Embryological Lateral Striate Artery Variants : Revised Concept of Recurrent Artery of Heubner, the Perforators to the Anterior Perforated Substance and Middle Cerebral Artery Variants

Percheron syndrome with memory impairment as chief manifestation: A case report

BACKGROUND

Percheron acute artery occlusion is a rare type of acute cerebral infarction.

CASE SUMMARY

An elderly male presented with sudden-onset near-memory and sensory impairments for 5 days. Upon admission, based on symptoms, signs, magnetic resonance imaging, and computed tomography findings, a diagnosis of Percheron syndrome was made. Subsequently, anti-platelet therapy, lipid-lowering treatment, cerebral circulation enhancement (such as the administration of calcium channel blockers to improve cerebral blood flow), and neurotrophic support (such as the use of drugs like citicoline to protect nerve cells) were immediately implemented, along with additional symptomatic treatments. The patient's symptoms were alleviated, following which he was discharged.

CONCLUSION

The diagnosis of acute occlusion of the Percheron artery requires rich clinical expertise and accurate imaging tools. Timely intervention and effective follow-up hold significant implications for optimizing patient recovery.

Neuroimaging of middle cerebral artery anomalies: a report of three cases

PURPOSE

This is a description of the main middle cerebral artery (MCA) anomalies from the neuroradiological and embryological point of view, discussing the practical implications and the association with other vascular diseases.

METHODS

Among the patients who underwent digital subtraction angiography (DSA) at our institution in a short time period (from 1 January 2021 to 31 December 2023), we selected three cases with high-quality images, representative for the main MCA anomalies, i.e., accessory, duplicated, and twig-like MCA.

RESULTS

We describe a series of three cases, illustrating the three main embryological anomalies of MCA, including accessory MCA, duplicated MCA, and twig-like MCA. All patients underwent neuroradiological investigations at our institution because of the acute occurrence of neurological symptoms and the findings are presented using computed tomography angiography (CTA), magnetic resonance angiography (MRA), and DSA with a detailed description. These three variants have a very low prevalence and they were reported and described more systematically in the Asian population than in the European population. Both noninvasive and invasive neuroimaging techniques were used for investigating these patients, and catheter angiography still provides the more informative content for precisely imaging the angioarchitecture of these variants and the association with aneurysms on other cerebral arteries. The knowledge of the embryology of these variants is of paramount importance in order to make easier their identification and reporting and to enhance their understanding.

CONCLUSIONS

MCA anomalies should be known and carefully checked in order to avoid misdiagnosis with disease and may affect the treatment of acute stroke.

Angioarchitecture of Twig-like Middle Cerebral Artery: the Looping Lenticulostriate Artery Anastomoses as an Angiographic Landmark for Hemorrhagic Presentation

PURPOSE

The twig-like middle cerebral artery (TL-MCA) is a vascular anomaly reconstituting the MCA-M1 segment through a plexiform arterial network. Most patients with TL-MCA have a high risk of hemorrhage, but the associated vascular anatomical risk factors are poorly understood. To investigate the angioarchitecture of TL-MCA in detail to distinguish the radiological differences between hemorrhagic and non-hemorrhagic onset.

METHODS

3214 cerebral digital subtraction angiography procedures were performed, and patients with TL-MCA were included and their clinical and anatomical characteristics were retrospectively reviewed.

RESULTS

12 patients (median age 47 years, and 9 women) with TL-MCA were included (incidence rate, 0.37%). Among them, four had hemorrhagic stroke, five had ischemic stroke, and three had no symptoms. Perforator anastomoses were identified in five patients (41.6%). Among the four patients with intraparenchymal hemorrhage (IPH), three had looping lenticulostriate artery (LSA) anastomoses and one had non-looping LSA anastomosis. One looping LSA anastomosis was discovered fortuitously in a patient explored for headaches. The recurrent artery of Heubner, which is responsible for the plexiform arterial network, was identified in 10 patients (83.3%). Angiographic evolutions (de novo TL-MCA) were observed in three patients, and one patient experienced a clinical evolution of a TL-MCA with non-looping LSA anastomosis, progressing from no symptoms to IPH.

