Artery Perforator Research Articles

Perforating artery flow velocity and pulsatility in patients with carotid occlusive disease. A 7 tesla MRI study.

Patients with carotid occlusive disease express altered hemodynamics in the post-occlusive vasculature and lesions commonly attributed to cerebral small vessel disease (SVD). We addressed the question if cerebral perforating artery flow measures, using a novel 7T MRI technique, are altered and related to SVD lesion burden in patients with carotid occlusive disease. 21 patients were included with a uni- (18) or bilateral (3) carotid occlusion (64±7 years) and 19 controls (65±10 years). Mean flow velocity and pulsatility in the perforating arteries in the semi-oval center (CSO) and basal ganglia (BG), measured with a 2D phase contrast 7T MRI sequence, were compared between patients and controls, and between hemispheres in patients with unilateral carotid occlusive disease. In patients, relations were assessed between perforating artery flow measures and SVD burden score and white matter hyperintensity (WMH) volume. CSO perforating artery flow velocity was lower in patients than controls, albeit non-significant (mean difference [95% confidence interval] 0.08cm/s [0.00-0.16]; p=0.053), but pulsatility was similar (0.07 [-0.04-0.18]; p=0.23). BG flow velocity and pulsatility did not differ between patients and controls (velocity = 0.28cm/s [-0.32-0.88]; p=0.34; pulsatility = 0.00 [-0.10-0.11]; p=0.97). Patients with unilateral carotid occlusive disease showed no significant interhemispheric flow differences. Though non-significant, within patients lower CSO (p=0.06) and BG (p=0.11) flow velocity related to larger WMH volume. Our findings suggest that carotid occlusive disease may be associated with abnormal cerebral perforating artery flow and that this relates to SVD lesion burden in these patients, although our observations need corroboration in larger study populations.

Uvećani perforator režnjevi prednjeg torakalnog i abdomonalnog zida - novi pristup autolognoj rekonstrukciji dojke

Aim. To develop methods for obtaining enlarged perforating flaps on the anterior surfaces of the thoracic and abdominal walls. Material and methods: The study included 16 patients with post-burn breast deformities aged from 5 to 22 years. In the upper part of the anterior surface of the chest, the flaps were formed on the basis of 2, 3 anterior intercostal artery perforator and thoracoacromial artery perforator with the inclusion of the vascular network of the thoracic branch of the supraclavicular artery. In the lower part of the thoracic and upper abdominal wall, there were also enlarged flaps based on the superior epigastric artery perforator with the connection of vascular networks 6, 7 anterior intercostal artery perforator and perforator deep inferior epigastric artery. The obtained flaps were moved by direct advancement, rotation and transposition methods. Results: The largest area of the wound defect was closed with flaps that were moved by rotation and it was 1.8 times larger than the area of wounds closed by direct advancement and 1.3 times larger than if using transposition flaps. The use of stretched perforating flaps from the anterior surface of the thoracic and abdominal walls allowed to obtain a positive result in 90.4% of cases with the short-term treatment, and in all cases with the long-term treatment. Conclusion: A simple technique based on the proposed methods can be widely used for the reconstruction of the upper and lower quadrants of the breast and intermammary and submammary spaces.

Cerebral disease of small vessels: morphological, neuropsychological and neurovisualization comparisons

