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BACKGROUND: Despite the proven effectiveness of endovascular therapy (EVT) in acute ischemic strokes (AIS) involving anterior circulation large vessel occlusions, isolated posterior cerebral artery (PCA) occlusions (iPCAo) remain underexplored in clinical trials. This study investigates the comparative effectiveness and safety of EVT against medical management (MM) in patients with iPCAo. METHODS: This multinational, multicenter propensity score-weighted study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. We included iPCAo patients treated with either EVT or MM. The primary outcome was the modified Rankin Scale (mRS) at 90 days, with secondary outcomes including functional independence, mortality, and safety profiles such as hemorrhagic complications. RESULTS: A total of 177 patients were analyzed (88 MM and 89 EVT). EVT showed a statistically significant improvement in 90-day mRS scores (OR = 0.55, 95% CI = 0.30-1.00, p = 0.048), functional independence (OR = 2.52, 95% CI = 1.02-6.20, p = 0.045), and a reduction in 90-day mortality (OR = 0.12, 95% CI = 0.03-0.54, p = 0.006) compared to MM. Hemorrhagic complications were not significantly different between the groups. CONCLUSION: EVT for iPCAo is associated with better neurological outcomes and lower mortality compared to MM, without an increased risk of hemorrhagic complications. Nevertheless, these results should be interpreted with caution due to the studys observational design. The findings are hypothesis-generating and highlight the need for future randomized controlled trials to confirm these observations and establish definitive treatment guidelines for this patient population.

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

Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies that target CGRP ligands or receptors, may cause a very rare side effect of reversible cerebral vasoconstriction syndrome (RCVS). This study is a case report of a patient who developed cerebral artery vasoconstriction documented on serial brain magnetic resonance angiography (MRA) scans without the typical manifestations of RCVS following galcanezumab loading dose. Case report: A 40-year-old female patient with high-frequency episodic migraine with visual aura on topiramate 100 mg/day developed transient numbness of the right upper and lower extremities and right face without headache and a normal neurological examination 10 min after a loading dose of galcanezumab, which resolved over the next 2 days. Magnetic resonance angiography brain imaging showed segmental arterial constriction of both middle cerebral arteries in the M1–2 segments and both posterior cerebral arteries in the P1–2 segments, which partial resolved in a subsequent study by the end of 6 months. There were no other supporting examination data, such as transcranial Doppler, which might provide additional information on the progression and improvement of the vasoconstriction. Her differential diagnosis included prolonged migraine sensory aura without headache, RCVS, or cerebral vasoconstriction secondary to the effect of an anti-CGRP monoclonal antibody. Further research needs to be conducted. Plain Language Summary: We report a case with numbness on the right upper and lower extremities and right face without headache 10 min after the loading dose of galcanezumab. These stroke-like symptoms resolved within 2 days. Cerebral blood vessels showed narrowing and then dilatation with residual narrowing of two or more vessels. The differential diagnosis is prolonged migraine aura without headache, reversible cerebral vasoconstriction syndrome, or cerebral vasoconstriction due to the effects of galcanezumab. [ABSTRACT FROM AUTHOR]

Objective Despite revascularization has been proven to be the optimal choice of moyamoya disease (MMD), many complications may occur in this context.. This study aimed to analyse the risk factors for new or expanded symptomatic infarctions of patients with MMD after revascularization. Methods Patients with MMD who received revascularization in our department were retrospectively enrolled, new or expanded cerebral infarction within a month after revascularization was the main concern. Basic and clinical information, and intraoperative conditions were evaluated. Univariate and multivariate analyses were performed to evaluate the risk factors. Receiver operating characteristic curve analysis was conducted to evaluate the efficiency of the risk factors. Results: Eventually, 108 consecutive patients received 174 surgeries were enrolled, experienced new or expanded infarction occured in 13 (7.47%) surgeries, which showed higher Suzuki stage on the non-operative side, more posterior cerebral artery (PCA) involvement, and more intraoperative hypotension compared to those without infarction(p < .05). The Suzuki stage on the non-operative side had the highest area under the curve (AUC) of 0.737, with a sensitivity of 0.692 and specificity of 0.783. Combination of the three factors showed better efficiency, with an AUC of 0.762, a sensitivity of 0.692, and a specificity of 0.907. Conclusions: Revascularization was a safe option for patients with MMD, higher Suzuki stage on the non-operative side, PCA involvement, and intraoperative hypotension might be the risk factors for new or expanded infarction after revascularization in patients with MMD. [ABSTRACT FROM AUTHOR]

This study applied alterations in partial pressure of end‐tidal carbon dioxide (PETCO2${{P}_{{\mathrm{ETC}}{{{\mathrm{O}}}_{\mathrm{2}}}}}$) to challenge dynamic cerebral autoregulation (dCA) responses across the cardiac cycle in both biological sexes. A total of 20 participants (10 females and 10 males; aged 19–34 years) performed 4‐min bouts of repeated squat–stand manoeuvres (SSMs) at 0.05 and 0.10 Hz (randomized orders) with PETCO2${{P}_{{\mathrm{ETC}}{{{\mathrm{O}}}_{\mathrm{2}}}}}$ clamped at ∼40 mmHg. The protocol was repeated for hypercapnic (∼55 mmHg) and hypocapnic (∼20 mmHg) conditions. Middle cerebral artery (MCA) and posterior cerebral artery (PCA) were insonated via transcranial Doppler ultrasound. Dynamic end‐tidal forcing clamped PETCO2${{P}_{{\mathrm{ETC}}{{{\mathrm{O}}}_{\mathrm{2}}}}}$, and finger photoplethysmography quantified beat‐to‐beat changes in blood pressure. Linear regressions were performed for transfer function analysis metrics including power spectrum densities, coherence, phase, gain and normalized gain (nGain) with adjustment for sex. During hypercapnic conditions, phase metrics were reduced from eucapnic levels (all P < 0.009), while phase increased during the hypocapnic stage during both 0.05 and 0.10 Hz SSMs (all P < 0.037). Sex differences were present with females displaying greater gain and nGain systole metrics during 0.10 Hz SSMs (all P < 0.041). Across PETCO2${{P}_{{\mathrm{ETC}}{{{\mathrm{O}}}_{\mathrm{2}}}}}$ stages, females displayed reduced buffering against systolic aspects of the cardiac cycle and augmented gain. Sex‐related variances in dCA could explain sex differences in the occurrence of clinical conditions such as orthostatic intolerance and stroke, though the effect of fluctuating sex hormones and contraceptive use on dCA metrics is not yet understood. [ABSTRACT FROM AUTHOR]

Background and Purpose: Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored. Methods: We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short‐term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge. Results: The median age of the cohort was 70 years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time‐to‐maximum (Tmax) >6 seconds (ρ =.55, p =.004), Tmax >8 seconds (ρ =.59, p =.002), Tmax >10 seconds (ρ =.6, p =.001), mismatch volume (ρ =.51, p =.008), and cerebral blood volume (CBV) < 34% (ρ =.59, p =.002). Conclusions: Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10 seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts. [ABSTRACT FROM AUTHOR]

