A novel intraoperative "Faucet" technique for assessing patency of superficial temporal artery to middle cerebral artery bypass and for prevention of microemboli.

PURPOSE: This technical note introduces the novel faucet technique, which enables neurosurgeons to evaluate the patency of a bypass during superficial temporal artery-middle cerebral artery bypass surgery. The technique is particularly useful when there is a lack of equipment such as micro-Doppler or indocyanine green in the operating rooms. This is often the case in Central Asian countries. METHODS: The faucet technique involves carefully examining the graft by gently opening a valve, comparable to a faucet, to observe the blood flow through the bypassed vessel. Overall, 36 procedures underwent the faucet technique for assessing the superficial temporal artery-middle cerebral artery bypass patency. RESULTS: The results indicate that the bypass remained patent in all cases, as confirmed through the intraoperative faucet technique, postoperative magnetic resonance angiography, or cerebral angiography. CONCLUSION: By visually inspecting the blood flow through the faucet technique, surgeons can confirm the effectiveness of the graft and ensure that the bypass remains unobstructed during the surgery.

Replaced posterior cerebral artery with early branching temporal artery diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of replaced posterior cerebral artery (PCA) in which all branches of the PCA arose from the anterior choroidal artery (AChA) with an early branching temporal artery. METHODS: An 83-year-old man with cerebral infarctions underwent cranial magnetic resonance (MR) imaging and MR angiography using a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. RESULTS: A large anomalous artery arose from the supraclinoid segment of the right internal carotid artery (ICA) and supplied all branches of the right PCA, mimicking fetal-type PCA. The temporal branch arose from the proximal segment of this artery. In MR angiographic source images, a tiny artery arose from the right ICA proximal to the origin of the anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). Thus, we concluded that the anomalous artery was a replaced PCA; all branches of the PCA arose from the AChA. CONCLUSION: We present a case involving a replaced PCA with an early branching temporal artery, as seen on MR angiography. Careful observation of MR angiographic source images is useful for identifying small arteries. To our knowledge, this is the first report of this combined variation in the relevant English-language literature.

EFFECT OF DIRECT SURGICAL REVASCULARIZATION ON CEREBRAL HEMODYNAMICS AND STROKE DEVELOPMENT IN PATIENTS WITH MOYAMOYA DISEASE.

Decreased cerebral blood flow (CBF) leads to impaired cerebral hemodynamics, which causes an increased risk of stroke. Revascularization has been shown to improve CBF in patients with moyamoya disease. The study is devoted to the retrospective study of clinical features and cerebral hemodynamic characteristics of 17 patients with moyamoya disease before, during and after surgical treatment using extracranial-intracranial (EC-IC) bypass by STA-MCA type. Patients underwent superficial temporal artery-middle cerebral artery bypass surgeries. All patients were carried out by DSA, MSCT-angiography, and MSCT-perfusion imagine (MSCTPI) before and 6 months after surgery. The hemodynamic parameters during MSCTPI, changes in cerebral vascular pattern, and clinical outcomes were evaluated. Cerebral blood flow and mean transit time (MTT) were measured using MSCT-perfusion imaging to identify areas of hypoperfusion. Intraoperative indocyanine green (ICG) analysis was performed to assess local cerebral hemodynamics before and after the creation of the STA-MCA bypass. Results showed that hemodynamics improved significantly on the surgery side after revascularization. After STA-MCA bypass CBF increased and MTT reduced by almost 2 times compared to the level before the bypass. The modified Rankin Scale scores demonstrated an improvement in the neurological status of patients following surgical revascularization. Thus, STA-MCA-type surgical revascularization significantly improved cerebral perfusion parameters and reduced the risk of stroke in patients with moyamoya disease. MSCTPI can serve as an effective and noninvasive method for monitoring cerebral hemodynamics in these patients. Intraoperative ICG angiography is a safe method that can display hemodynamic characteristics in the surgical area.

Ultrasonography of the superficial temporal and axillary arteries in giant cell arteritis diagnosis.

