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Lengyel B, Magyar-Stang R, Pál H, Debreczeni R, Sándor ÁD, Székely A, Gyürki D, Csippa B, István L, Kovács I, Sótonyi P, Mihály Z. Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis. J Clin Med 2024; 13:2487. [PMID: 38731014 PMCID: PMC11084304 DOI: 10.3390/jcm13092487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.
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Affiliation(s)
- Balázs Lengyel
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Hanga Pál
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Róbert Debreczeni
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Ágnes Dóra Sándor
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Dániel Gyürki
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Lilla István
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
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Hricisák L, Pál É, Nagy D, Delank M, Polycarpou A, Fülöp Á, Sándor P, Sótonyi P, Ungvári Z, Benyó Z. NO Deficiency Compromises Inter- and Intrahemispheric Blood Flow Adaptation to Unilateral Carotid Artery Occlusion. Int J Mol Sci 2024; 25:697. [PMID: 38255769 PMCID: PMC10815552 DOI: 10.3390/ijms25020697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis (CAS) affects approximately 5-7.5% of older adults and is recognized as a significant risk factor for vascular cognitive impairment (VCI). The impact of CAS on cerebral blood flow (CBF) within the ipsilateral hemisphere relies on the adaptive capabilities of the cerebral microcirculation. In this study, we aimed to test the hypothesis that the impaired availability of nitric oxide (NO) compromises CBF homeostasis after unilateral carotid artery occlusion (CAO). To investigate this, three mouse models exhibiting compromised production of NO were tested: NOS1 knockout, NOS1/3 double knockout, and mice treated with the NO synthesis inhibitor L-NAME. Regional CBF changes following CAO were evaluated using laser-speckle contrast imaging (LSCI). Our findings demonstrated that NOS1 knockout, NOS1/3 double knockout, and L-NAME-treated mice exhibited impaired CBF adaptation to CAO. Furthermore, genetic deficiency of one or two NO synthase isoforms increased the tortuosity of pial collaterals connecting the frontoparietal and temporal regions. In conclusion, our study highlights the significant contribution of NO production to the functional adaptation of cerebrocortical microcirculation to unilateral CAO. We propose that impaired bioavailability of NO contributes to the impaired CBF homeostasis by altering inter- and intrahemispheric blood flow redistribution after unilateral disruption of carotid artery flow.
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Affiliation(s)
- László Hricisák
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
| | - Éva Pál
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
| | - Dorina Nagy
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
| | - Max Delank
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
| | - Andreas Polycarpou
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- Mayo Clinic, College of Medicine and Science, Rochester, MN 55905, USA
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Ágnes Fülöp
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
| | - Péter Sándor
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary;
| | - Zoltán Ungvári
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, 1089 Budapest, Hungary
- The Peggy and Charles Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Zoltán Benyó
- Institute of Translational Medicine, Semmelweis University, 1094 Budapest, Hungary; (L.H.); (É.P.); (D.N.); (M.D.); (A.P.); (Á.F.); (P.S.)
- HUN-REN-SU Cerebrovascular and Neurocognitive Diseases Research Group, 1094 Budapest, Hungary
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Magyar-Stang R, Pál H, Csányi B, Gaál A, Mihály Z, Czinege Z, Csipo T, Ungvari Z, Sótonyi P, Varga A, Horváth T, Bereczki D, Koller A, Debreczeni R. Assessment of cerebral autoregulatory function and inter-hemispheric blood flow in older adults with internal carotid artery stenosis using transcranial Doppler sonography-based measurement of transient hyperemic response after carotid artery compression. GeroScience 2023; 45:3333-3357. [PMID: 37599343 PMCID: PMC10643517 DOI: 10.1007/s11357-023-00896-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/16/2023] [Indexed: 08/22/2023] Open
Abstract
Unhealthy vascular aging promotes atherogenesis, which may lead to significant internal carotid artery stenosis (CAS) in 5 to 7.5% of older adults. The pathogenic factors that promote accelerated vascular aging and CAS also affect the downstream portion of the cerebral microcirculation in these patients. Primary treatments of significant CAS are eversion endarterectomy or endarterectomy with patch plasty. Factors that determine adequate hemodynamic compensation and thereby the clinical consequences of CAS as well as medical and surgical complications of carotid reconstruction surgery likely involve the anatomy of the circle of Willis (CoW), the magnitude of compensatory inter-hemispheric blood flow, and the effectiveness of cerebral microcirculatory blood flow autoregulation. This study aimed to test two hypotheses based on this theory. First, we hypothesized that patients with symptomatic and asymptomatic CAS would exhibit differences in autoregulatory function and inter-hemispheric blood flow. Second, we predicted that anatomically compromised CoW would associate with impaired inter-hemispheric blood flow compensation. We enrolled older adults with symptomatic or asymptomatic internal CAS (>70% NASCET criteria; n = 46) and assessed CoW integrity by CT angiography. We evaluated transient hyperemic responses in the middle cerebral arteries (MCA) after common carotid artery compression (CCC; 10 s) by transcranial Doppler sonography (TCD). We compared parameters reflecting autoregulatory function (e.g., transient hyperemic response ratio [THRR], return to baseline time [RTB], changes of vascular resistance) and inter-hemispheric blood flow (residual blood flow velocity). Our findings revealed that CAS was associated with impaired cerebral vascular reactivity. However, we did not observe significant differences in autoregulatory function or inter-hemispheric blood flow between patients with symptomatic and asymptomatic CAS. Moreover, anatomically compromised CoW did not significantly affect these parameters. Notably, we observed an inverse correlation between RTB and THRR, and 49% of CAS patients exhibited a delayed THRR, which associated with decreased inter-hemispheric blood flow. Future studies should investigate how TCD-based evaluation of autoregulatory function and inter-hemispheric blood flow can be used to optimize surgical techniques and patient selection for internal carotid artery revascularization.
