Middle Cerebral Artery Ischemic Complications After Flow Diverter Deployment from Internal Carotid Artery Extending into M1 Segment.

AIM: To gain a better understanding of ischemia risk related to in-stent stenosis (ISS) or in-stent thrombosis (IST) of the middle cerebral artery (MCA) and lenticulostriate arteries after flow-diverting devices (FDD) deployment from the internal carotid artery (ICA) to proximal middle cerebral artery (M1). MATERIAL AND METHODS: Using data from a prospectively maintained database, we retrospectively evaluated patients who were treated with FDD between January 2015 and 2020 at a single academic center. Only patients with unruptured ICA aneurysms where the FDD was extended into M1 were included. RESULTS: In total, 89 patients with 94 ICA aneurysms were treated with FDD. A total of 34 patients with 36 aneurysms had FDD extending into M1. Of the 34 patients, four experienced MCA, and lenticulostriate territory ischemia. Three patients had in-stent thrombosis (IST), and one patient had severe in-stent stenosis (ISS). The overall ischemic complication rate was 17.6%, which resulted in a permanent neurological deficit in 11.7% of the patients. CONCLUSION: If the distance of the distal neck of the aneurysm to the ICA terminus (ICAT) is ≤5 mm, or if the aneurysm is located directly at the ICAT, FDD should be considered only as a last option when other treatment modalities are not suitable. In addition, in the treatment of distal ICA aneurysms, extra effort should be exerted during the procedure to deploy the FDD without extending into M1. However, when traditional microsurgical clipping and other endovascular procedures are not suitable, the use of FDD is effective in terms of high aneurysm occlusion rates and preventing aneurysm rupture.

Surgical repair of torn base of ruptured middle cerebral artery trifurcation aneurysm.

BACKGROUND: Treating complex middle cerebral artery (MCA) trifurcation aneurysms requires a delicate balance between achieving aneurysm obliteration and preserving vascular integrity. Various cerebral revascularization techniques, including bypass, and clip reconstruction are considered individually or in combination. METHODS: This case report outlines a successful repair of a ruptured neck and base of MCA trifurcation aneurysm using a suturing-clip reconstruction technique. Temporary aneurysm trapping was implemented, with maintained elevated blood pressure to ensure collateral perfusion during repair of ruptured base and neck of MCA aneurysm. CONCLUSION: The suturing-clip reconstruction exhibited long-term radiological stability, emerging as a valuable alternative for managing challenging MCA trifurcation aneurysms.

Rat Model of Middle Cerebral Artery Occlusion.

Stroke is the third-leading cause of death and the leading cause of acquired adult disability worldwide. Several ischemic stroke models are currently available. However, mimicking focal cerebral ischemia (FCI) is the most common. The formation of an embolic or thrombotic occlusion at or near the middle cerebral artery causes most events in FCI. The current protocol closely mimics the etiology of human stroke and ensures that the results obtained are highly relevant. The method described in this protocol yields reproducible results. The success of this model in ischemic research can be examined through the utilization of Doppler blood flow imaging equipment.

Comparable dynamic cerebral autoregulation and neurovascular coupling of the posterior cerebral artery between healthy men and women.

AIMS: Most studies focus on dynamic cerebral autoregulation (dCA) in the middle cerebral artery (MCA), and few studies investigated neurovascular coupling (NVC) and dCA in the posterior cerebral artery (PCA). We investigated NVC and dCA of the PCA in healthy volunteers to identify sex differences. METHODS: Thirty men and 30 age-matched women completed dCA and NCV assessments. The cerebral blood flow velocity (CBFV) and mean arterial pressure were evaluated using transcranial Doppler ultrasound and a servo-controlled plethysmograph, respectively. The dCA parameters were analyzed using transfer function analysis. The NCV was evaluated by eyes-open and eyes-closed (24 s each) periodically based on voice prompts. The eyes-open visual stimulation comprised silent reading of Beijing-related tourist information. RESULTS: The PCA gain was lower than that of the MCA in all frequency ranges (all p < 0.05). Phase was consistent across the cerebrovascular territories. The cerebrovascular conductance index (CVCi) and mean CBFV (MV) of the PCA were significantly higher during the eyes-open than eyes-closed period (CVCi: 0.50 ± 0.12 vs. 0.38 ± 0.10; MV: 42.89 ± 8.49 vs. 32.98 ± 7.25, both p < 0.001). The PCA dCA and NVC were similar between the sexes. CONCLUSION: We assessed two major mechanisms that maintain cerebral hemodynamic stability in healthy men and women. The visual stimulation-evoked CBFV of the PCA was significantly increased compared to that during rest, confirming the activation of NVC. Men and women have similar functions in PCA dCA and NCV.

