Glioblastoma with novel EGFR mutations (T790M and exon 20 insertion) yet unresponsive to osimertinib: A case report.

Glioblastoma (GBM) is a high-grade adult-type IDH-wildtype diffuse glioma, commonly harboring epidermal growth factor receptor (EGFR) amplification. Here, we describe a case of a 49-year-old man with a GBM harboring a TERT promoter mutation. Despite surgical and chemoradiation therapy, the tumor recurred. At that time, comprehensive genomic profiling by next-generation sequencing identified two rare mutations in EGFR: T790M and an exon 20 insertion. Based on these findings, the patient elected to undergo off-label therapy with osimertinib, a third-generation EGFR tyrosine kinase inhibitor that has shown promising results in non-small cell lung carcinoma, including metastatic to brain, with exactly the same EGFR mutations. Moreover, the drug has excellent central nervous system penetration. Even so, no clinical response was observed, and the patient succumbed to the disease. The lack of response may be related to the specific nature of the EGFR mutations, and/or other unfavorable tumor biology overriding any benefit from osimertinib.

Long-term treatment outcomes of pediatric low-grade gliomas treated at a university-based hospital.

PURPOSE: A multimodality approach is generally considered for pediatric low-grade gliomas (LGG); however, the optimal management remains uncertain. The objective of the study was to evaluate treatment outcomes of pediatric LGG, focusing on long-term survival and factors related to outcomes. METHODS: A retrospective review of 77 pediatric LGG cases treated at Ramathibodi Hospital, Thailand between 2000 and 2018 was performed. The inclusion criteria were all pediatric LGG cases aged ≤ 15 years. Diffuse intrinsic pontine gliomas and spinal cord tumors were excluded. RESULTS: The median follow-up time was 8.2 years (range, 0.6-19.7). The median age at diagnosis was 6.2 years (interquartile range, 3.6-11.4). Treatments modality included tumor surgery (93%), chemotherapy (40%), and radiation therapy (14%). The 10-year overall survival (OS) and 10-year progression-free survival were 94% and 59%, respectively, for the entire cohort. The 10-year OS was 100% in three subgroups of patients: pilocytic subtype, WHO grade 1 tumors, and recipient of gross total resection. After multivariable analysis, no tumor surgery had a significantly unfavorable influence on overall survival. CONCLUSIONS: With a multimodality approach, pediatric LGGs had excellent outcome. Gross total resection is the standard primary treatment. Chemotherapy is the alternative standard treatment in incomplete resection cases, unresectable patients, or patients with progressive disease. Radiation therapy should be reserved as a salvage treatment option because of late complications that usually affect patients' quality of life.

Nanocoating and biological evaluation of clindamycin- and rifampicin-loaded nanospheres impregnated silicone tube for antibacterial application.

Two types of nanospheres, namely clindamycin-loaded nanospheres (CN) and rifampicin-loaded nanospheres (RN) were successfully prepared using emulsion solvent evaporation technique. Poly(ε-caprolactone-random-d,l-lactide)-block-poly(ethylene glycol)-block-poly(ε-caprolactone-random-d,l-lactide) (PLEC) was used for preparing nanospheres. CN and RN were coated on an antibiotic-impregnated silicone tube surface by spray coating technique. The formulations of antibiotic-loaded nanospheres (CN and RN) and the amount of spray coating cycles were optimized. Drug-loading content (DLC), encapsulation efficiency, zeta potential, and size of nanospheres were characterized. The optimal ratios of PLEC to clindamycin; and PLEC to rifampicin were both at 2:1. Drug-loading contents of CN and RN were 2.62 ± 0.04% and 7.02 ± 0.02%, respectively. The optimum coating of 90 cycles was provided DLCs of 0.0637 ± 0.033 wt.% and 0.0613 ± 0.018 wt.% for rifampicin and clindamycin, respectively. The coating of silicone tube was able to prolong the release of both antibiotics for at least 30 days. Antibacterial activity test was performed using MRSA (ATCC 43300) and S. Epidermidis (ATCC 12228). Moreover, the cytotoxicity of antibiotic-loaded nanospheres coated on silicone tubes was evaluated. The coated silicone tube showed antibacterial activity for at least 28 days and was biocompatible with L929 cells.

Outcome of postoperative radiation therapy for pediatric intracranial ependymoma: a single-institution review.

