Characterization of Lenticulostriate Arteries and Its Associations With Vascular Risk Factors in Community-Dwelling Elderly

Lenticulostriate arteries (LSAs) supply blood to important subcortical areas and are, therefore, essential for maintaining the optimal functioning of the brain’s most metabolically active nuclei. Past studies have demonstrated the potential for quantifying the morphology of LSAs as biomarkers of vascular fragility or underlying arteriopathies. Thus, the current study aims to evaluate the morphological features of LSAs, their potential value in cerebrovascular risk stratification, and their concordance with other vascular risk factors in community-dwelling elderly people. A total of 125 community-dwelling elderly subjects who underwent a brain MRI scan were selected from our prospectively collected imaging database. The morphological measures of LSAs were calculated on the vascular skeletons obtained by manual tracing, and the number of LSAs was counted. Additionally, imaging biomarkers of small vessel disease were evaluated, and the diameters of major cerebral arteries were measured. The effects of vascular risk factors on LSA morphometry, as well as the relationship between LSA measures and other imaging biomarkers, were investigated. We found that smokers had shorter (p = 0.04) and straighter LSAs (p < 0.01) compared to nonsmokers, and the presence of hypertension is associated with less tortuous LSAs (p = 0.03) in community-dwelling elderly. Moreover, the middle cerebral artery diameter was positively correlated with LSA count (r = 0.278, p = 0.025) and vessel tortuosity (r = 0.257, p = 0.04). The posterior cerebral artery diameter was positively correlated with vessel tortuosity and vessel length. Considering the scarcity of noninvasive methods for measuring small artery abnormalities in the brain, the LSA morphological measures may provide valuable information to better understand cerebral small vessel degeneration during aging.

Treatment of a Giant Thrombotic M1 Segment Middle Cerebral Artery Aneurysm With Radial Artery Bypass and Distal Occlusion to Create a “Blind Sac” Following Endovascular Failure: 2-Dimensional Operative Video

The case is of a 36-yr-old male with a previously coiled aneurysm arising from the proximal M1 segment of the middle cerebral artery (MCA) just beyond the internal carotid artery (ICA) bifurcation who presented to our institution with subjective left hemiparesis, headache, and vomiting. Physical exam revealed a left facial droop, but neurological exam was otherwise normal, including full motor strength. Neuroimaging showed a large partially thrombosed aneurysm recurrence, measuring 5.2 cm, with obstructive hydrocephalus. Cerebral angiogram showed filling within a small portion of the aneurysm and marked stenosis of the MCA beyond the neck. A ventriculostomy was placed, and he underwent a pterional craniotomy for high-flow radial artery bypass from the common carotid artery to an M2 branch of the MCA and clip placement. This case demonstrates the creation of a blind sac by placing a clip on the MCA distal to the aneurysm and proximal to the lenticulostriate arteries for the treatment of a giant proximal M1 segment aneurysm. Postoperative digital subtraction angiography shows the MCA distribution, including the lenticulostriate arteries, filling through the radial artery bypass, and anterograde flow through the ICA, which perfuses up to and including the anterior choroidal artery. There is no residual filling of the aneurysm. The patient remained at his neurological baseline postoperatively and required ventriculoperitoneal shunt placement for hydrocephalus. At outpatient follow-up, computed tomography imaging showed decreased size of the thrombosed aneurysm, measuring 4.5 cm, and he had no neurological deficits. The patient gave informed consent for surgery and deidentified video recording of this case.

EARLY AGE ARTERIAL ISCHEMIC STROKE ASSOCIATED WITH MINERALIZING LENTICULOSTRIATAL ANGIOPATHY AND MILD TRAUMATIC BRAIN INJURY

Study aims: 1) to evaluate the significance of mineralizing angiopathy of lenticulostriate arteries (MALA) in the development of arterial ischemic stroke (AIS) in children; 2) to study clinical and neuroimaging signs of AIS that develops after a head injury and does not meet the criteria of known disease types. Material and methods: to achieve the first aim, groups were formed: 1) the main group – patients with AI, n=86, Me 2,9 years; control – healthy children, n=131, Me 3,2 years. In the compared groups, neurosonography (NSG) protocols were studied for MALA. For the second aim, anamnesis and data from a clinical neuroimaging examination of 106 patients with AIS (Me 2,9 years) were analyzed. Stroke type was identified by the Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation (CASCADE). Results: MALA increases the risk of AIS (ОR 16,15 [95% CI 5,43–48,1]). Stroke that does not meet the criteria of 1–5 types according to CASCADE is often associated with MALA. Clinical of AIS in patients with MALA are early age and mild head trauma (F=6,9, R=0,73, p<0,0001); the onset is marked by the absence of fever, vomiting, seizures, Glasgow coma scale 13, improvement in the first week (F=8,49, R=0,546, p<0,0001). Neuroimaging signs are the basal ganglia lacunar infarct and the absence of cerebral arteriopathy according to magnetic resonance angiography (F=52,8, R=0,402, p<0,0001). The percentage of this type stroke in children with AIS is 26,4%. Conclusion: MALA is a risk factor of AIS in children. AIS in infants which is associated with mineralizing angiopathy of lenticulostriate arteries and mild head trauma is an independent type of stroke. For its verification, computed tomography or NSG are needed.