Assessment of Neurovascular Coupling by Spectral Analysis of Cerebral Blood Flow Velocity With Transcranial Doppler.

OBJECTIVE: Neurovascular coupling (NVC) represents the increase in regional blood flow associated with neural activity. The aim here was to describe a new approach to non-invasive measurement of NVC by spectral analysis of the cerebral blood flow velocity (CBFV) with transcranial Doppler. METHODS: In a sample of 20 healthy participants, we monitored systolic CBFV in the left posterior cerebral artery (PCA) during off (eyes closed) and on (flickering checkerboard) periods. The contralateral middle cerebral artery was simultaneously monitored as a control. Each participant was submitted to three experiments, each having five cycles, with increasing duration of the cycles, from 10 s (0.1 Hz) to 20 s (0.05 Hz) and lastly 40 s (0.025 Hz), half the time for on and for off periods, constituting a total of 6 min. The successive cycles were expected to cause oscillation in CBFV in a sinusoidal pattern that could be characterized by spectral analysis. We also measured the classic CBFV overshoot as the relative increase in percentage of systolic CBFV from baseline. The relationship and agreement between the two methods were analyzed by linear regression and Bland-Altman plots. In every participant, a clear peak of amplitude in the PCA CBFV spectrum was discernible at 0.1, 0.05 and 0.025 Hz of visual stimulation. RESULTS: On average, this amplitude was 7.1 ± 2.3%, 10.9 ± 3.5% and 17.3 ± 6.5%, respectively. This response contrasted significantly with an absent peak in middle cerebral artery monitoring (p < 0.0001). The spectral amplitude and classic overshoot were highly correlated and linearly related (p < 0.0001). CONCLUSION: NVC can be quantified by the spectral amplitude of PCA CBFV at slower and higher frequencies of visual stimulation. This method represents an alternative to classic overshoot without the need for stimulus marking or synchronization.

Pathological changes in the lenticulostriate artery indicate the mechanisms leading to intracranial hemorrhage in Moyamoya disease: a case report.

This case report details the pathological findings of a vessel wall identified as the bleeding point for intracranial hemorrhage associated with Moyamoya disease. A 29-year-old woman experienced intracranial hemorrhage unrelated to hyperperfusion following superficial temporal artery-middle cerebral artery bypass surgery. A pseudoaneurysm on the lenticulostriate artery (LSA) was identified as the causative vessel and subsequently excised. Examination of the excised pseudoaneurysm revealed a fragment of the LSA, with a disrupted internal elastic lamina and media degeneration. These pathological findings in a perforating artery, akin to the circle of Willis, provide insights into the underlying mechanisms of hemorrhage in Moyamoya disease.

Assessment of the cerebroplacental ratio and uterine arteries in low-risk pregnancies in early labour for the prediction of obstetric and neonatal outcomes.

