Abstract WMP95: Endovascular Therapy Vs. Medical Management In Isolated Anterior Cerebral Artery Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Weighted Study
Hamza SalimManisha KoneruBenjamin PulliNimer AbushehabDhairya A. LakhaniBasel MusmarTobias D. FaizyJeremy J. HeitGuangming ZhuAdrien GuenegoAdam A. DmytriwVivek Yedavalli
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Introduction: Isolated anterior cerebral artery occlusions (iACAo) in acute ischemic stroke (AIS) patients present significant challenges due to their rarity and complex symptomatology. The efficacy of endovascular therapy (EVT) versus best medical management (BMM) for iACAo remains unclear. In light of context we aim in this investigation to assess the outcomes of these treatments. Methods: This multinational, multicenter study analyzed data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry. We included 108 patients with iACAo, who underwent either EVT or BMM. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse Probability of Treatment Weighting (IPTW) was applied to balance confounding variables between treatment groups. The primary outcome was functional independence at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality, and NIHSS score on day one post-EVT. Safety outcomes assessed hemorrhagic complications. Results: Of the 108 patients, 36 received BMM and 72 underwent EVT. The median age was 75 years (IQR 67-87), with 60 (56%) male patients overall. The primary outcome of 90-day mRS 0-2 was achieved in 40% of the cohort, with no significant difference between the EVT and BMM groups (38% vs. 45%, p=0.46). Procedural success (TICI 2b-3) was high in EVT patients at 91%, with a low sICH rate of 2.9%. The IPTW-adjusted analysis showed no significant association between EVT and improved functional outcomes (OR 1.17, 95% CI 0.23-6.02, p=0.85) or reduced mortality (23% overall; 25% EVT vs. 21% BMM, p=0.71). However, EVT was associated with higher NIHSS scores on day one post-stroke in crude analyses (OR 4.8, 95% CI 1.2-8.5, p=0.012), though this was not significant in the IPTW model (OR 2.2, 95% CI -0.51 to 4.8, p=0.11). Conclusions: In this propensity score-weighted analysis, EVT did not demonstrate superior functional outcomes compared to BMM in patients with iACAo. Nonetheless, EVT achieved high procedural success and low rates of symptomatic hemorrhage, indicating its safety. These findings highlight the need for randomized controlled trials to further explore EVT's potential role as a first-line or rescue therapy in iACAo patients, especially given the low recanalization rates with IV thrombolysis alone.Keywords:
Stroke
Anterior cerebral artery
Objectives To investigate the value of intracranial collateral circulation in patients with chronic middle cerebral artery (MCA) occlusion with transcranial color Doppler ultrasonography (TCD) and to establish the indicators of hemodynamic parameter and assess their accuracy.Methods A total of 140 consecutive patients with unilateral MCA occlusion diagnosed by digital subtraction angiography (DSA) in the Departments of Neurology and Neurosurgery, Xuan Wu Hospital, Capital Medical University, Beijing, China were included from September 2008 to February 2010.According to the leptomeningeal branch compensation showed on DSA, the patients were divided into no compensation (n =21) , simple anterior cerebral artery (ACA) compensation (n = 43) , simple posterior cerebral artery (PCA) compensation (n =28) , and ACA + PCA compensation (n =48) groups.TCD was used to detect the peak systolic velocity (PSV) of bilateral MCA, anterior cerebral artery (ACA) , and posterior cerebral artery (PCA).The ratios of ACA peak velocity on the ipsilateral side (d) and MCA peak velocity on the contralateral side (n) (dPSV_(ACA)/nPSV_(MCA)) , the ratios of ACA peak velocity on the ipsilateral side and ACA peak velocity on the contralateral side (dPSV_(ACA)/nPSV_(ACA)), as well as the ratios of PCA peak velocity on the ipsilateral side and PCA peak velocity on the contralateral side (dPSV_(PCA)/nPSV_(PCA)) were calculated.Taking ACA and PCA leptomeningeal branches open or not showed on DSA as a reference standard, the ROC curve was used to establish the optimal boundary values of hemodynamic parameters for evaluating ACA and PCA in participation of compensation, and the sensitivity, specificity, and accuracy were assessed.Results ①The dPSV_(ACA)/nPSV_(MCA) in the simple ACA compensation and ACA + PCA compensation groups were 1.341 ± 0.348 and 1.337 ±0.403 respectively, which were significantly higher than 0.883 ±0.256 in the no ACA compensation group.The dPSV_(ACA)/nPSV_(ACA) in the simple ACA compensation and ACA + PCA compensation groups were 1.660 ±0.753 and 1.670 ±0.404 respectively, which were significantly higher than 0.978 ±0.259 in the no ACA compensation group.The dPSV_(PCA)/nPSV_(PCA) in the simple PCA compensation and ACA + PCA compensation groups were 1.758 ±0.560 and 1.735 ±0.486 respectively, which were significantly higher than 1.210 ±0.336 in the no PCA compensation group.② The dPSV_(ACA)/nPSV_(MCA) ≥1.20 and dPSV_(ACA)/nPSV_(ACA) ≥1.25 were used as the optimal cutoff values of ACA compensation, and their accuracy were 65.7% and 78.5% respectively.The dPSV_(PCA)/nPSV_(PCA) 3= 1.45 were used as the optimal cutoff values of PCA compensation, and its accuracy was 75.0%.Conclusions TCD can be used as an examination method for evaluating ACA and PCA leptomeningeal branch compensation ability in patients with MCA occlusion. Establishment of TCD hemodynamic parameters has important clinical value for accurately assessing the status and prognosis of collateral circulation in patients with MCA occlusion.