PURPOSE: To report outcome of postoperative radiotherapy (RT) in both new and recurrent grade II and III intracranial ependymomas in children treated at Ramathibodi Hospital. MATERIALS AND METHODS: Between 2006 and 2017, 24 pediatric intracranial ependymomas treated with postoperative RT were retrospectively reviewed. The median age at diagnosis was 44.5 months (range, 4-165 months). There were 14 (58%) males. Fourteen (58%) patients had infratentorial tumor. The median maximal diameter of tumor at diagnosis was 4.45 cm (range, 2.2-10 cm). Fourteen (58%) patients had anaplastic tumor. Gross total resections were performed in 14 (58%) patients. The median prescribed dose was 54 Gy (range, 45-60 Gy). The median total treatment time was 43 days (range, 37-78 days). RESULTS: The median clinical follow-up time was 44.5 months (range, 1-146 months). There were nine recurrences, five of which occurred at the primary tumor site. The estimated 5-year progression-free survival rate was 56%. The estimated 5-year overall survival rate was 75%. Extent of resection was the only factor associated with improved progression-free survival and overall survival after univariate testing. Six from nine patients with recurrent diseases underwent further surgery or further RT. These six patients had better median overall survival than the three who did not. Acute complication was mostly transient and tolerable. No late radiation effect was found. CONCLUSIONS: Postoperative radiation is an effective treatment. GTR is associated with better PFS and OS. Aggressive salvage local treatments for recurrent patients can result in good overall survival. Longer follow-up is needed in account for late relapse.

Reported outcomes of children with newly diagnosed high-grade gliomas treated with nimotuzumab and irinotecan.

PURPOSE: The outcome of children with high-grade gliomas (HGGs) treated with radiation and adjuvant chemotherapy remains poor. The expression of epidermal growth factor receptor (EGFR) has been established in children with HGGs. This report demonstrated the outcomes of adjuvant nimotuzumab, an EGFR inhibitor, with irinotecan in pediatric HGGs. METHODS: Children with newly diagnosed HGGs were enrolled. Two weeks after surgery, nimotuzumab with a dose of 150 mg/m2 was given every week during radiation. After completion of radiation, a 4-week cycle of nimotuzumab (150 mg/m2) at week 1 and 3 and irinotecan (125 mg/m2) at week 1, 2, and 3 was given. RESULTS: Sixteen patients (5 females, 11 males), with a mean ± SD age of 8.2 ± 3.5 years were included. Tumors were located at the supratentorial region (50.0%), infratentorial region (43.8%), and both locations (6.2%). The 5-year PFS and OS were 19.9 ± 11.6 and 31.5 ± 13.0%, respectively. Median times of PFS and OS were 1.8 and 1.9 years, respectively. Prognostic factors related to good outcome were the location of tumor at the supratentorial region or outside brainstem and the extension of surgery. Side effects were minimal, with grade 1 anemia in three patients and diarrhea in one patient. Although, the adjuvant regimen of nimotuzumab and irinotecan slightly increases the overall outcome when compared to the historical study, the advantages of this protocol were minimal side effect, short period of hospitalization, and improved OS in patients who received extensive surgery.

Injectable SN-38-loaded Polymeric Depots for Cancer Chemotherapy of Glioblastoma Multiforme.

PURPOSE: SN-38, a potent chemotherapeutic drug, has not been used clinically because of its severe side effects and poor solubility. In this work, we aimed to evaluate the effect of dose and multiple injections of SN-38-loaded polymeric depots on antitumor efficacy and toxicity in vivo. METHODS: Preparation and characterization of SN-38-loaded depots were performed and evaluated in vitro using human glioblastoma cell line, U-87MG. Antitumor efficacy with different depot administrations including dose, position of depot injection and number of injections were evaluated in tumor model in nude mice. RESULTS: Depots encapsulated SN-38 with high encapsulation efficiency (~98.3%). High amount of SN-38 (3.0 ± 0.1 mg) was prolonged and controlled release over time and showed anticancer activity against U-87MG cell line in vitro. For one course administration, depots exhibited better antitumor efficacy and reduced toxicity compared to free SN-38. Elevated doses and multiple injections of SN-38-loaded depots and free SN-38 provided greater tumor growth inhibition and animal survival. All animals received SN-38-loaded depots were well tolerated and survived while most of those received free SN-38 died at day 30. Free SN-38 showed severe toxic effect compared to minimal toxicity from SN-38-loaded depots which was due to lower SN-38 level in systemic circulation. Fluorescence imaging and histopathology confirmed that SN-38 released from depots was detected throughout tumors 35 days post administration. CONCLUSIONS: SN-38-loaded depots were proved as a promising new treatment for highly invasive glioblastoma multiforme with low acute toxicity due to controlled release of SN-38.