Purpose: The main purpose of this study was to investigate the dimensions of cerebral arteries in the Thai population using digital subtraction angiography (DSA), with a focus on the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA). The research aimed to explore anatomical variations in diameters and lengths of these arteries across different sexes and age groups, which are crucial for cerebrovascular interventions. Methods: This retrospective study measured the diameters and lengths of the ACA, MCA, and PCA in 177 Thai patients with an average age of 47.6 years (range: 11–82 years) with normal cerebral angiograms. Digital subtraction angiography (DSA) was used for the measurements. Results: The study found significant sex-based differences in the mean diameters of the left ACA (males: 2.12 ± 0.28 mm, females: 1.92 ± 0.20 mm; p < 0.01), right MCA (males: 2.50 ± 0.25 mm, females: 2.31 ± 0.17 mm; p < 0.01), and left MCA (males: 2.44 ± 0.19 mm, females: 2.30 ± 0.17 mm; p < 0.01) with males exhibiting larger diameters. The right ACA length was significantly longer in males (15.46 ± 1.74 mm) compared to females (13.98 ± 1.92 mm; p < 0.01). While no significant age-related differences were observed in diameters, a significant increase in length with age was noted for the left ACA in the ≥ 60 years group (13.61 ± 1.64 mm) compared to the < 60 years group (12.63 ± 1.36 mm; p < 0.01). Among others, significant correlations were found between the diameters of the left ACA and right MCA (r = 0.699; p < 0.01), and a strong correlation between left ACA length and left PCA diameter (r = 0.975; p < 0.01). Conclusion: The findings provide invaluable data for tailoring neurosurgical approaches and designing angiographic equipment for the Thai population, emphasizing the importance of considering anatomical variations in clinical practice. These results highlight the necessity for personalized medical care based on anatomical differences to improve cerebrovascular intervention outcomes. [ABSTRACT FROM AUTHOR]

Purpose. Arterial supply of thalamus is complex and highly variable. In particular, the distribution pattern of thalamoperforating arteries received more attention some decades ago than in recent years. Methods. We are presenting the case of a 46-year-old patient with wake-up drowsiness, complex oculomotor disorder and dysarthria. He was investigated in the acute phase using non-contrast brain Computed Tomography (NCCT), CT Angiography (CTA), and in the following days Digital Subtraction Angiography (DSA) was performed Results. The NCCT showed a subacute ischemic stroke in the right anterior thalamus and rostral midbrain with normal findings on CTA. DSA imaged a variant of thalamic supply (Percheron type III), constituted by perforating branches arising from an artery bridging the P1 segments of both Posterior Cerebral Arteries (PCAs). Results. The thalamus has a complex and variable arterial supply, mainly in the pattern of paramedian thalamic-mesencephalic perforating arteries. The most reported variant is Percheron type IIb and supplies the paramedian thalami and the rostral midbrain. Type IIb occlusion usually causes a bilateral paramedian thalamic stroke, but rostral midbrain and anterior thalamus are involved in 57% and 19% cases. The rarer Type III variant probably prevented the bilateral extension of infarction and involved the territory of tuberothalamic and paramedian perforating arteries. Conclusions. Currently, DSA allows directly imaging variants in thalamic vascularization and better understanding the stroke mechanisms. In particular, in the presented case, a medium-sized vessel occlusion rather than a small vessel occlusion mechanism might be raised, leading to a different diagnostic pathway. [ABSTRACT FROM AUTHOR]

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

The article discusses the rehabilitation outcomes following acute subarachnoid hemorrhage (SAH) and the impact of early functional predictors and complications on these outcomes. A retrospective cohort study was conducted on patients with non-traumatic acute SAH undergoing rehabilitation. The study found that inpatient rehabilitation significantly improved functional independence, with most patients being discharged home. Complications during rehabilitation and their effects on discharge function were highlighted, emphasizing the need for effective prevention and management strategies. The study also identified factors such as motor weakness, dysphagia, and medical complications as predictors of poorer rehabilitation outcomes. [Extracted from the article]

Individuals who experience prolonged sitting daily are reported to be at risk of developing cerebrovascular disease, which is associated, in part, with attenuation in cerebral blood flow regulation. However, the effect of prolonged sitting on dynamic cerebral autoregulation (dCA), a crucial mechanism of cerebral blood flow regulation, remains unclear. Additionally, cerebrovascular disease occurs heterogeneously within cerebral arteries. The purpose of the present study was to examine the hypothesis that prolonged sitting attenuates dCA in the cerebral circulation heterogeneously. Twelve young, healthy participants were instructed to maintain a seated position for 4 h without moving their lower limbs. Mean arterial pressure and mean blood velocities of the middle cerebral artery (MCA Vm) and the posterior cerebral artery (PCA Vm) were measured continuously throughout the experiment. The dCA was assessed using transfer function analysis (TFA) with mean arterial pressure and either MCA Vm or PCA Vm. In the MCA, very low‐frequency TFA‐normalized gain decreased significantly during 4 h of prolonged sitting (P = 0.029), indicating an improvement rather than attenuation in dCA, despite a significant reduction in MCA Vm after 4 h of continuous sitting (P = 0.039). In the PCA, PCA Vm remained stable throughout the 4 h sitting period (P = 0.923), and all TFA parameters remained unchanged throughout the 4 h of sitting. Contrary to our hypothesis, these results suggest that the dCA in both the MCA and the PCA was well stabilized in healthy young individuals during acute prolonged sitting. [ABSTRACT FROM AUTHOR]

Background: Lateral Medullary Syndrome (LMS) is a posterior circulation stroke (PCS) that has a broad array of manifestations but most classically presents with Horner's syndrome, ipsilateral ataxia, and ipsilateral hyperalgesia. Although dysphagia is also common, isolated and single presentation of this alone is rare and there are only a few case reports of this in the literature. This presentation can bias a clinician's differential diagnosis and delay diagnosis. Case presentation: A previously healthy 53-year-old-male presented with a complaint of dysphagia. He had no PCS symptoms, a National Institute of Health Stroke Scale (NIHSS) of zero, and an otherwise unremarkable neurological exam. Stroke imaging including non-contrast computed tomography (NCCT) scan of his head and computed tomography angiography (CTA) scan of his head and neck revealed no acute abnormalities. He was found to be positive for Influenza A, but otherwise all other etiologies for his dysphagia were worked up, including consultation with other specialty services, without resolve. Two days later, the patient subsequently developed new right sided sensory deficits and left sided Horner's syndrome, in which a magnetic resonance imaging (MRI) scan of his head revealed an acute infarct of the left lateral medulla with likely thrombus in the left posterior inferior cerebellar artery (PICA). Conclusions: PCS is frequently missed due to the often-vague symptoms and reassuring negative imaging. This case highlights the variability of presentations that ED physicians may encounter. Nonetheless, a high index of suspicion for PCS should be maintained even in young patients without risk factors. Lastly, dysphagia is never normal, and this case demonstrates the need to reconsider neurogenic origin when other causes have been ruled out. [ABSTRACT FROM AUTHOR]

Background: Wide-necked aneurysms of the posterior communicating artery associated with a fetal posterior cerebral artery that arises from the neck or dome of the aneurysm is a clinical scenario that poses a challenge to endovascular methods. Case description: A patient presented with spontaneous subarachnoid hemorrhage and was found to have a 4 × 3 × 3 mm posterior communicating artery aneurysm. Of note the aneurysm projected superiorly and a fetal posterior communicating artery aneurysm arose from the neck of the aneurysm. After multidisciplinary discussion a treatment strategy of endovascular stent-assisted coiling was chosen. Given the unique morphology of the aneurysm a novel stent-inversion maneuver was used, in which the stent was deployed from the posterior communicating artery into the distal supra-clinoid internal carotid artery. The patient tolerated the procedure well and complete aneurysm occlusion was achieved. Conclusions: This case demonstrates a novel stent inversion technique that can be used for stent-assisted coiling of certain challenging aneurysms. [ABSTRACT FROM AUTHOR]

