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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]

Background: There are no established patient selection criteria for endovascular thrombectomy (EVT) for anterior cerebral artery (ACA) stroke. Methods: This was a retrospective cohort study of the 2016–2020 National Inpatient Sample in the United States. Isolated ACA-occlusion stroke patients with moderate-to-severe stroke symptoms (NIH stroke scale [NIHSS] ≥ 6) were included. Primary outcome was hospital discharge to home with self-care. Secondary outcomes include in-hospital mortality and intracranial hemorrhage (ICH). Confounders were accounted for by multivariable logistic regression. Results: 6685 patients were included; 335 received EVT. Compared to medical management (MM), EVT patients were younger (mean 67.2 versus 72.2 years; p = 0.014) and had higher NIHSS (mean 16.0 versus 12.5; p < 0.001). EVT was numerically but not statistically significantly associated with higher odds of home discharge compared to MM (aOR 2.26 [95%CI 0.99–5.17], p = 0.053). EVT was significantly associated with higher odds of home discharge among patients with NIHSS 10 or greater (aOR 3.35 [95%CI 1.06–10.58], p = 0.039), those who did not receive prior thrombolysis (aOR 3.96 [95%CI 1.53–10.23], p = 0.005), and those with embolic stroke etiology (aOR 4.03 [95%CI 1.21–13.47], p = 0.024). EVT was not significantly associated with higher rates of mortality (aOR 1.93 [95%CI 0.80–4.63], p = 0.14); however, it was significantly associated with higher rates of ICH (22.4% vs. 8.5%, p < 0.001). Conclusion: EVT was associated with higher odds of favorable short-term outcomes for moderate-to-severe ACA-occlusion stroke in select patients. Future studies are needed to confirm the efficacy of EVT in terms of longer term neurological outcomes. [ABSTRACT FROM AUTHOR]

Aneurysm arising from the A1 segment of the anterior cerebral artery is rare. Aneurysm of the A1 segment even being small tend to rupture early. They tend to develop along the with various vascular anomalies of the vessels arising from the A1 segment. Use of computational fluid dynamics and hemodynamic consideration is of importance in this aneurysm. In this report we describe a 57-year-old woman with a small, unruptured A1 segment aneurysm arising from the proximal segment of the posterior surface of A1, and pointing posterior-inferiorly with multiple perforators entangling around for which microsurgical clipping was done. Intraoperative clipping of the aneurysm and salvaging the multiple perforators were challenging. We report a rare case of an A1 segment aneurysm arising from the posterior surface facing with multiple perforators. It is of significance to understand that a small, unruptured A1 aneurysm can arise from the posterior surface of the A1 segment with projection posterior-inferiorly making it deeper in location with multiple perforators entangling it; hence, it is challenging to treat without causing neurological deficits. [ABSTRACT FROM AUTHOR]

Visual evoked potential (VEP) is an established modality that allows safe brain tumor resection and preservation of optical function. We herein present a case of a pediatric craniopharyngioma with significant improvement in the VEP amplitude detected during endoscopic transsphenoidal surgery (ETS) and obvious postoperative improvement in visual acuity. A 13-year-old boy presented with visual acuity disturbance in his right eye and was followed up for 5 months by an ophthalmologist. His visual acuity rapidly worsened, and a suprasellar lesion with calcification was found on brain computed tomography. The patient underwent tumor resection during ETS with intraoperative transcranial VEP monitoring. Gross total tumor resection was achieved without injury to the perforators, including the superior hypophyseal arteries. The VEP amplitude was unstable, and significant waves were not detectable before tumor resection; however, a positive wave was detected after removing most of the tumor and exposing the bilateral optic nerves and optic chiasm. Subsequently, negative and positive VEP waves were continuously detected. Visual acuity improved remarkably on postoperative day 10. This case demonstrated both a significant increase in the intraoperative VEP amplitude and rapid postoperative improvement in visual acuity. We surmised that the preoperative rapid worsening of visual dysfunction, intraoperative increase in the VEP amplitude, and significant postoperative improvement in visual acuity were associated with the compression of the optic nerves by the internal carotid artery, anterior cerebral artery, and tumor. [ABSTRACT FROM AUTHOR]

To analyze the correlation of carotid stenosis severity, the Plaque Reporting and Data System (RADS) score, arterial transit artifacts (ATAs), and cerebral blood flow (CBF) with clinical cerebral ischemic symptoms in patients with carotid artery stenosis (CAS). Sixty-one patients with unilateral internal carotid artery stenosis or occlusion (≥50% stenosis) diagnosed by ultrasound, Computed Tomography(CT) angiography, or Magnetic Resonance(MR) angiography in Yichang City Central People's Hospital from January 2022 to February 2024 were retrospectively enrolled and divided into two groups according to the presence or absence of symptoms. Both groups underwent MR plaque imaging and arterial spin labeling (ASL)-based 3.0 T MRI to compare the differences in stenosis degree, Plaque-RADS score, ATA grade, and CBF between the two groups. Binary regression analysis was used to identify the parameters with statistically significant differences between the two groups and to evaluate their diagnostic efficacy using the area under the workup curve of the subjects. The Plaque-RADS score, ATA grade, and CBF differences in the anterior cerebral artery(ACA)blood supply region were correlated with symptoms, and the areas under the ROC curves for the CBF differences in the ACA blood supply region, Plaque-RADS score, ATA grade and a joint model that combines all three to predict symptoms in CAS patients were 0.672, 0.796, 0.788 and 0.919, respectively. CBF, Plaque-RADS and ATAs were identified as independent risk factors for symptoms in patients with CAS and have a certain predictive value for symptoms, and the combined predictive value is greater, potentially providing a more effective imaging modality for clinical treatment and evaluation. • Arterial Transit Artifacts were found to be associated with cerebral ischemia symptoms. • The combination of Plaque-RADS and Arterial Transit Artifacts in predicting symptoms has a higher predictive value. • The PLD used for ASL scanning in this study was 2.0 s, further confirming the broad applicability of our results. [ABSTRACT FROM AUTHOR]

Aneurysms of the distal anterior cerebral artery (DACA) are rare but surgically challenging. Despite a known therapeutic implication of the aneurysm location on the DACA territory, the literature is unclear about its clinical and prognostic significance. Our surgical experience over the last 5 years was reviewed to compare the clinical, operative, and outcome characteristics between aneurysms located below the mid portion of the genu of the corpus callosum (called proximal aneurysms) to those distal to this point (called distal aneurysms). A prognostic factor analysis was done using uni and multivariable analysis. A total of 34 patients were treated (M: F = 1:2.3). The distal group had a higher frequency of poor clinical grade at presentation (n = 9, 47.4%) in contrast to (n = 2, 13.3%) proximal aneurysms (p = 0.039). Despite an overall tendency for a delayed functional improvement in these patients, the results were mainly due to favorable outcomes in the proximal group (favourable functional outcomes at discharge and at last follow-up being 80% and 86.7% respectively). On the multivariable analysis, only WFNS grade (> 2) at presentation (OR = 13.75; 95CI = 1.2–157.7) (p = 0.035) and application of temporary clips (AOR = 34.32; 95CI = 2.59–454.1) (p = 0.007), both of which were more in the distal group, independently predicted a poor long term functional outcome. Thus, the aneurysm location impacts the preoperative clinical grade, the intraoperative aneurysm rupture risk rate as well as the temporary clipping requirement. A combination of these factors leads to worse short and long-term functional outcomes in the distal DACA aneurysms. [ABSTRACT FROM AUTHOR]