CONCLUSIONS

In this small series, looping LSA anastomoses were mainly observed in TL-MCA with IPH. This anatomical disposition could represent a potential risk factor. The TL-MCA always affects the subpallial segment of the MCA-M1, and may be a subpallium-related pathology.

Middle cerebral artery fenestration with a contralateral early branching investigated through magnetic resonance angiography: an embryological view on an incidental finding

PURPOSE

Middle cerebral artery (MCA) anomalies are a small group of congenital variants, including fenestration, duplication and Twig-like MCA. Some other variants, i.e. in the branching pattern, have been described independently from the previous ones, but their association might raise an embryological reasoning.

METHODS

We are presenting an incidental finding in a patient undergoing brain Magnetic Resonance Imaging (MRI) and Angiography (MRA) for episodic headache, i.e. right MCA fenestration and left MCA very early branching. The patient was investigated only by MRA, being the finding incidental and non-pathological. Among the intracranial arteries, MCA has a lower rate of fenestrations and several embryological hypotheses have been proposed, different from the presumed mechanisms underlying vertebral and basilar artery fenestrations. Both fenestration and early branching in MCA in our case might resemble to a partial MCA duplication with proximal and distal fusion in the first and only a proximal fusion in the second one. The pattern of distribution of the early branches in the left MCA territory may support this view, together with the lenticulostriate perforating arteries origin.

CONCLUSIONS

The association of several MCA anomalies, as fenestration and early branching, might have a common genesis within the same embryological period.

The prevalence and anatomy of recurrent artery of Heubner: a meta analysis with neurosurgical considerations

BACKGROUND

The recurrent artery of Heubner (RAH) is typically the largest medial lenticulostriate branch of the anterior cerebral artery (ACA). Neurosurgical procedures such as aneurysm treatment on the anterior part of the circle of Willis can result in damage of the RAH leading to neurological deficits. The aim of this study was to identify the gaps and provide comprehensive data on the prevalence and anatomical characteristics of the RAH with neurosurgical considerations.

METHODS

The major electronic databases were thoroughly searched to identify the eligible studies. The information concerning study type, geographical origin, prevalence of the RAH, course and origin of the RAH, symmetry of origin and number of RAHs in each hemisphere, and morphometric data were extracted. The PRISMA guidelines were rigorously followed throughout the study. The AQUA tool was used to evaluate the reliability of included studies.

RESULTS

A total of 34 studies (n = 3645 hemispheres) were included in the meta-analysis. The analysis revealed that the RAH was present in 97.5% (95%CI: 95.5-98.6) of the hemispheres, originating most frequently from the A2 segment (42.2%, 95%CI: 35.0-49.7) or the ACoA-ACA junction (41.6%, 95%CI: 34.0-49.6), and coursing anteriorly (47.6%, 95%CI: 38.7-56.6) or superiorly (43.9%, 95%CI: 34.4-53.8) in relation to ACA. Almost a quarter of patients had more than one RAH, which was on average 22.82 mm (SD: 1.35, 95%CI: 20.16-25.47; I2 = 99.1%, p < 0.01) long and reached 0.76 mm (SD: 0.05, 95%CI: 0.66-0.85; I2 = 99.4%, p < 0.01) in diameter.

CONCLUSIONS

As the RAH is present in the majority of the population, it is important to be aware of the wide variations in its anatomy. This will help to prevent postoperative neurological deficits by avoiding undesirable complications during surgeries that are performed in close proximity to the anterior segment of the circle of Willis.

Anatomical Variations and Anomalies of the Middle Cerebral Artery

OBJECTIVE

Intracranial arteries have a high rate of variation, but a clear schematic overview is lacking. In this pictorial review we classify and depict all the variations and anomalies within the middle cerebral artery (MCA).

METHODS

PubMed was searched with the MeSH-term "Middle Cerebral Artery." Articles were selected based on their description of variants within the MCA. Cross-referencing was used to broaden the range of articles. The anatomical variants were then schematically drawn using the anteroposterior and lateral view during angiography of the internal carotid artery.