Anterior cerebral artery
Posterior cerebral artery
Digital subtraction angiography
Posterior communicating artery
Collateral circulation
Transcranial Doppler
Anterior communicating artery
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Environmental factors interfere on sickle cell anaemia (SCA). Transcanial Doppler (TCD) is important to evaluate cerebrovascular disease.To evaluate brain haemodynamic profile of children with SCA in Sergipe.Cross sectional study (group1: SCA patients aged 3-18; group2: age and sex matched healthy individuals). Baseline brain flow was evaluated.Group1=34 patients; group 2=81 controls. SCA patients had mean velocity (MV)=125.69 cm/s+/-23.40; pulsatility index (PI)=0.66+/-0.10; middle cerebral artery ratio (MCAr)=14.53+/-15.23; right anterior cerebral artery/right middle cerebral artery=0.77+/-0.20; left anterior cerebral artery/left middle cerebral artery=0.78+/-0.20. Controls had MV=79.44+/-15.54; PI=0.82+/-0.11; MCAr=13.19+/-13.77; right anterior cerebral artery/right middle cerebral artery=0.80+/-0.16; left anterior cerebral artery/left middle cerebral artery=0.84+/-0.18. MV and PI differences were statistically significant between groups. MV was related to age but not to gender.MV evaluation using TCD was similar to international standards and possible to be used in our setting.
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Transcranial Doppler
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Background and Purpose— To establish reference values of interhemispheric differences and ratios of blood flow Doppler parameters in the terminal internal carotid artery, middle cerebral artery, and anterior cerebral artery in children with sickle cell anemia. Methods— Fifty-seven out of 74 recruited children (mean age, 7.8±3.4 years; range limits, 3–14 years), who were free of neurological deficits and intracranial narrowing detectable by MRA and had flow velocities <170 cm/s by conventional transcranial Doppler ultrasound, underwent transcranial color-coded duplex ultrasonography. Reference limits of flow parameters corrected and uncorrected for the angle of insonation were estimated using tolerance intervals, with P =0.90 for all possible data values from 95% of a population. Results— Reference limits for left-to-right differences in cm/s in the mean angle-corrected and uncorrected flow velocities were −56 to 53 and −72 to 75 for middle cerebral artery, −49 to 57 and −81 to 91 for anterior cerebral artery, and −55 to 64 and −73 to 78 for terminal internal carotid artery, respectively. Respective reference limits for left-to-right velocity ratios were 0.31 to 1.84 and 0.38 to 1.75 for middle cerebral artery, 0.48 to 2.99 and 0.46 to 2.89 for anterior cerebral artery, and 0.61 to 2.56 and 0.56 to 2.23 for terminal internal carotid artery. Conclusions— The study provides reference limits of interhemispheric differences and ratios of blood flow Doppler parameters that may be helpful in identification of intracranial arterial narrowing in children with sickle cell disease undergoing ultrasound screening for stroke prevention.
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The color flow mapping method makes it possible to identify small vessels presently not detected on B‐mode imaging. The main cerebral arteries of normal human fetuses, anterior, middle, and posterior arteries, were investigated by color‐coded Doppler in 45 normal pregnancies. The Pourcelot index R was calculated at different stages of the pregnancy. The values of R (anterior cerebral artery), R (middle cerebral artery), and R (posterior cerebral artery) were compared in each fetus. No significant differences were found when comparing all of the R (anterior cerebral artery) and R (middle cerebral artery) or the R (anterior cerebral artery) and R (middle cerebral artery) at the same gestational age. On the contrary, for each fetus, at any gestational age, the R (anterior cerebral artery) and the R (middle cerebral artery) indices were significantly different (P < 0.01); the index in the middle cerebral artery was higher than that of the anterior cerebral artery. The same difference was observed when comparing R (posterior cerebral artery) and R (middle cerebral artery). The index of the middle cerebral artery was significantly higher than that of the posterior cerebral artery (P < 0.001). On the other hand, no significant difference was found between R (anterior cerebral artery) and R (posterior cerebral artery) at any gestational age (P = 0.4).
