Superficial Middle Cerebral Vein Research Articles

Colour-coded collateral and venous outflow patterns in estimating infarct progression and predicting functional independence for stroke patients in late time window.

To investigate whether cerebral collateral and venous outflow (VO) patterns on colour-coded multi-phase computed tomography angiography (mCTA) can estimate ischaemic core growth rate (IGR) and predict 90-day functional independence for patients with late-presenting acute ischaemic stroke (AIS). The retrospective analysis included 127 AIS patients with a late time window. All patients underwent baseline mCTA with colour-coded reconstruction and computed tomography perfusion. Both collateral score and VO score on colour-coded mCTA maps were analysed and recorded. The IGR was calculated as ischaemic core volume divided by the time from onset to imaging. A 90-day modified Rankin Scale score of 0-2 was defined as functional independence. Kendall's Tau-b analysis was used for nonparametric correlation analysis. Propensity scores, logistic regressions, and receiver operator characteristic (ROC) curves were applied to construct the prediction model. Moderate correlations were found between collateral delay and IGR (Tau-b = -0.554) and between VO and IGR (Tau-b = -0.501). High collateral score (odds ratio = 3.01) and adequate VO (odds ratio = 4.89) remained independent predictors for 90-day functional independence after adjustment. The joint predictive model, which integrated the VO score and clinical features, demonstrated an area under the ROC curve (AUC) of 0.878. The AUCs of collateral score and VO score were 0.836 and 0.883 for outcome prediction after adjustment. Cerebral collateral and VO patterns based on colour-coded mCTA can effectively predict infarct progression and 90-day clinical outcomes, even for AIS patients beyond the routine time window. Colour-coded mCTA is a readily understandable post-processing technique for the rapid assessment of collateral circulation and VO status in stroke imaging. A moderate correlation was observed between the characteristics of collateral delay/VO on colour-coded mCTA and IGR in patients with AIS. Both high-quality collateral circulation and "red superficial middle cerebral vein sign" can predict 90-day functional independence even for patients beyond the routine time window.

Anatomy of the Cavernous Sinus

The cavernous sinus is the crossroad of veins from various embryological origins, including the brain, eye, pituitary gland, dura, and cranium. Embryologically, the cavernous sinus is mainly formed from the pro-otic sinus; secondary anastomosis between the cavernous sinus and primitive tentorial sinus results in various anatomical variations in the drainage patterns of the superficial middle cerebral vein. Moreover, connections between the cavernous sinus and basal vein via the uncal vein, bridging vein, and petrosal vein from the superior petrosal sinus may exist. Retrograde drainage from the cavernous sinus into the cerebral veins is often observed in arteriovenous shunts involving the cavernous sinus, such as dural and carotid-cavernous fistulas, which are primarily treated using transvenous embolization. Understanding the anatomy of the cavernous sinus and its associated veins is essential for safe and reliable endovascular treatment.

The benefit of favorable venous outflow profile is mediated through reduced microvascular dysfunction in acute ischemic stroke.

Venous outflow (VO) is emerging as a marker of microvascular integrity in acute ischemic stroke. Using hemorrhagic transformation (HT) and infarct growth as mediators, we tested whether a favorable VO profile benefited functional outcome by reducing consequences of microvascular dysfunction. Patients receiving thrombectomy in three comprehensive stroke centers due to acute anterior circulation occlusion were included. VO was assessed semi-quantitatively by the opacification of ipsilateral vein of Labbé, Trolard and superficial middle cerebral vein. HT was graded on follow-up CT. Infarct growth volume (IGV) was the difference of final infarct volume and baseline core volume. The association of VO and functional independence (90-day modified Rankin Scale ⩽ 2) was examined by logistic regression. Mediation analysis was performed among VO, HT or IGV, and functional outcome in patients with or without recanalization, respectively. In 242 patients analyzed, VO was strongly correlated with functional independence and VO ⩾ 4 was defined favorable. In 175 patients recanalized, favorable VO was associated with a reduced risk of HT (OR = 0.82, 95% CI 0.71-0.95, p = 0.008), which accounted for 13.1% of the association between VO and favorable outcome. In 67 patients without recanalization, favorable VO was associated with decreased IGV (β = -0.07, 95% CI -0.11 to -0.02, p = 0.007). The association of favorable VO and functional independence was no longer significant (aOR = 4.84, 95% CI 0.87-38.87, p = 0.089) after including IGV in the model, suggesting a complete mediation. In patients with acute anterior large vessel occlusion, the clinical benefit of VO may be mediated through reduced microvascular dysfunction.

