Hereditary Hemorrhagic Telangiectasia with Recurrent Epistaxis, Telangiectasia, Hepatic Arteriovenous Malformation, and a Poorly Developed Middle Cerebral Artery in a Patient with a Novel Mutation in the ACVRL1 Gene.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant vascular disorder characterized by intractable epistaxis, mucocutaneous telangiectasias, and arteriovenous malformations (AVMs) in multiple organs, including the lungs, liver, gastrointestinal tract, brain, and spinal cord. We herein report a 50-year-old Japanese man with HHT who experienced recurrent epistaxis, telangiectasia in the cornea, apex of the tongue and fingers; hepatic AVM; and a poorly developed main arterial trunk in the right middle cerebral artery. A genetic analysis revealed a novel heterozygous mutation in the activin A receptor-like type 1 gene, with a frameshift mutation in NM_000020.3:c.826_836del (p.Ile276ProfsTer112).

Atherosclerosis-Like Spontaneous Middle Cerebral Artery Dissection.

The standard of care for treating acute large vessel occlusion is endovascular therapy. The most frequent cause of occlusion is either embolic occlusion or in situ thrombotic occlusion. However, occlusion resulting from intracranial dissection is extremely rare, especially in the middle cerebral artery. Prior to a thrombectomy or endovascular therapy, understanding and interpreting the angiographic findings is crucial for planning the appropriate treatment and preventing complications.

Endovascular treatment of unruptured aneurysm arising from duplicate origin of the middle cerebral artery - A case report and literature review.

Background: Duplicate origin of the middle cerebral artery (MCA) is a rare variation of MCA, often mislabeled as the fenestration of the M1 segment of MCA. Case Description: The authors treated an unruptured aneurysm, 8 mm in diameter, associated with a duplicate origin of MCA in a 42-year-old woman who underwent magnetic resonance imaging for transient vertigo. Clipping surgery was inapplicable due to the lack of space to insert clip blades between the neck and two origins of MCA. Under stent-assisted maneuver, the aneurysm sac was successfully obliterated using three coils, resulting in Raymond-Roy class 1 occlusion status. Digital subtraction angiography performed 3 months after the embolization showed complete obliteration of the aneurysm. So far, only 11 patients with aneurysms associated with duplicate origin of MCA have been reported. We performed a literature review of this very rare combination. The size of aneurysms ranged from 2 to 8 mm, with a mean of 5.2 mm. The neck of the aneurysm is mainly located at the corner between the inferior limb and the internal carotid artery. Ours is the youngest and has the largest aneurysm. Conclusion: Aneurysm can arise from duplicate origin of MCA, for which stent-assisted coiling may be an appropriate treatment modality.

CT perfusion for predicting intracranial atherosclerotic middle cerebral artery occlusion.

Backgrounds and purpose: Identifying the underlying cause of acute middle cerebral artery occlusion (MCAO) as intracranial atherosclerotic stenosis (ICAS) or embolism is essential for determining the optimal treatment strategy before endovascular thrombectomy. We aimed to evaluate whether baseline computed tomography perfusion (CTP) characteristics could differentiate ICAS-related MCAO from embolic MCAO. Methods: We conducted a retrospective analysis of the clinical and baseline CTP data from patients who underwent endovascular thrombectomy for acute MCAO between January 2018 and December 2022. Core volume growth rate was defined as core volume on CTP divided by onset to CTP time. Multivariate logistic analysis was utilized to identify independent predictors for ICAS-related acute MCAO, and the diagnostic performance of these predictors was evaluated using receiver operating characteristic curve analysis. Results: Among the 97 patients included (median age, 71 years; 60% male), 31 (32%) were diagnosed with ICAS-related MCAO, and 66 (68%) had embolism-related MCAO. The ICAS group was younger (p = 0.002), had a higher proportion of males (p = 0.04) and smokers (p = 0.001), a lower prevalence of atrial fibrillation (AF) (p < 0.001), lower NIHSS score at admission (p = 0.04), smaller core volume (p < 0.001), slower core volume growth rate (p < 0.001), and more frequent core located deep in the brain (p < 0.001) compared to the embolism group. Multivariate logistic analysis identified core volume growth rate (aOR 0.46, 95% CI 0.26-0.83, p = 0.01) as an independent predictor of ICAS-related MCAO. A cutoff value of 2.5 mL/h for core volume growth rate in predicting ICAS-related MCAO was determined from the receiver operating characteristic curve analysis, with a sensitivity of 81%, specificity of 80%, positive predictive value of 66%, and negative predictive value of 90%. Conclusion: Slow core volume growth rate identified on baseline CTP can predict ICAS-related MCAO. Further prospective studies are warranted to confirm and validate these findings.