BACKGROUND: The evidence-based management of human labor includes the antepartum identification of patients at risk for intrapartum hypoxia. However, available evidence has shown that most of the hypoxic-related complications occur among pregnancies classified at low-risk for intrapartum hypoxia, thus suggesting that the current strategy to identify the pregnancies at risk for intrapartum fetal hypoxia has limited accuracy. OBJECTIVE: To evaluate the role of the combined assessment of the cerebroplacental ratio (CPR) and uterine arteries (UtA) Doppler in the prediction of obstetric intervention (OI) for suspected intrapartum fetal compromise (IFC) within a cohort of low-risk singleton term pregnancies in early labor. METHODS: Prospective multicentre observational study conducted across four tertiary Maternity Units between January 2016 and September 2019. Low-risk term pregnancies with spontaneous onset of labor were included. A two-step multivariable model was developed to assess the risk of OI for suspected IFC. The baseline model included antenatal and intrapartum characteristics, while the combined model included antenatal and intrapartum characteristics plus Doppler anomalies such as CPR MoM < 10th percentile and mean UtA Doppler PI MoM ≥ 95th percentile. Predictive performance was determined by receiver-operating characteristics curve analysis. RESULTS: 804 women were included. At logistic regression analysis, CPR MoM < 10th percentile (aOR 1.269, 95 % CI 1.188-1.356, P < 0.001), mean UtA PI MoM ≥ 95th percentile (aOR 1.012, 95 % CI 1.001-1.022, P = 0.04) were independently associated with OI for suspected IFC. At ROC curve analysis, the combined model including antenatal characteristics plus abnormal CPR and mean UtA PI yielded an AUC of 0.78, 95 %CI(0.71-0.85), p < 0.001, which was significantly higher than the baseline model (AUC 0.61, 95 %CI(0.54-0.69), p = 0.007) (p < 0.001). The combined model was associated with a 0.78 (95 % CI 0.67-0.89) sensitivity, 0.68 (95 % CI 0.65-0.72) specificity, 0.15 (95 % CI 0.11-0.19) PPV, and 0.98 (0.96-0.99) NPV, 2.48 (95 % CI 2.07-2.97) LR + and 0.32 (95 % CI 0.19-0.53) LR- for OI due to suspected IFC. CONCLUSIONS: A predictive model including antenatal and intrapartum characteristics combined with abnormal CPR and mean UtA PI has a good capacity to rule out and a moderate capacity to rule in OI due to IFC, albeit with poor predictive value.

Safety and efficacy of the flow diverter device for treating middle cerebral artery aneurysms of the proximal (M1) segment related to the lenticulostriate arteries: A single-center experience.

BACKGROUND: Experience using flow diverter devices (FDDs) to treat proximal (M1) middle cerebral artery aneurysms associated with the lenticulostriate artery (M1A-LA) remains limited. This study aimed to examine the efficacy and safety of an FDD to manage M1A-LA. METHOD: Patients with M1A-LA who received FDD treatment at a single center were included in the analysis. Data on the baseline characteristics, postoperative conditions, and follow-up results of the participants were recorded and analyzed. The aneurysms were categorized into three subtypes based on morphology and location. Aneurysms confined to the M1 segment were categorized as subtype A. Those extending to the M2 segment were classified as subtype B. Aneurysms designated as subtype C were confined to the M1 segment but with another independent aneurysm in the distal artery and the presence of healthy vessels between the two. Subgroup analyses were conducted on these subtypes and aneurysm sizes. To assess the consistency of follow-up results, Cronbach's kappa/alpha was used to calculate inter-rater variability. Somers's D coefficient was used to assess the correlation between each subgroup and the imaging outcomes; Fisher's exact test was used to compare the variability among the subgroups. RESULT: The cohort comprised 11 patients. Their Modified Rankin Scale scores between the perioperative and follow-up periods did not differ. During the follow-up period, four patients had completely occluded aneurysms, and five patients had partial occlusions. The remaining patients did not present with changes in their aneurysms. The kappa coefficient was 0.864 (p < 0.001). M1A-LA was divided into subtypes A, B, and C. Subtype A (defined as an aneurysm completely located in the M1 segment) had a higher complete occlusion rate than that of subtypes B and C, Somers's D R/C correlation coefficient was 0.553, with a 95% confidence interval of 0.1229-0.9823 (p = 0.009). The radiographic follow-up findings were not significantly correlated with the size of the aneurysm (p = 0.121) or the use of coiling (p = 0.903). No significant differences in subtypes (p = 0.264), aneurysm size (p = 0.657), or coiling use (p > 0.999) were observed. CONCLUSION: FDDs were safe and possibly effective against M1A-LA. However, they were not as effective as for intracranial aneurysms in other locations. FDDs are a satisfactory treatment option for M1A-LA, particularly for subtype A aneurysms.