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Affiliation(s)
- Rita Magyar-Stang
- Department of Neurology, Semmelweis University, Budapest, Hungary.
- János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary.
| | - Hanga Pál
- Department of Neurology, Semmelweis University, Budapest, Hungary
- János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary
| | - Borbála Csányi
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Anna Gaál
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Zsófia Czinege
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Tamas Csipo
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience and Healthy Brain Aging, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 731042, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, OK, 73104, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Andrea Varga
- Department of Diagnostic Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Tamás Horváth
- Research Center for Sport Physiology, Hungarian University of Sports Science, Budapest, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Akos Koller
- Research Center for Sport Physiology, Hungarian University of Sports Science, Budapest, Hungary
- Department of Morphology & Physiology, Faculty of Health Sciences, and Translational Medicine Institute, Faculty of Medicine, and ELKH-SE, Cerebrovascular and Neurocognitive Disorders Research Group, Semmelweis University, Budapest, Hungary
- Department of Physiology, New York Medical College, Valhalla, NY, USA
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Li C, Meng J, Xu B, Li X, Li M, Du X, Li S, Ma W. Internal carotid artery stenosis: hemodynamics in the ipsilateral ACA affects CT angiography manifestations. Front Neurosci 2023; 17:1129570. [PMID: 37274206 PMCID: PMC10232745 DOI: 10.3389/fnins.2023.1129570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Objective This study aimed to evaluate whether CT angiography (CTA) manifestations in anterior cerebral artery a1 segment (A1) were related to the hemodynamics in patients with internal carotid artery stenosis (ICAS). Methods A total of 97 cases were selected. The degree of ICAS and symmetry of A1 were evaluated by CTA examination. Hemodynamic indexes were detected by transcranial Doppler (TCD). The differences in CTA presentations of A1 and hemodynamics between the vessels on the stenotic and contralateral sides were analyzed according to the different degrees of stenosis. The degree of ICAS according to the different manifestations of A1 and the hemodynamics of A1's adjacent vessels were also analyzed. Results In the case of unilateral ICAS, the difference in Vm of A1 between the stenotic and the contralateral side was the most significant relative to the stenosis degree. When unilateral ICAS was ≥70%, the presentation of A1 on the stenotic side was more slender or non-visualized compared to that on the contralateral side, while in cases with unilateral stenosis <70% or bilateral stenosis with a similar degree of stenosis, A1 were mainly symmetrical. When A1 on the side of ICAS was slender or non-visualized, the Vm of A1 was significantly slower than that on the contralateral side (P < 0.001). Conclusion The CTA manifestations of A1 on the side of ICAS embodied the overall changes of the intracranial hemodynamics after ICAS. A combination of TCD and CTA examination of A1 can assist in judging the location and degree of ICAS.
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Affiliation(s)
- Chun Li
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jihong Meng
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Baoxin Xu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaodong Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Miaomiao Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xue Du
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shaoyi Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weining Ma
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
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Independent role of circle of Willis for peri-procedural evaluation of carotid endarterectomy in patients with severe carotid stenosis. Clin Neurol Neurosurg 2021; 213:107102. [PMID: 34999387 DOI: 10.1016/j.clineuro.2021.107102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/21/2021] [Accepted: 12/15/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES In patients with severe carotid stenosis (CS), collateral circulation via circle of Willis (CoW) is considered a compensatory response to maintain blood flow. The aim of this study was to evaluate the impact of CoW in patients with severe CS throughout carotid endarterectomy (CEA). METHODS A database of patients (n = 124) undergoing CEA was sampled from 2013 to 2020. Severe CS was defined as 90-99% caliber stenosis and collateral circulation was identified by CoW opening. Baseline characteristics, Age-related white matter change (ARWMC) score, immediate neurologic events (INEs) and manifestations were recorded and compared. Correlation and regression analysis for CoW were further investigated. RESULTS All patients enrolled were divided into two groups regarding to the visualized CoW opening and complete CoW was noticed in 57 patients. The prevalence of complete CoW was higher among asymptomatic patients (n = 39, 68.4%), while higher percentage of TIA or previous stroke were noticed in incomplete CoW (n = 45, 67.2%). Patients with incomplete CoW had a significantly higher median ARWMC score and remarkable cerebral perfusion deficit (P < 0.05*). Totally, 4 INEs (6.0%) were noted in patients with incomplete CoW after CEA. Cerebral hyperperfusion syndrome (CHS) was noticed in 10 patients and early-phase of postoperative hypertension (EPOH) in 15 ones with incomplete CoW versus patients with complete CoW (14.9% and 22.4% vs 3.5% and 7.0%, P < 0.05). Correlation analysis showed strong relationship between CoW opening and peri-operative factors like pre-operative symptoms, ARWMC, CHS and EPOH (P < 0.05*). Overall, CoW opening was an independent predictor of both CHS and EPOH (95% CI, 0.021-0.715 and 0.060-0.949, P < 0.05*) with logistic regression. CONCLUSIONS Sufficient collateral circulation via CoW may promote ipsilateral cerebral perfusion and mitigate WMC in patients with severe CS. In addition, collaterals may improve the predictive power of the risk scale for post-procedural complications after CEA.
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Ma K, Bebawy JF. Electroencephalographic Burst-Suppression, Perioperative Neuroprotection, Postoperative Cognitive Function, and Mortality: A Focused Narrative Review of the Literature. Anesth Analg 2021; 135:79-90. [PMID: 34871183 DOI: 10.1213/ane.0000000000005806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Burst-suppression is an electroencephalographic pattern that results from a diverse array of pathophysiological causes and/or metabolic neuronal suppression secondary to the administration of anesthetic medications. The purpose of this review is to provide an overview of the physiological mechanisms that underlie the burst-suppression pattern and to present in a comprehensive way the available evidence both supporting and in opposition to the clinical use of this electroencephalographic pattern as a therapeutic measure in various perioperative settings.
