scholarly journals Fetal posterior communicating artery as a conduit for concurrent anterior and posterior circulation infarct: A case report

2021 ◽  
Vol 3 (4) ◽  
pp. 7-11
Author(s):  
Mohamed Azlam Mohamed Micdhadhu ◽  
Ko Hin Kho ◽  
Mazeda Murad ◽  
Irene Looi
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Sudden Onset ◽  
Posterior Circulation ◽  
Posterior Communicating Artery ◽  
Left Middle Cerebral Artery ◽  
Anterior Circulation ◽  
Stroke Treatment

Fetal type posterior cerebral artery (FTPCA) is a variant of posterior circulation of brain, in which the distal part of posterior cerebral artery (PCA) is perfused by a branch of internal carotid artery (ICA) via fetal posterior communicating artery (fetal PCOM). In the presence of fetal PCOM, a paradoxical concurrent infarction of anterior and posterior circulation may happen. We report a 67-year-old man who presented with sudden onset right sided weakness and aphasia, with National Institutes of Health Stroke Scale (NIHSS) score of 22 and clinically diagnosed to have left total anterior circulation infarct (TACI). Subsequently, he received IV Alteplase as a standard hyperacute ischemic stroke treatment. Computed tomography angiography (CTA) of brain showed left FTPCA with prominent left fetal PCOM. Subsequent computed tomography (CT) of brain showed concurrent left middle cerebral artery (MCA) and PCA territories infarct. CTA brain is commonly done in ischemic stroke cases to assess presence of large vessel occlusions and intracranial or extracranial atherosclerotic disease. However, this case depicts its additional role in detecting anatomical variants of cerebral circulation. In terms of clinical importance, presence of multiple territories infarction portends a poorer neurological outcome.

scholarly journals Reclassifications of ischemic stroke patterns due to variants of the Circle of Willis

2021 ◽  
pp. 174749302110483
Author(s):  
Ida Rangus ◽  
Lennart S Milles ◽  
Ivana Galinovic ◽  
Kersten Villringer ◽  
Heinrich J Audebert ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Magnetic Resonance ◽  
Magnetic Resonance Angiography ◽  
Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Circle Of Willis ◽  
Posterior Circulation ◽  
Correct Identification ◽  
Anterior Circulation ◽  
Ischemic Lesion

Background Variants of the Circle of Willis (vCoW) may impede correct identification of ischemic lesion patterns and stroke etiology. We assessed reclassifications of ischemic lesion patterns due to vCoW. Methods We analyzed vCoW in patients with acute ischemic stroke from the 1000+ study using time-of-flight magnetic resonance angiography (TOF MRA) of intracranial arteries. We assessed A1 segment agenesis or hypoplasia in the anterior circulation and fetal posterior cerebral artery in the posterior circulation. Stroke patterns were classified as one or more-than-one territory stroke pattern. We examined associations between vCoW and stroke patterns and the frequency of reclassifications of stroke patterns due to vCoW. Results Of 1000 patients, 991 had evaluable magnetic resonance angiography. At least one vCoW was present in 37.1%. VCoW were more common in the posterior than in the anterior circulation (33.3% vs. 6.7%). Of 238 patients initially thought to have a more-than-one territory stroke pattern, 20 (8.4%) had to be reclassified to a one territory stroke pattern after considering vCoW. All these patients had fetal posterior cerebral artery and six (30%) additionally had carotid artery disease. Of 753 patients initially presumed to have a one-territory stroke pattern, four (0.5%) were reclassified as having more-than-one territory pattern. Conclusions VCoW are present in about one in three stroke patients and more common in the posterior circulation. Reclassifications of stroke lesion patterns due to vCoW occurred predominantly in the posterior circulation with fetal posterior cerebral artery mimicking multiple territory stroke pattern. Considering vCoW in these cases may uncover symptomatic carotid disease.

scholarly journals Posterior cerebral artery stenosis and posterior circulation revascularization surgery in pediatric patients with moyamoya disease

2018 ◽  
Vol 21 (6) ◽  
pp. 632-638 ◽  
Author(s):  
Tomomi Kimiwada ◽  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Posterior Cerebral Artery ◽  
Posterior Circulation ◽  
Initial Diagnosis ◽  
Occipital Artery ◽  
Anterior Circulation ◽  
Before And After ◽  
Revascularization Surgery

OBJECTIVESome pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.METHODSThe presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.RESULTSTwenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.CONCLUSIONSPCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

scholarly journals Bilateral cerebral infarction associated with severe arteriosclerosis in the A1 segment: a case report