Isolated cerebral varices: clinical observations and literature review

The aim of the study is to present rare clinical cases of isolated cerebral varices, summarize scientific literature data on their diagnosis and treatment.The article describes 2 clinical observations of isolated cerebral varix, presents a literature review of this topic, as well as treatment tactics for patients with this pathology.In the first clinical observation, in a male 72‑year-old patient isolated cerebral varix was interpreted as distal saccular aneurysm of the right middle cerebral artery per computed angiography data. Surgical treatment was performed: from subtemporal approach in the area of the floor of the middle cranial fossa, cerebral varix, inflow and outflow veins were visualized. The inflow and outflow veins were clipped, aneurysm was resected and sent to histological examination. The patient was discharged on day 8 after surgery. Histological examination of the cerebral varix wall showed typical components for a venous wall, in particular, individual smooth muscle fibers, absence of elastic membrane.In the second clinical observation, in a female 59‑year-old patient magnetic resonance (MR) imaging, MR angiography and MR venography in the projection of anterior basal parts of the left temporal area showed an aneurysmal malformation transitioning into the superficial middle cerebral vein. Taking into consideration venous pathogenesis of the vascular lesion, dynamic observation of the patient was chosen.Isolated cerebral varix is a rare vascular pathology without a specific clinical and instrumental picture. To avoid erroneous diagnosis and determine further treatment tactics, additional examinations are recommended: MR imaging, MR angiography and MR venography.

The Basal or Sphenopetrosal Superficial Middle Cerebral Vein Type.

Background and Objectives: The adult superficial middle cerebral vein (SMCV) commonly drains into the middle cranial fossa. However, different embryonic types persist, in which the SMCV drains into the lateral sinus. The basal type of SMCV coursing on the middle fossa floor is a scarce variant. Materials and Methods: During a retrospective study of archived computed tomography angiography (CTA) and magnetic resonance angiography (MRA) files, three rare adult cases of the basal or sphenopetrosal type of SMCV were found and further documented. Results: In the first case, which was evaluated via CTA, the basal type of SMCV formed a sagittal loop. It continued on the middle fossa floor, over a dehiscent tegmen tympani, to drain into the lateral sinus. In the second case, documented via MRA, the basal type of SMCV's anterior loop was in the coronal plane and closely related to the internal carotid artery and the cavernous sinus. It continued with the basal segment over a dehiscent glenoid fossa of the temporomandibular joint (TMJ). In the third case, documented via CTA, the initial cerebral part of the SMCV had a large fenestration. The middle fossa floor coursed within a well-configured sulcus of the SMCV and received a tributary through the tympanic roof. Its terminal had a tentorial course. Conclusions: Beyond the fact that such rare variants of the SMCV can unexpectedly interfere with specific approaches via the middle fossa, dehiscences of the middle fossa floor beneath such variants can determine otic or TMJ symptoms. Possible loops and fenestrations of the SMCV should be considered and documented preoperatively.

Evaluation of Venous Structures that Are Involved in Transsylvian Approach Using 3D Rotational Venography.

In the transsylvian (TS) approach, as characterized by clipping surgery, the presurgical visualization of the superficial middle cerebral vein (SMCV) can help change the surgical approach to ensure safe microsurgery. Nevertheless, identifying preoperatively the venous structures that are involved in this approach is difficult. In this study, we investigated the venous structures that are involved in the TS approach using three-dimensional (3D) rotational venography (3D-RV) and evaluated the effectiveness of this method for presurgical simulation. Patients who underwent 3D-RV between August 2018 and June 2020 were involved in this retrospective study. The 3D-RV and partial maximum intensity projection images with a thickness of 5 mm were computationally reconstructed. The venous structures were subdivided into the following three portions according to the anatomic location: superficial, intermediate, and basal portions. In the superficial portion, predominant frontosylvian veins were observed on 31 (41%) sides, predominant temporosylvian veins on seven (9%) sides, and equivalent fronto- and temporosylvian veins on 28 (37%) sides. The veins in the intermediate (deep middle cerebral and uncal veins) and basal portions (frontobasal bridging veins) emptied into the SMCV on 57 (75%) and 34 (45%) sides, respectively. The 3D-RV images were highly representative of the venous structures observed during microsurgery. In this study, 3D-RV was utilized to capture the details of the venous structures from the superficial to the deep portions. Presurgical simulation of the venous structures that are involved in the TS approach using 3D-RV may increase the safety of microsurgical approaches.