The circle of Willis (CoW) is a critical, arterial structure that ensures balanced, cerebral-blood supply. The fetal-type posterior cerebral artery (f-PCA) is a CoW variant that can significantly affect hemodynamics and elevate the risk of cerebrovascular diseases. This study used computational fluid dynamics simulations and a patient-specific, three-dimensional model to evaluate the hemodynamic effects of the f-PCA variants on cerebral-blood flow and key hemodynamic indices—such as time-averaged wall-shear stress (TAWSS), oscillatory shear index (OSI), pulsatility index, and resistive index. The fetal ratio (FR) is defined as the ratio of the diameter of the posterior communicating artery (PCoA) to that of the first segment (P1) of the PCA. Our findings indicate that as the FR increases, the contribution of the basilar artery to the second segment (P2) of PCA decreases significantly. Specifically, the flow rate through ipsilateral P1 decreased by 40.0% for FR = 1 and 70.9% for FR = 2, with the internal carotid artery (ICA) compensating for this reduction. Moreover, variations in f-PCA led to significant increases in TAWSS and OSI in key arterial segments (including the ipsilateral P1, PCoA, and the anterior communicating artery), which are associated with a higher risk of aneurysm initiation and growth. Under conditions of unilateral stenosis in the ipsilateral ICA, f-PCA models exhibit a more complex and pronounced impact on blood flow than models without f-PCA, emphasizing the need for detailed hemodynamic assessments in clinical evaluations and preoperative planning to mitigate the risks associated with CoW anatomical variations. [ABSTRACT FROM AUTHOR]

This document provides abstracts of clinical case presentations from the 2024 Vascular Scientific Sessions of the Society for Vascular Medicine. The cases cover a range of vascular conditions and highlight the challenges in diagnosing and managing these conditions. Topics include pulmonary embolism, Erdheim-Chester disease, polycythemia vera, cyanoacrylate closure, antiphospholipid syndrome, heavy metal toxicity, aortic aneurysms, COVID-19 multisystem inflammatory syndrome, large vessel vasculitis, arterial dissections, acute limb ischemia, ruptured abdominal aortic aneurysm, deep venous thrombosis, thoracic outlet syndrome, carotidynia, adrenal leiomyosarcoma, aortic dissection, transgender health, giant cell arteritis, cancer-related venous thrombosis, and vasopressor-induced peripheral ischemia. The cases emphasize the need for prompt diagnosis, appropriate management, and consideration of alternative treatments when necessary. [Extracted from the article]

Treating complex posterior cerebral artery (PCA) aneurysms, such as fusiform, giant, and dissecting aneurysms, poses significant challenges. Parent artery occlusion carries a risk of ischemic stroke and fails to alleviate mass effects. This study aims to analyze the technical nuances and patient outcomes of treating complex PCA aneurysms, ranging from the P1 to P2P segments, using a Zygomatic Anterolateral Temporal Approach(ZATA) combined with flow reconstruction. This study was a retrospective study. Surgical treatment was performed on twelve patients with complex PCA aneurysms located in the P1 to P2P segments. Ten patients underwent flow reconstruction including Superficial Temporal Artery(STA)-Middle Cerebral Artery(MCA),Internal Maxillary Artery(IMA)—Radial Artery(RA)—MCA,STA-PCA(P2), and IMA-RA-PCA(P2). The aneurysm occlusion rate, surgical complications, and patient prognosis, including stroke occurrence/ modified Rankin Scale(mRS), were recorded and analyzed. Using the ZATA, all twelve complex PCA aneurysms were successfully clipped/resected/trapped. This included two high-position aneurysms (> 3 mm above the posterior clinoid process) at the P1/P2 junction and three P2P aneurysms. The mass effects of six large or giant aneurysms were resolved or alleviated. Postoperative and follow-up CTA/DSA confirmed the patency of the bypass vessels. Four patients experienced strokes in the perioperative period, with three ischemic and one hemorrhagic. The median follow-up period was 28.5 months. At the last follow-up, the good prognosis rate (mRS ≤ 2) was 83.3%, and one patient had died. Clipping/resection/trapping of aneurysms via the ZATA, combined with flow reconstruction, is a feasible option for treating complex PCA aneurysms from the P1 to P2P segments. This approach helps maintain or improve cerebral perfusion in the affected vascular territory. [ABSTRACT FROM AUTHOR]

Haemolytic Uraemic Syndrome (HUS) is a rare medical condition characterised by microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. Neurological complications are documented but rarely involve the cerebellum. We present a unique case of a 23-month-old male with HUS triggered by Escherichia coli-O157 (E.coli-O157) infection leading to an isolated cerebellar stroke. The patient initially presented with fever, bloody stools, and seizures. Confirmation of E.coli-O157 infection was obtained, and MRI revealed an isolated cerebellar stroke. Treatment included supportive care, anticoagulation for a right atrial thrombus, with gradual improvement observed. This case highlights the unusual occurrence of isolated cerebellar stroke in HUS patients, emphasising the importance of promptly recognizing manifestations of the central nervous system and the necessity for a multidisciplinary approach. Finally, a comprehensive literature review was conducted to identify cases of HUS patients with cerebellar involvement. [ABSTRACT FROM AUTHOR]

Aneurysms of the basilar trunk represent an exceptional challenge to the neurosurgeon, due to high mortality and surgical morbidity. We present a 69-year-old man with a giant dolichoectatic thrombotic basilar trunk aneurysm (BTA), who underwent right orbitozygomatic craniotomy, posterior cerebral artery (PCA) to right middle cerebral artery (MCA) bypass and trapping of the BTA. Unfortunately, patient died after surgery due to multiple foci of intraparenchymal haemorrhage and thrombosis of a short segment proximal to aneurysm trapped and his body was donated to the hospital, giving us the unique opportunity to compare intraoperative details with anatomical dissection findings, according to our previously published cadaveric neurosurgical research. The great and unique opportunity of this reported case, to learn by watching and watching again what has been done during surgery, to observe small vessels and brainstem perforators and to look at stiches of the bypass, SVG and the position of the clips, permits to refine the theoretical and practical skills for the treatment of complex aneurysms such as that one reported. [ABSTRACT FROM AUTHOR]

Purpose: To describe a case of replaced posterior cerebral artery (PCA) in which all branches of the PCA arose from the anterior choroidal artery (AChA) with an early branching temporal artery. Methods: An 83-year-old man with cerebral infarctions underwent cranial magnetic resonance (MR) imaging and MR angiography using a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. Results: A large anomalous artery arose from the supraclinoid segment of the right internal carotid artery (ICA) and supplied all branches of the right PCA, mimicking fetal-type PCA. The temporal branch arose from the proximal segment of this artery. In MR angiographic source images, a tiny artery arose from the right ICA proximal to the origin of the anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). Thus, we concluded that the anomalous artery was a replaced PCA; all branches of the PCA arose from the AChA. Conclusion: We present a case involving a replaced PCA with an early branching temporal artery, as seen on MR angiography. Careful observation of MR angiographic source images is useful for identifying small arteries. To our knowledge, this is the first report of this combined variation in the relevant English-language literature. [ABSTRACT FROM AUTHOR]