Plaque Distribution Correlates With Morphology of Lenticulostriate Arteries in Single Subcortical Infarctions

Background and Purpose: We aimed to use novel whole-brain vessel-wall magnetic resonance imaging (WB-VWI) to investigate the association between plaque distribution of middle cerebral artery (MCA) and morphological changes of the lenticulostriate arteries (LSAs) in single subcortical infarctions. Methods: Forty single subcortical infarction patients with no relevant MCA disease on magnetic resonance angiography were prospectively enrolled. Plaque location in the MCA was dichotomized as proximal (located adjacent to the LSA origin) or distal (located distal to the LSA origin) on whole-brain vessel-wall magnetic resonance imaging. The MCAs with proximal plaques were divided into the symptomatic and asymptomatic side, and asymptomatic side MCAs without proximal plaques were the control group. The morphological characteristics of the LSAs and features of proximal plaques were analyzed. Results: A total of 71 MCAs in 40 patients were analyzed (31 on the symptomatic side, 22 on the asymptomatic side, and 18 in the control group). Superior-wall plaques of MCAs were observed more frequently on the symptomatic side than the asymptomatic side (45.2% versus 9.1%, P =0.005). The wall area index, plaque burden, and remodeling index did not differ significantly between the symptomatic and asymptomatic side. The number of LSA branches was smaller ( P =0.011) in the symptomatic side (5.48±1.88) compared with the control group (6.83±1.92). The symptomatic side exhibited shorter average length of the LSAs (23.23±3.44 versus 25.75±3.76 mm, P =0.025) and shorter average distance of the LSAs (16.47±3.11 versus 21.53±4.76 mm, P <0.001) compared with the asymptomatic side. Conclusions: Superiorly distributed MCA plaques at the LSA origin are closely associated with morphological changes of the LSA in symptomatic MCAs, suggesting that the distribution, rather than the inherent features of plaques, determines the occurrence of single subcortical infarctions. Our findings provide insight into the etiologic mechanism of branch atheromatous disease in single subcortical infarctions.

Creation of a Middle Communicating Artery With External Carotid Artery-Radial Artery Graft-M2 Middle Cerebral Artery Interpositional Bypass and M2 Middle Cerebral Artery-M2 Middle Cerebral Artery Reimplantation for a Recurrent Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Dolichoectatic aneurysms of the middle cerebral artery (MCA) bifurcation pose unique treatment challenges.1 One treatment consists of an extracranial-intracranial (EC-IC) interpositional bypass and double-reimplantation of the M2 divisions.2-8 We present a variation of this construct in which an M2 MCA-M2 MCA end-to-side reimplantation was performed, creating a middle communicating artery (MCoA). The patient, a 61-yr-old woman, had previously undergone a “picket fence” clip reconstruction of an unruptured, giant left MCA bifurcation aneurysm in 2014.9 After the patient provided informed written consent for treatment, a 5-yr surveillance angiogram revealed substantial aneurysm regrowth opposite the clips. A pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. Proximal external carotid artery-radial artery graft (ECA-RAG) anastomosis was performed to arterialize the graft. The distal RAG was anastomosed end-to-side to the temporal division of the M2 segment, and the vessel proximal to the bypass inflow was transected from the aneurysm. We repurposed this “dead-end” as an MCoA by end-to-side reimplantation onto a branch of the frontal M2 trunk. The superior trunk was then clip occluded at its origin at the aneurysm. The aneurysm could not be proximally occluded due to lenticulostriate arteries arising from the back of the bifurcation. Postoperative angiography confirmed patency of the MCoA and its donor bypasses. The aneurysm no longer filled, and the lenticulostriate arteries were preserved. The patient was discharged on postoperative day 3 and made an excellent recovery (3-mo modified Rankin Scale [mRS] = 1). The MCoA is a novel construct that redistributed flow from the interpositional graft into the superior trunk, without the need for additional ischemia time while working with the inferior trunk. Used with permission from Barrow Neurological Institute.