OBJECTIVES: Giant cell arteritis (GCA) is the main systemic vasculitis in individuals aged ≥ 50 years. Color Doppler ultrasound (CDS) has an established role in GCA diagnosis and management. This study aims to assess the clinical characteristics associated with a positive CDS evaluation and the impact of additional axillary artery examination on diagnostic sensitivity. MATERIAL AND METHODS: We conducted a retrospective analysis of patients undergoing CDS of the superficial temporal arteries, with or without axillary artery assessment, at our hospital, between 2009 and 2023. Patients meeting the new 2022 diagnostic criteria for GCA were included and their characteristics were analyzed according to the presence of the halo sign on CDS. RESULTS: Of the 135 included patients (54 % female, mean age 75 ± 8 years), the halo sign was observed in 57 %, correlating with higher systemic symptom prevalence (61 % vs 42 %, p = 0.035), lower hemoglobin (p < 0.001), and higher erythrocyte sedimentation rate (p = 0.028). The halo sign inversely related to prior corticosteroid therapy (p = 0.033). Patients with axillary halo sign had fewer external carotid symptoms and a higher vertebral halo sign prevalence. Vertebral halo sign was associated with posterior circulation ischemic stroke (65 %, p < 0.001). Axillary artery studies improved diagnostic sensitivity by 9 %. CONCLUSION: In our study, the halo sign correlated with higher systemic symptoms and analytical abnormalities. Axillary artery examination enhanced CDS sensitivity, linked to severe outcomes like stroke. Prior corticosteroid therapy reduced CDS sensitivity. The correlation of clinical, laboratory, and ultrasound findings provides a more comprehensive understanding of GCA pathogenesis and evolution.

Superficial temporal artery aneurysm misdiagnosed in a patient with long-term migraine headache treatment: a case report.

BACKGROUND: Superficial temporal artery aneurysm is a rare vascular abnormality without specific clinical symptoms. In this case report, we present the case of a patient with superficial temporal artery aneurysm who was diagnosed with migraine headache at first. CASE PRESENTATION: A 60-year-old Iranian man with a previous history of headaches, who did not respond properly to the treatments following the initial diagnosis of migraine, presented with a painless lump in the left temporal region, and he was diagnosed with superficial temporal artery aneurysm via Doppler ultrasound. Finally, surgical removal of the left superficial temporal artery aneurysm was performed. CONCLUSIONS: This case shows the importance of vascular causes in the approach to headache etiologies, especially when the headache is prolonged without proper responses to treatment. Computed tomography angiography and magnetic resonance angiography are appropriate diagnostic methods for aneurysm detection that should be considered in future studies.

Clinical Manifestations and Prognosis of Giant Cell Arteritis: A Retrospective Cohort Study.

The aim of the study was to evaluate the clinical manifestations and survival of patients with giant cell arteritis (GCA). MATERIALS AND METHODS: . A retrospective study included 166 patients with newly diagnosed GCA. Clinical, laboratory, and instrumental data and three sets of classification criteria were used to confirm the diagnosis: the American College of Rheumatology (ACR) 1990, the revised ACR criteria of 2016 and/or the new ACR and European Alliance of Rheumatologic Associations (EULAR) 2022 criteria. Some of the patients underwent instrumental investigations: temporal artery ultrasound Doppler (n = 61), contrast-enhanced computed tomography (n = 5), CT angiography (n = 6), magnetic resonance imaging (n = 4), MR angiography (n = 3), and 18F-FDG PET/CT (n = 47). Overall and recurrence-free survival rates were analyzed using survival tables and Kaplan-Meier method. RESULTS: . The most frequent first manifestations of GCA were headache (81.8%), weakness (64%), fever (63.8%), and symptoms of rheumatic polymyalgia (56.6%). Changes in temporal arteries in color duplex scanning were detected in 44 out of 61 patients. GCs therapy was performed in all patients who agreed to be treated (n = 158), methotrexate was used in 49 out of 158 patients, leflunomide in 9 patients. In 45 (28.5%) out of 158 patients, a stable remission was achieved as a result of GC monotherapy; in 120 (75.9%) patients, long-term maintenance therapy with GCs was required to prevent exacerbations, including 71 (44.9%) patients in combination with methotrexate or other immunosuppressive drugs. The follow-up period of patients with a history of relapses was 21.0 (8.0-54.0) months. Relapses developed in 73 (46.2%) patients. The overall one-year survival rate was 97.1% [95% CI 94.3; 99.9], and the five-year survival rate of patients was 94.6% [95% CI 90.2; 99.0]. The one-year relapse-free survival rate was 86.4% [95% CI 80.5; 92.3], and the five-year relapse-free survival rate was 52.4% [95% CI 42.0; 62.8]. Twelve (7.2%) of 166 patients died. The cause of death was myocardial infarction in two patients, stroke in two patients, and breast cancer in one patient; in the remaining seven cases, the cause of death was not determined. CONCLUSIONS: : Given the high frequency of disease exacerbation, patients with GCA require long-term follow-up, especially during the first year after diagnosis.