Diagnostic feasibility of middle cerebral artery stenosis or occlusion evaluated by TCCS and CEUS: Repeatability, reproducibility, and diagnostic agreement with DSA.

AIM: This study aimed to evaluate the feasibility of transcranial color-coded sonography (TCCS) and contrast-enhanced ultrasound (CEUS) in assessing middle cerebral artery (MCA) stem stenosis or occlusion compared to digital subtraction angiography (DSA). METHODS: A total of 48 cases including 96 MCAs suspected stem stenosis or obstruction in the MCA were assessed by TCCS, CE-TCCS, and DSA. The diameters of the most severe stenosis (Ds), proximal normal artery (Dn), and diameter stenosis rate of MCA were measured using both the color doppler flow imaging (CDFI) modality of TCCS or CEUS and the CEUS imaging modality. The intraclass correlation coefficients (ICCs) and 95 % confidence intervals (CI) were evaluated, and a weighted Kappa value was used to evaluate the intra-observer agreement, inter-observer agreement, agreement between CDFI modality and DSA stenosis or occlusion, and agreement between CEUS imaging modality and DSA stenosis or occlusion. RESULTS: The ICC results indicated excellent repeatability and reproducibility (all ICCs > 0.75; weighted Kappa values >0.81). Compared with DSA, the weighted Kappa values and 95 % CIs of stenosis (the first measurement was taken by two observers) of CDFI modality and CEUS imaging modality were 0.175 (0.041, 0.308) and 0.779 (0.570, 0.988) for observers A and 0.181 (0.046, 0.316) and 0.779 (0.570, 0.988) for observers B respectively. CONCLUSION: This study indicates that inter- and intra-observer agreements were good for the direct method of measuring percentages of MCA stenosis by TCCS and CEUS. CEUS imaging modality is a new and reliable imaging modality approach to evaluate the MCAs stenosis and occlusion.

Noninvasive assessment of pressure distribution and fractional flow in middle cerebral artery using microbubbles and plane wave in vitro.

Fractional flow has been proposed for quantifying the degree of functional stenosis in cerebral arteries. Herein, subharmonic aided pressure estimation (SHAPE) combined with plane wave (PW) transmission was employed to noninvasively estimate the pressure distribution and fractional flow in the middle cerebral artery (MCA) in vitro. Consequently, the effects of incident sound pressure (peak negative pressures of 86-653 kPa), pulse repetition frequency (PRF), number of pulses, and blood flow rate on the subharmonic pressure relationship were investigated. The radio frequency data were stored and beamformed offline, and the subharmonic amplitude over a 0.4 MHz bandwidth was extracted using a 12-cycle PW at 4 MHz. The optimal incident sound pressure was 217 kPa without skull (sensitivity = 0.09 dB/mmHg; r2 = 0.997) and 410 kPa with skull (median sensitivity = 0.06 dB/mmHg; median r2 = 0.981). The optimal PRF was 500 Hz, as this value affords the highest sensitivity (0.09 dB/mmHg; r2 = 0.976) and temporal resolution. In addition, the blood flow rate exhibited a lesser effect on the subharmonic pressure relationship in our experimental setup. Using the optimized parameters, the blood pressure distribution and fractional flow (FFs) were measured. As such, the FFs value was in high agreement with the value measured using the pressure sensor (FFm). The mean ± standard deviations of the FF difference (FFm - FFs) were 0.03 ± 0.06 without skull and 0.01 ± 0.05 with skull.

Middle cerebral artery peak systolic velocity monitoring of fetal anemia during chemotherapy in pregnancy.