Arterial carbon dioxide ( Pa CO 2 ) and posture influence the middle (MCAv) and posterior (PCAv) cerebral artery blood velocities, but there is paucity of data about their interaction and need for an integrated model of their effects, including dynamic cerebral autoregulation (dCA). In 22 participants (11 males, age 30.2 ± 14.3 yr), blood pressure (BP, Finometer), dominant MCAv and nondominant PCAv (transcranial Doppler ultrasound), end-tidal CO2 (EtCO2, capnography), and heart rate (HR, ECG) were recorded continuously. Two recordings (R) were taken when the participant was supine (R1, R2), two taken when the participant was sitting (R3, R4), and two taken when the participant was standing (R5, R6). R1, R3, and R5 consisted of 3 min of 5% CO2 through a mask and R2, R4, and R6 consisted of 3 min of paced hyperventilation. The effects of Pa CO 2 were expressed with a logistic curve model (LCM) for each parameter. dCA was expressed by the autoregulation index (ARI), derived by transfer function analysis. Standing shifted LCM to the left for MCAv (P < 0.001), PCAv (P < 0.001), BP (P = 0.03), and ARI (P = 0.001); downward for MCAv and PCAv (both P < 0.001), and upward for HR (P < 0.001). For BP, LCM was shifted downward by sitting and standing (P = 0.024). For ARI, the hypercapnic range of LCM was shifted upward during standing (P < 0.001). A more complete mapping of the combined effects of posture and arterial CO2 on the cerebral circulation and peripheral variables can be obtained with the LCM over a broad physiological range of EtCO2 values. NEW & NOTEWORTHY: Data from supine, sitting, and standing postures were measured. Modeling the data with logistic curves to express the effects of CO2 reactivity on middle cerebral artery blood velocity (MCAv), posterior cerebral artery blood velocity (PCAv), heart rate, blood pressure (BP), and the autoregulation index (ARI), provided a more comprehensive approach to study the interaction of arterial CO2 with posture than in previous studies. Above all, shifts of the logistic curve model with changes in posture have shown interactions with Pa CO 2 that have not been previously demonstrated. [ABSTRACT FROM AUTHOR]

To examine the association between cerebral artery stenosis and depressive symptoms in elderly patients. The study participants were 365 patients aged ≥65 years who visited the psychiatric outpatient clinic, Samsung Medical Center between January 1, 2000, and December 31, 2019, and were diagnosed with depressive disorder. They had brain imaging tests including magnetic resonance angiography (MRA), psychological evaluations including the 15-item Geriatric Depression Scale (GDS-15), and lab tests. Individuals' cerebral artery stenosis was identified and the association with significant depressive symptoms was examined. Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.6 %). The mean score of GDS-15 in the stenosis group was 8.1 (SD, 3.8), higher than the mean GDS-15 score of 6.5 (SD, 4.0) for the group without stenosis (p < 0.001). Compared to no middle cerebral artery (MCA) stenosis, having MCA stenosis was associated with significant depressive symptoms (p = 0.005). Compared to no posterior cerebral artery (PCA) stenosis, having left PCA stenosis was associated with significant depressive symptoms (p = 0.022). In the multivariable linear regression analysis, only bilateral MCA stenosis had a positive association with the score of GDS-15 (p = 0.013). Bilateral MCA stenosis and left PCA stenosis are associated with significant depressive symptoms among elderly patients, with bilateral MCA stenosis positively associated with the severity of depression. • Cerebral artery stenosis was associated with depressive symptoms among elderly patients. • Bilateral middle cerebral artery stenosis was associated with significant depressive symptoms and the severity. • Left posterior cerebral artery stenosis was associated with significant depressive symptoms. [ABSTRACT FROM AUTHOR]

Aim: This study aims to explore the effectiveness and safety of Ginkgolide® in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) and moderate-to-severe stroke receiving intravenous alteplase thrombolysis (IVT). Methods: Ginkgolide with Intravenous Alteplase Thrombolysis in Acute Ischemic Stroke Improving Neurological Function (GIANT) was an open-label, prospective, multicenter, cluster-randomized clinical trial and included AIS patients in 24 centers randomized to the intervention of intravenous Ginkgolide® or control group within the first 24 h after IVT. LVO was defined as any occlusion of the internal carotid artery, M1 or M2 of the middle cerebral artery, A1 or A2 of the anterior cerebral artery, P1 of the posterior cerebral artery, and V4 of the vertebral artery or the basilar artery. Stroke severity was assessed with the National Institutes of Health Stroke Scale (minor ≤5; moderateto-severe >5). The primary outcome was a good outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. Secondary outcomes were early neurological improvement (ENI), defined as ≥18% increase in the National Institutes of Health Stroke Scale (NIHSS) score at 7 days compared to baseline and distribution of mRS at 3 months. Results: A total of 1,113 patients were included, with 268/913 (29.4%) presenting LVO and 508 (45.6%) presenting moderate-to-severe stroke. In patients with LVO, Ginkgolide® usage was independently associated with ENI (P = 0.001) but not with a good outcome (P = 0.154). In the moderate-to-severe stroke subgroup, Ginkgolide® was independently associated with both a good outcome (P = 0.009) and ENI (P = 0.028). Ginkgolide® did not increase the risk of hemorrhagic transformation (all P > 0.05). Conclusion: Using Ginkgolide® within 24-h after intravenous rt-PA is effective and safe in LVO and moderate-to-severe stroke patients. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to validate hyperintense vessel sign (HVS) on FLAIR imaging or posterior cerebral artery (PCA) laterality on MR angiography beyond 4.5 hours after stroke onset. Materials and methods: Data from acute ischemic stroke patients with internal carotid or middle cerebral artery occlusion who underwent CT perfusion imaging at baseline, follow-up MR perfusion imaging and angiography within 30 hours after stroke, without effective recanalization on follow-up imaging, were analysed retrospectively. Patients were separately classified as high or low HVS (>5 or ≤5 slices of HVS), and PCA laterality positive or negative group. We compared core and penumbra volumes at follow-up imaging and neurological outcomes between high or low HVS group, and between PCA laterality positive or negative group. Results: Of 49 patients analyzed, four patients with artifacts were excluded and 45 were classified into high (n = 23) or low (n = 22) HVS group. High group had a smaller core volume (median 32 ml versus 109 ml, p = 0.004), larger penumbra volume at follow-up (68 ml versus 0 ml, p = 0.001), and better outcomes (modified Rankin Scale at three months, 3 versus 5, p = 0.03). For PCA laterality analysis, 1 patient with previously occluded PCA was excluded and 48 patients were classified as positive (n = 22) or negative (n = 26). Positive group had larger core volume (116 ml versus 37 ml), and no significant differences in penumbral volumes or outcomes. Conclusion: Prominent HVS in later time was associated with small core volume, persistent penumbra volume and favorable outcomes. [ABSTRACT FROM AUTHOR]

Cranial nerve palsies can be presenting signs of intracranial aneurysms. There is a classic pairing between an aneurysmal vessel and adjacent nerves leading to cranial neuropathy. Isolated abducens nerve palsy can be a localizing sign of an unruptured vertebrobasilar circulation aneurysm. Aneurysms involving Anterior Inferior Cerebellar Artery (AICA) and Posterior Inferior Cerebellar Artery (PICA) have been reported to be associated with abducens nerve palsy. The symptoms in unruptured aneurysms are due to the mass effect on adjacent neurovascular structures. Most of the abducens nerve palsy resolves following microsurgical clipping. Here, we present a rare case of an unruptured Posterior Cerebral Artery (PCA) aneurysm presenting with abducens nerve palsy and diplopia associated with contralateral hemianopsia which markedly improved following endovascular coil embolization. [ABSTRACT FROM AUTHOR]