The term "cerebrovascular disease of small vessals" (CDSV) includes neuropathological, clinical and neuroimaging manifestations lesions of small perforating arteries, arterioles, capillaries, venules and small veins. CDSV, according to the pathogenetic classification of L. Pantoni, is divided into 6 types: sporadic non-amyloid microangiopathy (SNAMA); sporadic and hereditary cerebral amyloid angiopathy (CAA); hereditary CDSV (CADASIL, CARASIL, MELAS, Fabry disease, CDSV in mutations of COL4A1 gene and others); CDSV, mediated by inflammation and immune processes; venous collagenosis; other options. In 4 chapters of the review the following are considered: morphological and neuroimaging characteristics of CDSV; cognitive impairment and CDSV: morphological, neuropsychological and neuroimaging comparisons; natural aging of the brain: morphological, neuroimaging and neuropsychological comparisons; the influence of modified risk factors (hypertension, type 2 diabetes mellitus, radiation exposure) on the course of CDSV. Conclusions. Despite the threatening consequences of CDSV, its early clinical and instrumental diagnosis has not attracted proper attention of researchers. The subject of the vast majority of studies were: CDSV of moderate and severe degree, post-stroke conditions; neuroimaging criteria for the prognosis of acute cerebrovascular disease, Alzheimer's disease and dementia in the elderly and senile persons; age differences of CDSV and cognitive impairments (CI) in terms of the overall disease duration, and not in terms of the peculiarities of its manifestation in middle or avanced age. There are objective prerequisites for establishing a methodological framework for early diagnosis of CDSV that takes into account the age of patients and the presence of modifiable risk factors. These include: the existence of consensus on the definition, classification and neuroimaging features of CDSV; availability of effective cognitive scales, which are designed to screen and determine the domain affiliation of non-dementia CD; introduction of new neuroimaging technologies that allow molecular (diffusion) research and obtain images with submillimeter resolution. Two clinical observations serve as convincing evidence of the conclusions reached on the basis of the analysis of the scientific literature.

The value of diffusion weighted imaging in predicting the clinical progression of perforator artery cerebral infarction

ObjectivesTo investigate the value of diffusion weighted imaging (DWI) in predicting the clinical progression of perforator artery cerebral infarction. MethodsThe magnetic resonance imaging (MRI) data of patients with perforator artery cerebral infarction hospitalized in our hospital from October 2015 to February 2022 were analyzed retrospectively. Then we compared the differences of apparent diffusion coefficient (ADC) value, maximal size, location of cerebral infarction, clinical data and treatment plan between the two groups. ResultsA total of 81 patients with perforating artery cerebral infarction were included, with 33 patients in the progressive cerebral infarction (PCI) group and 48 patients in the non-progressive cerebral infarction (NPCI) group. The ADC value in the progressive group was lower than that in the non-progressive group (P < 0.001), and ADC value was an independent factor influencing the clinical progression (OR = 0.974, 95 %CI = 0.960–0.989, P = 0.001); The average area of cerebral infarction in the progressive group was larger than that in the non-progressive group (P = 0.004). There was no difference between the two groups (P > 0.05) in terms of clinical data and treatment plan. ConclusionsThe ADC value and maximal size of infarction were correlated with the clinical Progression. ADC value was an independent factor influencing the clinical progression of perforating artery cerebral infarction, which could be used for the prediction of clinical progress and provide guidance for the development of individualized treatment.

Highest resolution microCT scan of the human brainstem reveals putative anatomical basis for infrequency of medial medullary syndrome

Ischemic strokes affecting the medial medulla are exceedingly rare. The anatomical basis for the relative infrequency of this stroke syndrome has been largely uninvestigated due to historically coarse MRI and CT scan resolution. We capture and digitally dissect the highest-ever-resolution diffusible iodine-based contrast-enhanced CT (diceCT) scanned images of a cadaveric brainstem to map arterial territories implicated in medial medullary infarctions. 3D reconstructions show that within the anterior spinal artery territory previously implicated in medial medullary syndrome (MMS), there are numerous, small sulcal artery branches perforating the medulla within the anterior median fissure. These branches proceed in parallel through the anteroposterior depth of the medulla as expected; however, we also identify a network of intraparenchymal, rostrocaudal anastomoses between these sulcal perforating branches. This network of intraparenchymal sulcal artery anastomoses has never been described and may provide a significant collateral supply of oxygenated blood flow throughout the medial medulla. By ramifying deeper tissues, these anastomoses can help explain the infrequency of MMS.