2019 ◽  
Vol 47 (3) ◽  
pp. 1373-1377
Author(s):  
Jing Lin ◽  
Wenbiao Xian ◽  
Rong Lai ◽  
Jiaoxing Li ◽  
Yufang Wang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Anterior Communicating Artery ◽  
Left Middle Cerebral Artery ◽  
Large Artery ◽  
Anterior Circulation ◽  
The Right ◽  
Left Middle

Large artery atherosclerosis and cardioembolism are the two major subtypes of ischemic stroke. We herein describe a 75-year-old man with acute complete cerebral infarction in the typical territories of the bilateral anterior cerebral artery (ACA) and left middle cerebral artery. Brain magnetic resonance angiography showed that the right A1 segment of the ACA was affected by severe arteriosclerosis and that the right ACA other than the A1 segment was compensated by the left ACA through the anterior communicating artery. Acute cardioembolism only occluded the left anterior circulation but simultaneously blocked the right ACA due to decompensation. We presume that the bilateral cerebral infarctions were caused by chronic atherosclerosis and acute cardioembolism.

scholarly journals Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

2021 ◽  
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Adam A. Dmytriw ◽  
Waleed Brinjikji ◽  
Guilherme Dabus ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Computed Tomography Angiography ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

Abstract BACKGROUND Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. METHODS We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. RESULTS There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. CONCLUSIONS Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

Abstract W P400: Headache at the Onset of Anterior versus Posterior Circulation Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Caroline Cahill ◽  
Kiersten Espaillat ◽  
Emily Gilchrist ◽  
Michael Froehler
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Artery ◽  
Medical Center ◽  
Retrospective Chart Review ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Pain Pathways ◽  
Significant Difference ◽  
Chi Squared ◽  
The Rich

Background: Past evidence suggests that there is a higher incidence of onset headache with posterior rather than anterior circulation stroke. We sought to further explore this connection in order to better understand the mechanisms underlying onset headache and to examine this symptom in relation to ischemic stroke. Methods: A retrospective chart review was conducted of 253 patients who presented to Vanderbilt University Medical Center in 2013 with ischemic stroke in either the anterior or posterior circulation. The significant difference between the incidence of onset headache in the anterior and posterior circulation territories was analyzed using a chi-squared test of independence. The frequency of onset headache was compared between the two groups, as well as between more specific locations within the posterior circulation and the middle cerebral artery (MCA). Results: A total of 48 (19%) of patients reported experiencing onset headache. Of those, 12 (25%) suffered a stroke in the anterior circulation, while 28 (58%) suffered a stroke in the posterior circulation (The remaining 8 were excluded due to multiple infarcts or poorly defined territories). Analysis was done comparing the MCA, the posterior cerebral artery (PCA), and the vertebrobasilar territories. The frequency of onset headache was 21% for vertebrobasilar stroke, 6.1% for MCA stroke, and 33% for PCA stroke. Compared to the other areas, PCA stroke showed a significantly higher rate of headache as a symptom at onset (χ 2 = 18.60, p < 0.001, ϕc = 0.312). Furthermore, 20 (42%) of the 48 patients in this study who had reported onset headache were found to have suffered ischemia of the thalamus. Conclusions: Patients who suffered a stroke in the PCA territory were more likely to have experienced a headache at stroke onset. Given the rich blood supply to the thalamus from the posterior circulation, an additional mechanism linking ischemic stroke in the PCA to thalamic pain pathways should be further scrutinized as a possible cause for onset headache.

scholarly journals Medium cerebral artery thrombosis – radiological fing: hyperdense MCA sign – case report

2021 ◽  
Author(s):  
Bruno Custódio Silva ◽  
Vivianne Amanda do Nascimento ◽  
Maria Isabelle Nakano Vieira ◽  
Guilherme Rocha Spiller ◽  
Celso David Lago
Keyword(s):  
Ischemic Stroke ◽  
Case Report ◽  
Cerebral Artery ◽  
Radiological Finding ◽  
Vascular Diseases ◽  
Left Middle Cerebral Artery ◽  
Stroke Treatment ◽  
Temporal Lobes ◽  
Common Etiology ◽  
Treatment Prognosis