The locations of anterior cerebral artery (ACA) aneurysms vary, and various aneurysms can occur along the course of the ACA. Ruptured and some unruptured ACA aneurysms may require aggressive treatment to avoid bleeding or rebleeding. Although open surgery is an effective treatment for ACA aneurysms, endovascular treatment (EVT) is becoming an alternative treatment in select cases. EVT techniques for ACA aneurysms often vary and are performed on a case-by-case basis according to the nature and location of the aneurysm. To better understand the EVT strategy for ACA aneurysms, it is necessary to review EVT for ACA aneurysms. In this review, the following topics are discussed: ACA anatomy and anomalies, classifications of ACA aneurysms, the natural history of ACA aneurysms, open surgery and EVT statuses for ACA aneurysms, EVT techniques for various ACA aneurysms, and the prognosis and complications of EVT for ACA aneurysms. According to our review and experience, traditional coiling EVT is still the preferred therapy for most ACA aneurysms. For A1 aneurysms, EVT is challenging. After the selection of appropriate cases, deployment of a flow diverter and Woven EndoBridge device can result in a good prognosis for patients with ACA aneurysms. In addition, parent artery occlusion can be used to treat A1 aneurysms with good collateral circulation and some distal ACA aneurysms. In general, EVT is gaining popularity as an alternative treatment option for ACA aneurysms. [ABSTRACT FROM AUTHOR]

Objective: To explore the spatial relationship between A1 segment proximal anterior cerebral artery aneurysms and their main trunks, classify them anatomically and develop targeted treatment strategies. Methods: This single-center retrospective analysis involved 39 patients diagnosed with aneurysms originating from the proximal of A1 segment of the anterior cerebral artery (2014-2023). Classify the patient's aneurysm into 5 types based on the location of the neck involving the carrier artery and the spatial relationship and projection direction of the aneurysm body with the carrier artery, and outcomes from treatment methods were compared. Results: Among 39 aneurysms, 18 cases underwent endovascular intervention treatment, including 6 cases of stent assisted embolization, 1 case of flowdiverter embolization, 5 cases of balloon assisted embolization, and 6 cases of simple coiling. At discharged, the mRS score of all endovascularly treated patients was 0, and the GOS score was 5 at 6 months after discharge. At discharge, the mRS score of microsurgical clipping treated patients was 0 for 15 cases, 3 for 1 case, 4 for 1 case and 5 for 2 cases. Six months after discharge, the GOS score was 5 for 16 cases, 4 for 2 cases, 3 for 2 cases, and 1 for 1 case. GOS outcomes at 6 months were better for endovascularly treated patients (p = 0.047). Conclusion: Results showed better outcomes for the endovascular treatment group compared to microsurgical clipping at 6 months after surgery. The anatomical classification of aneurysms in this region may be of help to develop effective treatment strategies. [ABSTRACT FROM AUTHOR]

Background: In adults, moyamoya disease (MMD) often presents with slight neurocognitive impairment, which may result from frontal lobe hemodynamic insufficiency. Methods: In this study, we performed revascularization surgery by superficial temporal artery–anterior cerebral artery (ACA) direct bypass in 20 adults with MMD with poor anterograde ACA flow (Group M). The pre- and postoperative neurocognitive test results of these patients were retrospectively analyzed. The comparative group (Group C) included 23 patients with unruptured aneurysms or brain tumors who underwent craniotomy, as well as the same neurocognitive tests as Group M. We calculated the compositive frontal lobe function index (CFFI) based on the results of seven neurocognitive tests for each patient, and the difference between the pre- and postoperative CFFI values (CFFI Post − Pre) was compared between the two groups. Results: Frontal perfusion improved postoperatively in all patients in Group M. The CFFI Post − Pre was significantly higher in Group M than in Group C (0.23 ± 0.44 vs. − 0.20 ± 0.32; p < 0.001). After adjusting for postoperative age, sex, preoperative non-verbal intelligence quotient, and preoperative period of stress, Group M had a significantly higher CFFI Post − Pre than Group C in the multiple regression analysis (t value = 4.01; p < 0.001). Conclusion: Improving frontal lobe hemodynamics might be the key for improving neurocognitive dysfunction in adults with MMD. The surgical indication and method should be considered from the perspective of both stroke prevention and neurocognitive improvement or protection. [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]

Background: The differences in outcomes after aneurysmal subarachnoid hemorrhage (aSAH) between the sexes have not been concretely determined. This study aimed to evaluate the differences in epidemiology, outcomes, and risk factors between male and female patients with aSAH. Methods: We performed a multicenter, retrospective study of patients with aSAH from 2017 to 2020. We investigated the epidemiological differences between the two sexes. Propensity score matching (PSM) was used to compare short-term outcomes between the sexes. Binary logarithmic regression was performed to investigate the odds ratio (OR) for dependent survival in patients of different sexes. Results: A total of 5,407 consecutive patients with aSAH were included in this study, and the female-to-male ratio was 1.8:1. The peak incidence of aSAH occurred in the 6th and 7th decades in males and females, respectively. There were more female patients with internal carotid artery or posterior communicating artery aneurysms (53.2%), and there were more male patients with anterior cerebral artery or anterior communicating artery aneurysms (43.2%). The incidence of multiple aneurysms was greater in female patients (21.5% vs. 14.2%, P < 0.001). There was no significant difference in outcomes before and after PSM at discharge. The dependent survival risk was related only to the clinical condition on admission in women. In addition, age > 50 years (OR 1.88, 95% confidence interval 1.17–3.02; P = 0.01) and hypertension (OR 1.81, 95% confidence interval 1.25–2.61; P = 0.002) were also risk factors for male patients. Conclusions: There were more female patients with aneurysms than male patients in this study. Most aneurysm locations were different between the two groups. There was no significant difference in discharge outcomes before and after PSM. The risk factors for dependent survival were different between female and male patients. [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]

Key Clinical Message: In younger patients, including those with extensive infarction involving the anterior and middle cerebral artery regions of the right hemisphere, appropriate treatment for rare causes and goal‐oriented long‐term rehabilitation could improve severe hemiplegia and higher brain dysfunction, and allow for further education and employment. Although the number of young stroke patients is small, many have serious sequelae and rare causes. In addition to independence in activities of daily living, education and employment are desired. We present two cases of extensive infarction in the right cerebrum in patients who underwent rehabilitation with good outcomes. [ABSTRACT FROM AUTHOR]

This article explores the development and prenatal imaging of the corpus callosum (CC), a crucial structure in the brain that facilitates communication between the two hemispheres. Prenatal imaging techniques like ultrasound and MRI have made it possible to study the CC's development earlier than before. The article also discusses the various abnormalities that can be observed in the CC during prenatal imaging and the challenges in accurately describing and classifying these abnormalities. The authors propose a simplified classification system based on well-defined criteria to improve the diagnosis and prognosis of CC anomalies. [Extracted from the article]

The superior cerebellar artery (SCA) is a vessel anterior to the brainstem, usually originating from the basilar artery (BA). In this case, a different course of left SCA in a 74-year-old male cadaver was reported. The origin of the SCA was found to be a unilateral double root at the left side on the anterior surface of the pons. The distances of the starting points of roots to the bifurcation of BA were 31.09 mm on the right side, on the left side the rostral root was 33.84 mm and the caudal root was 30.95 mm. The diameter of the right SCA was 2.37 mm, the left rostral root was 2.05 mm and the caudal root was 1.24 mm. Knowing the course of SCA, and especially morphological variations, will be helpful for the clinical branches in preventing complications during surgical operations, evaluating angiographic examinations, and diagnosing and treating neurovascular diseases. [ABSTRACT FROM AUTHOR]