INTRODUCTION: Chemotherapy during pregnancy can increase the risk of fetal anemia. Severe fetal anemia can lead to the development of hydrops fetalis and potentially fetal demise. Hence, it is imperative to implement consistent monitoring methods in the context of chemotherapy treatment. This study aimed to diagnose and monitor fetal anemia using middle cerebral artery peak systolic velocity (MCA-PSV) as a diagnostic tool during chemotherapy in pregnant women. MATERIAL AND METHODS: The study employed a prospective analysis involving a case series of 15 patients diagnosed with cancer during pregnancy and subsequently underwent chemotherapy. MCA-PSV was used to identify fetal anemia. The patients were scheduled for ultrasound examinations of the MCA-PSV. The first examination was performed on the same day as the administration of chemotherapy, while the second occurred on the 10th day after chemotherapy. The measurement technique used in the study was based on the methodology proposed by Mari and Barr. The multiples of the median were calculated using the calculators provided by Medicina Fetal Barcelona. Based on these values anemia severity was determined. When moderate or severe anemia was identified, chemotherapy was individually modified. Additionally, a blood count analysis was conducted immediately after the delivery of the newborn. RESULTS: Five patients were diagnosed with fetal or newborn anemia. With MCA-PSV, we identified moderate fetal anemia in two patients and severe fetal anemia in one. The complete blood count testing of newborns revealed mild anemia in three patients. One case was unrelated to chemotherapy-induced anemia. During treatment, fetal anemia did not corelate with maternal anemia. CONCLUSIONS: In four cases of anemia the combination of cisplatin and iphosphamide was used as a chemotherapy agent. No anemia was observed in other drug combinations. Our findings suggest that MCA-PSV is a reliable method for identifying anemia and should be included in the treatment protocol for chemotherapy-induced fetal anemia.

Banxia Baizhu Tianma Tang decoction and modified Taohong Siwu combined with Western medicine to treat a patient with severe stenosis of the middle cerebral artery: A case report.

RATIONALE: Intracranial artery stenosis is an important cause of ischemic stroke, and MCA is one of the most common vessels causing intracranial artery stenosis. At present, there are 3 main treatments for MCA stenosis: medical drug therapy, surgery, and endovascular interventional therapy. PATIENT CONCERNS: We report a patient with severe middle cerebral artery stenosis, including his imaging and clinical manifestations. DIAGNOSIS: Severe stenosis of middle cerebral artery. INTERVENTIONS: Banxia Baizhu Tianma decoction combined with Taohong Siwu decoction combined with western medicine. OUTCOMES: The stenosis of M1 segment of middle cerebral artery was significantly improved, the stenosis rate was reduced from 70% to 30%, and the clinical symptoms of the patients basically disappeared. LESSONS: Banxia Baizhu Tianma decoction combined with Taohong Siwu plus subtraction combined with western medicine is effective in the treatment of middle cerebral artery stenosis.

Non-aneurysmal subarachnoid hemorrhage in aplastic or twig-like middle cerebral artery: A case report and literature review.

BACKGROUND: Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare vascular anomaly that can cause hemorrhagic and ischemic stroke. Ap/T-MCA can induce aneurysms due to the fragility of the vessel wall, consequently leading to subarachnoid hemorrhage. Herein, we report a case of Ap/T-MCA with subarachnoid hemorrhage without an aneurysm. CASE PRESENTATION: A 67-year-old man presented to our hospital with a sudden onset of headache. Computed tomography of the head revealed subarachnoid hemorrhage (SAH) in the left Sylvian fissure; however, no aneurysm was observed on digital subtraction angiography. Following conservative treatment, follow-up imaging showed no aneurysm or no recurrent stroke. CONCLUSION: Non-aneurysmal SAH is a possible indication of vessel wall fragility in Ap/T-MCA; however, a standardized treatment strategy for this condition remains to be established.

A foreign body that has been left for 20 years causes a pseudoaneurysm of the middle cerebral artery: a case report.