Introduction: Posterior cerebral artery (PCA) aneurysms represent up to 1% of all cerebral aneurysms. P1-P2 perforator aneurysms are thought to be even less prevalent and often require complex treatment strategies due to their anatomical and morphological characteristics, with risk of a perforator infarct. We studied the treatment of P1-P2 perforator aneurysms in a single-center cohort from a high-volume tertiary center, reporting clinical and anatomical characteristics, treatment strategies, and outcomes. Methods: A retrospective analysis of adult patients with a P1-P2 perforator aneurysm who presented at our institution between January 2000 and January 2023 was performed. The patients were analyzed for demographics, clinical presentation, imaging findings, treatment techniques, outcomes, and complications. Subgroup analyses between ruptured versus non-ruptured cases were included. Results: Out of 2733 patients with a cerebral aneurysm, 14 patients (0.5%) presented with a P1-P2 perforator aneurysm. All six patients with a ruptured aneurysm were treated by endovascular coiling, of whom one patient (16.7%) required surgical clipping of a recurrence. One out of eight (12.5%) patients with unruptured aneurysms was treated by surgical clipping. P1-P2 perforator aneurysms predominantly affected middle-aged individuals (median 59.5 years), with 10/14 (71.4%) being female. Endovascular coiling was the primary treatment modality overall, yielding favorable technical outcomes, however, it was complicated by a perforator infarct in two patients (33.3%) without new permanent morbidity or mortality secondary to treatment. Conclusions: P1-P2 perforator aneurysms are a rare subtype of intracranial aneurysm. Endovascular coiling could present an effective treatment modality; however, care should be taken for ischemic complications in the dependent perforator territory. Larger studies are required to provide more insights. [ABSTRACT FROM AUTHOR]

Plasminogen activation inhibitor-1 (PAI-1) plays a central role in thrombus formation leading to stroke; however, the contributions of PAI-1 to cellular damage in response to reactive oxygen species which are elevated during reperfusion are unknown. Given that PAI-1 can limit apoptosis, we hypothesized that PAI increases the resilience of cerebral arteries to H2O2 (200 µM). Cell death, mitochondrial membrane potential, and mitochondrial ROS production were evaluated in pressurized mouse posterior cerebral arteries from males and females. The effects of pharmacological and genetic inhibition of PAI-1 signaling were evaluated with the inhibitor PAI-039 (10 µM) and PAI-1 knockout mice, respectively. During exposure to H2O2, PCAs from male mice lacking PAI-1 had reduced mitochondrial depolarization and smooth muscle cell death, and PAI-039 increased EC death. In contrast, mitochondrial depolarization and cell death were augmented in female PCAs. With no effect of PAI-1 inhibition on resting mitochondrial ROS production, vessels from female PAI-1 knockout mice had increased mitochondrial ROS generation during H2O2 exposure. During acute exposure to oxidative stress, protein ablation of PAI-1 enhances cell death in posterior cerebral arteries from females while limiting cell death in males. These findings provide important considerations for blood flow restoration during stroke treatment. [ABSTRACT FROM AUTHOR]

Previous studies report contradicting age‐related neurovascular coupling (NVC). Few studies assess postural effects, but less investigate relationships between age and NVC within different postures. Therefore, this study investigated the effect of age on NVC in different postures with varying cognitive stimuli. Beat‐to‐beat blood pressure, heart rate and end‐tidal carbon dioxide were assessed alongside middle and posterior cerebral artery velocities (MCAv and PCAv, respectively) using transcranial Doppler ultrasonography in 78 participants (31 young‐, 23 middle‐ and 24 older‐aged) with visuospatial (VST) and attention tasks (AT) in various postures at two timepoints (T2 and T3). Between‐group significance testing utilized one‐way analysis‐of‐variance (ANOVA) (Tukey post‐hoc). Mixed three‐way/one‐way ANOVAs explored task, posture, and age interactions. Significant effects of posture on NVC were driven by a 3.8% increase from seated to supine. For AT, mean supine %MCAv increase was greatest in younger (5.44%) versus middle (0.12%) and older‐age (0.09%) at T3 (p = 0.005). For VST, mean supine %PCAv increase was greatest at T2 and T3 in middle (10.99%/10.12%) and older‐age (17.36%/17.26%) versus younger (9.44%/8.89%) (p = 0.004/p = 0.002). We identified significant age‐related NVC effects with VST‐induced hyperactivation. This may reflect age‐related compensatory processes in supine. Further work is required, using complex stimuli while standing/walking, examining NVC, aging and falls. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied. In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up. Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality. Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar. [ABSTRACT FROM AUTHOR]

Background and objective: The rupture risk of intracranial aneurysms (IAs) is related to their arterial origin, but whether the di erent segments of the artery have di erent risks and act as independent risk factors is still unknown. Our study aimed to investigate the rupture risk of IAs in di erent arterial segments in a large Chinese cohort. Methods: Imaging and clinical data of consecutive patients with IAs diagnosed by Computed Tomography angiography (CTA) from January 2013 to December 2022 were collected. Two neuroradiologists independently identified ruptured and unruptured IAs based on imaging and medical records. The internal carotid artery (ICA),middle cerebral artery (MCA), anterior cerebral artery (ACA), vertebral artery (VA), and posterior cerebral artery (PCA) were segmented according to the Bouthillier and Fischer segmentation methods. Stenoses of the proximal parent vessel were evaluated and documented. The Institutional Review Board (IRB) at Beijing Tiantan Hospital approved this retrospective study. Results: A total of 3,837 aneurysms {median size 3.5mm [interquartile range (IQR) 2.6--5.1mm]; 532 ruptured} were included in this study from2,968 patients [mean age: 57 years (IQR 50--64); male patients: 1,153]. Ruptured aneurysms were most commonly located in the posterior inferior cerebellar artery (PICA) (52.9%), anterior communicating artery (ACoA) (33.8%), other locations (33.3%), ACA (22.4%), and basilar artery (BA) (21.4%). The locations with the highest likelihood of rupture were the C7 ICA (21.3%), M2 MCA (24.0%), distal MCA (25.0%), and A2 ACA (28.1%). IAs originating from the C7 (p < 0.001), dM1 (p = 0.022), and dA1 (p = 0.021) segments were independent risk factors for rupture. IAs without stenosis of the proximal parent vessel were associated with a higher risk of rupture (p = 0.023). Conclusion: There are unique associations between the origins of aneurysms from various arterial segments. Aneurysms originating from the anterior communicating artery (ACoA), BA, PICA, A2, dA, C7, and M2 indicate a higher risk of rupture. Aneurysms originating from C4, C5, and C6 indicate a lower risk of rupture. C7 IAs, ACoA IAs, and PICA IAs seem to be independent risk factors. [ABSTRACT FROM AUTHOR]