Aim: Aneurysmal subdural hematoma (anSDH) is an uncommon condition associated with significant mortality risk. This study focused on the relationship between morphology and the perianeurysmal environment by comparing aneurysm location and clinical outcomes. Material and Methods: A total of 486 patients with aneurysmal subarachnoid hemorrhage were retrospectively analyzed for accompanying subdural hematoma (SDH) cases. Demographic information, rebleeding, discharge, and 6 months of the modified Rankin scale scores (favorable and unfavorable) were recorded. The aneurysms were divided into 3 groups: internal carotid artery (ICA), anterior cerebral artery (ACA), and middle cerebral artery (MCA). Other parameters included aneurysm morphology, SDH width, intracerebral hematoma (ICH) volume, the presence of intraventricular hematoma, and distance to the subdural space. Results: Concomitant SDH was detected in 19 (3.9%) patients. Aneurysms were located in the ICA, 10 (52.6%); MCA, 8 (42.1%); and ACA, one (5.3%). The mean size was 9.5±4.3 mm, and there was a significant difference in aneurysm size between the ICA and MCA (p=0.025). In six supraclinoid aneurysms (posterior communicating and anterior choroidal arteries), the aneurysm dome was in the inferior lateral projection. No significant differences were observed between patients with favorable and unfavorable modified Rankin scale in terms of clinical and aneurysm morphological characteristics, except for increased ICH volume (p=0.020) and shift effects (p=0.030). Conclusion: The size and dome projection of ICA supraclinoid segment aneurysms may be important risk factors for SDH. We also believe that aneurysm localization may have a limited impact on clinical outcomes in the context of SDH. [ABSTRACT FROM AUTHOR]

Background Collateral circulation is an important determinant of outcome in people with acute ischemic stroke due to large vessel occlusion (LVO). Objective To explore the impact of the circle of Willis (CW) anatomical characteristics ipsilateral to the occlusion site, particularly the posterior communicating artery (PComA) and the A1-portion of the anterior cerebral artery (A1-ACA), on stroke outcomes in a cohort of patients with LVO and middle cerebral artery (MCA) occlusion, undergoing endovascular thrombectomy (EVT). Methods This is a retrospective cohort study performed in a comprehensive tertiary stroke center. The study population consisted of consecutive patients with LVO with proximal MCA occlusion (M1) between June 2016 and April 2021, undergoing EVT. Demographic, clinical, and imaging information was extracted from patient files. Patency and diameters of ipsilateral A1-ACA and PComA were manually measured on admission CT angiography images in the core laboratory. Results One hundred and five patients with LVO comprised the study cohort, mean age 72.3 years, 43.8% were male, mean National Institutes of Health Stroke Scale score at admission 15.2. The cohort was grouped according to CW vessel characteristics. On univariate analysis, a well-developed PComA was associated with lower rates of hemorrhagic transformation (1.8% vs 14.3%, P=0.01) and a trend towards lower mortality rates (8.9% vs 20.4%, P=0.08). On multivariable regression analysis a well-developed PComA emerged as an independent predictor for survival (aOR=0.09, 95% CI 0.01 to 0.4 for survival at discharge, P=0.009, aOR=0.22, 95% CI 0.05 to 0.8 for survival at 90 days, P=0.02). Conclusions In a cohort of patients with LVO due to M1 occlusion undergoing EVT, a well-developed PComA was associated with significantly lower hemorrhagic transformation rates, a trend towards better functional outcomes, and independently predicted survival. Larger studies are needed to understand the differential effect of CW collateral conduits on stroke outcome and evaluate the practicality of incorporating such factors in the clinical decision-making process prior to EVT. [ABSTRACT FROM AUTHOR]

Background: The extent of ischemic injury in acute stroke is assessed in clinical practice using the Acute Stroke Prognosis Early CT Score (ASPECTS) rating system. However, current ASPECTS semi-quantitative topographic scales assess only the middle cerebral artery (MCA) (original ASPECTS) and posterior cerebral (PC-ASPECTS) territories. For treatment decision-making in patients with anterior cerebral artery (ACA) occlusions and internal carotid artery (ICA) occlusions with large ischemic cores, measures of all hemispheric regions are desirable. Methods: In this cohort study, anatomic rating systems were developed for the anterior cerebral (AC-ASPECTS, 3 points) and anterior choroidal artery (AChASPECTS, 1 point) territories. In addition, a total supratentorial hemisphere (H-ASPECTS, 16 points) score was calculated as the sum of the MCA ASPECTS (10 regions), supratentorial PC-ASPECTS (2 regions), AC-ASPECTS (3 regions), and ACh-ASPECTS (1 region). Three raters applied these scales to initial and 24  h CT and MR images in consecutive patients with ischemic stroke (IS) due to ICA, M1-MCA, and ACA occlusions. Results: Imaging ratings were obtained for 96 scans in 50 consecutive patients with age 74.8 (±14.0), 60% female, NIHSS 15.5 (9.25–20), and occlusion locations ICA 34%; M1-MCA 58%; and ACA 8%. Treatments included endovascular thrombectomy +/− thrombolysis in 72%, thrombolysis alone in 8%, and hemicraniectomy in 4%. Among experienced clinicians, inter-rater reliability for AC-, ACh-, and H-ASPECTS scores was substantial (kappa values 0.61–0.80). AC-ASPECTS abnormality was present in 14% of patients, and ACh-ASPECTS abnormality in 2%. Among patients with ACA and ICA occlusions, H-ASPECTS scores compared with original ASPECTS scores were more strongly associated with disability level at discharge, ambulatory status at discharge, discharge destination, and combined inpatient mortality and hospice discharge. Conclusion: AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS expand the scope of acute IS imaging scores and increase correlation with functional outcomes. This additional information may enhance prognostication and decision-making, including endovascular thrombectomy and hemicraniectomy. [ABSTRACT FROM AUTHOR]

Background: Patients with stroke secondary to isolated anterior cerebral artery (ACA) occlusions have poor outcomes. Whether tandemocclusions (TO) of the extracranial internal carotid (ICA) and the ACA carry even worse outcomes that remain unknown. Methods: Patients with TO involving ICA and ACA occlusions were identified from 14 participating centers from the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) project which is a multicenter, observational, cohort study with prospective accrual of data followed by retrospective data analysis. Patients with isolated ACA stroke served as controls. Results: Included were 92 patients with isolated ACA and 16 patients with ICA-ACA TO stroke. On univariate analyses, patients with TO had more severe strokes on admission [median NIHSS (IQR) 13.5 (9-21) vs. 8 (5-12), p = 0.003] and were more often treated with thrombectomy (81 vs. 40%, p = 0.002). Mortality rates were higher among TO patients (31 vs. 11%, p = 0.03). Rates of favorable functional outcomes were numerically lower among TO patients (38 vs. 60%) but the difference was not statistically significant (p = 0.09). On multivariate analyses, the presence of TO did not modify the chances for favorable outcomes. Conclusion: TO stroke with ICA and isolated ACA involvement is rare and results in more severe initial neurological deficits and higher mortality compared to those seen in patients with isolated ACA stroke. [ABSTRACT FROM AUTHOR]

Background and Purpose: Distal medium vessel occlusions (DMVOs) are a significant contributor to acute ischemic stroke (AIS), with collateral status (CS) playing a pivotal role in modulating ischemic damage progression. We aimed to explore baseline characteristics associated with CS in AIS‐DMVO. Methods: This retrospective analysis of a prospectively collected database enrolled 130 AIS‐DMVO patients from two comprehensive stroke centers. Baseline characteristics, including patient demographics, admission National Institutes of Health Stroke Scale (NIHSS) score, admission Los Angeles Motor Scale (LAMS) score, and co‐morbidities, including hypertension, hyperlipidemia, diabetes, coronary artery disease, atrial fibrillation, and history of transient ischemic attack or stroke, were collected. The analysis was dichotomized to good CS, reflected by hypoperfusion index ratio (HIR) <.3, versus poor CS, reflected by HIR ≥.3. Results: Good CS was observed in 34% of the patients. As to the occluded location, 43.8% occurred in proximal M2, 16.9% in mid M2, 35.4% in more distal middle cerebral artery, and 3.8% in distal anterior cerebral artery. In multivariate logistic analysis, a lower NIHSS score and a lower LAMS score were both independently associated with a good CS (odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.82‐0.95, p <.001 and OR: 0.77, 95% CI: 0.62‐0.96, p =.018, respectively). Patients with poor CS were more likely to manifest as moderate to severe stroke (29.1% vs. 4.5%, p <.001), while patients with good CS had a significantly higher chance of having a minor stroke clinically (40.9% vs. 12.8%, p <.001). Conclusions: CS remains an important determinant in the severity of AIS‐DMVO. Collateral enhancement strategies may be a worthwhile pursuit in AIS‐DMVO patients with more severe initial stroke presentation, which can be swiftly identified by the concise LAMS and serves as a proxy for underlying poor CS. [ABSTRACT FROM AUTHOR]