Transorbital ultrasound in the diagnosis of giant cell arteritis.

OBJECTIVES: The objective of this study was to prospectively evaluate the diagnostic efficacy of transorbital ultrasound (TOS) in patients newly diagnosed with giant cell arteritis (GCA), presenting with visual symptoms. METHODS: Patients with newly diagnosed, untreated GCA were examined using TOS, assessing central retinal artery flow velocity [peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI)], and optic nerve diameter (OND). Vascular ultrasound was conducted to evaluate the superficial temporal arteries, their branches, facial, axillary, carotid, and vertebral arteries. RESULTS: We enrolled 54 GCA patients, 27 with visual symptoms, and 27 healthy controls. Eyes of GCA patients with visual symptoms demonstrated significantly lower PSV and EDV (PSV: ß = -1.91; P = 0.029; EDV: ß = -0.57; P = 0.032) and significantly elevated OND (ß = 0.79; P = 0.003) compared with controls. RI did not significantly differ from controls (ß = -0.06, P = 0.129). Vascular ultrasound identified an average of 8.7 (SD ± 2.8) pathological vessels per GCA patient. A significant negative association was observed between the number of affected vessels and both PSV (P = 0.048) and EDV (P = 0.040). No association was found with RI (P = 0.249), while a positive significant association was noted with OND (P < 0.001). CONCLUSIONS: This study pioneers the application of TOS to assess structural eye changes in newly diagnosed, untreated GCA patients with visual symptoms. Our findings suggest reduced central retinal artery flow and increased optic nerve diameter as potential biomarkers for serious ocular involvement in GCA. The detected association between internal and external carotid artery involvement indicates a common pathophysiological mechanism underlying systemic and ocular manifestations of GCA.

The Common Carotid Artery in the Ultrasound Evaluation of Giant Cell Arteritis.

OBJECTIVES: Vascular ultrasound is commonly used to diagnose giant cell arteritis (GCA). Most protocols include the temporal arteries and axillary arteries, but it is unclear which other arteries should be included. This study investigated whether inclusion of intima media thickness (IMT) of the common carotid artery (CCA) in the ultrasound evaluation of GCA improves the accuracy of the examination. METHODS: We formed a fast-track clinic to use ultrasound to rapidly evaluate patients with suspected GCA. In this cohort study, patients referred for new concern for GCA received a vascular ultrasound for GCA with the temporal arteries and branches, the axillary artery, and CCA. RESULTS: We compared 57 patients with GCA and 86 patients without GCA. Three patients with GCA had isolated positive CCA between 1 and 1.49 mm, and 21 patients without GCA had isolated positive CCA IMT. At the 1.5-mm CCA cutoff, 4 patients without GCA had positive isolated CCA, and 1 patient with GCA had a positive isolated CCA. The sensitivity of ultrasound when adding carotid arteries to temporal and axillary arteries was 84.21% and specificity 65.12% at an intima media thickness (IMT) cutoff of ≥1 mm and 80.70% and 87.21%, respectively, at a cutoff of ≥1.5 mm. CONCLUSION: Measurement of the CCA IMT rarely contributed to the diagnosis of GCA and increased the rate of false-positive results. Our data suggest that the CCA should be excluded in the initial vascular artery ultrasound protocol for diagnosing GCA. If included, an IMT cutoff of higher than 1.0 mm should be used.

Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis : A Prospective Cohort Study.