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Posterior cerebral artery
Posterior communicating artery
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Transcranial Doppler ultrasonography can map the changes in blood velocity that result from stenosis or occlusion of the middle cerebral artery. To evaluate patterns of collateral blood flow in disease of the middle cerebral artery stem, we used both cerebral angiography and transcranial Doppler ultrasonography to study the systolic blood velocities in both anterior cerebral arteries in 10 consecutive patients with middle cerebral artery stenosis or occlusion. Five patients had no evidence of hemodynamically significant carotid disease and good-quality measurements of systolic velocity in each anterior cerebral artery. Two of the five patients had middle cerebral artery stem stenosis and the other three had occlusion. The ratios of mean blood velocity in the normal compared with the abnormal side for the five patients (mean 1.34 +/- 0.23, range 1.15-1.74) were significantly higher than ratios for 10 controls (mean 1.04 +/- 0.12, range 0.76 +/- 1.19) using an unpaired t test (t = 3.492, 0.0005 less than p less than 0.005). Our results suggest that transcranial Doppler ultrasound measurements of anterior cerebral artery blood velocity may be a useful index of collateral blood flow from the anterior cerebral artery territory into the middle cerebral artery territory. Changes in mean velocity ratio may document the evolution and adequacy of collateral blood flow over the cerebral convexity in middle cerebral artery stem disease. In addition, the changes in anterior cerebral artery blood velocity appear to be an important corroborative finding for middle cerebral artery stem occlusion.
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Transcranial Doppler
Collateral circulation
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The aim of this study was to ascertain whether dynamic cerebral autoregulation (CA) in the middle cerebral artery (MCA) is disturbed by cerebral infarctions outside the MCA territory.We estimated transfer function parameters gain and phase from simultaneous recordings of spontaneous oscillation in blood pressure and MCA cerebral blood flow velocity in 10 consecutive patients with isolated anterior cerebral artery (ACA) infarctions and in 22 consecutive patients with isolated posterior cerebral artery (PCA) infarctions. All ACA infarctions were in the motor, premotor, or supplementary motor cortex areas and presented with pronounced leg hemiparesis. Twenty-eight age- and sex-matched healthy subjects served as controls.Compared to controls, phase was significantly reduced in the MCA ipsilateral to the lesion site and in the contralateral MCA (unaffected hemisphere) in the very low (0.02-0.07 Hz) and low (0.07-0.15 Hz) frequency ranges in the ACA infarctions but not in the PCA infarctions. Gain was reduced only in the very low frequency range in the MCA contralateral to the ACA lesion site. Systemic factors were unrelated to phase and gain results.Bilateral impairment of MCA dynamic CA in patients with a unilateral ACA infarction is frequent.
Anterior cerebral artery
Posterior cerebral artery
Cerebral autoregulation
Diaschisis
Hemiparesis
Cerebral hemisphere
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The middle cerebral artery (MCA) is one of the major paired intracranial arteries involved in the formation of the circle of Willis. MCA is the most complex of the intracranial arteries mainly because it supplies the cerebral neocortex, which has been significantly developed in humans. The MCA is a recent phylogenetic acquisition and can be considered as a collateral branch of the anterior cerebral artery (ACA). Anomalies of the middle cerebral artery are less commonly reported than other intracranial arteries. Previously, described anomalies include accessory MCA, duplicated MCA, fenestration of MCA and variations of the branching patterns. Recently, several reports have been published describing unfused or twig-like MCA, in which the single MCA trunk is substituted by a collateral plexiform arterial network. This manuscript would like to report our unique case of an anomalous MCA origin from the anterior cerebral artery unassociated with duplication or accessory MCA.
Anterior cerebral artery
Anterior communicating artery
Circle of Willis
Posterior cerebral artery
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[Purpose] The purpose of this study was to investigate the effects of action observation training (AOT) on cerebral hemodynamic changes including cerebral blood flow velocity (CBFV) and cerebral blood flow volume (CBFvol) in healthy subjects. [Subjects] Fifteen healthy subjects participated in this study. [Methods] All subjects were educated regarding AOT, and systolic peak velocity (Vs) as well as mean flow velocity (Vm) in the middle cerebral artery (MCA), anterior cerebral artery (ACA), and posterior cerebral artery (PCA) were evaluated using functional transcranial doppler with a 2-MHz probe, before and after performing AOT. [Results] Healthy subjects showed significant differences in Vs and Vm in the MCA, ACA, and PCA after AOT compared with those before AOT. [Conclusion] Our findings indicate that AOT has a positive effect in terms of an increase in CBFV and CBFvol in healthy subjects, since the brain requires more blood to meet the metabolic demand during AOT.
Transcranial Doppler
Anterior cerebral artery
Posterior cerebral artery
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Anterior cerebral artery
Anterior communicating artery
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