This study describes our experiences with anterior choroidal artery (AChA) aneurysm clipping with a focus on visualizing the AChA just behind the aneurysm to identify the risk factors for adhesion of the AChA or its branches to the posterior wall of the AChA aneurysm. The initial segment of the AChA just behind the aneurysm was evaluated preoperatively using three-dimensional (3D) rotational angiography, and its course was designated as posteromedial, posterior, or posterolateral. The posterior aspect of the AChA aneurysm was inspected intraoperatively using an endoscope or micromirror. Based on 3D rotational angiography, the main trunk of the AChA showed a posteromedial (n = 47, 57.3%), posterior (n = 18, 22.0%), or posterolateral (n = 17, 20.7%) course just behind the aneurysm. Intraoperatively, 14.6% (12 of 82) of the clipped AChA aneurysms revealed an AChA branch adhered to the posterior wall of the aneurysm. A multivariate analysis revealed that the posterior or posterolateral course of the initial segment of the AChA was a statistically significant risk factor for adhesion of an AChA branch to the posterior wall of the aneurysm (odds ratio [OR] 21.083, 95% confidence interval [CI] 2.567–173.166, P = 0.005). The initial course of the AChA just behind an AChA aneurysm can be evaluated using 3D rotational angiography. In contrast to a posteromedial course, a posterior or posterolateral course of the AChA just behind an AChA aneurysm can be a significant risk factor for adhesion of an AChA branch to the posterior wall of an AChA aneurysm. [ABSTRACT FROM AUTHOR]

Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4–1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1–1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16–0.36), and thromboembolic events were observed after 3% (95%CI = 0.01–0.04) of procedures. Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin. [ABSTRACT FROM AUTHOR]

Objective: To confirm the usefulness of the extradural anterior clinoidectomy during the clipping of a low riding posterior communicating artery (PCoA) aneurysm through cadaver dissection. Methods: Anatomic measurements of 12 adult cadaveric heads (24 sides total) were performed to compare the microsurgical exposure of the PCoA and internal carotid artery (ICA) before and after clinoidectomy. A standard pterional craniotomy and transsylvian approach were performed in all cadavers. The distance from the ICA bifurcation to the origin of PCoA (D1), pre-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D2), post-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D3), pre-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D4) and post-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D5) and the distance of the ICA obtained after anterior clinoidectomy (D6) were measured. We measured the precise thickness of the blade for the Yasargil clip with a digital precision ruler to confirm the usefulness of the extradural anterior clinoidectomy. Results: Twenty-four sites were dissected from 12 cadavers. The age of the cadavers was 79.83±6.25 years. The number of males was the same as the females. The space from the proximal origin of the PCoA to the preclinoid-tentorium (D4) was 1.45±1.08 mm (max, 4.01; min, 0.56). After the clinoidectomy, the space from the proximal origin of the PCoA to the postclinoid-tentorium (D5) was 3.612±1.15 mm (max, 6.14; min, 1.83). The length (D6) of the exposed proximal ICA after the extradural clinoididectomy was 2.17±1.04 mm on the lateral side and 2.16±0.89 mm on the medial side. The thickness of the Yasargil clip blade used during the clipping surgery was 1.35 mm measured with a digital precision ruler. Conclusion: The proximal length obtained by performing an external anterior clinoidectomy is about 2 mm, sufficient for proximal control during PCoA aneurysm surgery, considering the thickness of the aneurysm clips. In a subarachnoid hemorrhage, performing an extradural anterior clinoidectomy could prevent a devastating situation during PCoA aneurysm clipping. [ABSTRACT FROM AUTHOR]

Neonates with congenital heart disease (CHD) have smaller brain volume at birth. High rates of placental vascular malperfusion lesions may play a role in disrupted brain development. This is a single-center retrospective cohort study of infants born between 2010 and 2019 who were diagnosed with a major cardiac defect requiring surgery in the first year of life. Doppler ultrasound RI of the middle cerebral artery (MCA) and anterior cerebral artery were calculated within the first 72 hours of life. Placentas were evaluated using a standardized approach. Over the study period, there were 52 patients with hypoplastic left heart syndrome (HLHS), 22 with single-ventricle right ventricular outflow tract obstruction (SV-RVOTO), 75 with a two-ventricle cardiac defect (2V), and 25 with transposition of the great arteries (TGA). MCA Doppler RI were significantly higher for all subgroups of CHD compared with control subjects (0.68 ± 0.11 in control subjects compared with 0.78 ± 0.13 in HLHS, P = 0.03; 0.77 ± 0.10 in SV-RVOTO, P = 0.002; 0.78 ± 0.13 in 2V, P = 0.03; and 0.80 ± 0.14 in TGA; P = 0.001) with the highest average MCA RI in the TGA group. In subgroup analyses, placental fetal vascular malperfusion in the 2V group was associated with higher MCA RI, but this relationship was not present in other subgroups, nor in regards to maternal vascular malperfusion. Major forms of CHD are associated with significantly higher cerebral artery RI postnatally, but placental vascular malperfusion lesions may not contribute to this hemodynamic adaptation. [ABSTRACT FROM AUTHOR]

Purpose: To describe a case of duplicated middle cerebral artery (MCA) combined with ipsilateral accessory MCA, forming a triplicated MCA, associated with the accessory anterior cerebral artery (ACA), forming a triplicated A2 segment of the ACA detected incidentally on magnetic resonance (MR) angiography. Methods: A 70-year-old woman with internal carotid artery (ICA) stenosis at the origin, which was detected by ultrasound, underwent cranial MR imaging and MR angiography of the intracranial region for an evaluation of brain and cerebral arterial lesions. The MR machine was a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. Results: Multiple ischemic white matter lesions are observed. No significant stenotic lesions were observed in intracranial arteries. The right duplicated MCA was originated from right distal ICA. And main MCA was originated from right ICA bifurcation. Right accessory MCA was arisen from the A2 segment of the right ACA. Thus, the right MCA was triplicated. There was also an accessory ACA forming a triplicated ACA at its A2 segment. These findings were clearly identified on partial volume-rendering (VR) images. Conclusion: We herein report a case of triplicated MCA associated with triplicated ACA. MCA variations are relatively rare, and this is the third case of triplicated MCA reported in relevant English-language literature. To identify multiple cerebral arterial variations, creating partial VR images using MR angiographic source images is useful. [ABSTRACT FROM AUTHOR]