BACKGROUND: Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in people older than 50 years. Any delay in diagnosis impairs patients' quality of life and can lead to permanent damage, particularly vision loss. OBJECTIVE: To evaluate a diagnostic strategy for GCA using color Doppler ultrasound of the temporal artery as a first-line diagnostic test, temporal artery biopsy (TAB) as a secondary test, and physician expertise as the reference method. DESIGN: Prospective multicenter study with a 2-year follow-up. (ClinicalTrials.gov: NCT02703922). SETTING: Patients were referred by their general practitioner or ophthalmologist to a physician with extensive experience in GCA diagnosis and management in one of the participating centers: 4 general and 2 university hospitals. PATIENTS: 165 patients with high clinical suspicion of GCA, aged 79 years (IQR, 73 to 85 years). INTERVENTION: The diagnostic procedure was ultrasound, performed less than 7 days after initiation of corticosteroid therapy. Only ultrasound-negative patients underwent TAB. MEASUREMENTS: Bilateral temporal halo signs seen on ultrasound were considered positive. Ultrasound and TAB results were compared with physician-diagnosed GCA based on clinical findings and other imaging. RESULTS: Diagnosis of GCA was confirmed in 44%, 17%, and 21% of patients by ultrasound, TAB, and clinical expertise and/or other imaging tests, respectively. Their diagnosis remained unchanged at 1 month, and 2 years for those with available follow-up data. An alternative diagnosis was made in 18% of patients. The proportion of ultrasound-positive patients among patients with a clinical GCA diagnosis was 54% (95% CI, 45% to 62%). LIMITATION: Small sample size, no blinding of ultrasound and TAB results, lack of an objective gold-standard comparator, and single diagnostic strategy. CONCLUSION: By using ultrasound of the temporal arteries as a first-line diagnostic tool in patients with high clinical suspicion of GCA, further diagnostic tests for patients with positive ultrasound were avoided. PRIMARY FUNDING SOURCE: Tender "Recherche CH-CHU Poitou-Charentes 2014."

Scalp necrosis following preoperative endovascular embolisation of the superficial temporal artery for meningioma.

A woman in her late 50s with a left frontal lobe convexity meningioma underwent an elective endovascular embolisation of the left middle meningeal artery and distal branches of the left superficial temporal artery prior to surgical resection of the tumour. On postoperative day 46, she developed scalp necrosis, leading to poor wound healing requiring wound debridement and a complex plastic surgery reconstruction with a rotational flap. Endovascular embolisation of vascular tumours prior to surgical resection does not come without risks. The lack of consistency in the literature regarding indication, technique and outcomes makes it difficult to define the exact role of preoperative meningioma embolisation.

Giant Cell Arteritis. / Riesenzellarteriitis.

Giant cell arteritis (GCA) is the most common primary vasculitis and is associated with potential bilateral blindness. Neither clinical nor laboratory evidence is simple and unequivocal for this disease, which usually requires rapid and reliable diagnosis and therapy. The ophthalmologist should consider GCA with the following ocular symptoms: visual loss or visual field defects, transient visual disturbances (amaurosis fugax), diplopia, eye pain, or new onset head or jaw claudication. An immediate ophthalmological examination with slit lamp, ophthalmoscopy, and visual field, as well as color duplex ultrasound of the temporal artery should be performed. If there is sufficient clinical suspicion of GCA, corticosteroid therapy should be initiated immediately, with prompt referral to a rheumatologist/internist and, if necessary, temporal artery biopsy should be arranged. Numerous developments in modern imaging with colour duplex ultrasonography, MRI, and PET-CT have the potential to compete with the classical, well-established biopsy of a temporal artery. Early determination of ESR and CRP may support RZA diagnosis. Therapeutically, steroid-sparing immunosuppression with IL-6 blockade or methotrexate can be considered. These developments have led to a revision of both the classification criteria and the diagnostic and therapeutic recommendations of the American College of Rheumatologists and the European League against Rheumatism, which are summarised here for ophthalmology.

Tomographic ultrasound for three-dimensional visualization of temporal arteries.

OBJECTIVE: Conventional two-dimensional ultrasound has been assessed for the non-invasive diagnosis of giant cell arteritis (GCA), but the results are operator dependent, resulting in low sensitivity. Tomographic three-dimensional (3D) ultrasound is a novel technique that enables the objective documentation of vessel geometry. Here, for the first time, its utility is assessed for visualizing temporal arteries. METHOD: The temporal artery of 14 healthy subjects and three subjects with suspected GCA was examined using tomographic 3D ultrasound. RESULTS: This technique enabled 3D mapping of the architecture of the temporal artery. The inner and outer vessel diameters showed considerable interindividual variability. However, calculation of the vessel wall fraction revealed the combination of vessel wall thickening and lumen narrowing, which may be indicative of GCA. CONCLUSIONS: This proof-of-concept study indicates that tomographic 3D ultrasound can be used for objective mapping of the temporal artery. The technique must be evaluated regarding its diagnostic sensitivity in GCA before it can be introduced in clinical practice.