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Purpose: The thalamo-mesencephalic (TM) branches of the posterior cerebral artery (PCA) supply critical structures. Previous descriptions of these vessels are inconsistent and almost exclusively rely on cadaver studies. We aimed to provide a neuroradiological description of TM vessels in vivo based on routine 3D rotational angiographies (3D-RA). Methods: We analyzed 3D-RAs of 58 patients with pathologies remote from the PCA. PCA-origins were considered. Delineation, origin and number of branches of the collicular artery (CA), the accessory CA (ACA), the posterior thalamoperforating artery (PTA), the thalamogeniculate artery (TGA), and the posterior medial (PMCA) and lateral (PCLA) choroid arteries were assessed. The PTAs were categorized based on Percheron's suggested classification. Results: A CA was identified in 84%, an ACA in 20%. The PTA was delineated in 100%. In 27%, PTA anatomy had features of several Percheron types (n = 7) or vessels emanating from a net like origin (n = 9). 26% had a type IIb PTA. A fetal type PCA origin with hypoplastic ipsilateral P1 was observed in 5 cases with type IIa (n = 2) or type IIb (n = 3) PTAs originating from contralateral P1. The TGA was identified in 85% of patients, with ≥ 2 branches in 67%. The PMCA was delineable in 41%, the PLCA in 100%. Conclusion: The prevalence of a proper "Artery of Percheron" type IIb PTA seems to be higher than previously reported. A fetal type P1-origin may be predictive of a type IIa/b PTA emanating from contralateral P1. 3D-RA may be useful for planning PCA interventions, as impairment of TM branches is a severe risk. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effects of tongdu tiaoshen acupuncture combined with estazolam tablets on cerebral blood flow, polysomnography index and neurotransmitter in patients with insomnia after ischemic stroke (CIS). Methods: 95 patients with insomnia after CIS of qi deficiency and blood stasis type were treated in our hospital from January 2021 to July 2023 were selected,patients were divided into control group (estazolam tablets treatment) 47 cases and study group (tongdu tiaoshen acupuncture combined with estazolam tablets treatment) 48 cases according to the random number table method. The chinese medicine syndrome scores, Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), polysomnography related indicators [awakening time (WASO), sleep latency (SOL) and total sleep time (TST)], serum neurotransmitters [norepinephrine (NE), 5-hydroxytryptamine (5-HT), 5-hydroxyindoleacetic acid (5-HIAA)], cerebral blood flow velocity of anterior cerebral artery, middle cerebral artery and posterior cerebral artery were compared between two groups. Results: After treatment, the main symptoms, secondary symptoms, total scores, PSQI and AIS scores in two groups decreased, and those in study group were lower than those in control group at the same time point (P＜0.05). After treatment, WASO, SOL and NE in two groups decreased, and those in study group were lower than those in control group at the same time point. TST, 5-HIAA and 5-HT increased, and those in study group were higher than those in control group at the same time point (P＜0.05). After treatment, the cerebral blood flow velocity of anterior cerebral artery, middle cerebral artery and posterior cerebral artery in two groups increased, and those in study group were higher than those in control group at the same time point (P＜0.05). Conclusion: Estazolam tablets and tongdu tiaoshen acupuncture of the combined treatment for insomnia patients after CIS, which can improve insomnia symptoms, improve sleep quality, and improve cerebral blood flow and neurotransmitter secretion. [ABSTRACT FROM AUTHOR]

Intra-procedural intrasaccular device migration is an uncommon complication of endovascular treatment of wide-neck aneurysms. We report the case of a 52-years old Caucasian male who presented with a 3 × 3 mm posterior facing top of the basilar aneurysm in which treatment with WEB-SL (Woven EndoBridge-single layer) device was tempted. Inadvertent WEB migration in the right posterior cerebral artery occurred after detachment. Two retrieval attempts were performed using a combined technique with two different stent-retrievers and a 5-Fr distal access catheter. Upon WEBectomy attempt, the device rolled over the stents, and the passages were unsuccessful. The device was successfully removed using a microSnare, catching and retrieving it inside the 5-Fr distal access catheter. Micro-Snare is an effective bail-out technique to recover migrated intrasaccular WEB devices in cerebral arteries. [ABSTRACT FROM AUTHOR]

The cerebellum, a major feature of the hindbrain, lies posterior to the pons and medulla and inferior to the posterior part of the cerebrum. It lies beneath the tentorium cerebelli in the posterior cranial fossa and consists of two lateral hemispheres connected by the vermis. The cerebellum is primarily supplied by three arteries originating from the vertebrobasilar system: the superior cerebellar artery (SCA), the anterior inferior cerebellar artery (AICA), and the posterior inferior cerebellar artery (PICA). However, variations of the cerebellar arteries may occur, such as duplication of the SCA, SCA creating a common trunk with the posterior cerebral artery, triplication of the AICA, and agenesis of PICA, amongst others. Knowledge of the arterial anatomy of the cerebellum is crucial, as inadequate blood supply to this region can result in diminished motor functioning, significantly impacting the quality of life for patients. The present study demonstrated the importance of adequate anatomical knowledge of the arteries supplying the cerebellum. The PubMed and Embase databases were searched to gather articles on the anatomical characteristics and variations of the arterial supply of the cerebellum. It is the most comprehensive and up-to-date review available in the literature. The possible variations of these vessels may be clinically silent or present with clinical symptoms such as neurovascular compression syndromes of the cranial nerves and aneurysms. With a comprehensive understanding of the cerebellar arterial system, physicians can enhance their diagnostic and treatment capabilities, ultimately leading to more effective management of cerebellar vascular-related issues and other neurological deficits. [ABSTRACT FROM AUTHOR]

In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH. [ABSTRACT FROM AUTHOR]

Purpose: The present case report aims to describe the rare coexistence of three variants of the cerebral arterial system diagnosed by computed tomography angiography (CTA). Methods: A retrospective study on head and neck CTAs was performed on a Greek adult population from the Department of Radiology, University Hospital of Larissa. An interesting case of an 80-year-old male was further investigated. Results: The cerebral arterial circle presented with a combination of three variations. The left anterior cerebral artery (ACA) was fenestrated 1.4 mm proximally to the anterior communicating artery formation. The left posterior cerebral artery (PCA) was also fenestrated, 5.5 mm distally to its origin from the basilar artery. Lastly, the right PCA originated from the ICA supraclinoid segment. Conclusions: This case report highlights an unusual coexistence of A1 and P1 segments fenestration with a fetal PCA, resulting in a unique cerebral circle. A1 segment fenestration has been previously reported as rare, while the PCA fenestration as extremely rare variant. Awareness of these rare variations could aid interventionists in their preoperative assessments. [ABSTRACT FROM AUTHOR]

Preterm neonates are at risk for neurodevelopmental impairment, especially those with intraventricular hemorrhage (IVH). Cerebral vasospasm (VSP) is a common complication after subarachnoid hemorrhage (SAH) in adult population, but it is unknown if preterm neonates with IVH may develop it. We prospectively enrolled premature newborns < 32 weeks with IVH and without IVH. All patients received serial transcranial sonography through the temporal window of the middle cerebral artery, anterior cerebral artery, posterior cerebral artery, and the internal carotid artery with transcranial Doppler sonography days 2, 4, and 10 of life. Cerebral blood velocities (CBFVs) were measured including median velocity flow (MV), peak systolic velocity (PSV), and maximum end-diastolic velocity (EDV). Resistance index and pulsatility index were calculated. VSP was defined as an increase of 50% in the baseline velocity per day and/or a Lindegaard ratio higher than 3. Fifty subjects were enrolled. None of the patients with IVH showed elevation of MV or a Lindegaard ratio > 3. There were no differences between IVH and without IVH groups regarding resistance index and pulsatility index. Conclusion: Preterm infants with IVH do not present a pattern of VSP analyzed by Doppler transcranial ultrasound in this pilot study. What is Known: •In adult population with subarachnoid hemorrhage the most treatable cause of cerebral ischemia is due cerebral vasospasm but is unknown if premature newborn may have vasospasm due the extravasation of blood in the context of intraventricular hemorrhage What is New: •In this pilot study we did not find in premature newborn with intraventricular hemorrhage signs of vasoespam measured by transcranial color doppler ultrasound [ABSTRACT FROM AUTHOR]