Objective To explore the long-term outcome of intracranial-intracranial side-to-side bypass for complex intracranial aneurysms. Methods Five patients with complex intracranial aneurysms underwent intracranial-intracranial side-to-side bypass performed by the same surgeon at The First Hospital of China Medical University from January 2015 to December 2023 were included. Two cases involved the A2 segment of anterior cerebral artery (ACA) and 3 cases involved the M2 segment of middle cerebral artery (MCA). Indocyanine green angiography (ICGA) was used intraoperatively, and CTA or DSA was used postoperatively to evaluate aneurysm occlusion and blood flow reconstruction. The modified Rankin Scale (mRS) was used to evaluate the neurological prognosis at one week, 3 months and the last follow-up. CT/ MRI examination was completed on the first day, one week and 3 months after operation to evaluate whether hemorrhagic or ischemic complications occurred. Results Five cases of complex intracranial aneurysms were all occluded accurately. Two cases underwent A3-A3 side-to-side anastomosis, and 3 cases underwent M2-M2 side-to-side anastomosis, among which one case added M1-radial artery (RA)-M2 intracranialintracranial bypass with RA as graft on the basis of M2-M2 side-to-side anastomosis. During the operation, ICGA confirmed that the side-to-side anastomosis and M1-RA-M2 bypass were unobstructed in 5 cases. The postoperative follow - up time was 23 (14, 71) months. No aneurysm was found in cerebrovascular imaging examination one week and 3 months after operation in 5 patients, and 9 to 12 months after operation in 3 patients. Five side - to - side anastomosis stomas and one M1 - RA - M2 graft were all unobstructed. At one week after operation, the mRS increased by 0-3 score compared with that before operation (4 score maintained unchanged before and after operation in one case, 2 score increased in one case, and 3 score increased in one case). In 2 unruptured cases, the mRS score was 1 score at one week after operation, and there was no change from that before operation. At 3 months after operation, the mRS scores of 5 cases were decreased (2 cases with 0 score, one case with 2 score, and 2 cases with 3 score); one case was lost at the last follow-up, and the mRS scores of other 4 cases decreased further (2 cases with 0 score, one case with 1 score, and one case with 2 score). No cerebral hemorrhage or cerebral ischemia occurred in the follow-up. Conclusions Intracranial-intracranial side-to-side bypass has good short-term and long-term patency and stable long-term clinical effect. It is a reliable technique for surgical treatment of complex intracranial aneurysms.

Cerebral hyperperfusion syndrome is a rare but serious complication after revascularization procedures for cerebrovascular diseases. Cerebral hyperperfusion syndrome can develop after treatment of acute ischemic stroke, including intravenous thrombolysis and endovascular treatment of large vessel occlusion. However, to the best of our knowledge, there are no previous reports describing cerebral hyperperfusion syndrome after endovascular treatment of medium vessel occlusion (eg, anterior cerebral artery A2/3 segment). We report a case of cerebral hyperperfusion syndrome after endovascular reperfusion therapy for medium vessel occlusion. A 70-year-old woman with a history of hypertension and dyslipidemia was transferred by ambulance to our hospital because of immobility and slurred speech. She had mild right lower extremity paralysis, and her symptoms appeared improved compared with onset. She was diagnosed with cerebral infarction in the left frontal lobe. After hospitalization, her neurological symptoms worsened and she was referred to our department. We performed endovascular reperfusion therapy for left anterior cerebral artery A2 occlusion. Recanalization was achieved with residual stenosis. Despite the lack of complications associated with the procedure, the patient had prolonged disorientation, severe hemiplegia, and aphasia. Arterial spin labeling demonstrated hyperperfusion in the left anterior cerebral artery area. The symptoms gradually improved under strict blood pressure control. This report provides evidence that cerebral hyperperfusion syndrome can occur even after endovascular treatment for medium vessel occlusion. Arterial spin labeling was useful in detecting hyperperfusion.

We aimed to investigate risk factors for the recurrence of distal anterior cerebral artery (DACA) aneurysms after endovascular treatment (EVT). The clinical and radiologic outcomes of DACA aneurysms treated with endovascular methods at a single tertiary hospital from September 2008 to December 2021 were retrospectively reviewed. We measured the angle between 2 distal branches of DACA aneurysms and categorized the angle as follows: 1) wide-angle (≥180°), and 2) narrow-angle type configuration (<180°). Univariate and multivariate analyses were performed to demonstrate the relationships between characteristics of DACA aneurysm and recurrence risk. In total, 132 DACA aneurysms were treated in our institution. Among these, 47 DACA aneurysms after EVT were included in this study. Forty patients underwent coil embolization without stent, 7 for stent-assisted coil embolization. At the last follow-up (mean 30.2 ± 24.2 months), overall recurrence rate was 23.4% (n = 11). Recurrence rate of the wide-angle type (9 of 23, 39.1%) was significantly greater than narrow-angle type (2 of 24, 8.3%) (P = 0.041; odds ratio 8.174, 95% confidence interval 1.094–61.066). Irregular shape of the DACA aneurysm also showed significantly greater recurrence rate (P = 0.011; odds ratio 10.663, 95% confidence interval 1.701–66.838) after endovascular treatment. The wide-angle between 2 distal branches of DACA aneurysm and irregular shape might be independent risk factors for the recurrence after endovascular treatment for DACA aneurysms. [ABSTRACT FROM AUTHOR]

This article discusses the use of transoral and transesophageal ultrasound techniques in diagnosing bilateral carotid artery and aortic dissections. The case study presented involves an 86-year-old female patient who experienced a sudden decline in consciousness and was admitted to the intensive care unit. Due to anatomical and procedural limitations, traditional carotid ultrasound techniques were not possible, so the transoral approach was used instead. The ultrasound findings, along with other diagnostic imaging, suggested the presence of bilateral carotid dissection. The article emphasizes the potential of transoral and transesophageal ultrasound as point-of-care tools in diagnosing carotid and aortic dissections, especially in situations where other advanced imaging methods are not available. [Extracted from the article]

Moyamoya syndrome (MMS) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis at the apices of the intracranial internal carotid arteries, including the proximal anterior cerebral arteries and middle cerebral arteries. Cerebral angiography images are used for detection through measurement. Systemic lupus erythematosus (SLE) is an autoimmune disease that can cause multisystemic involvement. The coexistence of SLE and MMS has been rarely reported in the literature. A 46-year-old male patient with malar rash, Raynaud phenomenon presented to the hospital with a complaint of weakness in the left lower extremity, which began 3 days before the date of the visit. In the diffusion magnetic resonance imaging, multiple diffusion restrictions were observed in the right frontal region. The patient underwent MR angiography, revealing stenosis in the terminal and supraclinoid segments of the right internal carotid artery, which made us consider moyamoya disease. This patient, with a malar rash and Raynaud's, a positive antibody profile, was diagnosed as a male with SLE accompanied by MMS. [ABSTRACT FROM AUTHOR]

Proximal or A1 segment anterior cerebral artery (ACA) aneurysms are rare aneurysms. They have certain unique properties when compared to all other intracranial aneurysms. They are smaller and prone to an early rupture. Thus, they need an aggressive intervention even when they are less than 7 mm in size. The technical difficulties that arise in their management are based on their location along the length and circumference of the ACA. Accordingly, they have been variously classified in literature. Their intimate relationship to the medial lenticulostriate perforators and the recurrent artery of Heubner is the prime factor in determining the surgical or endovascular strategy and outcome. These aneurysms are commonly associated with vascular anomalies, needing a thorough interpretation of preoperative angiograms. Though there are many series reporting the clinical features and management outcome of proximal ACA aneurysms, all are limited by a small sample size due to the rarity of the pathology. In this article, the pertinent literature related to the surgical nuances associated with dealing with A1 segment aneurysms is reviewed. The clinical presentation, associated anatomical characteristics, microsurgical management, role of endovascular therapy, and outcome are discussed. [ABSTRACT FROM AUTHOR]