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Affiliation(s)
- Kan Ma
- From the *Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology & Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Relationship between Circle of Willis Variations and Cerebral or Cervical Arteries Stenosis Investigated by Computer Tomography Angiography and Multitask Convolutional Neural Network. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6024352. [PMID: 34754409 PMCID: PMC8572634 DOI: 10.1155/2021/6024352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/27/2021] [Accepted: 10/03/2021] [Indexed: 11/18/2022]
Abstract
Circle of Willis (CoW) is the most critical collateral pathway that supports the redistribution of blood supply in the brain. The variation of CoW is closely correlated with cerebral hemodynamic and cerebral vessel-related diseases. But what is responsible for CoW variation remains unclear. Moreover, the visual evaluation for CoW variation is highly time-consuming. In the present study, based on the computer tomography angiography (CTA) dataset from 255 patients, the correlation between the CoW variations with age, gender, and cerebral or cervical artery stenosis was investigated. A multitask convolutional neural network (CNN) was used to segment cerebral arteries automatically. The results showed the prevalence of variation of the anterior communicating artery (Aco) was higher in the normal senior group than in the normal young group and in females than in males. The changes in the prevalence of variations of individual segments were not demonstrated in the population with stenosis of the afferent and efferent arteries, so the critical factors for variation are related to genetic or physiological factors rather than pathological lesions. Using the multitask CNN model, complete cerebral and cervical arteries could be segmented and reconstructed in 120 seconds, and an average Dice coefficient of 78.2% was achieved. The segmentation accuracy for precommunicating part of anterior cerebral artery and posterior cerebral artery, the posterior communicating arteries, and Aco in CoW was 100%, 99.2%, 94%, and 69%, respectively. Artificial intelligence (AI) can be considered as an adjunct tool for detecting the CoW, particularly related to reducing workload and improving the accuracy of the visual evaluation. The study will serve as a basis for the following research to determine an individual's risk of stroke with the aid of AI.
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Magnetic Resonance Angiogram Findings of Internal Carotid Artery Narrowing and Anterior Cerebral Artery Hypoplasia Associated With Optic Atrophy After Neonatal Extracorporeal Membrane Oxygenation. J Neuroophthalmol 2021; 41:e209-e211. [PMID: 33105409 DOI: 10.1097/wno.0000000000001072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
ABSTRACT We use MRA to elucidate a potential association of unilateral optic atrophy in infancy, ipsilateral internal carotid artery narrowing after extracorporeal membrane oxygenation, and ipsilateral hypoplasia of the A1 segment of the anterior cerebral artery.
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Müller MD, Seidel K, Peschi G, Piechowiak E, Mosimann PJ, Schucht P, Raabe A, Bervini D. Arterial collateral anatomy predicts the risk for intra-operative changes in somatosensory evoked potentials in patients undergoing carotid endarterectomy: a prospective cohort study. Acta Neurochir (Wien) 2021; 163:1799-1805. [PMID: 33099692 PMCID: PMC8116285 DOI: 10.1007/s00701-020-04624-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022]
Abstract
Background During carotid endarterectomy (CEA), significant amplitude decrement of somatosensory evoked potentials (SEPs) is associated with post-operative neurological deficits. Objective To investigate the association between an incomplete circle of Willis and/or contralateral ICA occlusion and subsequent changes in intra-operatively monitored SEPs. Methods We performed a retrospective analysis of a single center, prospective cohort of consecutive patients undergoing CEA over a 42-month period after reviewing the collateral arterial anatomy on pre-operative radiological imaging. The primary endpoint was an intra-operative decline in SEPs > 50% compared to the baseline value during arterial cross-clamping. Univariate and multivariate logistic regression analyses were performed to investigate a potential association between contralateral ICA occlusion, incomplete circle of Willis, and subsequent alteration in SEPs. Results A total of 140 consecutive patients were included, of which 116 patients (82.9%) had symptomatic carotid stenosis of at least 50% according to the classification used in the North American Carotid Surgery Trial (NASCET) (Stroke 22:711–720, 1991). Six patients (4.3%) showed contralateral ICA occlusion, 22 patients (16%) a missing/hypoplastic anterior communicating artery (Acom) or A1 segment, and 79 patients (56%) a missing ipsilateral posterior communicating artery (Pcom) or P1 segment. ICA occlusion and missing segments of the anterior circulation (missing A1 and/or missing Acom) were associated with the primary endpoint (p = 0.003 and p = 0.022, respectively). Conclusion Contralateral ICA occlusion and missing anterior collaterals of the circle of Willis increase the risk of intra-operative SEP changes during CEA. Pre-operative assessment of collateral arterial anatomy might help identifying patients with an increased intra-operative risk.
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Affiliation(s)
- Mandy D Müller
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Giovanni Peschi
- Department of Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Eike Piechowiak
- Department of Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- Department of Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
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Oumer M, Alemayehu M, Muche A. Association between circle of Willis and ischemic stroke: a systematic review and meta-analysis. BMC Neurosci 2021; 22:3. [PMID: 33478402 PMCID: PMC7818725 DOI: 10.1186/s12868-021-00609-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Circle of Willis is the main structure that provides constant and regular blood flow to the brain, protects the brain from ischemia. Stroke has remained the second leading cause of death globally in the last fifteen years. It is the fifth leading cause of death in the United States. It is also the leading cause of serious adult disability. Interlinked problems related to ischemic stroke are become increasing nowadays. Strong evidence is needed about the pooled measure of association between the circle of Willis (COW) and ischemic stroke. Therefore, this systematic review and meta-analysis were intended to provide compressive and up to date evidence on the association between the variations of COW and ischemic stroke using the available studies. Methods PubMed, Google Scholar, Science Direct, and Cochrane Library databases were systematically searched. All essential data were extracted using a standardized data extraction template. The heterogeneity across studies was assessed by using the Cochrane Q test statistic, I2 test statistic, and P-values. A fixed-effect model was used to estimate the pooled effect of the measure association between COW and ischemic stroke. Results In this meta-analysis, 2,718 participants were involved. The pooled measure of association between COW and ischemic stroke was 1.38 (95% CI 0.87, 2.19). Therefore, this indicated that the presence of any variation in COW was 1.38 times more likely to develop ischemic stroke as compared to the patent COW. The presence of hypoplasia/incompleteness in a posterior communicating artery (PcomA) [Pooled OR: 1.34 (95% CI 0.80, 2.25)] and anterior communicating artery (AcomA) [Pooled OR: 1.32 (95% CI 0.81, 2.19)] were a contributing factor for the development of ischemic stroke. Hypertension was the most common comorbid condition, followed by diabetes mellitus, smoking, coronary artery disease, and hyperlipidemia. Conclusions There was a non-significant positive association between COW variation and ischemic stroke in this meta-analysis.