Objective To investigate the role of sea-level cerebral blood flow (CBF) in predicting acute mountain sickness (AMS) using three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL). Methods Forty-eight healthy volunteers reached an altitude of 3,650 m by air after undergoing a head magnetic resonance imaging (MRI) including 3D-pCASL at sea level. The CBF values of the bilateral anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) territories and the laterality index (LI) of CBF were compared between the AMS and non-AMS groups. Statistical analyses were performed to determine the relationship between CBF and AMS, and the predictive performance was assessed using receiver operating characteristic (ROC) curves. Results The mean cortical CBF in women (81.65 ± 2.69 mL/100 g/min) was higher than that in men (74.35 ± 2.12 mL/100 g/min) (P < 0.05). In men, the cortical CBF values in the bilateral ACA, PCA, PICA, and right MCA were higher in patients with AMS than in those without. Cortical CBF in the right PCA best predicted AMS (AUC = 0.818). In women, the LI of CBF in the ACA was different between the AMS and non-AMS groups and predicted AMS with an AUC of 0.753. Conclusion Although the mechanism and prediction of AMS are quite complicated, higher cortical CBF at sea level, especially the CBF of the posterior circulatory system, may be used for prediction in male volunteers using non-invasive 3D-pCASL. [ABSTRACT FROM AUTHOR]

• Posterior circulation brain aneurysms carry a high risk of rupture, morbidity, and mortality. • Microsurgery is the treatment choice in settings with limited availability of endovascular devices. • Microsurgical clipping requires a technical proficiency to optimize clinical outcomes. • The described setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage. Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision. The authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0–2). The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage. [ABSTRACT FROM AUTHOR]

Background The novel Contour Neurovascular System (Contour) has been reported to be efficient and safe for the treatment of intracranial, wide-necked bifurcation aneurysms. Flow in the aneurysm and posterior cerebral arteries (PCAs) after Contour deployment has not been analyzed in detail yet. However, this information is crucial for predicting aneurysm treatment outcomes. Methods Time-resolved three-dimensional velocity maps in 14 combinations of patient-based basilar tip aneurysm models with and without Contour devices (sizes between 5 and 14 mm) were analyzed using four-dimensionsal (4D) flow MRI and numerical/image-based flow simulations. A complex virtual processing pipeline was developed to mimic the experimental shape and position of the Contour together with the simulations. Results On average, the Contour significantly reduced intra-aneurysmal flow velocity by 67% (mean w/ = 0.03m/s; mean w/o = 0.12m/s; p-value=0.002), and the time-averaged wall shear stress by more than 87% (mean w/ = 0.17Pa; mean w/o = 1.35Pa; pvalue= 0.002), as observed by numerical simulations. Furthermore, a significant reduction in flow (P<0.01) was confirmed by the neck inflow rate, kinetic energy, and inflow concentration index after Contour deployment. Notably, device size has a stronger effect on reducing flow than device positioning. However, positioning affected flow in the PCAs, while being robust in effectively reducing flow. Conclusions This study showed the high efficacy of the Contour device in reducing flow within aneurysms regardless of the exact position. However, we observed an effect on the flow in PCAs, which needs to be investigated further. [ABSTRACT FROM AUTHOR]

Objective To explore the efficacy and advantages of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms. Methods A total of 9 patients with complex intracranial aneurysms who underwent intracranial-intracranial bypass in Xiangya Hospital of Central South University from February 2014 to May 2020 were included, and were treated with grafts bypass or reimplantation of recipient arteries. All cases underwent CTA or DSA to detect the patent of grafts, whether aneurysms were completely clipped or resected and aneurysms recurrence occurred during the follow-up. Modified Rankin Scale (mRS) was used to evaluate the neurological prognosis at discharge and during the follow - up. Results Radial artery (RA) or great saphenous vein (GSV) was used for interposition in 4 cases, and recipient arteries were used for reimplantation in 5 cases. Of 4 cases of interposition, the cavernous sinus seoment of internal carotid artery (ICA)-GSV-ICA bypass was adopted in one case, middle cerebral artery (MCA) M2-RA-M2 bypass in one case, anterior cerebral artery (ACA) A3-GSV-A3 bypass in one case, posterior cerebral artery (PCA) P2 - RA - P2 bypass in one case. Of 5 cases of reimplantation, MCA M2 inferior trunk was reimplanted to M2 superior trunk in one case, ACA A3 was reimplanted to contralateral A3 in 2 cases, the posterior inferior cerebellar artery (PICA) was reimplanted to the anterior inferior cerebellar artery (AICA) in 2 cases. CTA in 3 d postoperatively showed all cases grafts were patent and aneurysms disappeared. After 3 months of discharge, 2 were lost to follow-up. The other 7 cases kept the patency of grafts and no new aneurysms, and were constantly followed up, with an average follow-up time of 30.71 months, and mRS score was 1 or lower. Conclusions Intracranial-intracranial bypass can be applied for complex intracranial aneurysms that are difficult for conventional surgical treatment to solve. Compared with extracranial - intracranial bypass, its grafts are shorter and its hemodynamics features are more in line with physiological conditions. [ABSTRACT FROM AUTHOR]

The article "Pure arterial malformation: Reports of two rare cases" published in the Journal of Neurosciences in Rural Practice discusses the rare condition of intracranial pure arterial malformation (PAM), characterized by tortuous and dilated arteries forming an arterial mass without a venous component. The text presents two cases of PAM affecting different age groups and brain territories, managed conservatively. Diagnosis of PAM requires CT/MRA and DSA, with treatment options ranging from conservative management to surgical interventions based on symptomatology. The article emphasizes the need for further research and collaboration to enhance understanding and patient care for this uncommon condition. [Extracted from the article]

Purpose: To investigate the effect of intravenous MgSO4 on maternal cerebral hemodynamics as well as the association between altered Doppler indices of the ophthalmic arteries and ocular lesions in patients with preeclampsia. Methods: After each of the 15 included patients was diagnosed with preeclampsia, MgSO4 was infused followed by transcranial Doppler tests of the indices of the ophthalmic, anterior, middle, posterior cerebral, vertebral, and basilar arteries, followed by a second MgSO4 infusion. The peak, mean, diastolic velocity, and pulsatile and resistance indices of each artery were automatically measured during testing. Based on the emergent data, the cerebral perfusion pressure, resistance-area product, and cerebral flow index were calculated. Results: The cerebral perfusion pressure of the posterior cerebral arteries significantly decreased following the infusion of MgSO4 (p < 0.05). Before the infusion of MgSO4, cerebral perfusion pressure and cerebral flow index of the ophthalmic arteries were significantly increased (p < 0.05) in the preeclamptic pregnant patients with ocular lesions compared those without ocular lesions. After the infusion of MgSO4, the cerebral perfusion pressure and cerebral flow index of both ophthalmic arteries were slightly decreased, but the difference was not significant. Conclusions: Altered Doppler indices following the infusion of MgSO4 suggest significant changes in the hemodynamics of the posterior cerebral and ophthalmic arteries that are particularly related to the neurological signs and symptoms of women with preeclampsia. These findings may improve the understanding of the mechanism of the cerebral complications of preeclampsia. Advancing comprehension of these underlying mechanisms is postulated to play a pivotal role in the mitigation of hypertensive encephalopathy associated with preeclampsia. [ABSTRACT FROM AUTHOR]