Background Over the last two decades, there have been development of approaches that are minimally invasive but achieve maximum effective results with minimal morbidity. The supraorbital keyhole approach (SOKHA) through the transciliary incision is minimally invasive approach that permits effective management of skull base lesions with minimal injury to the soft tissue and surrounding brain. Aims The aim of this study was to evaluate the efficacy and safety of SOKHA for skull base lesions. Settings and Design This is a prospective study in a tertiary neurosurgical teaching institute in a metropolitan city. Materials and Methods Twenty-one patients of various pathology were operated using the SOKHA through the "eye-brow incision." The pathologies included pituitary adenoma, craniopharyngioma, epidermoid, tuberculum sella, and planum sphenoidale meningioma. The authors describe in detail the surgical approach employed by them for these various pathologies. Results All neoplastic lesions in this series could be addressed effectively with near total or total excision. No fresh postoperative deficits were noted except a case who developed ipsilateral anterior cerebral artery infarction that resulted in lower limb weakness. One patient developed postoperative abscess requiring surgical excision. At follow-up, all patients revealed a cosmetic scar hidden by the eye brow. Conclusion The SOKHA is an effective minimally invasive procedure with proven safety for the management of anterior, selected middle skull base lesions and to provide excellent cosmesis with minimal trauma to the adjacent brain. The authors, however, feel that it is technically demanding and surgeons should employ a stepwise progression from simple to more complex lesions. [ABSTRACT FROM AUTHOR]

Background & Objective: The prevalence of hyponatremia in subarachnoid hemorrhage (SAH) was 30-55%. There was lack of evidence about predictive factors and clinical outcomes of hyponatremia in SAH patients. This study aimed to evaluate factors associated with hyponatremia following SAH and to review the clinical outcomes and treatment of hyponatremia in SAH patients. Method: This is a retrospective cohort study. SAH patients presented during January 2013 to January 2019 were reviewed. They were divided into 2 groups: SAH with normonatremia and SAH with hyponatremia. Clinical data, laboratory profile, aneurysm characteristics and clinical outcomes were recorded and analyzed. Result: A total number of 278 patients with SAH were included, 139 patients in each group. The populations were female 66% with mean age of 56 years old and mean serum sodium (Na) level 132 mmol/L. Aneurysm location associated with hyponatremia; anterior cerebral artery (ACA) (OR 4.2, 95%CI 1.4-13.0, p-value 0.009) and posterior cerebral artery (PCA) (OR 3.7, 95%CI 1.2-11.5, p-value 0.017). Aneurysms clipping procedure was also associated with hyponatremia (OR 4.0, 95%CI 1.8-8.8, p-value < 0.001). Conclusion: ACA and PCA aneurysms and aneurysms clipping procedure were risk factors for hyponatremia following SAH. Mild hyponatremia was not associated with morbidity and mortality in SAH patients. [ABSTRACT FROM AUTHOR]

Purpose: Knowledge of neurovascular anatomy is vital for neurosurgeons, neurologists, neuro-radiologists and anatomy students, amongst others, to fully comprehend the brain's anatomy with utmost depth. This paper aims to enhance the foundational knowledge of novice physicians in this area. Method: A comprehensive literature review was carried out by searching the PubMed and Google Scholar databases using primary keywords related to brain vasculature, without date restrictions. The identified literature was meticulously examined and scrutinized. In the process of screening pertinent papers, further articles and book chapters were obtained through analysis and additional assessing of the reference lists. Additionally, four formalin-fixed, color latex-injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089 USA). Using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002 USA). Ulterior anatomical dissection was documented in microscopic images. Results: Encephalic circulation functions as a complex network of intertwined vessels. The Internal Carotid Arteries (ICAs) and the Vertebral Arteries (VAs), form the anterior and posterior arterial circulations, respectively. This work provides a detailed exploration of the neurovascular anatomy of the anterior circulation and its key structures, such as the Anterior Cerebral Artery (ACA) and the Middle Cerebral Artery (MCA). Embryology is also briefly covered, offering insights into the early development of the vascular structures of the central nervous system. Cerebral venous system was detailed, highlighting the major veins and tributaries involved in the drainage of blood from the intracranial compartment, with a focus on the role of the Internal Jugular Veins (IJVs) as the primary, although not exclusive, deoxygenated blood outflow pathway. Conclusion: This work serves as initial guide, providing essential knowledge on neurovascular anatomy, hoping to reduce the initial impact when tackling the subject, albeit the intricate vasculature of the brain will necessitate further efforts to be conquered, that being crucial for neurosurgical and neurology related practice and clinical decision-making. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to investigate the morphometric properties of the internal carotid artery (ICA) by measuring the diameters and angles of its segments and exploring variations related to sex and the presence of aneurysms. Methods: Digital subtraction angiography (DSA) images were utilized from 130 aneurysm patients and 75 non-aneurysm individuals to create 3D ICA models using 3D Slicer software. Segment diameters were measured via Autodesk Meshmixer 3.5.474 and angles were evaluated using ImageJ software. Results: In total, DSA images of 130 aneurysm patients and 75 individuals with normally reported carotid systems were evaluated. It was found that the intracranial aneurysms (IAs) were predominantly formed on the anterior cerebral artery (ACA) in males (%43), whereas in females IAs were frequently localized in the C6 segment (31.7%) and middle cerebral artery (MCA) (30.2%). In the control group, the evaluation of gender differences in segment diameters and angles revealed that males had significantly larger C4 and C5 segment diameters (4.62 vs. 4.32 mm and 4.41 vs. 4.09 mm, respectively) and a greater C6 angle (146.9° vs. 139.7°) compared to females. Comparisons between patients with an aneurysm at the anterior cerebral artery (ACA) and the control group revealed that the ACA group had wider diameters in the C1 (4.88 vs. 4.53 mm), C3 (4.65 vs. 4.4 mm), C5 (4.51 vs. 4.25 mm), and ACA (2.36 vs. 2.06 mm) segments. Additionally, the ACA group had wider angles in the ACA (104.1° vs. 94.1°) and C6 segments (147.7° vs. 143.3°), whereas the control group exhibited wider angles in the middle cerebral artery (MCA) segment (141.5° vs. 135.5°) compared to the ACA aneurysm group. Patients with anterior cerebral artery (ACA) aneurysms exhibited larger diameters in C1, C3, C5, C6, and ACA segments compared to the control group. Additionally, while the control group had larger MCA angle, patients with ACA aneurysms had larger angles in C6 segment and ACA. Conclusion: Our results demonstrated that formation of aneurysms is affected by anatomical configuration of the ICA as well as sex characteristics, particularly regarding the ACA and MCA bifurcation angles, which showed associations with aneurysms in the respective branches. [ABSTRACT FROM AUTHOR]

Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our institution. The inclusion criterion was extravasation or coil protrusion during CE. Postoperative data were used to confirm rupture points, and computational fluid dynamics (CFD) analysis was performed to assess hemodynamic characteristics, focusing on maximum pressure (Pmax) and wall shear stress (WSS). IPR occurred in six aneurysms (1.3%; three ruptured and three unruptured), with a dome size of 4.7 ± 1.8 mm and a D/N ratio of 1.5 ± 0.5. There were four aneurysms in the internal carotid artery (ICA), one in the anterior cerebral artery, and one in the middle cerebral artery. ICA aneurysms were treated using adjunctive techniques (three balloon-assisted, one stent-assisted). Two aneurysms (M1M2 and A1) were treated simply, yet had relatively small and misaligned domes. CFD analysis identified the rupture point as a flow impingement zone with Pmax in five aneurysms (83.3%). Time-averaged WSS was locally reduced around this area (1.3 ± 0.7 [Pa]), significantly lower than the aneurysmal dome (p < 0.01). Hemodynamically unstable areas have fragile, thin walls with rupture risk. A microcatheter was inserted along the inflow zone, directed towards the caution area. These findings underscore the importance of identifying hemodynamically unstable areas during CE. Adjunctive techniques should be applied with caution, especially in small aneurysms with axial misalignment, to minimize the rupture risk. [ABSTRACT FROM AUTHOR]