A Case of Migration of Pipeline Embolization Device Causing Rupture during Treatment of an Unruptured Vertebral Artery Dissecting Aneurysm

Endoluminal reconstruction of an intracranial aneurysm using flow-diverting devices, such as the pipeline embolization device (PED), is a new treatment modality with good clinical outcomes. The device was originally indicated for challenging cases, such as wide-necked large or giant aneurysms, and is gaining popularity as a reliable treatment for nearly all intracranial aneurysms. The overall complication rate of flow-diverting devices use is 17.0%, including occlusion of side-branching or perforating arteries, rerupture of the aneurysm, in-stent thrombosis, and, rarely, stent migration. We report a rare complication of the PED: delayed migration of the PED after successful stent implantation during treatment of an unruptured vertebral artery dissecting aneurysm, which resulted in rupture of the aneurysm. Further, we discuss technical steps that can be taken to prevent this potential complication.

Feasibility of distal transradial access for coronary angiography and percutaneous coronary intervention: an observational and prospective study in a Latin-American Centre

Background Distal transradial access (dTRA) as a refinement of the conventional transradial access (TRA) has advantages in terms of risk of radial artery occlusion (RAO). In order to evaluate the real-world feasibility and safety of dTRA as the default access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI) in a Latin-American centre, this prospective observational registry was conducted. Methods Consecutive patients with a prior assessment for CAG and/or PCI were enrolled in this single-centre prospective registry from October 2018 to March 2019. The primary endpoints were the success rate of CAG and PCI. Secondary endpoints included the success rate of puncture of the distal radial artery, complications at the puncture site and puncture time. Results The success rates of CAG and PCI were 100% (155/155) and 97% (69/71), respectively. Puncture time and fluoroscopic time were 52 ± 19 seconds and 16.3 ± 35.4 minutes, respectively. Haemostasis time was 142 ± 45 min. A total of 19 (12.5%) puncture site complications occurred, including 18 (11.6%) minor haematomas and one (0.6%) arterial perforation, in which the artery was patent at the one-month follow-up. Five patients complained of left thumb numbness at a one-month follow-up. No distal radial artery occlusion, pseudoaneurysm, or arteriovenous fistula occurred. Conclusions The success and complication rates of ldTRA support the feasibility and safety of this procedure using the appropriate materials in previously selected patients.

Target Embolization of Complex Vertebral Artery Dissecting Aneurysm with Endovascular Reconstructive Technique Using Cone-Beam Computed Tomography Angiography: Technical Note

Detailed vasculature of vertebral artery dissecting aneurysms (VADAs) is often complicated owing to the irregular structure with the intimal flap/double lumen. Our aim was to present an endovascular reconstructive technique with assessment of detailed vasculature and the relationship between dissection and surrounding vessels using cone-beam computed tomography angiography (CBCT-A). The study included 6 cases with complex vertebral artery dissecting aneurysm. Selective digital subtraction angiography initially identified the location and shape of dissection. CBCT-A was then performed with selective injection into the affected vertebral artery. Luminal morphology of the dissection and surrounding arterial anatomy were assessed using CBCT-A. CBCT-A clearly demonstrated luminal morphology of the intimal flap/double lumen, the entrance into the pseudolumen, and the entire dissecting segment. Tiny perforator arteries were also identified. In all 6 cases, target coil embolization for the pseudolumen and stent placement using an LVIS stent for the entire dissecting segment were successfully performed with the aid of information obtained from CBCT-A. No complications occurred in the perioperative period, and improvement of dissection was identified in the follow-up period. Target embolization of complex vertebral artery dissecting aneurysm with endovascular reconstructive technique with special reference to the detailed anatomy of dissection using CBCT-A would be useful for safe and effective treatment results.

Morphologic and morphometric characteristics of the adductor minimus in Korean: its topographic relationship with respect to neighbouring anatomical structure and clinical significance.