The association between cortical venous outflow and futile recanalization in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation

Objective: To explore the association of baseline venous outflow (VO) profile with futile recanalization in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation. Methods: The clinical and imaging data of patients presented with large vessel occlusion in the anterior circulation and underwent emergency endovascular treatment at Huashan Hospital from March 2015 to December 2021 were retrospectively included in the study. All patients were assessed by the National Institutes of Health Stroke Scale (NIHSS) at baseline.Baseline VO profile was determined by a 0-6 semi-quantitative scoring system which assessed opacification of the ipsilateral superficial middle cerebral vein, vein of Labbé and vein of Trolard on single-phase CT angiography (CTA) images. A 90-day telephone follow-up was performed and functional outcome was evaluated by 90 d modified Rankin scale (mRS). Successful recanalization of the occluded artery, defined as final modified Thrombolysis in Cerebral Infarction scale (mTICI) 2b-3, was considered to be futile if patients failed to achieve functional independence (90 d mRS 0-2). Univariate analysis and receiver operating characteristic (ROC) curve analysis were used to explore the optimal cutoff predicting functional indendence. The associations between cortical VO in ischemic area and futile recanalization were evaluated using binary logistic regression analysis and backward linear regression based on Akaike information criterion (AIC). Results: A total of 150 patients met the inclusion criteria, with 92 males (61.3%) and 58 females (38.7%). The median age [M(Q1, Q3)]was 71 (61, 78) years and the median baseline National Institute of Health Stroke Scale (NIHSS) score [M(Q1, Q3)]was 15 (11, 18). Univariate logistic regression analysis showed that baseline VO was associated with 90-day functional independence (OR=1.587, 95%CI: 1.185-2.1873). After classifying VO into two categories based on the receiver operating characteristic (ROC) curve, VO≥4 showed an independent association with functional independence (OR=5.133, 95%CI: 1.530-9.361) after adjusting for age, baseline glucose, NIHSS score, baseline infarct core volume, modified Tan (mTan) score, hypoperfusion intensity ratio (HIR), etiological classification, recanalization, presence of any hemorrhagic transformation and final infarct volume. Futile recanalization was observed in 44 (48.4%) of the 91 patients who achieved successful recanalization. Stepwise logistic regression revealed that VO≥4 was an independent protective factor for futile recanalization (OR=0.234, 95%CI: 0.054-0.878). Moreover, in patients with mTICI 2c-3, VO≥4 showed a stronger association with futile recanalization (OR=0.018, 95%CI: 0-0.255). Conclusion: A favorable VO profile at onset protects against futile recanalization in patients with large vessel occlusion in the anterior circulation, and provides a simple and feasible auxiliary method for predicting the prognosis of endovascular therapy in such patients.

Synchronous Superficial Middle Cerebral Vein Outflow Correlates Favorable Tissue Fate After Mechanical Thrombectomy for Acute Ischemic Stroke

The purpose of this study was to determine the association between hemispheric synchrony in venous outflow at baseline and tissue fate after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). A two-center retrospective analysis involving AIS patients who underwent MT was performed. The four cortical veins of interest include the superficial middle cerebral vein (SMCV), sphenoparietal sinus (SS), vein of Labbé (VOL), and vein of Trolard (VOT). Baseline computed tomography perfusion data were used to compare the following outflow parameters between the hemispheres: first filling time (△FFT), time to peak (△TTP) and total filling time (△TFT). Synchronous venous outflow was defined as △FFT=0. Multivariable regression analyses were performed to evaluate the association of venous outflow synchrony with penumbral salvage, infarct growth, and intracranial hemorrhage (ICH) after MT. A total of 151 patients (71.4±13.2 years, 65.6% women) were evaluated. Patients with synchronous SMCV outflow demonstrated significantly greater penumbral salvage (41.3 mL vs. 33.1 mL, P=0.005) and lower infarct growth (9.0 mL vs. 14.4 mL, P=0.015) compared to those with delayed SMCV outflow. Higher △FFTSMCV (β=-1.44, P=0.013) and △TTPSMCV (β=-0.996, P=0.003) significantly associated with lower penumbral salvage, while higher △FFTSMCV significantly associated with larger infarct growth (β=1.09, P=0.005) and increased risk of ICH (odds ratio [OR]=1.519, P=0.047). Synchronous SMCV outflow is an independent predictor of favorable tissue outcome and low ICH risk, and thereby carries the potential as an auxiliary radiological marker aiding the treatment planning of AIS patients.

