Embolus trajectory through a physical replica of the major cerebral arteries.

BACKGROUND AND PURPOSE: The observed distribution of cerebral infarcts varies markedly from expectations based on blood-flow volume or Doppler embolus detection. In this study, we used an in vitro model of the cerebral arteries to test whether embolus microspheres encountering the circle of Willis are carried proportionally to volume flow or express a preferred trajectory related to arterial morphology or embolus size. METHODS: Our model consisted of a patient-specific silicone replica of the cerebral macrocirculation featuring physiologically realistic pulsatile flow of a blood-mimicking fluid at approximately 1000 mL/min and an input pressure of approximately 150/70 mm Hg. Particles of 200, 500, and 1000 microm diameter with equivalent density to thrombus were introduced to the carotid arteries and counted on exiting the model outlets. RESULTS: The middle cerebral arteries (MCAs) of the replica attracted a disproportionate number of emboli compared with the anterior cerebral arteries; 98%+/-3% of 1000 microm and 93%+/-2% of 500 microm emboli entered the MCA compared with 82%+/-5% of the flow. The observed distribution of large emboli was consistent with the ratio of MCA:anterior cerebral artery infarcts, approximately 95% of which occur in territories supplied by the MCA. With decreasing embolus size, the distribution of emboli approaches that of the flow (approximately 89% of 200 microm emboli took the MCA). CONCLUSIONS: Embolus trajectory through the cerebral arteries is dependent on embolus size and strongly favors the MCA for large emboli. The 70:30 ratio of MCA:anterior cerebral artery emboli observed by Doppler ultrasound is consistent with the trajectories of small emboli that tend to be asymptomatic.

Robustness against interfraction prostate movement in scanned ion beam radiation therapy.

PURPOSE: To assess the robustness of scanned ion beam treatment plans against the interfraction internal target motion and evaluate the limits of validity of target-based isocenter realignment for prostate cancer radiation therapy. METHODS AND MATERIALS: For 12 prostate patients, scanned beam carbon ion treatment plans were prepared using 2 lateral opposed beams and the raster scanning technique with different clinical target volume (CTV) to planning target volume (PTV) margins (2-10 mm). Internal target motion of 2-15 mm in anteroposterior (AP), superoinferior (SI), and left-to-right (LR) directions was simulated by displacing the CTV contours with respect to the computed tomography data. The plans were recalculated with and without target-based isocenter realignment and the CTV coverage was assessed. RESULTS: For CTV shifts within the applied planning margin, the CI-98% is greater than 98.0%, both with and without isocenter realignment. Without realignment, because of the sharp lateral gradients, the CI-98% shows rapid fall as soon as the target shift exceeds the applied planning margin for all displacement directions. With isocenter realignment, the coverage improves notably for shifts in AP and SI directions and the CI-98% is restored to >95.0% for plans optimized with a 2-mm margin, >97% with a 3-mm margin, and >98% with larger margins. For large corrections, predominately in AP direction, cold spots in the CTV may occur. Their magnitude is dependent on the patients' individual anatomies. CONCLUSIONS: Within the physiological limits of internal prostate movement, target-based isocenter realignment results in improved CTV coverage for shifts in AP and SI directions exceeding the applied planning margin. Assuming optimal patient setup reproducibility (eg, immobilization, setup error correction, patient preparation protocols), hence negligible interfraction bone and soft-tissue variations, changes in traversed densities resulting from target-based realignment applied with a reduced planning margin do not induce significant dose deterioration in most of the cases.