The aim of this study was to clarify the morphologic and morphometric characteristics of the adductor minimus (AMi) and to observe its topographic relationships relative to the adjacent anatomical structures. This study investigated 54 thighs of 27 Korean cadavers. The AMi was a small and flat muscle observed in 94.4% of the specimens. It originated from the inferior ramus of the pubis as the upper part of the adductor magnus (AMa), and inserted from the lesser trochanter to the upper part of the linea aspera. The AMi was completely separate from the AMa in 63.0% of the specimens. The medial circumflex femoral artery was always found at the superior border of the AMi, while the first and second perforating arteries were found inferior to the muscle in 55.6% and 37.0% of specimens, respectively. A supernumerary muscle was found with the AMi in 42.6% of the specimens, and it originated from the inferior ramus of the pubis and inserted into the posterior side of the lesser trochanter. The obturator externus and AMi were found superoposterior and inferior to the supernumerary muscle, respectively, while the posterior branch of the obturator nerve passed underneath it. The results of this study may provide physicians with the accurate anatomical knowledge that they require for managing groin pain and applying a regional nerve block with ultrasound guidance in this adductor region.

Individualized Cerebral Artery Protection Strategies for the Surgical Treatment of Parasellar Meningiomas on the Basis of Preoperative Imaging.

ObjectiveParasellar meningiomas (PMs) represent a cohort of skull base tumors that are localized in the parasellar region. PMs tend to compress, encase, or even invade the cerebral arteries and their perforating branches. The surgical resection of PMs without damaging neurovascular structures is challenging. This study aimed to analyze functional outcomes in a series of patients who underwent surgery with individualized cerebral artery protection strategies based on preoperative imaging.MethodsA retrospective review was performed on a single surgeon’s experience of the microsurgical removal of PMs in 163 patients between January 2012 and March 2020. Individualized approaches with a bidirectional dissection strategy were used. Cerebral artery invasion classification, neurological outcomes, MRC Scale for muscle strength, and Karnofsky performance scale were used to assess tumor vascular invasion, functional outcome, and patient quality-of-life outcomes, respectively.ResultsTotal resection (Simpson grade I or II) was achieved in 114 patients (69.9%) in our study. A total of 44.7% of patients had improved vision at consecutive follow-ups, 51.1% were stable, and 3.8% deteriorated. Improvements in cranial nerves III, IV, and VI were observed in 41.1%, 36.2%, and 44.8% of patients, respectively. The mean follow-up time was (38.8 ± 27.9) months, and the KPS at the last follow-up was 89.6 ± 8.5. Recurrence was observed in eight patients (13.8%) with cavernous sinus meningiomas, and the recurrence rates in anterior clinoid meningiomas and medial sphenoid wing meningiomas were 3.8% and 2.8%, respectively.ConclusionsPreoperative imaging is important in the selection of surgical approaches. Maximum tumor resection and cerebral artery protection can be achieved concurrently by utilizing the bidirectional dissection technique. Individualized cerebral artery protection strategies provide great utility in improving a patient’s quality of life.

Relationship of brainstem infarction to rupture of nonsaccular vertebrobasilar aneurysms.

Symptomatic nonsaccular vertebrobasilar aneurysms (NSVBAs) are associated with high rates of aneurysm-related death. Anecdotal evidence suggests that brainstem infarction may be a harbinger of aneurysm rupture. The authors aimed to investigate the association between brainstem infarction and subsequent NSVBA rupture. The clinical records and radiographic imaging studies of patients presenting to the authors' institution between 1996 and 2019 for evaluation and management of an NSVBA were retrospectively reviewed to determine the effect of perforating artery infarction on the natural history of NSVBAs. Kaplan-Meier curves for patients with and patients without perforator infarction were constructed, and predictors of aneurysm rupture were identified using a multivariate Cox proportional hazards model. There were 98 patients with 591.3 person-years of follow-up who met the inclusion criteria for analysis. There were 20 patients who experienced perforator infarction during follow-up. Ten patients (10.2%) experienced aneurysm rupture during follow-up and 26 patients (26.5%) died due to aneurysm-related complications, with annual rates of rupture and aneurysm-related death of 1.7% and 4.4%, respectively. Five patients with a perforator infarction later experienced aneurysm rupture, with a median time between infarction and rupture of 3 months (range 0-35 months). On multivariate analysis, the presence of intraaneurysmal thrombus (risk ratio [RR] 4.01, 95% confidence interval [CI] 1.12-14.44, p = 0.033) and perforator infarction (RR 6.37, 95% CI 1.07-37.95, p = 0.042) were independently associated with risk of aneurysm rupture. NSVBAs continue to be extremely challenging clinical entities with a poor prognosis. These results suggest that brainstem infarction due to perforating artery occlusion may be a harbinger of near-term aneurysm rupture.

