scholarly journals Topographic Evolution of Anterior Cerebral Artery Infarction and Its Impact on Motor Impairment

2021 ◽  
pp. 1-11
Author(s):  
Tharani Thirugnanachandran ◽  
Henry Ma ◽  
Jason Vuong ◽  
Melissa Mitchell ◽  
Chloe Wong ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Primary Motor Cortex ◽  
Anterior Cerebral Artery ◽  
Motor Deficit ◽  
Vessel Occlusion ◽  
Fiber Tracts ◽  
Human Connectome Project ◽  
Motor Outcome ◽  
Proportional Contribution ◽  
The Impact

<b><i>Introduction:</i></b> Motor deficit is common following anterior cerebral artery (ACA) stroke. This study aimed to determine the impact on the motor outcome, given the location of descending corticofugal fiber tracts (from the primary motor cortex [M1], dorsal and ventral premotor area [PMdv], and supplementary motor area [SMA]) and the regional variations in collateral support of the ACA territory. <b><i>Methods:</i></b> Patients with ACA vessel occlusion were included. Disruption to corticofugal fibers was inferred by overlap of tracts with a lesion on computed tomography perfusion at the onset and on magnetic resonance imaging (MRI) poststroke. The motor outcome was defined by dichotomized and combined National Institute of Health Stroke Scale (NIHSS) sub-scores for the arm and leg. Multivariate hierarchical partitioning was used to analyze the proportional contribution of the corticofugal fibers to the motor outcome. <b><i>Results:</i></b> Forty-seven patients with a median age of 77.5 (interquartile range 68.0–84.5) years were studied. At the stroke onset, 96% of patients showed evidence of motor deficit on the NIHSS, and the proportional contribution of the corticofugal fibers to motor deficit was M1-33%, SMA-33%, and PMdv-33%. By day 7, motor deficit was present in &#x3c;50% of patients and contribution of M1 fiber tracts to the motor deficit was reduced (M1-10.2%, SMA-61.0%, PMdv-28.8%). We confirmed our findings using publicly available high-resolution templates created from Human Connectome Project data. This also showed a reduction in involvement of M1 fiber tracts on initial perfusion imaging (33%) compared to MRI at a median time of 7 days poststroke (11%). <b><i>Conclusion:</i></b> Improvements in the motor outcome seen in ACA stroke may be due to the relative sparing of M1 fiber tracts from infarction. This may occur as a consequence of the posterior location of M1 fiber tracts and the evolving topography of ACA stroke due to the compensatory capacity of leptomeningeal anastomoses.

Azygous Anterior Cerebral Artery Acute Occlusion Managed With Endovascular Mechanical Thrombectomy: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (4) ◽  
pp. 514-515 ◽  
Author(s):  
Leonardo Rangel-Castilla ◽  
Adnan H Siddiqui
Keyword(s):  
Cerebral Artery ◽  
Cerebral Blood Volume ◽  
Mechanical Thrombectomy ◽  
Anterior Cerebral Artery ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Acute Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Azygous Anterior Cerebral Artery

Abstract Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3 × 30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4 × 40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

Endovascular treatment of anterior cerebral artery occlusions

2021 ◽  
pp. neurintsurg-2021-017735
Author(s):  
Mayank Goyal ◽  
Petra Cimflova ◽  
Johanna Maria Ospel ◽  
René Chapot
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Ct Perfusion ◽  
Correct Diagnosis ◽  
Motor Deficit ◽  
Anterior Communicating Artery ◽  
Routine Basis ◽  
Multiphase Ct ◽  
High Level