Anatomical variations and flow alterations of the uncal vein and its clinical implications in petroclival meningiomas.

The Uncal vein (UV), downstream of the deep middle cerebral vein (DMCV), has a similar drainage pattern to the superficial middle cerebral vein (SMCV) and may be involved in venous complications during the anterior transpetrosal approach (ATPA). However, in petroclival meningioma (PCM), where the ATPA is frequently used, there are no reports evaluating drainage patterns of the UV and the risk of venous complications associated with the UV during the ATPA. Forty-three patients with petroclival meningioma (PCM) and 20 with unruptured intracranial aneurysm (control group) were included. Preoperative digital subtraction angiography was used to evaluate UV and DMCV drainage patterns on the side of the tumor and bilaterally in patients with PCM and the control group, respectively. In the control group, the DMCV drained to the UV, UV and BVR, and BVR in 24 (60.0%), eight (20.0%), and eight (20.0%) hemispheres, respectively. Conversely, the DMCV in the patients with PCM drained to the UV, UV and BVR, and BVR in 12 (27.9%), 19 (44.2%), and 12 (27.9%) patients, respectively. The DMCV was more likely to be drained to the BVR in the PCM group (p < 0.01). In three patients with PCM (7.0%), the DMCV drained only to the UV, and furthermore, the UV drained to the pterygoid plexus via the foramen ovale, posing a risk for venous complications during the ATPA. In the patients with PCM, the BVR functioned as a collateral venous pathway of the UV. Preoperative evaluation of the UV drainage patterns is recommended to reduce venous complications during the ATPA.

Clinical characteristics, angiographic findings and treatment outcomes of carotid cavernous fistula in Makassar, Indonesia: a single-centre experience

BackgroundCarotid cavernous fistula (CCF) is an abnormal arteriovenous shunt between the carotid artery or its branches, with the cavernous sinus. It is still common in developing countries, and is mostly due to traumatic origin. Endovascular treatment has emerged as the primary mode of treatment of CCF. This is the first study describing the clinical manifestation, angiographic characteristic, and the challenges we face in endovascular treatment of CCF cases in Makassar, Indonesia.ResultsThis descriptive study was conducted between January 2019 to March 2022. We reviewed medical records and angiograms of all patients diagnosed with CCF at the Wahidin General Hospital, Makassar. Clinical manifestations, angiogram results, treatment, and outcome data were analyzed. A total of 23 patients were included in this study, with 17 (73.9%) direct CCF (Barrow type A) and 6 (26.1%) indirect CCF (Barrow type B, C, D). The mean age of patients were 32 years old. The three most common clinical manifestations were proptosis (n = 21, 91.3%), headache (n = 14, 60.8%), and chemosis (n = 14, 60.8%). The three most common drainage routes were via the superior ophthalmic vein (n = 23, 100%), inferior petrosal sinus (n = 12, 52.1%), and superficial middle cerebral vein (n = 6, 26.0%). All patients with direct CCF (n = 17) had endovascular treatment, resulting in 13 cases with complete occlusion (76.5%), 3 cases with incomplete occlusion (17.6%), and 1 (5.9%) procedure cancelled due to difficult navigation. Occlusion of fistula was best achieved with detachable coil, with a technical success rate of 90%. In indirect CCF (n = 6), 4 patients were treated conservatively and 2 with endovascular treatment, with complete occlusion in 2 patients.ConclusionsCarotid cavernous fistula patients commonly presented with orbital symptoms, headache, or neuro-ophthalmologic signs. The most common drainage pattern is via anterior route. Posterior, superior and lateral drainage were not found in indirect CCF. Endovascular treatment is an effective method for fistula closure, especially in the case of direct fistula. Challenges in endovascular treatment are related to the anatomy of the fistula and cavernous sinus.