Exploration of chest wall perforator vascular anatomy on standard breast MRI: A potential aid to chest wall perforator flap planning

Local chest wall perforator flaps (CWPFs) are a volume replacement technique permitting breast-conserving surgery in patients who otherwise may require a mastectomy. These flaps are based on one or more perforating arteries arising from the lateral chest wall that travel through the soft tissue and into the sub-dermal plexus to perfuse the flap. Examples include the lateral intercostal and lateral thoracic artery perforators (LICAP and LTAP, respectively). Cross-sectional imaging of perforating vessels is not routinely performed, and vessels are mapped pre- and peri-operatively using a hand-held acoustic doppler device. As many breast cancer patients undergo pre-operative MRI scanning for oncological purposes, we investigated the role of MRI in mapping the vascular anatomy to aid with the surgical planning of CWPFs. We collated data retrospectively on a cohort of breast cancer patients who underwent breast MRI as part of routine pre-operative imaging. Axial 3D high-resolution dynamic contrast-enhanced MRI sequences with multiplanar reconstructions were analysed by a consultant radiologist. The presence and calibre of lateral chest wall perforator vessels were assessed. Fifty patients were suitable for inclusion. A consistent pattern of lateral chest wall vasculature was observed. Forty-eight patients (96%) demonstrated a bilateral lateral thoracic artery (LTA) descending inferiorly along the chest wall with two-thirds of these communicating with perforating intercostal vessels. True independent LICAP vessels were identified in six patients. From our observations, lateral CWPFs are dependent on an intricate intercommunication between intercostal vessels and the LTA which in turn supply perforators to the lateral chest wall donor site.

Transcranial direct electrical stimulation for hand function in a stroke patient with severe upper limb paralysis due to lenticulostriate artery occlusion: a case report

BackgroundTranscranial direct current stimulation, a therapeutic modality to modulate the excitability of injured and uninjured brain hemispheres in stroke patients, is expected to be effective in treating upper limb paralysis. We describe the use of transcranial direct current stimulation to improve the function and frequency of use of the paralyzed hand of a patient with lenticulostriate artery occlusion.Case presentationA Japanese man in his fifties developed a left internal hindfoot perforator branch infarction owing to lenticulostriate artery occlusion, and presented with severe right upper and lower limb paralysis. Multiple interventions for the paralyzed hand, primarily robot therapy, did not noticeably change his hand function or frequency of use in daily life. Therefore, transcranial direct current stimulation was used in combination with upper limb functional exercises for 20 minutes a day, five times a week, for 6 weeks. Consequently, scores for the hand items of the Fugl–Meyer Assessment of the upper extremities improved, and pain and subluxation around the shoulder joint were reduced. Furthermore, the frequency of use and the quality of movement of the paralyzed hand were improved.ConclusionsUpper limb functional training and transcranial direct current stimulation improved the function and frequency of use of the paralyzed hand in a stroke patient with severe upper limb paralysis, suggesting that this combined intervention could effectively improve hand function in patients with severe upper limb paralysis.

