Low Bifurcation of The Left Common Carotid Artery Associated With Klippel–Feil Syndrome And Severe Stenosis of The Bilateral Proximal Middle Cerebral Artery

BackgroundThe bifurcate position of the common carotid artery is protean. It is most often locating between the C3 and C5 vertebral levels.Intrathoracic bifurcation of common carotid artery is a rare anatomic finding,and an association with bilateral segmental severe stenosis of middle cerebral artery has not been reported in the past literature .we report a case of low bifurcation of the left common carotid artery associated with Klippel–Feil syndrome and severe stenosis of the bilateral proximal middle cerebral artery.Case PresentationA 47-years old woman presented with dizziness and sleep disturbance,whose computed tomography angiography image incidentally revealed an intrathoracic bifurcation of the left common carotid artery associated with bilateral segmental severe narrowing of middle cerebral artery（MCA）.The left transverse process and spinous process of C3-4 fused and posterior arch of atlas did not fuse on Volume rendered（VR） imaging. ConclusionWe should not only pay attention to the variation of the neck vessels, but also to the serious secondary changes of intracranial vessels caused by neck vessels variation. Low carotid bifurcation may cause chronic progressive stenosis /occlusion of the proximal MCA or severe ischemic stroke events .

No Association Between Thrombus Perviousness and Cardioembolic Stroke Etiology in Basilar Artery Occlusion Stroke

Background: Thrombus perviousness (TP) quantified by thrombus attenuation increase (TAI) assessed on acute non-contrast computed tomography (NCCT) and CT angiography (CTA) may be associated with stroke etiology in anterior circulation ischemic stroke. We investigated whether TP is associated with stroke etiology and recanalization after mechanical thrombectomy in patients with acute basilar artery occlusion (BAO).Methods: Eighty patients with complete BAO and in-house acute imaging from a prospectively maintained database were included. Two raters independently segmented the complete thrombus on co-registered NCCT and CTA to determine TAI in Hounsfield units (HUCTA–HUNCCT); averaged values of the raters were used for analysis. Recanalization to modified treatment in cerebral ischemia (mTICI) score 2b/3 was considered successful, and 90-day modified Rankin Scale score 0–2 was considered favorable.Results: TAI did not differ between patients with different stroke etiologies; median TAI in patients with cardioembolic stroke (n = 36) was −0.47 (interquartile range −4.08 to 7.72), 1.94 (−8.14 to 10.75) in patients with large artery atherosclerosis (LAA; n = 25), and −0.99 (−6.49 to 5.40) in patients with stroke of undetermined origin (n = 17; p = 0.955). Binary logistic regression analyses did not identify TAI as an independent indicator of cardioembolic stroke (adjusted odds ratio [OR] vs. LAA stroke: 1.0 [95% CI: 0.95–1.0], p = 0.751). There was no association with successful recanalization (adjusted OR 1.4 [0.70–2.7], p = 0.345) or favorable outcome (adjusted OR 1.1 [95% CI: 0.94–1.2], p = 0.304).Conclusion: In contrast to proximal middle cerebral artery occlusions, TP in BAO patients is not associated with cardioembolic stroke etiology. Larger confirmatory studies to establish the potential role of TP for clinical applications should focus on patients with anterior circulation stroke.

Partially thrombosed middle cerebral artery-lenticulostriate artery aneurysm with native radiological examinations suggesting proximal lenticulostriate artery aneurysm: A case report

Background: Preservation of the lenticulostriate artery (LSA) is crucial. LSAs usually cannot be spared with LSA aneurysms, when surgical clipping/excision or endovascular embolization of the LSA itself is performed. On the other hand, the LSA should be separated and preserved for proximal middle cerebral artery (M1)-LSA aneurysms. Case Description: We report a case of M1-LSA aneurysm with native radiological examinations suggesting LSA aneurysm. The highlight of this unusual case was that during surgery, the aneurysm orifice was almost covered with thrombus and blood flow in an aneurysm that appeared separate from M1. Partial thrombectomy-clip reconstruction was performed, and M1 and LSAs were well preserved. Conclusion: Even with currently developed radiological modalities, thrombosed intracranial aneurysms may be misdiagnosed, depending on intraluminal flow conditions. Intraoperative findings from craniotomy sometimes contribute to a better understanding of the pathophysiology and decisions on appropriate treatment strategy.

Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study

Background and purpose Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. Materials and methods Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. Results In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. Conclusion Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

Early Thrombectomy Protects the Internal Capsule in Patients With Proximal Middle Cerebral Artery Occlusion

Background and Purpose: Proximal middle cerebral artery (MCA) occlusions impede blood flow to the noncollateralized lenticulostriate artery territory. Previous work has shown that this almost inevitably leads to infarction of the dependent gray matter territories in the striate even if perfusion is restored by mechanical thrombectomy. Purpose of this analysis was to evaluate potential sparing of neighboring fiber tracts, ie, the internal capsule. Methods: An observational single-center study of patients with proximal MCA occlusions treated with mechanical thrombectomy and receiving postinterventional high-resolution diffusion-weighted imaging was conducted. Patients were classified according to internal capsule ischemia (IC+ versus IC−) at the postero-superior level of the MCA lenticulostriate artery territory (corticospinal tract correlate). Associations of IC+ versus IC− with baseline variables as well as its clinical impact were evaluated using multivariable logistic or linear regression analyses adjusting for potential confounders. Results: Of 92 included patients with proximal MCA territory infarctions, 45 (48.9%) had an IC+ pattern. Longer time from symptom-onset to groin-puncture (adjusted odds ratio, 2.12 [95% CI, 1.19–3.76] per hour), female sex and more severe strokes were associated with IC+. Patients with IC+ had lower rates of substantial neurological improvement and functional independence (adjusted odds ratio, 0.26 [95% CI, 0.09–0.81] and adjusted odds ratio, 0.25 [95% CI, 0.07–0.86]) after adjustment for confounders. These associations remained unchanged when confining analyses to patients without ischemia in the corona radiata or the motor cortex and here, IC+ was associated with higher National Institutes of Health Stroke Scale motor item scores (β, +2.8 [95% CI, 1.5 to 4.1]) without a significant increase in nonmotor items (β, +0.8 [95% CI, −0.2 to 1.9). Conclusions: Rapid mechanical thrombectomy with successful reperfusion of the lenticulostriate arteries often protects the internal capsule from subsequent ischemia despite early basal ganglia damage. Salvage of this eloquent white matter tract within the MCA lenticulostriate artery territory seems strongly time-dependent, which has clinical and pathophysiological implications.

Abstract P466: Comparison of Three Automated Ct Perfusion Software Packages for Thrombectomy Eligibility and Final Infarct Volume Prediction

Introduction: We aimed to compare the perfusion parametric maps and the determination of predicted ischemic core between three automated CT perfusion software packages: RAPID (IschemaView), Viz CTP (Viz.ai) and e-Mismatch (Brainomix). Methods: Retrospectively review of a prospective database spanning September 2018-November 2019 with the following inclusion criteria: 1) acute large vessel occlusion strokes (LVOS) involving the intracranial internal carotid artery or proximal middle cerebral artery (M1 segment), 2) available CTP images, 3) final complete/near-complete endovascular reperfusion (eTICI2c-3) and 4) follow-up imaging with final infarct volume (FIV) assessment. Results: A total of 242 cases were included. There was a strong correlation for rCBF<30% between RAPID and Viz CTP (r s =0.844, p<.001) as well of RAPID and e-Mismatch (r s =0.833, p<.001). Similarly, strong correlation for Tmax>6s were observed between RAPID and Viz CTP (r s =0.892, p<0.001) as well for RAPID and e-Mismatch (r s =0.752, p<.001). The accuracy for FIV prediction was found to be moderate in all three packages (RAPID: r s =0.637, p<.001; Viz CTP: r s =0.601, p<.001; e-Mismatch: r s =0.605, p<.001)(Figure). Ghost core (defined as FIV overestimation >10ml within 6 hours from stroke onset) was identified in 10 (15.9%) RAPID, 15 (23.8%) Viz CTP and 3 (4.7%) e-Mismatch cases. Conclusion: The key CTP parameters for the RAPID, Viz CTP and e-Mismatch packages strongly correlate. CTP predictability of final infarct volume remains moderate and requires further evaluation.

Impact of Clot Shape on Successful M1 Endovascular Reperfusion

Objectives: The susceptibility-vessel-sign (SVS) allows thrombus visualization, length estimation and composition, and it may impact reperfusion during mechanical thrombectomy (MT). SVS can also describe thrombus shape in the occluded artery: in the straight M1-segment (S-shaped), or in an angulated/traversing a bifurcation segment (A-shaped). We determined whether SVS clot shape influenced reperfusion and outcomes after MT for proximal middle-cerebral-artery (M1) occlusions.Methods: Between May 2015 and March 2018, consecutive patients who underwent MT at one comprehensive stroke center and who had a baseline MRI with a T2* sequence were included. Clinical, procedural and radiographic data, including clot shape on SVS [angulated/bifurcation (A-SVS) vs. straight (S-SVS)] and length were assessed. Primary outcome was successful reperfusion (TICI 2b-3). Secondary outcome were MT complication rates, MT reperfusion time, and clinical outcome at 90-days. Predictors of outcome were assessed with univariate and multivariate analyses.Results: A total of 62 patients were included. 56% (35/62) had an A-SVS. Clots were significantly longer in the A-SVS group (19 mm vs. 8 mm p = 0.0002). Groups were otherwise well-matched with regard to baseline characteristics. There was a significantly lower rate of successful reperfusion in the A-SVS cohort (83%) compared to the S-SVS cohort (96%) in multivariable analysis [OR 0.04 (95% CI, 0.002–0.58), p = 0.02]. There was no significant difference in long term clinical outcome between groups.Conclusion: Clot shape as determined on T2* imaging, in patients presenting with M1 occlusion appears to be a predictor of successful reperfusion after MT. Angulated and bifurcating clots are associated with poorer rates of successful reperfusion.