BACKGROUND: We report a patient with extensive subarachnoid hemorrhage caused by the rupture of a middle cerebral artery pseudoaneurysm from a foreign body that had been left for two decades. CASE PRESENTATION: A 74-year-old male patient from Han nationality was admitted to the emergency department of our hospital with impaired consciousness for 1 hour. Cranial computed tomography examination indicated a massive subarachnoid hemorrhage with intraventricular blood accumulation, and a high-density short strip dense shadow was seen in the M1 segment of the right middle cerebral artery, considering the possibility of a foreign body. Subsequently, a cerebral angiography was suggested; the foreign body was seen through the right middle cerebral artery, and the aneurysm was seen in the lower wall, so a pseudoaneurysm was considered. The emergent surgical intervention involved the clipping of the pseudoaneurysm and intracranial extraction of the foreign body. Unfortunately,the patient ultimately expired due to severe pulmonary infection. CONCLUSION: Intracranial pseudoaneurysm caused by foreign body has been rarely reported previously, and microsurgical treatment of an intracranial pseudoaneurysm caused by a foreign body is a good choice.

Impaired dynamic cerebral autoregulation measured in the middle cerebral artery in patients with vertebrobasilar ischemia is associated with autonomic failure.

OBJECTIVES: To assess whether vertebrobasilar artery ischemia (VBI) affects cortical cerebral blood flow (CBF) regulation. MATERIAL AND METHODS: 107 consecutive patients (mean age 65 ± 15 years; women 21) with VBI underwent structured stroke care with assessment of dynamic cerebral autoregulation (dCA) in both middle cerebral arteries (MCAs) by transfer function analysis using spontaneous oscillations of blood pressure (BP) and CBF velocity that yields by extraction of phase and gain information in the very low (0.02-0.07 Hz), low (0.07-0.15 Hz) and high frequency (0.15-0.5 Hz) ranges. Additionally, power spectrum analysis of BP and heart rate variability (HRV) was performed. The control group consists of 29 age- and sex-matched healthy persons. RESULTS: Compared to controls, phase in the VBI patients was significantly reduced and gain increased in the very low frequencies (VLF), in the low (LF), phase was significantly reduced only ipsilaterally. In the high frequencies (HF), phase reduction was only marginally significant. BP power spectral density (PSD) was much higher in the patients than in the controls across all frequencies. In the PSD of heart rate variability the controls but not the patients exhibited a strong peak around 0.11Hz, while the patients, but not the controls, exhibit a strong peak around 0.36 Hz. In regression analysis, patient's phase and gain results were not related to age, sex, arterial hypertension, diabetes mellitus, renal dysfunction, heart failure as indicated by left ventricular ejection fraction, stroke subtype, presence or absence of cerebral small vessel disease. CONCLUSION: Patients with VBI exhibit bilateral cortical autoregulation impairment in association with an autonomic nervous system disbalance. GOV IDENTIFIER: NCT04611672.

Management of fetuses with apparent normal growth and abnormal cerebroplacental ratio: A risk-based approach near term.