Luteolin-7-O-ß-d-Glucuronide Attenuated Cerebral Ischemia/Reperfusion Injury: Involvement of the Blood-Brain Barrier.

Ischemic stroke is a common cerebrovascular disease with high mortality, high morbidity, and high disability. Cerebral ischemia/reperfusion injury seriously affects the quality of life of patients. Luteolin-7-O-ß-d-glucuronide (LGU) is a major active flavonoid compound extracted from Ixeris sonchifolia (Bge.) Hance, a Chinese medicinal herb mainly used for the treatment of coronary heart disease, angina pectoris, cerebral infarction, etc. In the present study, the protective effect of LGU on cerebral ischemia/reperfusion injury was investigated in an oxygen-glucose deprivation/reoxygenation (OGD/R) neuronal model and a transient middle cerebral artery occlusion (tMCAO) rat model. In in vitro experiments, LGU was found to improve the OGD/R-induced decrease in neuronal viability effectively by the MTT assay. In in vivo experiments, neurological deficit scores, infarction volume rates, and brain water content rates were improved after a single intravenous administration of LGU. These findings suggest that LGU has significant protective effects on cerebral ischemia/reperfusion injury in vitro and in vivo. To further explore the potential mechanism of LGU on cerebral ischemia/reperfusion injury, we performed a series of tests. The results showed that a single administration of LGU decreased the content of EB and S100B and ameliorated the abnormal expression of tight junction proteins ZO-1 and occludin and metalloproteinase MMP-9 in the ischemic cerebral cortex of the tMCAO 24-h injury model. In addition, LGU also improved the tight junction structure between endothelial cells and the degree of basement membrane degradation and reduced the content of TNF-α and IL-1ß in the brain tissue. Thereby, LGU attenuated cerebral ischemia/reperfusion injury by improving the permeability of the blood-brain barrier. The present study provides new insights into the therapeutic potential of LGU in cerebral ischemia.

Neferine inhibits BMECs pyroptosis and maintains blood-brain barrier integrity in ischemic stroke by triggering a cascade reaction of PGC-1α.

Blood-brain barrier disruption is a critical pathological event in the progression of ischemic stroke (IS). Most studies regarding the therapeutic potential of neferine (Nef) on IS have focused on neuroprotective effect. However, whether Nef attenuates BBB disruption during IS is unclear. We here used mice underwent transient middle cerebral artery occlusion (tMCAO) in vivo and bEnd.3 cells exposed to oxygen-glucose deprivation/reoxygenation (OGD/R) injury in vitro to simulate cerebral ischemia. We showed that Nef reduced neurobehavioral dysfunction and protected brain microvascular endothelial cells and BBB integrity. Molecular docking, short interfering (Si) RNA and plasmid transfection results showed us that PGC-1α was the most binding affinity of biological activity protein for Nef. And verification experiments were showed that Nef upregulated PGC-1α expression to reduce mitochondrial oxidative stress and promote TJ proteins expression, further improves the integrity of BBB in mice. Intriguingly, our study showed that neferine is a natural PGC-1α activator and illustrated the mechanism of specific binding site. Furthermore, we have demonstrated Nef reduced mitochondria oxidative damage and ameliorates endothelial inflammation by inhibiting pyroptosis to improve BBB permeability through triggering a cascade reaction of PGC-1α via regulation of PGC-1α/NLRP3/GSDMD signaling pathway to maintain the integrity of BBB in ischemia/reperfusion injury.

Qualifying Event and Recurrence of Ischemic Stroke in Symptomatic Artery Occlusion: A Post Hoc Analysis of CMOSS.