Neurovascular coupling (NVC) uniquely describes cerebrovascular response to neural activation and has demonstrated impairments following concussion in adult patients. It is currently unclear how adolescent patients experience impaired NVC acutely following concussion during this dynamic phase of physiological development. The purpose of this study was to investigate NVC in acutely concussed adolescent patients relative to controls. We recruited patients presenting to a sports medicine practice within 28 days of a concussion or a musculoskeletal injury (controls). Transcranial Doppler ultrasound was used to measure changes in patients' posterior cerebral artery (PCA) velocity in response to two progressively challenging visual tasks: (1) reading and (2) visual search. Each task was presented in five 1-min trials (20 sec eyes closed/40 sec eyes open). Resting PCA velocity data were derived by averaging PCA velocity across a 2-min baseline period that preceded the visual tasks. Filtered task data were converted to time-series curves representing 40 consecutive 1-sec averages for each trial. Curves were then averaged across the five trials and time-aligned to stimulus onset (eyes open) to generate a single ensemble-averaged 40-sec curve representing NVC response for each participant for each task. Independent t tests were used to assess group differences (concussion vs. control) in resting PCA velocity. Separate linear mixed-effects models were used to evaluate group differences (concussion vs. control) in NVC response profiles for both visual tasks and group-by-task interaction. Twenty-one concussion patients (female = 8 [38.1%]; age = 14.4 ± 1.9 years) and 20 controls (female = 7 [35.0%]; age = 14.4 ± 1.9 years) were included in our analysis. Average resting PCA velocity did not significantly differ between concussion patients (36.6 ± 8.0 cm/sec) and controls (39.3 ± 8.5 cm/sec) (t39 = 1.06; p = 0.30). There were no significant group differences in relative NVC response curves during the reading task (F1,1560 = 2.23; p = 0.14) or the visual search task (F1,1521 = 2.04; p = 0.15). In contrast, the differential response to task (e.g., increase from reading task to visual search task) was significantly greater in concussion patients than in controls (p < 0.0001). The NVC response to the visual search task was 7.1% higher than the response to reading in concussion patients relative to being 5.5% higher in controls. Our data indicate that concussed patients present with a significantly greater response to more difficult tasks than do controls, suggesting that concussed adolescents require increased neural resource allocation as task difficulty increases. The study provides insight into the neurophysiological consequences of concussion in adolescent patients. [ABSTRACT FROM AUTHOR]

Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not. [ABSTRACT FROM AUTHOR]

Transient neurological deficits (TNDs) are known to develop after direct bypass for Moyamoya disease and may be risk factors for subsequent stroke. However, the factors involved in the development of TNDs and stroke after indirect revascularization alone, including their association with subsequent stroke, remain unclear. The purpose of this study was to investigate this issue. The subjects of the study were 30 patients with Moyamoya disease who underwent a total of 40 indirect revascularization procedures at our institution. Clinical and radiological data were collected retrospectively. To examine factors associated with the development of postoperative TND/stroke/asymptomatic disease, the clinical characteristics of each group were statistically compared. The mean age at surgery was 7 years (range 1–63). TNDs developed after surgery in 9 out of 40 patients (22.5%). Stroke in the acute postoperative period occurred in 3 patients (7.5%), all of whom experienced cerebral infarctions. Demographic data and preoperative clinical information were not different between the groups. However, posterior cerebral artery involvement on preoperative imaging was significantly associated with the development of TNDs and stroke (P = 0.006). Furthermore, postoperative stroke was associated with unfavorable outcomes (P = 0.025). Posterior cerebral artery involvement is significantly associated with the occurrence of TNDs. In contrast, TNDs after indirect revascularization have little relationship with the subsequent development of stroke. TNDs usually resolve without new strokes, and a better understanding of this particular pathology could help establish an optimal treatment regimen. [ABSTRACT FROM AUTHOR]

Isolated vertigo induced by posterior circulation ischemia (PCIV) can further progress into posterior circulation infarction. This study aimed to explore the diagnostic values of three-dimensional pseudo-continuous arterial spin labeling (3D-PCASL) combined with territorial arterial spin labeling (t-ASL) and magnetic resonance angiography (MRA) in visualizing and evaluating PCIV, seeking improved diagnostic tools for clinical guidance. 28 PCIVs (11 males, 17 females, aged from 55 to 83 years, mean age: 69.68 ± 9.01 years) and 28 healthy controls (HCs, 12 male, 16 female, aged from 56 to 87 years, mean age: 66.75 ± 9.86 years) underwent conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), MRA, 3D-PCASL, and t-ASL. We compared the incidence of anatomic variants of the posterior circle of Willis in MRA, cerebral blood flow (CBF) and anterior collateral blood flow on postprocessing maps obtained from 3D-PCASL and t-ASL sequence between PCIVs and HCs. Chi-square test and paired t -test were analyzed statistically with SPSS 24.0 software. 7 PCIVs (7/28, 25%) and 6 HCs (6/28, 21%) showed fetal posterior cerebral artery (FPCA) on MRA, including 1 HC, and 6 PCIVs with FPCA appeared hypoperfusion. 18 PCIVs (64%) and 2 HCs (7%) showed hypoperfusion in the posterior circulation (PC), including 1 HC and 7 PCIVs displayed anterior circulation collateral flow. Chi-square analyses demonstrated a difference in PC hypoperfusion between PCIVs and HCs, whether in the whole or FPCA-positive group assessment (P < 0.05). Paired t -test showed that the CBF values were significant difference for the bilateral PC asymmetrical perfusion in the PCIVs (P < 0.01). When compared to the bilateral PC symmetrical non-hypoperfusion area in the PCIVs and HCs, the CBF values were not significant (P > 0.05). The CBF values of the PC in PCIVs were lower than in HCs (P < 0.05). The reduction rate in the hypoperfusion side of the bilateral PC asymmetrical perfusion of the PCIVs ranged from 4% to 37%, while the HCs reduction rate was 7.7%. The average PC symmetrical perfusion average reduction rate of the PCIVs was 52.25%, while the HCs reduction rate was 42.75%. 3D-PCASL is a non-invasive and susceptible method for detecting hypoperfusion in PC, serving as a potential biomarker of PCIV. The suspected hypoperfusion in PC may be attributed to the emergence of FPCA and the manifestation of anterior collateral flow when combining t-ASL and MRA sequences. These findings demonstrated that 3D-PCASL combined with t-ASL and MRA sequences are the potential method to identify PCIV, leading to early diagnosis of PCIV and reducing the risk of progressing into infarction. [ABSTRACT FROM AUTHOR]

This article discusses a case study of a Spanish-speaking male who experienced traumatic superior oblique palsy (SOP) and dry eye after being hit in the eye. The patient's symptoms improved with the use of prism lenses and lubricating eye drops. The article emphasizes the importance of differentiating between acquired and congenital cases of SOP and ruling out other potential causes. It also provides information on the diagnosis and management of SOP, including the use of the prism-measured alternate cover test and treatment options such as temporary prism correction and surgery. [Extracted from the article]