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Affiliation(s)
- Mohammed Oumer
- Department of Human Anatomy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara, Ethiopia. .,Department of Epidemiology, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara, Ethiopia.
| | - Mekuriaw Alemayehu
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara, Ethiopia
| | - Abebe Muche
- Department of Human Anatomy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara, Ethiopia
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Emrecan B, Çekirdekoğlu K. Unilateral or bilateral cerebral perfusion in hemiarch replacement: A prospective randomized study. J Card Surg 2020; 36:680-686. [PMID: 33355947 DOI: 10.1111/jocs.15268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. METHODS Forty-two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. RESULTS There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p = .170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p = .018) whereas cross-clamp time and cardiopulmonary bypass times were not (p = .693 and p = .584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p = .484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. CONCLUSION The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short.
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Affiliation(s)
- Bilgin Emrecan
- Department of Cardiac and Vascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Kadir Çekirdekoğlu
- Department of Cardiac and Vascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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Hamming AM, van Walderveen MAA, Mulder IA, van der Schaaf IC, Kappelle LJ, Velthuis BK, Ferrari MD, Terwindt GM, Visser MC, Schonewille W, Algra A, Wermer MJH. Circle of Willis variations in migraine patients with ischemic stroke. Brain Behav 2019; 9:e01223. [PMID: 30772952 PMCID: PMC6422794 DOI: 10.1002/brb3.1223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 12/18/2018] [Accepted: 12/22/2018] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Migraine is a risk factor for stroke, which might be explained by a higher prevalence in anatomical variants in the circle of Willis (CoW). Here, we compared the presence of CoW variants in patients with stroke with and without migraine. MATERIALS AND METHODS Participants were recruited from the prospective Dutch acute Stroke Study. All participants underwent CT angiography on admission. Lifetime migraine history was assessed with a screening questionnaire and confirmed by an interview based on International Classification of Headache Disorders criteria. The CoW was assessed for incompleteness/hypoplasia (any segment <1 mm), for anterior cerebral artery asymmetry (difference > 1/3), and for posterior communicating artery (Pcom) dominance (Pcom-P1 difference > 1/3). Odds ratios with adjustments for age and sex (aOR) were calculated with logistic regression. RESULTS We included 646 participants with stroke, of whom 52 had a history of migraine. Of these, 45 (87%) had an incomplete or hypoplastic CoW versus 506 (85%) of the 594 participants without migraine (aOR: 1.47; 95% CI: 0.63-3.44). There were no differences between participants with and without migraine in variations of the anterior or posterior CoW, anterior cerebral artery asymmetry (aOR: 0.86; 95% CI: 0.43-1.74), or Pcom dominance (aOR: 0.64; 95% CI: 0.32-1.30). There were no differences in CoW variations between migraine patients with or without aura. CONCLUSION We found no significant difference in the completeness of the CoW in acute stroke patients with migraine compared to those without.
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Affiliation(s)
- Arend M Hamming
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Inge A Mulder
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke C Visser
- Department of Neurology, VU Medical Center, Amsterdam, The Netherlands
| | | | - Ale Algra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,The Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Banga PV, Varga A, Csobay-Novák C, Kolossváry M, Szántó E, Oderich GS, Entz L, Sótonyi P. Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting. J Vasc Surg 2018; 68:1764-1771. [PMID: 29983353 DOI: 10.1016/j.jvs.2018.03.429] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/30/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. METHODS We prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. RESULTS Of the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. CONCLUSIONS An iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.
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Affiliation(s)
- Péter Vince Banga
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary.
| | - Andrea Varga
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Csaba Csobay-Novák
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | | | - Emese Szántó
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - László Entz
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
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Multidetector CT angiography of the Circle of Willis: association of its variants with carotid artery disease and brain ischemia. Eur Radiol 2018; 29:46-56. [PMID: 29922933 PMCID: PMC6291432 DOI: 10.1007/s00330-018-5577-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/17/2018] [Accepted: 05/29/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE (1) to estimate the prevalence of Circle of Willis (CoW) variants in patients undergoing carotid endarterectomy, (2) to correlate these variants to controls and (3) cerebral ischemia depicted by computed tomography (CT). MATERIALS AND METHODS After Institutional Review Board approval, data of 544 carotid endarterectomy patients (331 males, mean age 69±8 years) and 196 controls (117 males, mean age 66±11 years) who underwent brain CT and carotid CT angiography (CTA) were retrospectively analysed. Two observers independently classified each CoW segment as normal, hypoplastic (diameter <0.8 mm) or non-visualized. Four groups of CoW variants based on the number of hypoplastic/non-visualized segments were correlated with clinical data (ANOVA, χ2 and multivariate logistic regression analysis). Intra- and inter-observer agreement was estimated using Cohen κ statistics. RESULTS High prevalence of CoW variants (97%) and compromised CoW (81%) was observed in the study group and significant difference was found in the distribution of CoW variants compared to controls (p<0.001), internal carotid artery (ICA) stenosis being the only independent predictor of CoW morphology (p<0.001). Significant correlation was found between CoW configuration and brain ischemia in the study group (p=0.002). ICA stenosis of ≥90% was associated to higher rate of ipsilateral A1 hypoplasia/non-visualization (p<0.001). Intra- and inter-observer agreement was from substantial to almost perfect (Cohen κ=0.75-1.0). CONCLUSION Highly variable CoW morphology was demonstrated in patients undergoing endarterectomy compared to controls. Likely compromised CoW in relation to cerebral ischemia was observed in a large cohort of carotid endarterectomy subjects. KEY POINTS • CoW variant distribution significantly differed in the study and control groups (p<0.001). • ICA stenosis was the only independent predictor of CoW morphology (p<0.001). • Severely compromised CoW configuration showed significant association with brain ischemia (p=0.002).
