iliac crest segments in 25% of cases; the inguinal segment gave rise to only one perforating branch. The number of the musculocutaneous perforating branches was 1 (58.3%) or 2 (41.7%). In the 4 patients undergoing mandibular reconstruction, the DCIAPF survived in all cases with good recovery of the donor site wound. Satisfactory facial appearance with good oral morphology and occlusal relationship was achieved at 1 month postoperatively in all the patients. None of the patients experienced obvious functional abnormalities at the donor site, and imaging examination confirmed successful reconstruction of the oromandibular defects in all the cases. A good understanding of the anatomic characteristics of the perforator vessels of the DCIA combined with imaging examinations and digital surgery technology facilitates the harvest of DCIAPF for repairing mandibular body or angle defects complicated by oral soft tissue defects.

Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction

To explore the surgical technique, effectiveness, and safety of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction. Between December 2016 and February 2019, 6 cases of early breast cancer received modified radical surgery, lower abdominal flap was applied for one- or two-staged breast reconstruction. The average age of the patients was 34.6 years (range, 29-56 years). The disease duration ranged from 2 to 16 months, with an average of 9.5 months. The tumor was located in the upper outer quadrant in 4 cases and the lower outer quadrant in 2 cases. Pathological examination showed that they were all invasive ductal carcinoma. Four cases of breast cancer were in stage Ⅰ and 2 cases was in stage Ⅱ. During operation, the inferior epigastric artery perforators were found to be close to the upper edge of the flap and/or near the umbilical cord in 4 cases, the inferior epigastric artery perforator vessels were relatively small (<0.3 mm) in 2 cases; and the breast was reconstructed with muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator. The length, width, and thickness of the flap were (28.9±0.2), (12.1±0.4), and (4.4±0.3) cm, respectively. The length of the vascular pedicle was (11.5±0.2) cm and the weight of the flap was (420.5±32.7) g. All 6 muscle-sparing rectus abdominis myocutaneous flaps were successful, and the breast incisions healed by first intention. There was no vascular crisis, donor site effusion, hematoma, or infection. All 6 patients were followed up 12-36 months (mean, 26.8 months). The reconstructed breast had a good shape, good elasticity, and no flap contracture or deformation; only linear scars left at the donor site of the flap, and the abdominal wall function was not affected. During follow-up, there was no breast cancer recurrence and metastasis. When the inferior epigastric artery perforators are too close to the upper edge of the flap and/or near the umbilical cord, the vascularity of lower abdominal flap can be ruined, harvested in form of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator can efficiently ensure blood supply safety.

137 Giant Lipomas of The Hand; A Case Series and Review of a Rare Tumour

Abstract Introduction Whilst lipomas are the most common tumour of the human body, it is rare in the hand. Less than 50-cases are reported in the literature. We present six-cases from a specialist hand unit, UK, presenting over a 10-year period. All patients had a distinct swelling within the affected hand which was growing in size. Method Patients were investigated with MRI and given the benign appearance; no pre-excision biopsies were performed. All excised tissue was sent for histology. Only one patient reported altered neurology of the hand, describing altered sensation within the ulnar nerve distribution of the index finger. Results In all cases, the lipoma originated in the deep palmar space from adipose tissue surrounding the deep palmar arch. They all extended distally, along natural tissue planes, encasing neurovascular and tendinous structures. In two cases the lipoma extended into the dorsum of the hand, following the perforating artery between the index and middle metacarpal heads. The lipomas all spread radialwards, penetrating the thenar muscles. The largest was 13x12x4cm in size. Conclusions Giant lipoma is a rare cause of symptomatic swelling of the hand. Compression of structures is extremely rare, but careful excision is critical as neurovascular bodies are classically enveloped within the growing lipoma.

Perforator preservation technologies (PPT) based on a new neuro-interventional classification in endovascular treatment of perforator involving aneurysms (piANs)

BackgroundTreatment of perforator involving aneurysm (piAN) remains a challenge to open and endovascular neurosurgeons. Our aim is to demonstrate a primary outcome of endovascular therapy for piANs with the use of perforator preservation technologies (PPT) based on a new neuro-interventional classification.MethodsThe piANs were classified into type I: aneurysm really arises from perforating artery, type II: saccular aneurysm involves perforating arteries arising from its neck (IIa) or dome (IIb), and type III: fusiform aneurysm involves perforating artery. Stent protection technology of PPT was applied in type I and III aneurysms, and coil-basket protection technology in type II aneurysms. An immediate outcome of aneurysmal obliteration after treatment was evaluated (satisfactory obliteration: the saccular aneurysm body is densely embolized (I), leaving a gap in the neck (IIa) or dome (IIb) where the perforating artery arising; fusiform aneurysm is repaired and has a smooth inner wall), and successful perforating artery preservation was defined as keeping the good antegrade flow of those perforators on postoperative angiography. The periprocedural complication was closely monitored, and clinical and angiographic follow-ups were performed.ResultsSix consecutive piANs (2 ruptured and 4 unruptured; 1 type I, 2 type IIa, 2 type IIb, and 1 type III) in 6 patients (aged from 43 to 66 years; 3 males) underwent endovascular therapy between November 2017 and July 2019. The immediate angiography after treatment showed 6 aneurysms obtained satisfactory obliteration, and all of their perforating arteries were successfully preserved. During clinical follow-up of 13–50 months, no ischemic or hemorrhagic event of the brain occurred in the 6 patients, but has one who developed ischemic event in the territory of involving perforators 4 h after operation and completely resolved within 24 h. Follow-up angiography at 3 to 10M showed patency of the parent artery and perforating arteries of treated aneurysms, with no aneurysmal recurrence.ConclusionsOur perforator preservation technologies on the basis of the new neuro-interventional classification seem feasible, safe, and effective in protecting involved perforators while occluding aneurysm.

