Twiglike MCA: A Not-So-Common Cerebral Vascular Anomaly

Congenital anomalies of the MCA are rare compared with the rest of the intracranial vasculature. An aplastic MCA, known as a twiglike MCA, is the result of replacement of MCA trunk by a plexiform network of small vessels. In this report, we aim to review the radiologic features of a twiglike MCA and its differential diagnosis, helping the reader differentiate this entity from more common pathologies to avoid unnecessary further investigation.

Intracraniaal infectieus aneurysma: belang van vroegtijdige diagnose

Intracranial aneurysm: importance of early detection A 45-year old woman presented at the emergency department with a decreased level of consciousness. She was under treatment for acute myeloid leukemia. An MRI scan of the brain showed diffuse vasoconstriction of the intracranial vasculature, suggestive for vasculitis. Aspergillus fumigatus was discovered in the cerebrospinal fluid (CSF), for which antimycotic treatment was initiated. Because of further neurological decline (acute decreased consciousness, unilateral gaze impairment and irregular obstructive respiration pattern) a CT scan was performed which showed diffuse subarachnoid and intraventricular hemorrhaging. CT-angiography showed an aneurysm at the left posterior inferior cerebellar artery. Because of the severe clinical condition of the patient, there was no indication for invasive therapy.

Quantitative Assessment of the Intracranial Vasculature of Infants and Adults Using iCafe (Intracranial Artery Feature Extraction)

Comprehensive quantification of intracranial artery features may help to assess and understand regional variations of blood supply during early brain development and aging. We analyzed vasculature features of 27 healthy infants during natural sleep, 13 infants at 7-months (7.3 ± 1.0 month), and 14 infants at 12-months (11.7 ± 0.4 month), and 13 older healthy, awake adults (62.8 ± 8.7 years) to investigate age-related vascular differences as a preliminary study of vascular changes associated with brain development. 3D time-of-flight (TOF) magnetic resonance angiography (MRA) acquisitions were processed in iCafe, a technique to quantify arterial features (http://icafe.clatfd.cn), to characterize intracranial vasculature. Overall, adult subjects were found to have increased ACA length, tortuosity, and vasculature density compared to both 7-month-old and 12-month-old infants, as well as MCA length compared to 7-month-old infants. No brain laterality differences were observed for any vascular measures in either infant or adult age groups. Reduced skull and brain sharpness, indicative of increased head motion and brain/vascular pulsation, respectively, were observed in infants but not correlated with length, tortuosity, or vasculature density measures. Quantitative analysis of TOF MRA using iCafe may provide an objective approach for systematic study of infant brain vascular development and for clinical assessment of adult and pediatric brain vascular diseases.

Comparative study of intracranial access in thrombectomy using next generation 0.088 inch guide catheter technology

BackgroundMost conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation.MethodsThis is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement.ResultsEach study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0–2%, and 10.26% were deceased.ConclusionsTracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.

Co-existing of craniofacial fibrous dysplasia and cerebrovascular diseases: A Series of 22 Cases and Review of the Literature

Background: Craniofacial fibrous dysplasia is a fairly rare condition. Some literature have reported a few patients with craniofacial fibrous dysplasia suffering from vascular abnormalities. This study aimed to describe the possible coexistence of craniofacial fibrous dysplasia and cerebrovascular diseases for the first time.Method: We retrospectively reviewed the 1175 patients with craniofacial fibrous dysplasia in Beijing Tiantan Hospital and the information of the 22 patients found to be coexisted with cerebrovascular diseases were described. In addition, we performed a systematic review for cases of craniofacial fibrous dysplasia with vascular abnormalities.Result: 22 out of 1175 patients (1.9%) were identified to be diagnosed with craniofacial fibrous dysplasia and cerebrovascular diseases including 9 intracranial aneurysms, 4 venous malformations, 2 arteriovenous malformations, 1 moyamoya disease, 2 intracranial venous stenosis and 4 cerebral ischemia with a mean age of 38.18 years old. Only 2 patients were managed surgically for craniofacial fibrous dysplasia and 6 patients were treated with neurosurgery for cerebrovascular diseases. 8 patients were closely followed and only 1 patient’s symptoms worsened.Conclusion: Craniofacial fibrous dysplasia might cause constriction of the intracranial vessels and alteration of the overall hemodynamics of the intracranial vasculature resulting in various cerebrovascular diseases. Multimodal screening and examinations seems reasonable for patients with craniofacial fibrous dysplasia for throughout treatment and prognosis evaluations