BACKGROUND: Subarachnoid hemorrhage (SAH) represents a severe injury to the brain and is associated with a high mortality (40%). Several experimental SAH models are described in the literature requiring specialized equipment and a high degree of surgical expertise. Our goal was to validate a simplified, cost-effective model to permit future studies of SAH. METHODS: SAH was induced by injection of homologous blood into the cisterna magna. Perfusion-fixation then perfusion of gelatinous India ink was performed. Brains and brainstems were collected and imaged for analysis of cerebral vasospasm. Triphenyl tetrazolium chloride (TTC) staining was used to analyze brain tissue cell death 24 hours following stroke. A composite neuroscore was utilized to assess SAH-related neurologic deficits. RESULTS: Anterior cerebral artery and basilary artery diameters were significantly reduced at 24 hours post SAH induction. Middle cerebral artery diameter was also reduced; however, the results were not significant. TTC staining showed no infarcted tissue. Neuroscores were significantly lower in the SAH mice, indicating the presence of functional deficits. CONCLUSIONS: This simplified model of SAH elicits pathological changes consistent with those described for more complex models in the literature. Therefore, it can be used in future preclinical studies examining the pathophysiology of SAH and novel treatment options. [ABSTRACT FROM AUTHOR]

Objective: During cerebral aneurysm embolization of the anterior circulation, the guiding catheter (GC) should be placed as distally as possible in the cervical internal carotid artery (ICA) to secure the maneuverability of the microcatheter and distal access catheter. However, if the shape of the tip of the GC does not appropriately match the course of the ICA, blood stasis might occur. We investigated whether shaping the tip of the GC into an S-shape would allow more stable catheterization to the distal ICA than the conventional GC with an angled tip. Methods: We included patients with cerebral aneurysms of the anterior circulation who were treated at our institution from April 2019 to April 2021. First, we evaluated the cervical ICA course in these patients through cerebral angiography and classified the courses into type S, type I, and type Z. Then, we focused on the most frequently encountered type-S cervical ICA to investigate the forging effect of the GC tip into an S-shape. We evaluated the lateral view of the carotid angiograms to examine whether the catheter tip reached the foramen magnum (FM) without interrupting ICA blood flow. The effects of age, sex, side, a history of hypertension and smoking, and an S-shape modification of the GC tip on the outcome of GC placement were analyzed. Results: A total of 67 patients were included in this study. The tip of the GC was placed at the FM in 27 cases. Among these factors, only the S-shape modification was significantly associated with whether the GC could be placed at the level of the FM (p <0.0001). Conclusion: By forging the tip of the GC into an S-shape, the GC can be safely advanced to the distal part of the cervical ICA, which may contribute to the improved maneuverability of microcatheters. [ABSTRACT FROM AUTHOR]

• The main objective of the article was to study the safety on the anterior cerebral artery after FD coverage of the A1 artery. • The study results indicate that covering the A1 artery did not significantly affect blood flow in the perfused area of the anterior cerebral artery. Perfusion was ensured through side branch compensation and abundant anastomotic branches. • All ischemic complications were observed in the study occurred in the perioperative period and could be ameliorated by conservative treatment or interventional procedures, and patients had a good prognosis. • Risk of ischemic complications related to the anterior cerebral artery even if the anterior communicating artery is open after FD placement. Few studies on ischemic complications and flow changes after a flow diverter covering the anterior cerebral artery. The purpose of the study was to explore the ischemic complications and anatomical alterations associated with the flow diverter after it covers the anterior cerebral artery. In this single-center study, patients treated with FD covering the anterior cerebral artery at the First Affiliated Hospital of Zhengzhou University were retrospectively collected. The primary endpoint was ischemic complications related to the anterior cerebral artery. Secondary endpoints were anatomical changes in the anterior cerebral artery postoperatively and at follow-up. A total of 59 patients were included in this study. Four (6.8%) patients presented with ischemic stroke symptoms. Immediately after the procedure, complete occlusion of A1 and decreased blood flow was observed in 13 (22.0%) and 21 patients (35.6%), respectively. At follow-up, A1 artery was occluded in 34 patients (57.6%) and decreased blood flow was observed in 10 patients (16.9%). Symptoms of neurological deficits related to the anterior cerebral artery were not observed in all patients at follow-up. Coverage of A1 is safe, with a low incidence of ischemic stroke, when using an FD to treat aneurysms. Risk of reduced perfusion of the anterior cerebral artery postoperatively even if the anterior communicating artery is open. In cases with A1 occlusion, the blood flow in the distal the anterior cerebral artery can be adequately compensated by opening the anterior communicating artery and good vascular anastomoses. [ABSTRACT FROM AUTHOR]

Background Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO. Method This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2--3--4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques. Results A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03). Conclusion Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times. [ABSTRACT FROM AUTHOR]

Background Medium vessel occlusions (MeVOs) comprise a large proportion of all stroke events. We performed a multicenter study of MIVI Q catheters, a novel design that optimizes suction forces without an increase in lumen diameter, for the treatment of MeVOs, aiming to evaluate its efficacy and safety. Methods Databases of two US and two UK centers were retrospectively reviewed for MeVO patients (M2- M3, anterior cerebral artery (ACA), or posterior cerebral artery (PCA)) treated with Q catheters. Outcomes were assessed as successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2b), first pass effect (FPE), and modified FPE (mFPE) as single pass achieving mTICI ≥2c and mTICI≥2b, respectively, and 90 day modified Rankin Scale (mRS) score. Results 69 patients were included (median age 71 years, IQR 56--82.5; 52.2% men). Median National Institutes of Health Stroke Scale (NIHSS) score at admission was 14, and Alberta Stroke Program Early CT Score (ASPECTS) was 9. Primary (without large vessel occlusion (LVO)) and secondary (with LVO) MeVOs represented 47.8% and 52.2% of cases, respectively. Q catheters used were Q3 (47.8%), Q4 (33.3%), Q5 (10.1%), and Q6 (8.7%). mTICI≥2b was achieved in 92.8% of patients, with FPE in 47.8%, and mFPE in 68.1%. Two (2.9%) intraprocedural complications (symptomatic intracranial hemorrhage) occurred. 50% (27/54) achieved an mRS score of ≤2 at the 90 day follow-up. The median NIHSS at admission was significantly higher in secondary than in primary MeVOs (19.5 vs 12, P=0.009). The rate of mRS ≤2 at 90 days was significantly higher in primary than in secondary MeVOs (77.3% vs 31.3%, P=0.002). Conclusions Treatment of MeVO patients with Q catheters resulted in optimal angiographic and clinical outcomes. Although angiographic results were similar between primary and secondary MeVOs, the former had less severe presenting NIHSS and better outcomes at 90 days than the latter. [ABSTRACT FROM AUTHOR]

Background: A relationship between the geometry and symmetry of Willis' circle and intracranial aneurysms was reported for anterior communicating and posterior communicating (PCom) aneurysms. A similar association with the middle cerebral artery (MCA) aneurysms instead appeared weaker. Methods: We reviewed 432 patients from six Italian centers with unilateral MCA aneurysms, analyzing the relationship between the caliber and symmetry of Willis' circle and the presence of ruptured and unruptured presentation. CT-angiograms were evaluated to assess Willis' circle geometrical characteristics and the MCA aneurysm side, dimension and rupture status. Results: The hypoplasia of the first segment of the anterior cerebral artery (A1) was in approximately one-quarter of patients and PCom hypoplasia was in almost 40%. About 9% had a fetal PCom ipsilaterally to the aneurysm. By comparing the aneurysmal and healthy sides, only the PCom hypoplasia appeared significantly higher in the affected side. Finally, the caliber of the internal carotid artery (ICA) and the first segment of MCA (M1) caliber were significantly greater in patients with unruptured aneurysms, and PCom hypoplasia appeared related to the incidence of an ipsilateral MCA aneurysm and its risk of rupture. Conclusions: Although according to these findings asymmetries of Willis' circle are shown to be a risk factor for MCA aneurysm formation and rupture, the indifferent association with ipsilateral or contralateral hypoplasia remains a datum of difficult hemodynamic interpretation, thereby raising the concern that this association may be more casual than causal. [ABSTRACT FROM AUTHOR]