Impaired intracranial venous outflow profiles are associated with poor outcome in stroke after reperfusion therapy: A hypoperfusion-matched intracranial venous scale

PurposeArterial blood flow provided prognostic information in acute ischemic stroke (AIS). However, part of the patients with favorable arterial blood flow still suffered from poor outcomes after reperfusion therapy. We aimed to verify the hypothesis that intracranial venous outflow profiles (both cortical and deep) within the hypoperfusion area were associated with clinical outcome in AIS patients who received reperfusion therapy. MethodWe performed a retrospective analysis of prospectively collected data from anterior circulation AIS patients. All patients underwent pretreatment CTP and received reperfusion therapy. We constructed a 5-point hypoperfusion-matched Intracranial Venous Scale (hypo-IVS) from the sum of the contrast enhancement degree (1, attenuated contrast enhancement; 0, complete contrast enhancement) of 4 typical veins (superficial middle cerebral vein, vein of Labbé, vein of Trolard, and internal cerebral vein) whose outflow territories had matched hypoperfusion. Logistic and ordinal regression were used to analyze the association between hypo-IVS and clinical outcome. ResultsA total of 751 patients were included. Higher Hypo-IVS was significantly associated with poor outcome (3-month mRS of >2; OR = 1.194; 95 % CI: 1.014–1.407; p = 0.033). The adjusted ORs for poor outcome and high 24-hour NIHSS were 1.172 (95 %CI: 1.035–1.328; p = 0.012) and 1.176 (95 %CI: 1.030–1.330; p = 0.010) in ordinal regression, respectively. Hypo-IVS > 2 was an independent risk factor of poor outcome (75.2 % vs 40.8 %; OR = 1.932; 95 %CI: 1.158–3.224; p = 0.012). ConclusionsIntracranial venous outflow profiles deliver prognostic information in AIS and the hypo-IVS is a helpful tool to predict clinical outcomes after reperfusion therapy.

Abstract 5: Malignant Venous Outflow Profile Predicts Futile Recanalization After Endovascular Thrombectomy.

Objective: To explore the association of baseline venous outflow from the occluded cerebral territory and futile recanalization (FR) in patients with acute ischemic stroke due to large vessel occlusion (LVO) in the anterior circulation. Methods: Consecutive patients from a prospectively maintained stroke database were included in this study if they presented with a multimodal CT-confirmed LVO in the anterior circulation and underwent thrombectomy within 24 hours after stroke onset. Excellent recanalization of the occluded artery, defined as final mTICI 2c-3 on digital subtraction angiography, was considered to be futile if patients fail to achieve functional independence (modified Rankin Scale of 0-2) at 90 days. Baseline venous outflow profile was determined by a 7-point semi-quantitative scoring system which assessed ipsilateral venous opacification of the vein of Labbe, Trolard and superficial middle cerebral vein on single-phase CTA source images. Hypoperfusion intensity ratio (HIR, defined as delay time &gt;6 seconds/delay time &gt;3 seconds) was applied to evaluate tissue-level collateral status. Results: 145 patients met the inclusion criteria. Multivariable logistic regression analysis showed that malignant venous outflow (OR 4.30 [95% CI 1.41-14.57]; p =0.013) was independently associated with functional dependence regardless of age, glucose, HIR, early neurologic deterioration, hemorrhagic transformation and final infarct volume. FR was observed in 24/52 (46%) recanalized patients. Stepwise logistic regression revealed a poor venous outflow profile at presentation as an independent predictor of FR (OR 7.04 [95% CI 1.29-50.16]; p =0.03) adjusted for baseline NIH Stroke Scale score, HIR and presence of hemorrhagic transformation. Conclusion: A malignant venous outflow profile at baseline is associated with FR in patients with LVO. The mechanism by which poor venous outflow from the occluded territory hinders clinical recovery despite prompt successful thrombectomy remains to be determined.