Transition to Adulthood for Pediatric Moyamoya Patients

Moyamoya is a progressive arteriopathy of the intracranial vasculature, predominantly affecting the terminal branches of the internal carotid artery. Treatment is predicated on surgical revascularization to reduce the risk of stroke. For patients diagnosed and treated as children, it is important to recognize the long-term implications of the disease, for example, that moyamoya is treatable, but not curable. Pediatric moyamoya patients face unique challenges as they transition to adulthood as a consequence of the chronic nature of this disorder. Successful long-term care requires a strategy that incorporates ongoing longitudinal disease monitoring, coordination of care between physician teams, and anticipation of socioeconomic factors that change over time. This article provides an approach to transition care to adult caregivers for pediatric moyamoya patients with a specific focus on the three key stakeholders in the process: the neurosurgeon, the primary care physician, and the individual patient.

The intracranial vasculature of canines represents a model for neurovascular ischemia and training residents and fellows in endovascular neurosurgery

Background We describe use of a canine model to evaluate physiological effects and neuroprotective strategies in the setting of cerebral ischemia and endovascular neurosurgery training. Methods We performed transfemoral digital subtraction cerebral and cervical angiography on eight anesthetized dogs. Angiographic images of cerebral arteries were obtained following cannulation of the femoral artery. Cerebral ischemia models were made after angiography. Results The canine cerebral vasculature exhibited extensive tortuosity of the carotid and vertebral arteries. Conversely, the bilateral anterior spinal arteries were easily catheterized using microcatheters and microguidewires. The basilar artery and its branches were facilely cannulable. Circle of Willis continuity sans hypoplasia or aplasia of its constitutive segments was appreciated in all animals. The middle cerebral arteries could be easily accessed via the posterior communicating arteries. We generated an empirically evaluable therapeutically interventional experimental animal model of cerebral ischemia by occluding the middle cerebral artery using small coils for a duration between 15 and 60 min. Conclusion Unique amenability of the canine intracranial vasculature to selective and microcatheter cannulation renders experimentally induced cerebral, cerebellar, and brainstem via occlusion of the supratentorial and infratentorial arteries a simple matter. The neural vasculature irrigating the canine cerebrum, brainstem, and cerebellum may consequently prove useful in helping young and nascent endovascular neurosurgeons in developing and refining their skills of microcatheter navigation and manipulation and deployment of therapeutic devices to achieve effective occlusion of aneurysms, arteriovenous malformations, arteriovenous fistulas, and neoplasms of the intracranial cavity.

Software-based simulation for preprocedural assessment of Tubridge flow diverter sizing: a validation study

Background: The purpose of this single-center retrospective review was to validate the use of a software-based simulation of Tubridge flow diverter (FD) in the treatment of intracranial aneurysms. In a single-center cohort of 17 patients undergoing aneurysm treatment with the Tubridge flow divert, we analyzed their pre- and post-procedural angiographic studies to compare the manufacturer-given nominal length (NL), software calculated simulated length (SL), and the actual measured length (ML) of the flow divert using software. Results: Data for the 3 lengths of all 17 patients treated with Tubridge flow diverts were collected and analyzed in this study. Error discrepancy was calculated by mean squared error (ML to NL 10.64; SL to NL 9.95 p>0.05), mean absolute error (ML to NL 2.64; SL to NL 2.60 p>0.05), and mean error (NL to ML 1.26; SL to ML 2.59 p>0.05). Conclusions: The SL was usually greater than the NL given by the manufacturer, indicating significant change in length in most cases. The residual comparing the ML to the NL was significant, as was when comparing the SL to the NL. The assessment of the Tubridge flow diverter using software simulation is safe and effective and the accurate calculating of FD length contributed to the right-sized FD for optimal placement in intracranial vasculature.