Should all patients with polymyalgia rheumatica have a vascular ultrasound assessment?

There is a growing appreciation that both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely interrelated conditions that have significant overlap in aetiology, clinical characteristics and treatment regimens. Subclinical GCA in PMR is becoming increasingly recognised, and there is evolving evidence that this may be a more aggressive disease phenotype than PMR. Ultrasound (US) lends itself well as a screening tool for GCA in PMR; it is inexpensive, non-invasive, widely available, lacks ionising radiation, may be performed at the bedside and is recommended by EULAR as a first-line investigation for suspected GCA. There is insufficient evidence to currently recommend that all patients with PMR should have a US assessment for vascular involvement. However, as clinical and laboratory parameters alone do not accurately diagnose patients with subclinical GCA, we suggest that vascular US will be increasingly performed by rheumatologists in practice to identify these patients with PMR, preferably as part of larger prospective outcome studies.

Performance of a fast-track pathway for giant cell arteritis in Waikato, Aotearoa New Zealand.

AIMS: Giant cell arteritis (GCA) is the most common primary vasculitis in adults over 50 years of age. To facilitate early diagnosis and reduce harms from corticosteroids and temporal artery biopsies, fast-track pathways have been established. We review the benefits of the fast-track pathway set up in Waikato, Aotearoa New Zealand. METHODS: Patients were collected prospectively as part of the fast-track pathway from 2014 to 2022. Their records were then reviewed retrospectively to collect data on clinical features, investigations and treatment. RESULTS: There were 648 individual patients over the study period who had a colour Doppler ultrasound (CDUS) of the temporal arteries. There were 17 true positive CDUS, giving a sensitivity of 10.3% (95% confidence interval [CI] 6.3-15.5%) and specificity of 99.8% (95% CI 99.1-100%). Patients with GCA and a positive scan had significantly fewer steroids than those with GCA and a negative scan (p=0.0037). There were 376 patients discharged after a CDUS who did not have a diagnosis of GCA, resulting in reduced corticosteroid and temporal artery biopsy exposure. CONCLUSIONS: This is a real-life study that reflects the benefits of fast-track pathways in Aotearoa New Zealand to patients and healthcare systems. It also shows the effect of corticosteroids on positive CDUS, an important consideration when setting up an fast-track pathway.

Angiographic measurement of the superficial temporal artery for potential use in cerebral bypass surgery: a combined radiological and cadaveric study.

PURPOSE: This study aims to investigate the microsurgical anatomy of the superficial temporal artery (STA), explore the relationship between STA length and lumen diameter, and develop a reliable radiologic method for selecting STA segments for bypass surgery. METHODS: This study used 10 cadaveric dissections (20 STAs, both sides) and 20 retrospective radiological examinations (40 STAs, both sides), employing curved multiplanar reformation and flow color lookup table (CLUT) DICOM processing. Measurements included vessel lumen diameters and luminal cross-sectional thicknesses 3 mm proximal to the STA bifurcation, 3 mm distal to the frontal branch, 5 cm distal to the frontal branch, 3 mm distal to the parietal branch, and 5 cm distal to the parietal branch. The distance between the STA bifurcation and the superior zygomatic border (SZB) was also measured. In our analysis, descriptive statistics encompassed mean, standard deviation (SD), standard error, minimum and maximum values, and distributions. Comparative statistics were performed using Student's t-test, with statistical significance set at p < 0.05. RESULTS: There were no statistically significant differences between STA measurements of bifurcation distances (p = 0.88) and lumen diameters (p = 0.46) between cadavers and radiological measures. However, lumen thicknesses were larger in frontal branches than parietal branches at the seventh and eighth centimeter (p = 0.012, p = 0.039). Branches became thinner distally from the zygoma in both cadavers and radiological image measurements. CONCLUSION: The CLUT DICOM processing radiological measures provided the high-precision required to enable pre-surgical vessel selection for extracranial-intracranial bypass. The results show that STA vessel luminal diameters are sufficient (> 1 mm) for bypass surgery in the first 9 cm but gradually decrease after that. Also shown is that the choice of frontal versus parietal branches depends on individual anatomical features; therefore, careful preoperative radiological examination is critical.