Background: Perioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting. Case presentation: A 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow. Conclusion: Subclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering. [ABSTRACT FROM AUTHOR]

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the supraclinoid internal carotid artery. As a result of chronically decreased brain perfusion, eloquent areas of the brain become hypoperfused, leading to cognitive changes in patients. Repeated infarcts and bleeds produce clinically apparent neurologic deficits. 1) To study the functional and neuropsychological outcome in MMD after revascularization surgery. 2) To find postrevascularization correlation between functional and neuropsychological improvement and radiologic improvement. A single-center prospective and analytic study was carried out including 21 patients with MMD during the study period from March 2021 to December 2022. Patients were evaluated and compared before and after revascularization for functional, neuropsychological, and radiologic status. Postoperative functional outcome in terms of modified Rankin Scale score showed improvement in 33.33% of cases (P = 0.0769). An overall improving trend was observed in different neuropsychological domains in both adult and pediatric age groups. However, the trend of neuropsychological improvement was better in adults compared with pediatric patients. Radiologic outcome in the form of the Angiographic Outcome Score (AOS) significantly improved after revascularization (P = 0.0001). There was a trend toward improvement in magnetic resonance imaging (MRI) perfusion in the middle cerebral artery and anterior cerebral artery territories, 4.7% (P = 0.075) and 9.33% (P = 0.058) respectively, compared with preoperative MRI perfusion. After revascularization, significant improvement occurred in functional and neuropsychological status. This result was also shown radiologically as evidenced by improvement in MRI perfusion and cerebral angiography. [ABSTRACT FROM AUTHOR]

Aphasia assessment primarily examines an individual's syntax, nouns, and verbs. However, modifiers, such as adjectives and number words, and bound morphemes can be the subject of considerable difficulty for individuals with aphasia. The Morphosyntactic Generation (MorGen) targets nouns, modifiers, and bound inflectional morphemes in two-word phrases among people with aphasia. The purpose of this work is to provide the first report of the MorGen in hyperacute-acute aphasia. In doing so, we aim to (1) examine the MorGen's concurrent validity with common assessments of aphasia; (2) describe performance in modifiers by people with acute aphasia; and (3) associate MorGen performance with extent of lesioned vascular territories in acute stroke. 62 adult English speakers within the first 14 days of left hemisphere ischemic stroke and 61 healthy control participants completed the MorGen. In addition to receiving the MorGen, participants with stroke received the Western Aphasia Battery (WAB), Boston Naming Test, and Hopkins Action Naming Assessment. Clinical MRIs were analyzed for the extent of lesion in the vascular territory of the left anterior, medial, and posterior cerebral artery, as well as the left posterior choroidal and thalamoperforator arteries. Aim 1: Performance on the MorGen demonstrated consistently high, significant correlations with that on the WAB, Boston Naming Test, and Hopkins Action Naming Assessment. Aim 2: Individuals who had a stroke but were within functional limits (WFL) on the WAB performed significantly worse than healthy controls on the MorGen, driven by differences in adjective performance. When controlling for aphasia severity, those with fluent aphasia performed significantly better in their production of nouns, plurals, number, size, and color than those who had non-fluent aphasia, but both groups were similarly inclined to omit genitive marking. Aim 3: Lesions in the territory of the temporal branch of the posterior cerebral artery were associated with poorer performance in nouns, size, and color. Lesions in the territory of the anterior cerebral artery were associated with poorer performance in numbers. This work highlights the value of the MorGen as a tool for post-stroke language evaluation that complements the skills captured in more widely-used assessments such as the WAB and BNT. [ABSTRACT FROM AUTHOR]

Clinically, circle of Willis (CoW) is prone to anomaly and is also the predominant incidence site of intracranial aneurysms (IAs). This study aims to investigate the hemodynamic characteristics of CoW anomaly, and ascertain the mechanism of IAs initiation from the perspective of hemodynamics. Thus, the flow of IAs and pre-IAs were analyzed for one type of cerebral artery anomaly, that is, anterior cerebral artery A1 segment (ACA-A1) unilateral absence. Three patient geometrical models with IAs were selected from Emory University Open Source Data Center. IAs were virtually removed from the geometrical models to simulate the pre-IAs geometry. For calculation methods, a one-dimensional (1-D) solver and a three-dimensional (3-D) solver were combined to obtain the hemodynamic characteristics. The numerical simulation revealed that the average flow of Anterior Communicating Artery (ACoA) is almost zero when CoW is complete. In contrast, ACoA flow increases significantly in the case of ACA-A1 unilateral absence. For per-IAs geometry, the jet flow is found at the bifurcation between contralateral ACA-A1 and ACoA, which exhibits characteristics of high Wall Shear Stress (WSS) and high wall pressure in the impact region. It triggers the initiation of IAs from the perspective of hemodynamics. The vascular anomaly that leads to jet flow should be considered as a risk factor for IAs initiation. [ABSTRACT FROM AUTHOR]

Morphological and morphometric variants of the anterior communicating artery (AComA) have been described by multiple studies; however, a complete classification system of all possible morphological variants with their prevalence is lacking. The current systematic review with meta-analysis combines data from different databases, concerning the AComA morphological and morphometric variants (length and diameter). Emphasis was given to the related clinical implications to highlight the clinical value of their knowledge. The typical AComA morphology occurs with a pooled prevalence (PP) of 67.3%, while the PP of atypical AComA is 32.7%. The identified AComA morphological variants (artery's hypoplasia, absence, duplication, triplication, differed shape, fenestration, and the persistence of a median artery of the corpus callosum- MACC) were classified in order of frequency. The commonest presented variants were the AComA hypoplasia (8%) and the anterior cerebral artery (ACA) fusion (5.9%), and the rarest ones were the MACC persistence (2.3%), and the AComA triplication (0.7%). The knowledge of those variants is essential, especially for neurosurgeons operating in the area. Given the high prevalence of AComA aneurysms, an adequate and complete classification of those variants is of utmost importance. [ABSTRACT FROM AUTHOR]

Introduction: Wada test is well-known to assess lateralization of memory and language functions; however, super-selective Wada (ss-Wada) to evaluate motor leg function is rare. We present a ss-Wada test within the anterior cerebral artery (ACA) to assess the motor function of the leg. Methods: Retrospective chart review. Results: Comprehensive phase-I/II surgical evaluation revealed an ictal focus around the left post-central gyrus with immediate involvement around the left para-central regions. To avoid potential right leg motor dysfunction with the surgery, the patient underwent a ss-Wada procedure. Angiography revealed bilateral ACAs were supplied by the left A1 segment. Super-selective microcatheter injection of amobarbital into the left ACA was performed to avoid cross-filling the contralateral ACA. The ss-Wada test confirmed no right leg motor impairment. Afterward, a craniotomy with direct cortical stimulation confirmed that the left-sided ictal/peri-ictal zone had no clear leg motor function. The patient underwent disconnection of that region and remained seizure-free at 10-month post-op follow-up without any motor or sensory deficits in the right limbs. Conclusion: This case demonstrates the proof of concept for ss-Wada in assessing lower extremity motor function. The ss-Wada procedure accurately predicted no motor deficits in the right leg, consistent with preserved motor function post-surgery. [ABSTRACT FROM AUTHOR]

This summary describes a surgical procedure for treating paraclinoid internal carotid artery aneurysms. The procedure involves accessing the aneurysm through a contralateral interoptic approach, which avoids the need for an anterior clinoidectomy or excessive manipulation of the optic nerve. The authors provide detailed steps of the procedure, including incising the lamina terminalis, dissecting the optic nerve, and using microsurgical techniques to dissect and clip the aneurysm. They also discuss the advantages and drawbacks of microsurgical treatment compared to endovascular therapy. The authors conclude that the contralateral interoptic approach is a safe and effective alternative for treating small- to medium-sized paraclinoid aneurysms. [Extracted from the article]