Introduction: Vascular diseases are the leading cause of death in the world. Although major advances in neuroimaging and stroke treatment have contributed to a decrease in mortality, strokes occupy second place in the list. Case report: A 75-year-old man is admitted to emergency with an altered neurological examination: right hemiplegia, Broca’s aphasia and dysphagia. Conscience was preserved. Computed tomography (CT) was performed, which showed the radiological finding of hyperdense MCA sign, confirming the diagnosis of ischemic stroke with involvement of the left middle cerebral artery branch. The treatment, in this case, was outside the criteria for thrombolytics. Discussion: Irrigation of the brain is done by Willis polygon. One of the essential branches is the medium cerebral artery (MCA), the most important termination of the internal carotid arteries, responsible for blood supply of the dorsolateral hemifacial of both cerebral hemispheres, irrigating the frontal, parietal and temporal lobes. The imaging exam in suspected cases of stroke focuses on confirming its diagnosis and etiology, location of the lesion, extent of ischemic evolution, therapeutic treatment and prognosis. CT is the main modality of neuroimaging for stroke and an important radiological finding is the hyperdense artery sign, which is more common in MCA and demonstrates an evolving or impending infarction and is secondary to a plunger housed in this vessel. Therefore, it is an important early tomographic sign of ischemic stroke found on non-contrast blood CT. Conclusion: Ischemic stroke is the most common etiology among strokes. The diagnosis must be based mainly on anamnesis and image exam, such as a CT scan. The CT performed helps to guide treatment, prognosis and clinical evolution. Finally, the recognition of the hyperdense MCA sign, found in the first 6 hours, is also extremely helpful for stroke classification.

scholarly journals Automated Detection of Intracranial Large Vessel Occlusions on Computed Tomography Angiography

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2790-2798 ◽  
Author(s):  
Shalini A. Amukotuwa ◽  
Matus Straka ◽  
Heather Smith ◽  
Ronil V. Chandra ◽  
Seena Dehkharghani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Middle Cerebral Artery Occlusion ◽  
Negative Predictive Value ◽  
Cerebral Artery ◽  
Predictive Value ◽  
Artery Occlusion ◽  
Anterior Circulation ◽  
Cerebral Artery Occlusion

Background and Purpose— Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke. Methods— Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients’ computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion. Results— CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60–80). Median processing time was 158 seconds (IQR, 150–167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion. Conclusions— The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.

scholarly journals Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke

2021 ◽  
pp. 0271678X2098239
Author(s):  
Adam E Goldman-Yassen ◽  
Matus Straka ◽  
Michael Uhouse ◽  
Seena Dehkharghani
Keyword(s):  
Ischemic Stroke ◽  
Selection Criteria ◽  
Arterial Input Function ◽  
Anatomic Variation ◽  
Input Function ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Perfusion Time

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

scholarly journals The anesthetic approach for endovascular recanalization therapy depends on the lesion site in acute ischemic stroke

2021 ◽  
Author(s):  
Kilian Fröhlich ◽  
Gabriela Siedler ◽  
Svenja Stoll ◽  
Kosmas Macha ◽  
Thomas M. Kinfe ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Posterior Circulation ◽  
Neurological Deficits ◽  
Stroke Severity ◽  
Lesion Volume ◽  
Middle Cerebral Artery Territory ◽  
Cerebral Lesion

Abstract Purpose Endovascular therapy (EVT) of large-vessel occlusion in acute ischemic stroke (AIS) may be performed in general anesthesia (GA) or conscious sedation (CS). We intended to determine the contribution of ischemic cerebral lesion sites on the physician’s decision between GA and CS using voxel-based lesion symptom mapping (VLSM). Methods In a prospective local database, we sought patients with documented AIS and EVT. Age, stroke severity, lesion volume, vigilance, and aphasia scores were compared between EVT patients with GA and CS. The ischemic lesions were analyzed on CT or MRI scans and transformed into stereotaxic space. We determined the lesion overlap and assessed whether GA or CS is associated with specific cerebral lesion sites using the voxel-wise Liebermeister test. Results One hundred seventy-nine patients with AIS and EVT were included in the analysis. The VLSM analysis yielded associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas. Stroke severity and lesion volume were significantly higher in the GA group. The prevalence of aphasia and aphasia severity was significantly higher and parameters of vigilance lower in the GA group. Conclusions The VLSM analysis showed associations between GA and ischemic lesions in the left hemispheric middle cerebral artery territory and posterior circulation areas including the thalamus that are known to cause neurologic deficits, such as aphasia or compromised vigilance, in AIS-patients with EVT. Our data suggest that higher disability, clinical impairment due to neurological deficits like aphasia, or reduced alertness of affected patients may influence the physician’s decision on using GA in EVT.

scholarly journals Predictors for affected stroke territory and outcome of acute stroke treatments are different for posterior versus anterior circulation stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
H. Handelsmann ◽  
L. Herzog ◽  
Z. Kulcsar ◽  
A. R. Luft ◽  
S. Wegener
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Patient Characteristics ◽  
Posterior Circulation ◽  
University Hospital ◽  
Outcome Predictors ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
The University ◽  
Median Admission

AbstractDistinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790–0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935–0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111–3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806–0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory.

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