There are limited data on endovascular treatment (EVT) for anterior cerebral artery (ACA) occlusions. This review focuses on aspects related to ACA EVT: ACA anatomy, clinical and imaging findings, prognosis of ACA stroke, and ACA thrombectomy techniques. The ACA anatomy, and the regions supplied by the ACA, are highly variable; frequent anatomical variants include azygos ACA, triplicated ACA and fenestrations of the anterior communicating artery. ACA occlusions can be classified based on occlusion location, their continuity with other vessel occlusions (isolated ACA occlusion vs ACA occlusion as part of a carotid T occlusion) and etiology (primary—spontaneous ACA occlusion, vs secondary—spontaneous or iatrogenic due to clot fragmentation/migration). Symptoms of ACA stroke differ in severity and nature due to large inter-individual variations in territorial ACA blood supply. Generally, ACA strokes are severely disabling, and the typical clinical hallmark is a motor deficit of the contralateral lower extremity. Advanced imaging (CT perfusion, multiphase CT angiography) increases the likelihood of the correct diagnosis of ACA stroke and should be obtained on routine basis.Available data for ACA EVT suggest its feasibility and safety while clinical outcomes are often unfavorable with conservative management. Therefore, the potential benefit of EVT seems obvious. An optimized endovascular approach for ACA thrombectomy comprises the development and use of smaller and softer devices that can be delivered through small microcatheters with an optimized vector of force. Ultimately, generating high-level evidence for ACA EVT from randomized trials remains warranted.

THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 610-617 ◽  
Author(s):  
Leonie Jestaedt ◽  
Mirko Pham ◽  
Andreas J. Bartsch ◽  
Ekkehard Kunze ◽  
Klaus Roosen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Balloon Angioplasty ◽  
Anterior Cerebral Artery ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Fisher Exact Test ◽  
Computed Tomographic ◽  
Fisher Grade ◽  
The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (&gt;70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P &lt; 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

scholarly journals Unruptured Aneurysm: Vasospasm after Surgery and Endovascular Treatment

2001 ◽  
Vol 7 (1) ◽  
pp. 37-39 ◽  
Author(s):  
O. Gutiérrez ◽  
J.G.M.P. Caldas ◽  
J.P. Rabello
Keyword(s):  
Cerebral Artery ◽  
Therapeutic Strategy ◽  
Anterior Cerebral Artery ◽  
Ruptured Aneurysm ◽  
Motor Deficit ◽  
Computed Tomography Scan ◽  
Ongoing Research ◽  
Pathological Conditions ◽  
Clinical Consequences ◽  
Tomography Scan

Arterial cerebral vasospasm in different pathological conditions other than subarachnoid haemorrhage (SAH) caused by ruptured aneurysm is uncommon. The haemodynamics-clinical consequences of such conditions makes a quick diagnosis, vital to choose the best therapeutic strategy. A 55-year-old woman presented chronic headache. Computed tomography scan revealed an image suggesting carotid aneurysm on the left which was confirmed by digital angiography in the ophthalmic segment. Programmed surgery of clipping aneurysm was carried out without complications. The patient remained without morbidity for the first 16 hours, then she developed progressive aphasia, right motor deficit and loss of consciousness. The angiography showed severe vasospasm in horizontal segments of anterior cerebral artery (A1) and middle cerebral artery (M1). Vasodilatation with topic papaverine by selective microcatheterism in A1 and M1 segments achieved clinical-radiological success in time. The patient was discharged on the seventh day, with Glasgow Coma Scale (GCS) 15/15 and slight right hemiparesis. Vasospasm pathogenesis in conditions other than SAH from ruptured aneurysm remains a scientific frontier for ongoing research. We know about the short half-life effect of papaverine and believe that the success in this particular case was accurate and definite due to the fact that the mechanism of the spasm presented no bleeding in the subarachnoid cisterns.

ANTERIOR CEREBRAL ARTERY AMPUTATION AND SALVAGE REPAIR OF INTERNAL CAROTID ARTERY TEAR

Neurosurgery ◽  
2009 ◽  
Vol 65 (4) ◽  
pp. E820-E822 ◽  
Author(s):  
Scott D. Wait ◽  
Steven W. Chang ◽  
Brendan D. Killory ◽  
William L. White ◽  
Robert F. Spetzler
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Anterior Cerebral Artery ◽  
Primary Repair ◽  
Suture Repair ◽  
Collateral Flow ◽  
The Impact