Subtemporal, Transapical, and Transcavernous Approach to Clip Low-Lying Basilar Tip Aneurysm: 2-Dimensional Operative Video.

Basilar tip aneurysm clipping is technically challenging because of the depth of operative corridor, rarity in presentation, and important perforators supplying deep, critical structures. Two major approaches to basilar tip aneurysms include (1) a frontotemporal (transorbital) trans-sylvian approach for most aneurysms and (2) a modified subtemporal approach for aneurysms with low-lying necks. A 53-yr-old woman presented to our institution with a large unruptured basilar tip aneurysm notable for a low, broad neck (6.4 mm). After discussion of risks and benefits of endovascular vs surgical options, the patient consented to operative intervention. She underwent a right frontotemporal craniotomy with zygomatic osteotomy, intradural petrous apicectomy, elective sectioning of the fourth cranial nerve (CN IV), and intracavernous removal of the dorsum sellae and posterior clinoid process to provide more space for aneurysm dissection. After temporary clipping of the basilar artery, the perforating arteries were dissected free from the aneurysm and the aneurysm occluded with 2 fenestrated clips. Important technical nuances of the approach include (1) achieving ample working room for temporary occlusion aneurysm dissection, (2) careful dissection of the perforators and contralateral P1, and (3) utilization of 2 fenestrated clips to accommodate and preserve the ipsilateral P1 segment. Postoperative angiogram showed complete aneur-ysmal occlusion. Postoperatively, the patient demonstrated mild cognitive impairment and a right CN IV palsy. At 6-wk follow-up, cognition recovered to normalcy. More recently, at 12-mo follow-up, the patient noted intermittent diplopia. Formal neuro-ophthalmologic assessment confirmed persistence of a CN IV palsy treated with prism lenses but no other neurological deficits.

Velocity and Pulsatility Measures in the Perforating Arteries of the Basal Ganglia at 3T MRI in Reference to 7T MRI.

Cerebral perforating artery flow velocity and pulsatility can be measured using 7 tesla (T) MRI. Enabling these flow metrics on more widely available 3T systems would make them more employable. It is currently unknown whether these measurements can be performed at 3T MRI due to the lower signal-to-noise ratio (SNR). Therefore, the aim of this study is to investigate if flow velocity and pulsatility in the perforating arteries of the basal ganglia (BG) can be measured at 3T MRI and assess the agreement with 7T MRI measurements as reference. Twenty-nine subjects were included, of which 14 patients with aortic coarctation [median age 29 years (21–72)] and 15 controls [median age 27 years (22–64)]. Using a cardiac-gated 2D phase-contrast MRI sequence BG perforating arteries were imaged at 3T and 7T MRI and perforating artery density (Ndensity, #/cm2), flow velocity (Vmean, cm/s) and pulsatility index (PI) were determined. Agreement between scanner modalities was assessed using correlation and difference plots with linear regression. A p-value ≤ 0.05 indicated statistical significance. It was shown that perforating artery flow velocity and pulsatility can be measured at 3T MRI (Ndensity = 0.21 ± 0.11; Vmean = 6.04 ± 1.27; PI = 0.49 ± 0.19), although values differed from 7T MRI measurements (Ndensity = 0.95 ± 0.21; Vmean = 3.89 ± 0.56; PI = 0.28 ± 0.08). The number of detected arteries was lower at 3T (5 ± 3) than 7T MRI (24 ± 6), indicating that 3T MRI is on average a factor 4.8 less sensitive to detect cerebral perforating arteries. Comparison with 7T MRI as reference showed some agreement in Ndensity, but little to no agreement for Vmean and PI. Equalizing the modalities’ sensitivity by comparing the detected arteries on 7T MRI with the highest velocity with all vessels detected on 3T MRI, showed some improvement in agreement for PI, but not for Vmean. This study shows that it is possible to measure cerebral perforating artery flow velocity and pulsatility at 3T MRI, although an approximately fivefold sample size is needed at 3T relative to 7T MRI for a given effect size, and the measurements should be performed with equal scanner field strength and protocol.