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Göksu EÖ, Koç P, Küçükseymen E, Ünal A, Genç F, Gencer ES, Yaman A. The association of the circle of Willis anomaly and risk of stroke in patients with carotid artery disease. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:429-432. [PMID: 28746428 DOI: 10.1590/0004-282x20170054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 02/14/2017] [Indexed: 11/21/2022]
Abstract
Results In this retrospective study, we analyzed 175 patients who presented at our outpatient stroke clinic between January, 2013 and June, 2015 with either unilateral symptomatic or asymptomatic carotid artery disease, and who had had CT angiography imaging performed. Demographic properties, carotid artery stenosis and the anomaly of the circle of Willis was recorded. Conclusion There was no statistically significant difference in patients with symptomatic and asymptomatic carotid artery disease in terms of the anomaly of the circle of Willis.
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Affiliation(s)
- Eylem Özaydın Göksu
- Antalya Education and Research Hospital, Department of Neurology, Antalya, Turkey
| | - Pınar Koç
- Antalya Education and Research Hospital, Department of Radiology, Antalya, Turkey
| | - Elif Küçükseymen
- Antalya Education and Research Hospital, Department of Neurology, Antalya, Turkey
| | - Ali Ünal
- Akdeniz University, Department of Neurology, Antalya, Turkey
| | - Fatma Genç
- Antalya Education and Research Hospital, Department of Neurology, Antalya, Turkey
| | | | - Aylin Yaman
- Antalya Education and Research Hospital, Department of Neurology, Antalya, Turkey
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Dong MX, Hu L, Huang YJ, Xu XM, Liu Y, Wei YD. Cerebrovascular risk factors for patients with cerebral watershed infarction: A case-control study based on computed tomography angiography in a population from Southwest China. Medicine (Baltimore) 2017; 96:e7505. [PMID: 28700499 PMCID: PMC5515771 DOI: 10.1097/md.0000000000007505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To determine cerebrovascular risk factors for patients with cerebral watershed infarction (CWI) from Southwest China.Patients suffering from acute ischemic stroke were categorized into internal CWI (I-CWI), external CWI (E-CWI), or non-CWI (patients without CWI) groups. Clinical data were collected and degrees of steno-occlusion of all cerebral arteries were scored. Arteries associated with the circle of Willis were also assessed. Data were compared using Pearson chi-squared tests for categorical data and 1-way analysis of variance with Bonferroni post hoc tests for continuous data, as appropriate. Multivariate binary logistic regression analysis was performed to determine independent cerebrovascular risk factors for CWI.Compared with non-CWI, I-CWI had higher degrees of steno-occlusion of the ipsilateral middle cerebral artery, ipsilateral carotid artery, and contralateral middle cerebral artery. E-CWI showed no significant differences. All the 3 arteries were independent cerebrovascular risk factors for I-CWI confirmed by multivariate binary logistic regression analysis. I-CWI had higher degrees of steno-occlusion of the ipsilateral middle cerebral artery compared with E-CWI. No significant differences were found among arteries associated with the circle of Willis.The ipsilateral middle cerebral artery, carotid artery, and contralateral middle cerebral artery were independent cerebrovascular risk factors for I-CWI. No cerebrovascular risk factor was identified for E-CWI.
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Affiliation(s)
- Mei-Xue Dong
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
| | - Ling Hu
- Department of Neurology, The Fifth People's Hospital of Chongqing, Chongqing, China
| | - Yuan-Jun Huang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
| | - Xiao-Min Xu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
| | - Yang Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
| | - You-Dong Wei
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
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CTA Characteristics of the Circle of Willis and Intracranial Aneurysm in a Chinese Crowd with Family History of Stroke. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1743794. [PMID: 26881211 PMCID: PMC4736327 DOI: 10.1155/2016/1743794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/31/2015] [Accepted: 08/10/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The vascular morphology in crowd with family history of stroke remains unclear. The present study clarified the characteristics of the intracranial vascular CoW and prevalence of intracranial aneurysms in subjects with family history of stroke. METHODS A stratified cluster, random sampling method was used for subjects with family history of stroke among rural residents in Jixian, Tianjin, China. All the subjects underwent a physical examination, head computed tomography (CT) scan, and cephalic and cervical computed tomography angiography (CTA) scan. Anatomic variations in the Circle of Willis and cerebrovascular disease in this population were analyzed. RESULTS In the crowd with similar living environment, stable genetic background, and family history of stroke and without obvious nerve function impairment (1) hypoplasia or absence of A1 segment was significantly different in gender (male versus female: 9.8% versus 18.8%, p = 0.031), especially the right-side A1 (male versus female: 5.9% versus 16.4%, p = 0.004). (2) Hypoplasia or absence of bilateral posterior communicating arteries was more common in men than women (58.2% versus 45.3%, p = 0.032). Unilateral fetal posterior cerebral artery was observed more often in women than men (17.2% versus 8.5%, p = 0.028). (3) The percentage of subjects with incomplete CoW did not increase significantly with age. Compared to healthy Chinese people, the crowd had a higher percentage of incomplete CoW (p < 0.001). (4) No obvious correlation between risk factors and CoW was found. (5) The prevalence of aneurysm was 10.3% in the special crowd. CONCLUSIONS The certain variations of CoW showed significant relation to gender, but not to age in people with family history of stroke. The incomplete circle may be a dangerous factor that is independent of common risk factors for stroke and tend to lead to cerebral ischemia in the crowd with family history of stroke. The prevalence of intracranial aneurysm is comparatively high in the present subjects compared to other people.