Abstract OBJECTIVE We describe a novel technique used to repair an unanticipated tear of the internal carotid artery (ICA) requiring anterior cerebral artery (ACA) amputation to allow primary repair of the arteriotomy. CLINICAL PRESENTATION A 59-year-old woman underwent an orbitozygomatic craniotomy to treat a large, suprasellar, thyroid-stimulating hormone-secreting adenoma. During resection, an incidental ICA tear occurred opposite the exit of the middle cerebral artery. TECHNIQUE After an ICA tear on the wall opposite the middle cerebral artery occurred, clips were placed on the ICA, middle cerebral artery, and ACA. Primary closure was not feasible without critically stenosing the ICA. The ipsilateral ACA was clipped and amputated just distal to its origin. The relaxation afforded by amputating the ACA allowed primary suture repair of the arteriotomy. A clip was placed on the proximal ACA stump. The distal ACA stump revealed good backflow and was also clipped. CONCLUSION When an arteriotomy of a large intracranial artery cannot be repaired primarily, creative alternatives must be considered. Amputation of a branch artery with sufficient collateral flow is a method to afford adequate relaxation for primary repair of an arteriotomy. This novel method should be considered in the armamentarium of neurosurgeons to minimize the impact of potentially disastrous vascular complications.

scholarly journals A review of endovascular treatment for medium vessel occlusion stroke

2021 ◽  
pp. neurintsurg-2021-017321
Author(s):  
Johanna Maria Ospel ◽  
Mayank Goyal
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Intravenous Thrombolysis ◽  
Standard Of Care ◽  
Current Standard ◽  
Vessel Occlusion ◽  
Clear Guideline ◽  
Being There

Medium-vessel occlusions (MeVOs), that is, occlusions of the M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery segments, account for 25%–40% of all acute ischemic stroke cases. Clinical outcomes of MeVO stroke with intravenous thrombolysis, which is the current standard of care, are moderate at best. With improving imaging technologies and a growing literature, MeVOs are increasingly recognized as a target for endovascular treatment (EVT). For the time being, there is limited but promising evidence for the safety and efficacy of MeVO EVT, and many neurointerventionists are already routinely offering EVT for MeVO stroke, despite the lack of clear guideline recommendations. In this article, we review the evidence on endovascular treatment for MeVO stroke and summarize the available literature on current imaging strategies, commonly used EVT selection criteria, EVT techniques, and outcome assessment for MeVO stroke.

scholarly journals Impact of eloquent motor cortex-tissue reperfusion beyond the traditional thrombolysis in cerebral infarction (TICI) scoring after thrombectomy

2020 ◽  
pp. neurintsurg-2020-016834
Author(s):  
Radoslav Raychev ◽  
Hamidreza Saber ◽  
Jeffrey L Saver ◽  
Jason D Hinman ◽  
Scott Brown ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Motor Cortex ◽  
Cerebral Infarction ◽  
Cerebral Artery ◽  
Primary Motor Cortex ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Stroke Disability ◽  
Symptomatic Intracranial Hemorrhage ◽  
The Impact