BACKGROUND: The authors aimed to elucidate the relationship between latest ischemic event and the incidence of subsequent ischemic stroke in patients with symptomatic artery occlusion. METHODS AND RESULTS: We analyzed the association between qualifying event-the latest ischemic event (transient ischemic attack [TIA] or stroke)-and the incidence of ipsilateral ischemic stroke in patients with symptomatic artery occlusion treated with medical therapy alone in CMOSS (Carotid or Middle Cerebral Artery Occlusion Surgery Study). The incidence of CMOSS primary outcomes, including any stroke or death within 30 days after randomization or ipsilateral ischemic stroke between 30 days and 2 years, between the bypass surgical and medical groups, stratified by qualifying events, was also compared. Of the 165 patients treated with medical therapy alone, 75 had a TIA and 90 had a stroke as their qualifying event. The incidence of ipsilateral ischemic stroke did not significantly differ between patients with a TIA and those with a stroke as their qualifying event (13.3% versus 6.7%, P=0.17). In multivariate analysis, the qualifying event was not associated with the incidence of ipsilateral ischemic stroke. There were no significant differences in the CMOSS primary outcomes between the surgical and medical groups, regardless of the qualifying event being TIA (10.1% versus 12.2%, P=0.86) or stroke (6.7% versus 8.9%, P=0.55). CONCLUSIONS: Among patients with symptomatic artery occlusion and hemodynamic insufficiency, the risk of subsequent ipsilateral ischemic stroke does not appear to be lower in patients presenting with a TIA compared with those with a stroke. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01758614.

Combined duplicate origin and early bifurcated middle cerebral artery diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of combined duplicate origin and early bifurcated middle cerebral artery (MCA) incidentally diagnosed using magnetic resonance (MR) angiography. METHODS: A 51-year-old woman with an unruptured left MCA aneurysm underwent cranial MR angiography with a 3-Tesla scanner for presurgical evaluation. MR angiography was performed using a standard 3-dimensional time-of-flight technique. RESULTS: An unruptured left MCA aneurysm at the M1-M2 junction was identified. The maximum aneurysm diameter was 9 mm. Two almost equally sized right MCAs arose from the terminal segment of the right internal carotid artery. These two channels soon anastomosed, and the temporal branch arose from the inferior channel. The aneurysm was successfully treated with coil embolization. CONCLUSION: We herein report a case of a combined duplicate origin and early bifurcated MCA. This variation can also be regarded as anastomosis between the main MCA and the duplicated MCA. This variation has been previously reported as segmental duplication of the MCA. This is the third case of this rare MCA variation reported in the relevant English-language literature. The term "segmental duplication" may be confused with duplicate origin of the MCA, in which only one artery is located distal to the fusion.

The effects of habitual resistance exercise training on cerebrovascular responses to lower body dynamic resistance exercise: A cross-sectional study.

Dynamic resistance exercise (RE) produces sinusoidal fluctuations in blood pressure with simultaneous fluctuations in middle cerebral artery blood velocity (MCAv). Some evidence indicates that RE may alter cerebrovascular function. This study aimed to examine the effects of habitual RE training on the within-RE cerebrovascular responses. RE-trained (n = 15, Female = 4) and healthy untrained individuals (n = 15, Female = 12) completed four sets of 10 paced repetitions (15 repetitions per minute) of unilateral leg extension exercise at 60% of predicted 1 repetition maximum. Beat-to-beat blood pressure, MCAv and end-tidal carbon dioxide were measured throughout. Zenith, nadir and zenith-to-nadir difference in mean arterial blood pressure (MAP) and mean MCAv (MCAvmean) for each repetition were averaged across each set. Two-way ANOVA was used to analyse dependent variables (training × sets), Bonferroni corrected t-tests were used for post hoc pairwise comparisons. Group age (26 ± 7 trained vs. 25 ± 6 years untrained, P = 0.683) and weight (78 ± 15 vs. 71 ± 15 kg, P = 0.683) were not different. During exercise average MAP was greater for the RE-trained group in sets 2, 3 and 4 (e.g., set 4: 101 ± 11 vs. 92 ± 7 mmHg for RE trained and untrained, respectively, post hoc tests all P = < 0.012). Zenith MAP and zenith-to-nadir MAP difference demonstrated a training effect (P < 0.039). Average MCAvmean and MCAvmean zenith-to-nadir difference was not different between groups (interaction effect P = 0.166 and P = 0.459, respectively). Despite RE-trained individuals demonstrating greater fluctuations in MAP during RE compared to untrained, there were no differences in MCAvmean. Regular RE may lead to vascular adaptations that stabilise MCAv during RE.