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Karatas A, Coban G, Cinar C, Oran I, Uz A. Assessment of the Circle of Willis with Cranial Tomography Angiography. Med Sci Monit 2015; 21:2647-52. [PMID: 26343887 PMCID: PMC4576924 DOI: 10.12659/msm.894322] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The circle of Willis is a major collateral pathway important in ischemic conditions. The aim of our study was to assess the structural characteristics of the circle of Willis within the Turkish adult population, along with variations and arteries involved in the measurement of diameters and lengths on cranial computed tomography angiography (CTA). Material/Methods One hundred adult patients who underwent CTA images were evaluated retrospectively. Results Results of the study revealed 82% adult, 17% fetal, and 1% transitional configurations. A complete polygonal structure was observed in 28% of cases. Variations of the circle of Willis were more common in the posterior portion. Hypoplasia was found to be the most common variation and was observed as a maximum in the posterior communicating artery (AComP). Conclusions The patency and size of arteries in the circle of Willis are important in occlusive cerebrovascular diseases and cerebrovascular surgery. Although CTA is an easily accessible non-invasive clinical method for demonstrating the vascular structure, CTA should be evaluated taking into account image resolution quality and difficulties in the identification of small vessels.
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Affiliation(s)
- Ayse Karatas
- Department of Neurosurgery, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey
| | - Gokmen Coban
- Department of Neurosurgery, Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Celal Cinar
- Department of Radiology, Ege University School of Medicine, Izmir, Turkey
| | - Ismail Oran
- Department of Radiology, Ege University School of Medicine, Izmir, Turkey
| | - Aysun Uz
- Department of Anatomy, Ankara University School of Medicine, Ankara, Turkey
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The influence of an unilateral carotid artery stenosis on brain oxygenation. Med Eng Phys 2014; 36:905-14. [DOI: 10.1016/j.medengphy.2014.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/24/2014] [Accepted: 03/31/2014] [Indexed: 11/23/2022]
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Altinbas A, Hendrikse J, Algra A, van Zandvoort MJE, Brown MM, Bonati LH, de Borst GJ, Kappelle LJ, van der Worp HB. Ipsilateral foetal-type posterior cerebral artery is associated with cognitive decline after carotid revascularisation. BMC Neurol 2014; 14:84. [PMID: 24739135 PMCID: PMC4021499 DOI: 10.1186/1471-2377-14-84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 02/24/2014] [Indexed: 11/12/2022] Open
Abstract
Background Stenosis of the internal carotid artery has been associated with cognitive impairment and decline. However, studies testing the effect of carotid revascularisation on cognition have had conflicting results. This may in part be explained by variation in the flow territory of the carotid artery. In 12 to 36% of the patients, the posterior cerebral artery is mainly or exclusively supplied by the internal carotid artery via a foetal-type posterior cerebral artery. In these patients, ipsilateral carotid artery stenosis is likely to result in a larger area with hypoperfusion than in case of a normal posterior cerebral artery. Patients with a foetal-type posterior cerebral artery could therefore benefit more from revascularisation. We compared the effects of carotid revascularisation on cognition between patients with a foetal-type and those with a normal posterior cerebral artery. Methods Patients with symptomatic internal carotid artery stenosis ≥ 50%, enrolled in the International Carotid Stenting Study (ICSS) at a single centre, underwent detailed neuropsychological examinations before and 6 months after revascularisation. Cognitive test results were standardized into z-scores, from which a cognitive sumscore was calculated. The primary outcome was the change in cognitive sumscore between baseline and follow-up. Changes in cognitive sumscore were compared between patients with an ipsilateral foetal-type and those with a normal posterior cerebral artery, as assessed with CT or MR angiography. Results Of 145 patients enrolled in ICSS at the centre during the study period, 98 had both angiography at baseline and neuropsychological examination at baseline and at 6-months follow-up. The cognitive sum score decreased by 0.28 (95% confidence interval, 0.10 to 0.45) in 13 patients with an ipsilateral foetal-type posterior cerebral artery and by 0.07 (95% CI, 0.002 to 0.15) in 85 patients with a normal posterior cerebral artery (mean difference, -0.20; 95% CI, -0.40 to -0.01). This did not change essentially after adjustment for baseline factors. Conclusion An ipsilateral foetal-type posterior cerebral artery appears to increase cognitive decline after carotid revascularisation. Our findings have to be reproduced in an independent study before further implications can be made.
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Affiliation(s)
- Aysun Altinbas
- Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands.