Abstract WP99: Impact Of Venous Delay Evaluated Before And After Mechanical Thrombectomy On Stroke Outcome

Introduction: We aimed to evaluate venous delay before and after treatment as a marker of radiological and clinical outcome in stroke patients receiving endovascular treatment (EVT). Methods: Prospective cohort of patients with anterior intracranial occlusion undergoing EVT. Brain MRI was performed on arrival (pre-EVT), &lt;2h after EVT (post-EVT), and 5 days after stroke. Final infarct volume was segmented on DWI at 5 days. We evaluated the veins of Labbé, Trolard and the superficial middle cerebral vein at both hemispheres on the dynamic MR angiography (dmRA) pre-EVT and post-EVT. For each vein we calculated a standardized venous delay measure:[(time to maximum venous contrast filling in the healthy hemisphere-time to maximum venous contrast filling in the affected hemisphere)/time to maximum venous contrast filling in the healthy hemisphere]x100. We defined venous delay as the value of the most delayed vein in each patient. We assessed the association between venous delay pre-EVT and post-EVT and final infarct volume and modified Rankin Scale (mRS) at 90 days, using multivariable regressions adjusted by successful reperfusion (mTICI≥2b) and other relevant variables. Results: From 98 included patients (median NIHSS 17, final mTICI≥2b 86%), 89 pre-EVT dMRIs and 88 post-EVT dMRIs were evaluable. The median venous delay pre-EVT and post-EVT were -31.9[-58.1;-16.7]% and -13.5[-34.5;-7.5]%, respectively. Venous delay pre-EVT was not related to infarct volume or clinical outcome. When final mTICI≥2B, venous asymmetry decreased but still persisted. For each 10% of increment in venous delay post-EVT, there was an adjusted increase of 0.12[0.05-0.19]ml in the final infarct volume. Venous delay post-EVT was independently associated with mRS at 90 days (cOR 1.013 [95%CI 1.001-1.0256]). Conclusion: Cortical vein delay assessed after but not before EVT, is associated with a larger final infarct volume and with a worse clinical outcome.

Delayed filling of the superficial middle cerebral vein in acute large artery occlusion.

ObjectiveThis study aimed to determine whether baseline delayed filling of the superficial middle cerebral vein (SMCV) was an independent cause of stroke prognosis in patients with acute anterior large vessel occlusion (LVO).MethodsConsecutive patients with acute LVO [middle cerebral artery M1 ± intracranial internal carotid artery (ICA)] between March 2019 and May 2020 were included. Delayed SMCV was defined as delayed filling of SMCV in the affected side compared with the normal side throughout the venous phase on four-dimensional computed tomographic angiography (4D-CTA) reconstructed from CT perfusion imaging. The modified Rankin scale (mRS) was used to evaluate the prognosis of these patients 3 months after stroke.ResultsOf 54 patients in total, 47 (87.0%) patients presented with baseline delayed SMCV, and 36 (76.6%) patients achieved SMCV reversal (ipsilateral delayed SMCV reversed to bilateral symmetrical SMCV) after reperfusion therapy. Successful reperfusion was independently associated with SMCV reversal [odds ratio (OR) = 69.328, 95% confidence interval (CI) = 2.818–175.342]. A significant association between baseline SMCV delay and a 3-month poor outcome (OR = 19.623, 95% CI = 1.567–245.727, p = 0.021) was observed using a multivariable regression analysis. Compared with patients with persistent delayed SMCV, patients with reversed SMCV did not show a significant difference in the risk of a 3-month poor outcome (OR = 1.177, 95% CI = 0.147–9.448).ConclusionsIn patients with acute LVO, baseline delayed SMCV was an independent cause of poor stroke prognosis, and SMCV reversal cannot reverse the 3-month stroke prognosis. Therefore, the evaluation of baseline SMCV filling status should be strengthened in clinical practice.

Intravenous tPA (Tissue-Type Plasminogen Activator) Correlates With Favorable Venous Outflow Profiles in Acute Ischemic Stroke.

Intravenous tPA (tissue-type plasminogen activator) is often administered before endovascular thrombectomy (EVT). Recent studies have questioned whether tPA is necessary given the high rates of arterial recanalization achieved by EVT, but whether tPA impacts venous outflow (VO) is unknown. We investigated whether tPA improves VO profiles on baseline computed tomography (CT) angiography (CTA) images before EVT. Retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion undergoing EVT triage. Included patients underwent CT, CTA, and CT perfusion before EVT. VO profiles were determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full. Pial arterial collaterals were graded on CTA, and tissue-level collaterals were assessed on CT perfusion using the hypoperfusion intensity ratio. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analysis, we determined the correlation between tPA administration and favorable VO profiles. Seven hundred seventeen patients met inclusion criteria. Three hundred sixty-five patients received tPA (tPA+), while 352 patients were not treated with tPA (tPA-). Fewer tPA+ patients had atrial fibrillation (n=128 [35%] versus n=156 [44%]; P=0.012) and anticoagulants/antiplatelet treatment before acute ischemic stroke due to large vessel occlusion onset (n=130 [36%] versus n=178 [52%]; P<0.001) compared with tPA- patients. One hundred eighty-five patients (51%) in the tPA+ and 100 patients (28%) in the tPA- group exhibited favorable VO (P<0.001). Multivariable regression analysis showed that tPA administration was a strong independent predictor of favorable VO profiles (OR, 2.6 [95% CI, 1.7-4.0]; P<0.001) after control for favorable pial arterial CTA collaterals, favorable tissue-level collaterals on CT perfusion, age, presentation National Institutes of Health Stroke Scale, antiplatelet/anticoagulant treatment, history of atrial fibrillation and time from symptom onset to imaging. In patients with acute ischemic stroke due to large vessel occlusion undergoing thrombectomy triage, tPA administration was strongly associated with the presence of favorable VO profiles.