Linear late gadolinium enhancement in the basal anterior septum and lateral wall may represent the contrast enhancement of vessels: A CMR and CCTA comparison study

BackgroundThe purpose of this paper was to verify that the linear high-intensity signal on late gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) may represent the contrast enhancement of vessels rather than scars or fibrosis, and to assess whether this linear high-intensity signal will affect the quantification of myocardial fibrosis in patients with hypertrophic cardiomyopathy (HCM). MethodsA total of 58 patients who underwent both coronary computed tomography angiography (CCTA) and LGE-CMR in our hospital were ultimately enrolled. The definitions of positive linear LGE (LLGE+) were as follows: (1) LLGE in the basal anterior septum or lateral wall, and (2) LLGE observable at 10 mm or more. All other patients were regarded as negative LLGE (LLGE-). In LLGE+ patients, the length of the LLGE located in the anterior septum and lateral wall was compared with the length of the septal perforator artery and the circumflex artery on CCTA, respectively. For nine patients with HCM, the LGE% was measured before and after removal of LLGE. ResultsAmong the 58 patients, 40 showed LLGE+ and 18 showed LLGE-. For patients with LLGE in the anterior septum, there was a strong correlation between LLGE and anterior septal perforator arteries in length (r=0.887, p<0.001). For patients with LLGE in the lateral wall, LLGE also correlated well with the circumflex arteries in length (r=0.962, p<0.001). In nine patients with HCM, the LGE% decreased significantly after the removal of LLGE [9.50 (7.70 – 17.35)% vs. 8.80 (6.20 – 15.55)%, p<0.05]. ConclusionsThe LLGE in the anterior septum and lateral wall may represent contrast enhancement of the anterior septal perforator artery and the circumflex artery, respectively. This LLGE may overestimate the extent of myocardial fibrosis in patients with HCM.

Non‐Invasive Assessment of Damping of Blood Flow Velocity Pulsatility in Cerebral Arteries With MRI

BackgroundDamping of heartbeat‐induced pressure pulsations occurs in large arteries such as the aorta and extends to the small arteries and microcirculation. Since recently, 7 T MRI enables investigation of damping in the small cerebral arteries.PurposeTo investigate flow pulsatility damping between the first segment of the middle cerebral artery (M1) and the small perforating arteries using magnetic resonance imaging.Study TypeRetrospective.SubjectsThirty‐eight participants (45% female) aged above 50 without history of heart failure, carotid occlusive disease, or cognitive impairment.Field Strength/Sequence3 T gradient echo (GE) T1‐weighted images, spin‐echo fluid‐attenuated inversion recovery images, GE two‐dimensional (2D) phase‐contrast, and GE cine steady‐state free precession images were acquired. At 7 T, T1‐weighted images, GE quantitative‐flow, and GE 2D phase‐contrast images were acquired.AssessmentVelocity pulsatilities of the M1 and perforating arteries in the basal ganglia (BG) and semi‐oval center (CSO) were measured. We used the damping index between the M1 and perforating arteries as a damping indicator (velocity pulsatilityM1/velocity pulsatilityCSO/BG). Left ventricular stroke volume (LVSV), mean arterial pressure (MAP), pulse pressure (PP), and aortic pulse wave velocity (PWV) were correlated with velocity pulsatility in the M1 and in perforating arteries, and with the damping index of the CSO and BG.Statistical TestsCorrelations of LVSV, MAP, PP, and PWV with velocity pulsatility in the M1 and small perforating arteries, and correlations with the damping indices were evaluated with linear regression analyses.ResultsPP and PWV were significantly positively correlated to M1 velocity pulsatility. PWV was significantly negatively correlated to CSO velocity pulsatility, and PP was unrelated to CSO velocity pulsatility (P = 0.28). PP and PWV were uncorrelated to BG velocity pulsatility (P = 0.25; P = 0.68). PWV and PP were significantly positively correlated with the CSO damping index.Data ConclusionOur study demonstrated a dynamic damping of velocity pulsatility between the M1 and small cerebral perforating arteries in relation to proximal stress.Level of Evidence4Technical EfficacyStage 1