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Incompleteness of the Circle of Willis is Related to EEG-based Shunting During Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2013; 46:631-7. [DOI: 10.1016/j.ejvs.2013.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 09/05/2013] [Indexed: 11/23/2022]
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Sano A, Hirano T, Watanabe K, Izumi T, Endo N, Ito T, Inagawa S. Preoperative evaluation of the vertebral arteries and posterior portion of the circle of Willis for cervical spine surgery using 3-dimensional computed tomography angiography. Spine (Phila Pa 1976) 2013; 38:E960-7. [PMID: 23609201 DOI: 10.1097/brs.0b013e318296e542] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective analysis using prospectively collected data from 3-dimensional computed tomography angiography (3D-CTA). OBJECTIVE To investigate the frequency of anomalous vertebral arteries (VA) and variations of the posterior portion of the circle of Willis (PPCW) using 3D-CTA for preventing perioperative iatrogenic vascular complications. SUMMARY OF BACKGROUND DATA Some studies have reported that preoperative 3D-CTA is useful for determining the VA blood flow in the cervical spine. However, preoperative 3D-CTA has not been used for evaluating PPCW, which functions as vessels collateral to the basilar artery in the case of iatrogenic VA injury. METHODS The study included 100 consecutive patients (61 males and 39 females; mean age, 60.4 ± 15.4 yr; range, 11-86 yr) who underwent cervical decompression and/or instrumentation between April 2008 and May 2012. We measured the diameters of the VA (VAD), posterior communicating artery (PCOMD), first segment of the posterior cerebral artery (P1D), and basilar artery (BAD) twice and determined the frequency of anomalous VA and PPCW variations. RESULTS Hypoplastic VA, hypoplastic PCOM, and hypoplastic P1 were detected in 11 (11.0%), 81 (81.0%), and 13 patients (13.0%), respectively. Hypoplastic PCOM-P1 and hypoplastic basilar artery were observed in 87 (87.0%) and 3 patients (3.0%), respectively. Overall, 47 patients (47.0%) possessed some degree of abnormal VA blood flow.There were 7 patients (7.0%) with both unilaterally hypoplastic VA and bilaterally hypoplastic PCOM-P1s, in whom iatrogenic VA injury on the dominant side could have caused lethal vascular complications. We termed the hypoplastic VA of the contralateral side without collateral vessels as "critical VA." CONCLUSION The VAs and PPCW vary considerably. Preoperative 3D-CTA provides important information for preventing tragic vascular complications caused by iatrogenic VA injury. Taking the risk of radiation into consideration, we recommend this method for patients at the highest risk for iatrogenic VA injury.
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Affiliation(s)
- Atsuki Sano
- Department of Orthopaedic Surgery, Niigata University Medical and Dental General Hospital, Niigata, Japan.
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Gounis MJ, Wakhloo AK, Chueh JY. Preclinical Investigations for Thrombectomy Devices--Does it Translate to Humans? Stroke 2013; 44:S7-S10. [DOI: 10.1161/strokeaha.111.000692] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Drummond JC, Lee RR, Howell JP. Focal Cerebral Ischemia After Surgery in the “Beach Chair” Position. Anesth Analg 2012; 114:1301-3. [DOI: 10.1213/ane.0b013e31823aca46] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Han A, Yoon DY, Chang SK, Lim KJ, Cho BM, Shin YC, Kim SS, Kim KH. Accuracy of CT angiography in the assessment of the circle of Willis: comparison of volume-rendered images and digital subtraction angiography. Acta Radiol 2011; 52:889-93. [PMID: 21828003 DOI: 10.1258/ar.2011.110223] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Computed tomography angiography (CTA) is increasingly used for non-invasive imaging of the cerebrovascular diseases. PURPOSE To evaluate the accuracy of CTA in the assessment of the variation of the segment calibers of the circle of Willis. MATERIAL AND METHODS One hundred and 17 patients with acute SAH (51 men and 66 women, mean age 50.9 years) who underwent CTA using a 16 detector-row CT scanner and DSA were evaluated retrospectively. The CTA and DSA studies were performed within 24 h after the onset of symptoms and within 24 h of each other. A total of 819 arterial segments (A-comA, right and left A1 segment, right and left P-com A, and right and left P1 segment) of the circle of Willis were determined to be aplastic (grade 1), hypoplastic (grade 2), or normal-sized (grade 3) by blinded observers evaluating CTA volume-rendered images. The CTA results were then compared with findings on the corresponding DSA images (reference standard). RESULTS The overall agreement between CTA and DSA was 92.4%. We had 62 (7.6%) cases of disagreement (58 cases of under-estimation and four cases of over-estimation by CTA) between tow modalities. The sensitivity and specificity of CTA in the detection of aplastic and normal-sized segments were more than 90%. In contrast, subgroup analysis of the hypoplastic segments showed a sensitivity of 52.6% and a specificity of 98.2%. CONCLUSION CTA is highly accurate in the assessment of anatomical variations of the circle of Willis; however, its sensitivity is limited in depicting hypoplastic segments.
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Affiliation(s)
- Ari Han
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
| | - Dae Young Yoon
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
| | - Suk Ki Chang
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
| | - Kyoung Ja Lim
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
- Department of Radiology, Kangwon National University College of Medicine, Chuncheon, Kangwon-do
| | - Byung-Moon Cho
- Department of Neurosurgery, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
| | - Yoon Cheol Shin
- Department of Thoracic Surgery, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul
| | - Sam Soo Kim
- Department of Radiology, Kangwon National University College of Medicine, Chuncheon, Kangwon-do
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
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Schirmer CM, Atalay B, Malek AM. Endovascular recanalization of symptomatic flow-limiting cervical carotid dissection in an isolated hemisphere. Neurosurg Focus 2011; 30:E16. [DOI: 10.3171/2011.2.focus1139] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Object
Internal carotid artery dissection (ICAD) is a common cause of stroke in young patients, which may lead to major transient or permanent disability. Internal carotid artery dissection may occur spontaneously or after trauma and may present with a rapid neurological deterioration or with hemodynamic compromise and a delayed and unstable neurological deficit. Endovascular intervention using stent angioplasty can be used as an alternative to anticoagulation and open surgical therapy in this setting to restore blood flow through the affected carotid artery.
Methods
The authors present the cases of 2 patients with flow-limiting symptomatic ICAD leading to near-complete occlusion and without sufficient collateral supply. Both patients had isolated cerebral hemispheres without significant blood flow from the anterior or posterior communicating arteries. In both cases, the patients demonstrated blood pressure–dependent subacute unstable neurological deficits as a result of the hemodynamic compromise resulting from the dissection.