Successful Treatment of Large Occipital Encephalocele Presenting with Bilateral Vocal Cord Paralysis: A Case Report.

large subtorcular occipital encephalocele in neonate carries higher risk of associated hindbrain anomalies and secondary process for neurological deterioration which predict the surgical outcomes and long-term prognosis. The dysfunction of the lower cranial nerves often leads to worsening of neurological status from poor respiratory function and repeated aspiration pneumonia. The aims of repairing encephalocele include a good closure of the defect, preservation or restoration of neurological functions and better cosmetic results. The author presented a successful surgical strategy for management of a 4-month-old infant with a large subtorcular occipital encephalocele presented with bilateral vocal cord paralysis and swallowing dysfunction. A step by step approach unlocked the main mechanism(s) of reversible lower cranial dysfunctions in this specific situation, including the increased intracranial pressure and shifting of the axis of lower brain stem.

Deep Brain Stimulation of Anterior Thalamic Nuclei for Intractable Epilepsy in Thailand: Case Report

Neurostimulation can be an alternative treatment for medically intractable epilepsy, especially when the resective surgery could not be performed. The author reported a case of 19-year-old, right-handed male patient who had a history of intractable epilepsy for 11 years after post viral encephalitis associated with status epilepticus. Following the failure of antiepileptic medications and then resective surgery, anterior thalamic deep brain stimulation (DBS) was performed. Indirect targeting of anterior thalamic nuclei could not be used because of asymmetric brain shift from prior multilobar resections. Direct targeting of anterior thalamic nuclei from MRI T1 sequence, Short Tau Inversion Recovery (STIR) sequence combined neurophysiological mapping by microelectrode recording were used as a technique for implantation of DBS electrodes. The stimulation was turned on with 145 Hz, pulse width 90 microseconds, 5 volts with cycling mode 1 minute "on" and 5 minutes "0ff". The antiepileptic medications continued the same as pre-operative state. Sixty percent seizure reduction was achieved in 24 months after surgery. There were no side effects of DBS during the follow-up period. Anterior thalamic DBS can be performed safely with satisfactory seizure outcomes. Direct targeting of anterior thalamic nuclei combination with microelectrode recording can be very helpful, especially when asymmetric basal ganglion structures were detected.

Treatment of a brain abscess caused by Scedosporium apiospermum and Phaeoacremonium parasiticum in a renal transplant recipient.

Cerebral mycosis is a significant cause of morbidity among immunocompromised populations. We present here a case of cerebral infection with Scedosporium apiospermum and Phaeoacremonium parasiticum in a 49-year-old renal transplant recipient. Fourteen years after renal transplantation, the patient presented with invasive pulmonary aspergillosis treated with intravenous liposomal amphotericin B. The patient had clinical and radiographic improvement. However, 6 weeks later, the patient presented with cerebral infection. Magnetic resonance imaging revealed multiple rim enhancing brain abscesses. Brain and cerebrospinal fluid cultures ultimately grew Scedosporium apiospermum and Phaeoacremonium parasiticum. The patient was treated with voriconazole for 6 months and had clinical and radiologic improvement. We believe this is the first reported case of co-infection of the brain with scedosporiosis and phaeohyphomycosis in a renal transplant recipient, who had received intravenous liposomal amphotericin B. Voriconazole may represent a new therapeutic option for these simultaneous infections in the brain.

Antibacterial and biocompatibility studies of triple antibiotics-impregnated external ventricular drainage: In vitro and in vivo evaluation.