Abstract 11571: Defining the Distance Between the His Bundle and Septal Perforator Arteries

Introduction: Left bundle branch pacing (LBBP) is an emerging pacing modality in which the LBBP lead is screwed through the interventricular septum towards the left bundle branch in the left septal subendocardium. Damage to a septal perforating branch of the left anterior descending coronary artery is a potential complication. Objective: To define the distance between the His bundle and the first septal perforator artery to guide safe LBBP lead placement. Methods: Clinically indicated coronary CT angiograms (CCTA) at our institution were reviewed. The intersection of the tricuspid annulus and the base of the non-coronary cusp of the aortic valve represented the location of the His bundle. The intersection of a line joining the His bundle location with the RV apex with the first septal perforator was determined. The distance between the His Bundle and this intersection was measured and recorded. Values were analyzed using standard statistical methods. T-tests were used for continuous variables. Results: A total of 50 consecutive CCTAs were included in this study, 30 men and 20 women, average age 55.4 ± 14.1 years. Medical history included HTN (64%), and diabetes (50%) and CAD (10%). LVH was present in 9 patients (18%) but was mild in all cases. Heart failure was present in 9 patients (18%), 4 of whom had systolic dysfunction with an average EF for the study being 57.0%. The mean left ventricular internal diameter at end diastole (LVIDd) and interventricular septum thickness (IVS) were 46.7 mm and 10.2 mm, respectively. The mean distance from the His Bundle to the first septal perforator was 27.2 ± 7.7 mm, median 26.9 mm, range 13.0 to 44.7 mm. There was no significant difference by gender for mean distance (28.1 mm men vs 25.6 mm women, p=0.26). There was no significant association between LVIDd or IVS and the His Bundle-Septal Perforator distance (r 2 =0.02 and r 2 =0.002, respectively). Conclusions: Using CCTA, we defined the distance between the His bundle and the first septal perforator. Operators implanting LBBP leads can use these measurements to guide safe lead placement.

Endovascular treatment of anterior inferior cerebellar artery trunk aneurysms.

The anterior inferior cerebellar artery (AICA) is a very slender and anatomically variable artery that gives off many important perforating arteries that feed the brainstem and nerve-related arteries that feed the inner ear and labyrinth. AICA trunk aneurysms are rare entities that are also difficult to manage. At present, endovascular treatment (EVT) is the preferred choice; however, the understanding of EVT for AICA trunk aneurysms is limited. In this article, we present a literature review on EVT for AICA trunk aneurysms. To promote understanding, we would also provide some illustrative educational cases of our institute. Aneurysms along the AICA trunk can occur alone (isolated AICA aneurysm) or secondary to cerebrovascular shunts (flow-related AICA aneurysm). According to their anatomical location, they can also be divided into proximal and distal types. At present, EVT is the mainstream treatment, mainly including selective coiling with parent artery preservation and parent artery occlusion. Both coils and liquid embolization materials can be used. For AICA trunk aneurysms, EVT is a reasonable choice and should be based on the specific anatomical location, pathology, and collateral circulation. However, there is still controversy as to the specific type of treatment that should be chosen.

Superficial Thinning of the DIEP Flap: A Safe Option to Achieve an Aesthetic Reconstructed Breast in the Obese Patient.

Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes. The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques. All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique. The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients. Therapeutic, IV.

Subarachnoid Hemorrhage from Ruptured Aneurysm in the Middle Cerebral Artery and Anterior Cerebral Artery Trunk: A Single-Center Study

