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

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.

A CADAVERIC STUDY ON ANATOMICAL VARIATIONS IN POSTERIOR COMMUNICATING ARTERY

INTRODUCTION:The posterior communicating artery is the main anastomotic channel of circle of willis.It joins internal carotid artery and vertebra-basilar arterial system. The size of posterior communicating artery varies frequently.The hypoplasia or aplasia of posterior communicating artery can detrmine the prognosis of neurological diseases. AIM:To study the variations and caliber of posterior communicating artery MATERIALS AND METHODS: A total of 104 specimens were collected,cleaned ,dissected and xed in formalin.Anatomical variations and caliber of posterior communicating artery were carefully recorded and photographed. RESULTS: In the present study,the hypoplasia of posterior communicating artery was one of the frequent variations which were observed in 16.7% of the subjects followed by aplasia in 15.5% and duplication in 1% . CONCLUSION: Awareness of these variations is important in diagnosis of neurological disorders and in neurovascular surgeries.

Approach to Common Visual Complaints Presenting to the Outpatient Neurologist

Visual complaints are commonly encountered by the practicing neurologist. We review assessment of vision loss, diplopia, and positive visual phenomena, all of which require a thoughtful evaluation to localize disease and refine management. While many causative entities are unlikely to cause poor visual outcomes, including dry eyes, migraine, and congenital strabismus, others may threaten vision, life, or both, such as posterior communicating artery aneurysms, pituitary apoplexy, or temporal arteritis. A systematic approach to vision loss and diplopia is reviewed along with focused differential diagnoses.

Selection bias in patients proposed for neurosurgical versus endovascular treatment of aneurysms of the posterior communicating artery

Background Microsurgical clipping and endovascular coiling are viable treatment options for posterior communicating artery (PComA) aneurysms, but there are still major limitations to evidence-based decisions regarding standard-of-care treatment. In this study, we aimed at assessing potential selection biases that may influence our ability to extract conclusions about the comparative effectiveness or efficacy of the aneurysm treatment. Objective To study the patient/aneurysm characteristics as possible biases in the option for endovascular or neurosurgical treatment of PComA aneurysms. Methods A single-center, retrospective cohort study was performed, including all patients with treated PComA aneurysms with neurosurgical clipping or endovascular coiling between January 2010 and January 2021. Clinical and morphological data were collected from electronic records, and statistical analysis was performed. Results A total of 64 patients was eligible for inclusion; 24 (37.5%) patients were proposed for neurosurgical treatment, while 40 (62.5%) for endovascular treatment; 10 patients (25%) crossed over to the clipping group whereas none crossed over to the coiling side. Actual treatment analysis showed significantly higher diameters of mother vessel (t-test, p = 0.034) and aneurysm neck (Mann–Whitney, p = 0.029) in the clipping group and higher aspect and dome-to-neck ratios in the endovascular group (Mann–Whitney, p = 0.008). A significantly higher vasospasm frequency was found in the clipping group but only in the intention-to-treat analysis (Chi-square, p = 0.032). Conclusion Significant morphological differences between effective endovascular and surgical groups and differences in intention-to-treat analysis may limit the validity of a direct comparison between treatment options and suggest the presence of a possible selection bias.

Premammillary Artery Infarction after Microsurgical Clipping of Unruptured Posterior Communicating Artery Aneurysm: Risk Factors, Surgical, and Anatomical Considerations

Purpose Posterior communicating artery (PCoA) aneurysm is common and sometimes requires microsurgery; however, as data on premammillary artery (PMA) infarction after clipping is scarce, we retrospectively reviewed cases of post-clipping PMA infarction to analyze incidence, independent risk factors of infarction, and anatomical considerations. Methods Data from 569 consecutive patients who underwent microsurgical clipping for unruptured PCoA aneurysm between January 2008 and December 2020 were included. Patients were categorized into the normal or the PMA infarction group. Statistical analyses and comparisons between the two groups were used to determine the influence of various factors. Results The normal group included 515 patients while the PMA infarction group had 31. The mean length of hospital stay was significantly longer in the PMA infarction group (10.3 ± 9.1 days) than in the normal group (6.5 ± 6.4 days; p < 0.0001). The distribution of Glasgow Outcome Scale (GOS) at discharge was significantly different between the two groups (p ≤ 0.0001) but was not so at 6 months after discharge (p = 0.0568). Multivariate-logistic-regression analysis identified aneurysm size (odds ratio [OR], 1.194; 95% confidence interval [CI], 1.08–1.32; p = 0.0005) and medial direction of aneurysm (OR, 4.615; 95% CI, 1.224–17.406; p = 0.0239) as independent risk factors of post-clipping PMA infarction. Conclusions Surgeons must beware of PMA infarction after clipping of large aneurysms that are medial in direction. Intraoperative verification of the patency of the PCoA and the PMA from various angles using various intraoperative methods can reduce morbidity due to PMA infarction.