Hydrocephalus is a neurological disease caused by an unusually high level of cerebrospinal fluid (CSF), which can be relieved by external ventricular drainage (EVD) insertion. However, the infection can lead to complications during the use of EVD. In this study, EVD was impregnated with three synergistic antibiotics, including rifampicin, clindamycin, and trimethoprim, to improve the antibacterial property. The impregnated drainage was studied for its characteristics in vitro and in vivo. Drug loading determination revealed that rifampicin had the highest concentration in the tube, followed by clindamycin and trimethoprim, respectively. In vitro cytotoxicity and hemolytic studies showed no toxic effects from antibiotics-impregnated EVD on fibroblast and red blood cells. For antibacterial testing, the impregnated EVD exhibited antibacterial activity against Staphylococcus aureus MRSA and Staphylococcus epidermidis up to 14 and 90 days, respectively. Moreover, biocompatibility and drug release into the bloodstream and surrounding tissues were investigated by implantation in rabbits for 30 days. Histology and morphology results showed that fibroblast cells began to adhere to the drainage surface and inflammatory cell numbers were noticeably small after the long-term implantation. In addition, there was no drug leakage to the bloodstream and surrounding tissues. Hence, this impregnated EVD can potentially be used for antibacterial application.

Preparation and biocompatibility study of in situ forming polymer implants in rat brains.

We describe the development of polymer implants that were designed to solidify once injected into rat brains. These implants comprised of glycofurol and copolymers of D: ,L: -lactide (LA), ε-caprolactone and poly(ethylene glycol) (PLECs). Scanning electron microscopy (SEM) and gel permeation chromatography (GPC) showed that the extent of implant degradation was increased with LA: content in copolymers. SEM analysis revealed the formation of porosity on implant surface as the degradation proceeds. PLEC with 19.3% mole of LA: was chosen to inject in rat brains at the volume of 10, 25 and 40 µl. Body weights, hematological and histopathological data of rats treated with implants were evaluated on day 3, 6, 14, 30 and 45 after the injection. Polymer solution at the injection volume of 10 µl were tolerated relatively well compared to those of 25 and 40 µl as confirmed by higher body weight and healing action (fibrosis tissue) 30 days after treatment. The results from this study suggest a possible application as drug delivery systems that can bypass the blood brain barrier.

Emergency surgical removal of a migrated coil during embolization of a giant internal carotid artery aneurysm: illustrative case.

BACKGROUND: Coil migration during endovascular treatment for an intracranial aneurysm is rare. When it occurs intraoperatively, it often mandates prompt endovascular retrieval or, as a salvage maneuver, microsurgical extraction if it fails endovascularly. OBSERVATIONS: The authors presented a case of immediate coil migration during embolization of a giant intracranial cavernous segment of the internal carotid aneurysm. The patient immediately underwent emergency surgical extraction after unsuccessful endovascular retrieval attempts. The migrated coil was successfully removed through the M1 segment of the middle cerebral artery. The patient had full recovery without new neurological deficits. Four years after the incident, she was living independently. Previous case reports of emergency surgical removal of immediate coil migration were provided. LESSONS: Surgical extraction of migrated coil after unfeasible endovascular retrieval served as an alternative salvage procedure. Hybrid neurological angiography in the operating suite may prevent unnecessary transfer and provide better real-time visualization of the migrated coil.

In vivo catheterization study of chlorhexidine-loaded nanoparticle coated Foley urinary catheters in male New Zealand white rabbits.

Foley urinary catheters were coated with chlorhexidine-loaded nanoparticles (CHX-NPs), encapsulated in the form of micelles and nanospheres. Both of nanoparticles were deposited by multilayer nanocoating through dip and spray coating on the catheter surface both inner and outer surface. In our previous studies, the nanocoating of Foley urinary catheters was studied for chlorhexidine release, degradation, antibacterial evaluation, cytotoxicity assessment, hemocompatibility, skin irritation, skin sensitization, and stability during storage. The results demonstrated the antimicrobial functions and biocompatibility of the coated catheters. In this study, coated urinary catheters were inserted in the bladders of rabbits for 7 day to investigate their efficacy. Histopathology results showed no inflammation, redness, or swelling on bladder and urethra tissues. Surface morphology comparison of uncoated catheters in the control group and coated catheters in the treatment group revealed more encrustation and crystallization on uncoated catheter than on coated catheter, indicating that catheters coated with CHX-NPs showed efficacy in delaying encrustation and bacterial colonization. These findings suggest that nanocoating of urinary catheters can potentially enhance the biocompatibility of medical devices.

Biocompatibility and stability during storage of Foley urinary catheters coated chlorhexidine loaded nanoparticles by nanocoating: in vitro and in vivo evaluation.