Objective: Ruptured anterior cerebral artery (ACA) trunk aneurysms and middle cerebral artery (MCA) trunk aneurysms are rare, and little is known about them. This study was conducted to determine the difference between these and other types of aneurysms.Methods: We performed a retrospective review of patients diagnosed with subarachnoid hemorrhage over an 8-year period at a single institution. We analyzed the characteristics, clinical factors, and radiological components of aneurysms at the trunk portion of A-1 and M-1. Descriptive analysis and univariate analysis for factors were performed to determine the differences of ACA A-1 portion trunk and MCA M-1 portion trunk aneurysms from other ACA and MCA aneurysms, respectively.Results: Univariate logistic regression modeling showed that trunk aneurysms in MCA M-1 had a smaller dome size (p=0.026) and dome/neck ratio (p=0.048) than other MCA aneurysms. Likewise, through univariate logistic regression modeling, the ACA group showed differences in dome size including age (p=0.001) as well as dome size (p=0.038) and dome neck ratio (p=0.041) in the A1 region.Conclusion: MCA M-1 and ACA A-1 trunk aneurysms are likely to have several different characteristics such as small in size and a lower dome/neck ratio. Also, due to their close locations to the perforator arteries, there is a high possibility of perforator artery injury when treating these aneurysms. Thus, careful attention is required when setting the treatment methods, and further studies about these aneurysms are needed.

How to Map All Your Flap Perforators in 2 Minutes

INTRODUCTION: Imaging modalities are changing clinical practice in plastic surgery and becoming more compact, more affordable, and easier to use. Over the last two decades, 3D imaging, ICG angiography, and virtual surgical planning have become commonplace for operative decision-making. Recently, mobile thermal imaging has demonstrated accuracy and consistency in determining perforator locations and visualizing the functional angiosomes.1 A study by Khouri et al in 1992 showed that the sensitivity of surface-temperature recording is 98%, and its predictive value is 75%.2 We sought to investigate whether recovery-enhanced mobile thermal imaging can be used to rapidly and reliably design perforator flaps. METHODS: Thermal imaging was compared with Doppler perforator mapping in five volunteers. Volunteers underwent traditional flap markings on one thigh and mobile thermal imaging (FLIR One Pro, FLIR Systems, Inc., Willsonville, Oreg.) on their contralateral thigh. In the traditional group, a line was drawn from the ASIS to the superolateral border of the patella with a 3-cm-radius circle at the midpoint, followed by perforator identification with a Doppler.3 On the contralateral thigh, ice cooling was performed for 10 seconds followed by inspection with the thermal camera. Time to identify at least three perforators, determination of perforator dominance, and perforator concordance were recorded. Additionally, in two consecutive patients undergoing anterolateral thigh flap reconstruction, flap design was examined based on traditional markings versus thermal imaging. RESULTS: Perforator identification was more rapid (136 seconds versus 232 seconds) and more likely to demonstrate perforator dominance (five versus one) using thermal imaging compared with traditional markings (P < 0.05). In both patients undergoing ALT flap reconstruction, three perforators were located with traditional and thermal imaging markings. In patient one, the middle perforator demonstrated dominance and true anastomoses to the surrounding perforators. In patient two, the transverse branch perforator demonstrated maximal intensity and poor connections to the distal perforators. After this, proximal perforator was divided and the thermal imaging worsened, resulting in resection of the proximal flap and change in flap design. Perforator location matched computed tomography angiographic findings in both patients. No postoperative flap compromise was encountered. CONCLUSIONS: Thermal imaging with ice cooling appears highly effective at rapid perforator and angiosome identification-based flap design. Recovery-enhanced thermography by ice cooling allows for dynamic visualization of angiosome perfusion area. Given improvement in technology and decreasing costs, mobile thermal imaging may become a reliable tool in flap design and flap monitoring. REFERENCES: 1. Pereira N, Valenzuela D, Mangelsdorff G, et al. Detection of perforators for free flap planning using smartphone thermal imaging. Plast Reconstr Surg. 2018;141(3):787–792. 2. Khouri RK, Shaw WW. Monitoring of free flaps with surface-temperature recordings: is it reliable? Plast Reconstr Surg. 1992;89(3):495–499; discussion 500–502. 3. Saint-Cyr M, Oni G, Lee M, et al. Simple approach to harvest of the anterolateral thigh flap. Plast Reconstr Surg. 2012;129(1):207–211.