RESULTS

A total of 29 unique medical illustrations were made, depicting variation in number of vessels; variation in vessel origin; and variation in morphology.

CONCLUSIONS

The MCA provides vital blood supply to the frontal, parietal, temporal, and central brain structures. An overview of these variations is important to diagnose and treat patients with MCA-related pathology correctly and safely. They can aid in distinguishing pathology from normal anatomical variance; aid neurosurgeons during aneurysmal clipping or arteriovenous malformation resections; and aid interventional radiologists during thrombectomy or coiling. This article provides a summary regarding current knowledge of anatomical variations within the MCA, their prevalence and clinical relevance. A total of 29 unique illustrations were made, depicting currently known variants. We encourage all who diagnose, treat, and study the MCA to use this overview for a uniform and better understanding of its anatomy.

The clinical, radiological, and surgical characteristics of anterior perforated substance glioma: a retrospective study

BACKGROUND

To explore the clinical, radiological, and surgical characteristics of anterior perforated substance (APS) gliomas.

METHODS

Twenty patients with APS glioma who were treated with surgery between March 2019 and January 2022 from Tiantan hospital were retrospectively reviewed. The clinical, histological and radiological data were collected.

RESULTS

Twenty patients, including 7 males (55%) and 13 females (45%), with a mean age at diagnosis of 37.9 years (range, 28-53 years) underwent operative intervention for APS. Headaches and dizziness were the most common preoperative symptoms in the majority patients (14, 70%). Based on radiological features of MRI, the APS was classified into two subtypes, type A and type B. Seven patients (40%) in type A indicated a clear tumor margin, while 13 patients (60%) in type B showed an ill-defined margin. The surgical approach including frontal, temporal, and coronal frontal incisions for type A and type B tumors, respectively. Three patients in type A received total resection, while one patient in type B were total resected. Pathologically, 12 cases (60%, 12/20) were diagnosed as astrocytoma and 8 cases (20%, 8/20) were oligodendroglioma. Meanwhile, 17 cases (85%, 17/20) had MGMT promotor methylation.

CONCLUSION

In this study, we performed the first systematic research of patients with APS glioma. Most of patients with APS presented headaches and dizziness symptoms. The APS glioma was further divided into two major radiological subtypes with relevant different surgical approaches. The APS glioma in type A were more likely to receive total resection.

Deep Cerebral Perforators: Anatomical Distribution and Clinical Symptoms: An Overview

The anatomic distribution of the deep cerebral perforators is considered either a given or subject to enormous variability. Most published overviews on this topic only report findings from a limited number of anatomic dissections, and no attempt has been made to date to provide a comprehensive overview of all published data. A comprehensive literature search was performed on MEDLINE, Embase, and Google Scholar with the help of an information specialist. Three types of studies were included: (1) articles that described the anatomy and distribution territories of perforator groups arising from the arteries of the circle of Willis; (2) studies that evaluated the anatomy of the deep cerebral perforators using imaging techniques; and (3) studies that evaluated either microsurgically or radiologically confirmed perforator occlusion and reported the (magnetic resonance imaging-confirmed) distribution territory of the infarction together with a description of the clinical symptoms associated as a result of the infarction. A total of 2715 articles were screened and 53 were included. Of these, 40 dealt with the anatomic and imaging anatomy of perforator groups (37 reported results of dissections and 3 results of imaging studies), with a total of 2421 hemispheres investigated. Another 13 articles with 680 patients were included that evaluated perforator infarction territories. The deep cerebral perforator distribution shows large variability with poor concordance rates among reported studies, with the exception of the posterior communicating and anterior choroidal artery perforators. Despite the assumption that cerebral perforator anatomy is a given, studies show large variability in the anatomic distribution of various perforator groups. Perforator anatomy and relationships between perforator groups, as well as potential collateral circulation in these territories should be prioritized as a research topic in cerebrovascular disease in the near future.