Anatomical variations of dominant anastomotic veins in the superficial cortical venous system

BackgroundUnderstanding the anatomy of the anastomotic veins (AV) of the superficial cortical venous system (SCVS), viz. Superficial Sylvian vein (SSV) - also known as the superficial middle cerebral vein; vein of Labbe (VL) and vein of Trolard (VT), are imperative for neurosurgical procedures. This study aimed to investigate variant anatomical patterns of dominance of the AV, to elucidate the haemodynamically balanced SCVS, by reporting variations between the presence, diameter and dominant patterns of the AV. MethodsTwo hundred lateral angiograms were included, depicting left and right cerebral hemispheres of the same patient (n = 100 patients). Angiograms were analysed and variations recorded. Results were statistically compared against laterality, age, sex and ethnicity. ResultsPresence of the VL had the highest occurrence (96.5%), whereas the SSV and VT had an occurrence of 75.5% and 64.5%, respectively. This study reports presence of double veins of the AV: SSV (12.0%), VL (22.0%) and VT (19.5%). Furthermore, presence of a triple vein for each AV is reported. Diameters for the SSV, VL and VT were 1.99 ± 0.500 mm, 2.18 ± 0.579 mm and 2.14 ± 0.472 mm, respectively. Statistically significant relationships were established between diameters and the SSV, VL, VT and VT2 (double VT). Seven types of dominant patterns were recorded: Equilibrium; singular dominance of SSV, VL and VT; co-dominance of SSV/VL, SSV/VT and VL/VT. The Equilibrium dominant pattern of drainage had the highest occurrence (54.5%). ConclusionPatterns of dominance of these AV can aid the neurosurgeon in curbing the risk of iatrogenic injury and postoperative infarcts even after an otherwise successful surgery.

Petrobasal Vein: A Previously Unrecognized Vein Directly Connecting the Superior Petrosal Sinus with the Emissary Vein of the Foramen Ovale.

The superior petrosal sinus terminates anteriorly at the cavernous sinus and posteriorly at the transverse sinus. Venous variations directly connecting the superior petrosal sinus and the emissary veins of the foramen ovale are not well-recognized. We present a connecting vein, provisionally named the petrobasal vein. Biplane cerebral angiography of the bilateral internal carotid arteries and the vertebral artery acquired in 267 patients was retrospectively reviewed by 2 neuroradiologists with special interest in the existence and course of the petrobasal vein. The petrobasal vein was observed to lie anterior-posteriorly on the superior surface of the petrosal bone and connected to the midportion of the superior petrosal sinus and the emissary veins of the foramen ovale in 41 patients (15%) and sides (7.9%); it drained into the pterygoid plexus. The petrobasal vein was observed on VAG in 21 patients, on ICAG alone in 8 patients (9 sides), on both VAG and ICAG in 12 patients, and on ICAG in 1 patient. In the patients in whom the petrobasal vein was visualized on the ICAs, the superficial middle cerebral vein drained into a combination of the pterygoid plexus via the emissary veins of the foramen ovale and the superior petrosal sinus. The petrobasal vein, an unknown vein directly connecting the superior petrosal sinus and the emissary veins of the foramen ovale and draining into the pterygoid plexus, can occasionally be identified on cerebral angiography as a variant drainage route from the cerebellum and brainstem veins and/or from the superficial middle cerebral vein. The petrobasal vein is thought to be a remnant of the primitive tentorial sinus.