BackgroundTargeted eloquence-based tissue reperfusion within the primary motor cortex may have a differential effect on disability as compared with traditional volume-based (thrombolysis in cerebral infarction, TICI) reperfusion after endovascular thrombectomy (EVT) in the setting of acute ischemic stroke (AIS).MethodsWe explored the impact of eloquent reperfusion (ER) within primary motor cortex (PMC) on clinical outcome (modified Rankin Scale, mRS) in AIS patients undergoing EVT. ER-PMC was defined as presence of flow on final digital subtraction angiography (DSA) within four main cortical branches, supplying the PMC (middle cerebral artery (MCA) – precentral, central, postcentral; anterior cerebral artery (ACA) – medial frontal branch arising from callosomarginal or pericallosal arteries) and graded as absent (0), partial (1), and complete (2). Prospectively collected data from two centers were analyzed. Multivariate analysis was conducted to assess the impact of ER-PMC on 90-day disability (mRS) among patients with anterior circulation occlusion who achieved partial reperfusion (TICI 2a and 2b).ResultsAmong the 125 patients who met the study criteria, ER-PMC distribution was: absent (0) in 19/125 (15.2%); partial (1) in 52/125 (41.6%), and complete (2) in 54/125 (43.2%). TICI 2b was achieved in 102/125 (81.6%) and ER-PMC was substantially higher in those patients (P<0.001). In multivariate analysis, in addition to age and symptomatic intracranial hemorrhage, ER-PMC had a profound independent impact on 90-day disability (OR 6.10, P=0.001 for ER-PMC 1 vs 0 and OR 9.87, P<0.001 for ER-PMC 2 vs 0), while the extent of total partial reperfusion (TICI 2b vs 2a) was not related to 90-day mRS.ConclusionsEloquent PMC-tissue reperfusion is a key determinant of functional outcome, with a greater impact than volume-based (TICI) degree of partial reperfusion alone. PMC-targeted revascularization among patients with partial reperfusion may further diminish post-stroke disability after EVT.

scholarly journals Anterior Cerebral Artery Stroke: Role of Collateral Systems on Infarct Topography

Stroke ◽  
2021 ◽  
Author(s):  
Tharani Thirugnanachandran ◽  
Richard Beare ◽  
Melissa Mitchell ◽  
Chloe Wong ◽  
Jason Vuong ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Computer Model ◽  
Anterior Cerebral Artery ◽  
Artery Occlusion ◽  
Anterior Cingulate ◽  
Anterior Communicating Artery ◽  
Cingulate Gyrus ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Background and Purpose: The circle of Willis (CoW) and leptomeningeal anastomoses play an important role in transforming infarct topography following middle cerebral artery occlusion. Their role in infarct topography following anterior cerebral artery occlusion is not well understood. The aim of this study was to evaluate the role of the CoW and leptomeningeal anastomoses in modifying regional variation in infarct topography following occlusion of the anterior cerebral artery and its branches. Methods: Perfusion and magnetic resonance imaging of patients with anterior cerebral artery stroke and evidence of vessel occlusion were segmented and manually registered to standard brain template for voxel-wise comparison. Next, a computer model of the cerebral arteries was formulated as network of nodes connected by cylindrical pipes. The experiments included occlusion of successive branches of the anterior cerebral artery while the configurations of the CoW were varied. Results: Forty-seven patients with a median age of 77.5 years (interquartile range, 68.0–84.5 years) were studied. The regions with the highest probabilities of infarction were the superior frontal gyrus (probability =0.26) and anterior cingulate gyrus (probability =0.24). The regions around the posterior cingulate gyrus (probability =0.08), paracentral lobule (probability =0.05), precuneus and superior parietal lobule (probability =0.03) had a low probability of infarction. Following occlusions distal to the anterior communicating artery, the computer model demonstrated an increase in flow (>30%) in neighboring cortical arteries with leptomeningeal anastomoses. Conclusions: Traditionally the CoW has been regarded as the primary collateral system. However, our computer model shows that the CoW is only helpful in redirecting flow following proximal vessel occlusions (pre-anterior communicating artery). More important are leptomeningeal anastomoses, which play an essential role in distal vessel occlusions, influencing motor outcome by modifying the posterolateral extent of infarct topography.

scholarly journals Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion

2021 ◽  
pp. 131-136
Author(s):  
Tomoyuki Yoshihara ◽  
Ryuzaburo Kanazawa ◽  
Takanori Uchida ◽  
Tetsuhiro Higashida ◽  
Hidenori Ohbuchi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Active Zone ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Maximum Intensity Projection ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Mca Occlusion ◽  
The Impact

<b><i>Background:</i></b> The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. <b><i>Methods:</i></b> This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. <b><i>Results:</i></b> We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5–1.9] vs. 1.2 [1.2–1.5] mm, <i>p</i> = 0.007) and shorter length (7.1 [4.9–9.7] vs. 12.3 [7.2–15.8] mm, <i>p</i> = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). <b><i>Conclusion:</i></b> In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

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