Foley urinary catheters were coated by chlorhexidine-loaded micelles and chlorhexidine-loaded nanospheres. In our prior study, the nanocoating of Foley urinary catheter was investigated for chlorhexidine-release study, degradation, antibacterial evaluation, and cytotoxicity assessment. These studies presented the 1 month antibacterial property of nanocoating deposited via the layers of micelles and nanospheres. In this study, we evaluated the biocompatibility of these catheters, including hemocompatibility, skin irritation, skin sensitization, and stability during the age of coated urinary catheter. Results demonstrated that coated urinary catheters presented slight hemolysis, whereas skin irritation on rabbit and skin sensitization on Dunkin Hartley guinea pig showed no signs of dermal toxicity, which indicated that inflammation, redness, and swelling did not occur. Moreover, the stability of coated urinary catheters during storage indicated no change in chlorhexidine peaks by high performance liquid chromatography. Information from these studies supports the biocompatibility of coated urinary catheters via nanocoating and their use as indwelling devices to prevent urinary tract infections.

Simplified approach for pathological diagnosis of diffuse gliomas in adult patients.

The most recent WHO classification (2016) for gliomas introduced integrated diagnoses requiring both phenotypic and genotypic data. This approach presents difficulties for countries with limited resources for laboratory testing. The present study describes a series of 118 adult Thai patients with diffuse gliomas, classified by the WHO 2016 classification. The purpose was to demonstrate how a diagnosis can still be achieved using a simplified approach that combines clinical, morphological, immunohistochemical, and fewer molecular assays than typically performed. This algorithm starts with tumor location (midline vs. non-midline) with diffuse midline glioma identified by H3 K27M immunostaining. All other tumors are placed into one of 6 categories, based on morphologic features rather than specific diagnoses. Molecular testing is limited to IDH1/IDH2 mutations, plus co-deletion of 1p/19q for cases with oligodendroglial features and TERT promoter mutation for cases without such features. Additional testing for co-deletion of 1p/19q, TERT promoter mutation and BRAF mutations are only used in selected cases to refine diagnosis and prognosis. With this approach, we were able to reach the integrated diagnosis in 117/118 cases, saving 50 % of the costs of a more inclusive testing panel. The demographic data and tumor subtypes were found to be similar to series from other regions of the world. To the best of our knowledge, this is to the first reported series of diffuse gliomas in South-East Asia categorized by the WHO 2016 classification system.

Cerebral aspergillosis and cerebral candidiasis; a retrospective analysis of clinicopathologic features in Ramathibodi Hospital.

OBJECTIVE: Determine and compare the clinicopathological findings of cerebral aspergillosis with cerebral candidiasis. MATERIAL AND METHOD: The medical records with cerebral aspergillosis and cerebral candidiasis in Ramathibodi Hospital between January 1997 and December 2008 were analyzed. The criterion for the diagnosis of cerebral aspergillosis and cerebral candidiasis was the evidence of fungal elements from histopathologic section. The age, gender neurological manifestations, duration of symptom, associated underlying disease, predisposing risk factor, laboratory data, extent of systemic organ involvement and treatment outcome were analyzed. RESULTS: The present study included cerebral aspergillosis (n = 41) and candidiasis (n = 15). There were 23 male and 33 female patients. The mean and median ages at diagnosis were 39.7 and 45 years, respectively (range, 1 month to 87 years). The clinical presentations included alteration of consciousness (69.6%), fever (60.7%), weakness of the extremity (14.3%), cranial nerve palsy (12.5%), headache (12.59%) and seizure (5.4%). One third of the cases had underlying hematologic malignancy. The cerebral aspergillosis and cerebral candidiasis were associated with corticosteroids treatment in 32.1%. The frequent associated sites of fungal infection included the lungs (73.2%), alimentary tract (33.9%) and sinonasal tract (19.6%). CONCLUSION: A diagnosis of cerebral aspergillosis and cerebral candidiasis requires a high index of suspicion especially in immunocompromised patients who presented with alteration of consciousness, fever, focal neurological deficit, headache, and seizure. The patients with cerebral aspergillosis and cerebral candidiasis manifest with similar clinicopathologic features. However, the sinonasal tract infection and abscess formation are more common in cerebral aspergillosis. Associated alimentary tract infection is commonly seen in cerebral candidiasis.

Cost-effectiveness analysis of epilepsy surgery in children and adolescents with drug resistant focal epilepsy at three years in a tertiary care epilepsy center in Thailand.