Time-resolved assessment of cortical venous drainage on multiphase CT angiography in patients with acute ischemic stroke.

Cortical vein opacification is not routinely assessed in patients presenting with acute ischemic stroke (AIS), and the value of temporal assessment of venous outflow is not known. We evaluated the utility of assessing cortical venous drainage over time using multiphase CT angiography (mCTA). Cortical venous drainage was assessed in patients from the Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy prospective multicenter cohort study of patients with symptoms of AIS with ICA and/or middle cerebral artery occlusion on baseline mCTA. Opacification of vein of Labbe, sphenoparietal sinus, superficial middle cerebral vein, and vein of Trolard of the affected hemisphere was graded as no (0), partial (1), or full (2) opacification in each mCTA phase. The venous opacification scores for each phase were added to generate a total venous score (TVS) (range 0-24). Primary outcome was 90-day modified Rankin score. Repeated measures analysis was used to assess the effect of phase timing on venous score on outcome. Of 432 patients, 284 (65.7%) had proximal arterial occlusions. Median venous opacification score per phase (range 0-8) was 3 (IQR 1-6) in the first phase and increased in the second and third phases [median (IQR): 6 (5-8) and 8 (6-8), respectively] of the mCTA. In a multivariable analysis adjusting for age, baseline National Institutes of Health Stroke Scale, and Albertastrokeprogram early CT score, a significant association between TVS and 90-day mRS was noted ([adjusted cOR for TVS 6-11: 0.16 (95% CI 0.05-0.51); TVS 12-17: 0.18 (95% CI 0.06-0.57); TVS 18-24: 0.20 (0.06-0.63)]. Repeated measures analysis of venous scores from all three phases showed a significant effect of time/phase on TVS (p < 0.001). This study concludes that venous opacification over time on multiphase CTA is associated with 90-day clinical outcome. There was however no added benefit of venous scoring vis-a-vis arterial collateral assessment in predicting outcome.

Sphenoparietal sinus and superficial middle cerebral vein thrombosis: A case report and review of literature

BackgroundCerebral venous sinus thrombosis is rare and might be overlooked by healthcare providers. It often occurs in the transverse sinuses, superior sagittal sinus, and the vein of Trolard. Sphenoparietal sinus (SPS) and/or superficial middle cerebral vein (SMCV) thrombosis is rare and only 12 cases reported in the literature. Case descriptionWe report a 47-year-old woman with iron deficiency anemia associated with myoma uteri who developed left SPS and SMCV thrombosis. She presented with sudden unconsciousness, right hemiplegia, and aphasia. Brain computed tomography showed subcortical hemorrhages in the left frontal and temporal lobes. Magnetic resonance imaging did not reveal the cause of the bleeding. Although antihypertensive treatment with nicardipine was initiated, she deteriorated into coma the next day and underwent emergency decompressive craniectomy. Thrombosis of the SMCV was identified during surgery. Re-examination of preoperative T2 star-weighted imaging revealed thrombosis of the SPS and SMCV. ConclusionAll but one of the reviewed cases had the thrombosis develop on the left side, which may be attributed to anatomical and brain functional laterality. When an edematous change or cortical hemorrhage of unknown cause is encountered within the perisylvian region, especially on the left side, the possibility of SPS and SMCV thrombosis should be considered.

Isolated thrombosis of cortical veins – Clinical and radiological correlation

Isolated cortical venous thrombosis (ICVT) is a relatively rare clinical entity with non-specific clinical presentations. Anatomical variations in cortical veins and the lack of a gold standard imaging feature make the diagnosis of ICVT challenging. Headache and seizures were the most common presentations. The Vein of Trolard followed by superficial middle cerebral vein (SMCV) were the most commonly involved. Susceptibility Weighted Imaging (SWI) cord sign was observed in 100% of the cases. CT cord sign and filling defects on contrast enhanced CT were evident in 46.7% and 10% of the cases, respectively. Notably, in the absence of filling defect visualized on contrast CT, MRI, replacement of flow void was the surrogate marker for the ICVT. A high index of clinical suspicion, a thorough understanding of neurovascular anatomy, multiparametric, multiplanar MRI protocol is required to diagnose this rare entity. A serpiginous blooming structure within the subarachnoid space identifiable in less than two contiguous sections on SWI in the vicinity of haemorrhagic infarction should alert the clinician to the imaging possibility of ICVT.