Multimodality imaging guiding a challenging septal perforator artery stenting

Silva, Mariana R.; Rodrigues, Alberto; Manuel, Ana M.; Ferreira, Nuno; Braga, Pedro; Fontes-Carvalho, Ricardo Author Information

Stroke due to middle cerebral artery aneurysm clipping when the intraoperative angiogram was normal

ObjectiveAn intraoperative angiogram (IOA) may be used to check the clipping of middle cerebral artery (MCA) aneurysms. This study analyzes the occurrence of a stroke when the IOA was normal as this has not been looked into before. MethodsThe records of all patients with a normal IOA after MCA aneurysm clipping were reviewed. Patients who woke up with a stroke were selected for this study and analyzed in detail. ResultsThirty-one patients with 34 aneurysms had a normal IOA. Of those, 7 woke up with a new deficit from perforator or small artery ischemia resulting in a stroke rate of 22.6%. Five out of the 7 strokes were potentially avoidable. ConclusionAn IOA is still an important tool to check the adequacy of clip placement. However, our experience has taught us that the intent to use it should not lessen the amount of time spent dissecting and exposing the aneurysm as completely as possible. The urge to clip the neck and hope that the IOA will be favorable, when the aneurysm is not maximally exposed, should be resisted. Ideally, a full 360 degrees dissection of the aneurysm should be done to identify perforators and small arteries en passage before clipping. If this had been done, it is likely that the stroke rate would have dropped towards 6.5%.

Hemifacial spasm caused by a tortuous recurrent perforating artery: A case report

IntroductionWhen the culprit vessel in hemifacial spasm (HFS) is hard to determine, this is a challenge in microvascular decompression (MVD) surgery. In such a situation, small arteries such as perforators to the brainstem might be suspected. But small arteries are omnipresent near the facial nerve root exit/entry zone (fREZ). How to decide whether a given small artery is responsible for HFS is unclear. MethodWe report a case with a previously unreported form of neurovascular impingement, in which the culprit was found to be the recurrent perforating artery (RPA) from the anterior inferior cerebellar artery (AICA). An aberrant anatomic configuration of the RPA was found intraoperatively, which we thought was responsible for generating focal pressure on the facial nerve. Case reportA 62-year-old woman presented with a 1-year history of paroxysmal but increasingly frequent twitching in her right face. MRI showed tortuosity of the vertebral artery and apparently marked neurovascular impingement on the asymptomatic left side, while only the right AICA could be implicated as the possible culprit. Hemifacial spasm was diagnosed based on the typical clinical manifestation, and MVD was performed. The pre-meatal segment of the AICA was found not to be impinging the facial nerve at any susceptible portion near the fREZ: root exit point, attached segment, or root detachment point. The real culprit was in fact the RPA. This occult culprit vessel was tortuous, forming a coil-shaped twist which was interposed between the facial nerve and the intermediate nerve near the root detachment point. Focal pressure atrophy of the nerve was clearly observed at the compressing site. The patient achieved total spasm relief immediately after surgery, and remained spasm-free at 1-year follow-up, without any postoperative complications. ConclusionMVD is the only curative treatment for hemifacial spasm, but with a failure rate of around 10%. Mistaking the real culprit has been reported to be the most likely reason for surgical failure. Therefore, intraoperative identification of atypical occult forms of vascular compression is of importance to improve surgical outcome. In the present case, the RPA formed a coil-shaped twist, which inflicted focal vascular compression causing hemifacial spasm. We recommend careful inspection of the recurrent perforating artery during MVD for HFS, and decompressing any such neurovascular impingement.

English

BACKGROUND The external iliac artery passes behind the inguinal ligament into the front of the thigh as the femoral artery (FA). The FA gives off many branches both superficial and deep. The profunda femoris artery (PFA) is one of the deep branches given off in the femoral triangle in front of the thigh. The PFA gives off the medial circumflex femoral artery (MCFA) and the lateral circumflex femoral arteries (LCFA) and continues downwards giving off the first, second and third perforating arteries. The PFA terminates as the fourth perforating artery. Many variations in the circumflex branches of the PFA have been found by various authors. These variations are of great significance during procedures done in front part of the thigh. METHODS This is a descriptive cadaveric study. We dissected the thighs of 57 embalmed bodies. We looked for the medial (MCFA) and lateral (LCFA) circumflex arteries which are branches of PFA. Each artery was followed till its termination. The distance of their origin from the point of the origin of PFA from the FA was measured and noted. The distance between pubic symphysis and anterior superior iliac spine was measured using black silk and measuring scale. The midpoint was marked using skin marking pen and an incision extending from anterior superior iliac spine to pubic symphysis was made. Another incision was made from the above midpoint to the midpoint of a horizontal incision at the level of knee joint. Femoral sheath was identified and incised. Femoral artery, profunda femoris artery and its circumflex branches were identified. The modes of origin of MCFA and LCFA were noted. The distance of origin of these from the origin of PFA were measured. Variations in the branching pattern of MCFA and LCFA were looked for and noted down. RESULTS We found that in 83 % of the total cases MCFA took origin from PFA and its origin was from the FA in 13 %. In 84 % of total cases LCFA arose from PFA on the right side and 70 % on the left side. A common stump of origin was noted in 3 cases. CONCLUSIONS Medial and lateral circumflex branches of PFA exhibit wide variations. KEY WORDS Medial Circumflex Femoral Artery, Lateral Circumflex Femoral Artery, Variations in Origin and Branching