Results
Both patients underwent careful microwire-based selection of the true lumen followed by confirmatory microinjection and subsequent exchange-length microwire-based recanalization using tandem telescoping endovascular stenting. In both cases the neurological state improved, and no permanent neurological deficit ensued.
Conclusions
The treatment of ICAD may be difficult in patients with subacute unstable neurological deficits related to symptomatic hypoperfusion, especially in the setting of a hemodynamically isolated hemisphere. Anticoagulation alone may be insufficient in these patients. Although there is no widely accepted guideline for the treatment of ICAD, the authors recommend stent-mediated endovascular recanalization in cases of symptomatic flow-limiting hemodynamic compromise, especially in cases of an isolated hemisphere lacking sufficient communicating artery compensatory perfusion.
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A multidetector CT angiography study of variations in the circle of Willis in a Chinese population. J Clin Neurosci 2011; 18:379-83. [DOI: 10.1016/j.jocn.2010.07.137] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 04/19/2010] [Accepted: 07/24/2010] [Indexed: 11/22/2022]
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Bokkers R, van Laar P, van der Zwan A, Mali W, Hendrikse J. Mixed perfusion: A combined blood supply to the brain tissue by multiple arteries. J Neuroradiol 2010; 37:201-10. [DOI: 10.1016/j.neurad.2010.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 01/27/2010] [Accepted: 01/28/2010] [Indexed: 11/27/2022]
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Different strokes for different folks: the rich diversity of animal models of focal cerebral ischemia. J Cereb Blood Flow Metab 2010; 30:1412-31. [PMID: 20485296 PMCID: PMC2949237 DOI: 10.1038/jcbfm.2010.66] [Citation(s) in RCA: 213] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
No single animal model is able to encompass all of the variables known to affect human ischemic stroke. This review highlights the major strengths and weaknesses of the most commonly used animal models of acute ischemic stroke in the context of matching model and experimental aim. Particular emphasis is placed on the relationships between outcome and underlying vascular variability, physiologic control, and use of models of comorbidity. The aim is to provide, for novice and expert alike, an overview of the key controllable determinants of experimental stroke outcome to help ensure the most effective application of animal models to translational research.
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Hadlock J, Beach KW. Velocity variability in ultrasonic Doppler examinations. ULTRASOUND IN MEDICINE & BIOLOGY 2009; 35:949-954. [PMID: 19285375 DOI: 10.1016/j.ultrasmedbio.2008.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 12/12/2008] [Accepted: 12/16/2008] [Indexed: 05/27/2023]
Abstract
Ultrasonic Doppler examination with spectral waveform has been used for the classification and surveillance of carotid artery stenosis for over 25 years. Progression/regression between examinations can be identified with 95% confidence if the velocity measurements change by more than two times the root mean square difference (RMSD) of the repeat measurement. Peak systolic velocity and end diastolic velocity measurements at a Doppler angle of 60 degrees were repeated in 47 carotid examinations. Measurement difference between sonographers and between instruments was tabulated. Root mean square difference was 11 cm/s (RMS%D = 11%) for systolic and 7 cm/s (RMS%D = 21%) for diastolic velocity measurements (excluding one severe stenosis case). Results for differences between sonographers and between instruments were similar to the overall results. In serial arterial studies using this Doppler velocimetry method, a difference exceeding 23 cm/s (21%) systolic, or 14 cm/s (42%) diastolic velocity indicates a significant (2 x RMSD) hemodynamic change.
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Affiliation(s)
- Jean Hadlock
- Division of Vascular Surgery, University of Washington, Seattle, WA 98195, USA
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Chueh JY, Wakhloo AK, Gounis MJ. Neurovascular modeling: small-batch manufacturing of silicone vascular replicas. AJNR Am J Neuroradiol 2009; 30:1159-64. [PMID: 19321626 DOI: 10.3174/ajnr.a1543] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Realistic, population based cerebrovascular replicas are required for the development of neuroendovascular devices. The objective of this work was to develop an efficient methodology for manufacturing realistic cerebrovascular replicas. MATERIALS AND METHODS Brain MR angiography data from 20 patients were acquired. The centerline of the vasculature was calculated, and geometric parameters were measured to describe quantitatively the internal carotid artery (ICA) siphon. A representative model was created on the basis of the quantitative measurements. Using this virtual model, we designed a mold with core-shell structure and converted it into a physical object by fused-deposit manufacturing. Vascular replicas were created by injection molding of different silicones. Mechanical properties, including the stiffness and luminal coefficient of friction, were measured. RESULTS The average diameter, length, and curvature of the ICA siphon were 4.15 +/- 0.09 mm, 22.60 +/- 0.79 mm, and 0.34 +/- 0.02 mm(-1) (average +/- standard error of the mean), respectively. From these image datasets, we created a median virtual model, which was transformed into a physical replica by an efficient batch-manufacturing process. The coefficient of friction of the luminal surface of the replica was reduced by up to 55% by using liquid silicone rubber coatings. The modulus ranged from 0.67 to 1.15 MPa compared with 0.42 MPa from human postmortem studies, depending on the material used to make the replica. CONCLUSIONS Population-representative, smooth, and true-to-scale silicone arterial replicas with uniform wall thickness were successfully built for in vitro neurointerventional device-testing by using a batch-manufacturing process.
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Affiliation(s)
- J Y Chueh
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Ali Ghanba A, Samadi Rad B, Ashrafian F, Tayefi Nas H. A Study of Arterial Variation of Willis Circle in 100 Human Brain in East Azarbaijan, Iran. JOURNAL OF MEDICAL SCIENCES 2008. [DOI: 10.3923/jms.2008.747.750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hendrikse J, Klijn CJM, van Huffelen AC, Kappelle LJ, van der Grond J. Diagnosing Cerebral Collateral Flow Patterns: Accuracy of Non-Invasive Testing. Cerebrovasc Dis 2008; 25:430-7. [PMID: 18349537 DOI: 10.1159/000121344] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/02/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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