Epilepsy surgery is proven as a cost-effective treatment in developed countries, especially in adults with drug resistant epilepsy (DRE). This study is aimed to demonstrate the cost-effectiveness of epilepsy surgery in children and adolescents with DRE at three years compared with those who were eligible for surgery but received medical treatment. This study was conducted from January 2014 to December 2018. Clinical data were obtained from a retrospective chart review. Direct medical costs, including epilepsy surgery, inpatient and outpatient treatment were retrieved from the finance department. Direct non-medical costs were collected from the family interview. The effectiveness was determined by percent seizure reduction and quality of life assessed by EQ-5D scores. Decision tree analysis using TreeAge Pro® 2018 was deployed to determine the cost-effectiveness. Seventeen patients had epilepsy surgery and 19 were in the medical group. Seizure freedom was noted in 52% and 16% in the surgical and medical groups, respectively. Incremental cost-effectiveness ratio (ICER) was 743,040 THB (22,793 USD) per 1 QALY and 3302 THB (101 USD) per 1% seizure reduction. The study did not demonstrate cost-effectiveness of epilepsy surgery in the short term compared with Thailand's threshold (160,000 THB (4908 USD) per 1 QALY). Epilepsy surgery may be cost-effective if evaluated beyond three years.

Carboplatin-based regimen in pediatric intracranial germ-cell tumors (IC-GCTs): effectiveness and ototoxicity.

BACKGROUND: Induction chemotherapy with carboplatin followed by radiotherapy has been used for many years for treating intracranial germ-cell tumors (IC-GCTs) in Thailand. The objective of this study was to assess treatment outcomes, focusing on survival and ototoxicity. METHODS: The outcomes of all patients with IC-GCT treated at Ramathibodi Hospital and the Prasat Neurological Institute between 2000 and 2017 were reviewed and analyzed, including all patient characteristics and treatment modalities. Five-year overall survival (OS) and event-free survival (EFS) were analyzed using the Kaplan-Meier method, and factors affecting survival were compared using the log-rank test. RESULTS: Fifty-three patients age 1-14 years (median, 11 years) were included in this study. The median follow-up time was 63 months. The 5-year EFS and OS rates were 94.3% and 96.2% for all patients, respectively. No statistical difference in OS or EFS was observed between the data of recipients in the carboplatin-based and historical cisplatin-based therapies in our institutes. Concerning radiotherapy, omission of radiotherapy or focal irradiation results in worse long-term survival outcomes, but reduction in dose of radiotherapy to less than 40 Gy did not cause any negative impact on survival rates. Furthermore, carboplatin was associated with lower rates of hearing loss than cisplatin (5.7% vs 87.5%). CONCLUSIONS: Induction chemotherapy with carboplatin-based regimens was associated with excellent survival rates and low ototoxicity in patients with IC-GCT. Radiotherapy should be given to all patients with a minimal volume equivalent to whole-ventricular radiotherapy, during which doses of lower than 40 Gy can be effectively used.

Malignant craniopharyngioma; case report and review of the literature.

A case of malignant craniopharyngioma in a 46-year-old woman presenting clinically with visual disturbance and bifrontal headache is reported. Histopathologic examination of the suprasellar mass showed a lesion characterized by nests of epithelial cells with a basaloid appearance, round-to-oval nuclei, moderate pleomorphism, hyperchromasia, increased nuclear cytoplastic ratio and high mitotic activity. Immunohistochemically, the tumor cells were positive for Ki-67 (44.3%), p53 (98%), and p63 (100%), but negative for estrogen and progesterone receptors. Clinical and pathologic features with a brief review of the relevant literature for malignant craniopharyngioma as a novel member of tumors of the suprasellar region, is discussed.

Variation of the recurrent artery of Heubner in human cadavers.

Study the normal anatomical and variation of the recurrent artery of Heubner (RAH) in fifty Thai cadaveric brains were studied under operating microscope. The anterior communicating artery (ACoA) located at the orbital surface of gyrus rectus about 50% and medial surface of gyrus rectus about 50%. The recurrent artery of Heubner originated from the anterior cerebral artery part 2 (ACA2) 60.4%, junction of ACoA 31.9%, and anterior cerebral artery part 1 (ACA1) 7.7%. Ninety-two percent of the origins of the RAH were identified within 2 mm from the proximal and distal of ACoA. The most common site of its origin from main artery was at its lateral surface 91.0%. The courses of RAH in relation to ACA1 segment were found anteriorly 63.4%, superiorly 29.9% and posteriorly 6.7%, respectively.