INTRODUCTION: Cerebroplacental ratio (CPR) has been shown to be an independent predictor of adverse perinatal outcome at term and a marker of failure to reach the growth potential (FRGP) regardless of fetal size, being abnormal in compromised fetuses with birthweight above the 10th centile. The main aim of this study was to propose a risk-based approach for the management of pregnancies with normal estimated fetal weight (EFW) and abnormal CPR near term. MATERIAL AND METHODS: This was a retrospective study of 943 pregnancies, that underwent an ultrasound evaluation of EFW and CPR at or beyond 34 weeks. CPR values were converted into multiples of the median (MoM) and EFW into centiles according to local references. Pregnancies were then divided into four groups: normal fetuses (defined as EFW ≥10th centile and CPR ≥0.6765 MoM), small for gestational age (EFW <10th centile and CPR ≥0.6765 MoM), fetal growth restriction (EFW <10th centile and CPR <0.6765 MoM), and fetuses with apparent normal growth (EFW ≥10th centile) and abnormal CPR (<0.6765 MoM), that present FRGP. Intrapartum fetal compromise (IFC) was defined as an abnormal intrapartum cardiotocogram or pH requiring cesarean delivery. Risk comparisons were performed among the four groups, based on the different frequencies of IFC. The risks of IFC were subsequently extrapolated into a gestational age scale, defining the optimal gestation to plan the birth for each of the four groups. RESULTS: Fetal growth restriction was the group with the highest frequency of IFC followed by FRGP, small for gestational age, and normal groups. The "a priori" risks of the fetal growth restriction and normal groups were used to determine the limits of two scales. One defining the IFC risk and the other defining the appropriate gestational age for delivery. Extrapolation of the risk between both scales placed the optimal gestational age for delivery at 39 weeks of gestation in the case of FRGP and at 40 weeks in the case of small for gestational age. CONCLUSIONS: Fetuses near term may be evaluated according to the CPR and EFW defining four groups that present a progressive risk of IFC. Fetuses in pregnancies complicated by FRGP are likely to benefit from being delivered at 39 weeks of gestation.

Plaque features of the middle cerebral artery are associated with periprocedural complications of intracranial angioplasty and stenting.

PURPOSE: The identification of plaque features in the middle cerebral artery (MCA) may help minimize periprocedural complications and select patients suitable for percutaneous transluminal angioplasty and stenting (PTAS). However, relevant research is lacking. METHODS: We retrospectively included patients with symptomatic MCA stenosis who received PTAS. All patients underwent intracranial vessel wall MRI (VWMRI) before surgery. Periprocedural complications (PC) included ischemic and hemorrhagic stroke within 30 days. Stenosis location, MCA shape, plaque eccentricity and distribution, plaque thickness and length, and enhancement ratio were compared between patients with and without PC. RESULTS: Sixty-six patients were included in the study, of which 12.1% (8/66) had PC. Of the eight patients with PC, seven (87.5%) had superior wall plaques. In the non-PC group (n = 58), nine (17%) patients had superior wall plaques. Compared with patients without PC, those with PC had more frequent superior wall plaques (17% vs 87.5%, p < 0.001) and s-shaped MCAs (19% vs 50%, p = 0.071), different stenosis locations (p = 0.012), thicker plaques (1.58 [1.35, 2.00] vs 1.98 [1.73, 2.43], p = 0.038), and less frequent inferior wall plaques (79.2% vs 12.5%, p < 0.001). Multivariate analysis showed that only the presence of superior wall plaques (OR = 41.54 [2.31, 747.54]) was independently associated with PC. CONCLUSION: MCA plaque features were highly correlated with PC in patients with symptomatic MCA stenosis who underwent PTAS.

Vertebral Artery to Middle Cerebral Artery Bypass for Flow Augmentation.

BACKGROUND AND IMPORTANCE: Extracranial-intracranial bypass remains an enduring procedure for a select group of patients suffering from steno-occlusive cerebrovascular disease. Although the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is most familiar among neurosurgeons, particular circumstances preclude the use of an STA donor. In such cases, alternative revascularization strategies must be pursued. CLINICAL PRESENTATION: A 63-year-old female presented with symptoms of hemodynamic insufficiency and was found to have left common carotid artery occlusion at the origin. She experienced progressive watershed ischemia and pressure-dependent fluctuations in her neurological examination despite maximum medical therapy. The ipsilateral STA was unsuitable for use as a donor vessel. We performed an extracranial vertebral artery (VA) to MCA bypass with a radial artery interposition graft. CONCLUSION: This technical case description and accompanying surgical video review the relevant anatomy and surgical technique for a VA-MCA bypass. The patient was ultimately discharged home at her preoperative neurological baseline with patency of the bypass. The VA can serve as a useful donor vessel for cerebral revascularization procedures in pathologies ranging from malignancies of the head and neck to cerebral aneurysms and cerebrovascular steno-occlusive disease.