Cerebral Hemodynamics and Vagally Mediated HRV Associated with High- and Low-frequency Yoga Breathing: An Exploratory, Randomized, Crossover Study.

Background: Volitionally modifying respiration leads to changes in middle cerebral arterial (MCA) blood flow. The effect of changes in breath rate on MCA blood flow has not been reported. Aims and Objectives: To determine the effect of slow (bumblebee yoga breathing) and fast (high frequency yoga breathing) yoga breathing techniques on MCA blood flow and vagally mediated heart rate variability. Materials and Methods: Thirty participants (mean age ± standard deviation, 27.3 ± 4.2 years) were assessed on 2 separate days practicing either high frequency yoga breathing (HFYB, breath frequency 54.2/min) or slow frequency bumblebee yoga breathing (BBYB, breath frequency 3.8/min) in random order to determine the effects of changes in breath frequency on MCA hemodynamics. Assessments included transcranial Doppler sonography, vagally mediated heart rate variability (VmHRV), and respiration. Results: Both HFYB and BBYB (i) reduced MCA flow velocities, i.e., peak systolic, end diastolic, and mean flow velocities, and (ii) increased MCA pulsatility indices. There was an increase in VmHRV during BBYB based on increased power in high frequency (HF) and low frequency (LF). LF reflects VmHRV for slow breath frequencies. In BBYB the average breath rate was 3.8 breaths/min. In contrast, VmHRV decreased during HFYB (based on reduced HF power; repeated measures analysis of variance, P < 0.05, all cases). Conclusion: Hence, irrespective of the differences in breath frequency, both HFYB and BBYB appear to reduce MCA flow velocities and increase the resistance to blood flow bilaterally, although the VmHRV changed in opposite directions. MCA velocity and pulsatility changes are speculated to be associated with low global neural activity during yoga breathing.

Relationship between ultrasound parameters of the umbilical and middle cerebral arteries and intrauterine fetal distress.

BACKGROUND: By comprehensively analyzing the blood flow parameters of the umbilical and middle cerebral arteries, doctors can more accurately identify fetal intrauterine distress, as well as assess its severity, so that timely interventions can be implemented to safeguard the health and safety of the fetus. AIM: To identify the relationship between ultrasound parameters of the umbilical and middle cerebral arteries and intrauterine distress. METHODS: Clinical data of pregnant women admitted between January 2021 and January 2023 were collected and divided into the observation and control groups (n = 50 each), according to the presence or absence of intrauterine distress. The ultrasound hemodynamic parameters of the uterine artery (UtA), fetal middle cerebral artery (MCA), and umbilical artery (UmA) were compared with neonatal outcomes and occurrence of intrauterine distress in the two groups. RESULTS: Comparison of ultrasonic hemodynamic parameters, resistance index (RI), pulsatility index (PI), and systolic maximal blood flow velocity of UmA compared to diastolic blood flow velocity (S/D), revealed higher values of fetal MCA, PI, and S/D of UmA in pregnant women with UtA compared to controls (P < 0.05), while there was no difference between the two groups in terms of RI (P < 0.05) The incidence of a neonatal Apgar score of 8-10 points was lower in the observation group (66.7%) than in the control group (90.0%), and neonatal weight (2675.5 ± 27.6 g) was lower than in the control group (3117.5 ± 31.2 g). Further, cesarean section rate was higher in the observation group (70.0%) than in the control group (11.7%), and preterm labor rate was higher in the observation group (40.0%) than in the control group (10.0%). The incidence of fetal distress, neonatal growth restriction and neonatal asphyxia were also higher in the observation group (all P < 0.05). CONCLUSION: Fetal MCA, UmA, and maternal UtA hemodynamic abnormalities all develop in pregnant women with intrauterine distress during late pregnancy, which suggests that clinical attention should be paid to them, and monitoring should be strengthened to provide guidance for clinical intervention.

3D exoscopic versus microscopic superficial temporal artery to middle cerebral artery bypass surgery for moyamoya disease - a comparative series.

PURPOSE: Superficial temporal artery to middle cerebral artery (STA-MCA) direct bypass surgery is the most common surgical procedure to treat moyamoya disease (MMD). Here, we aim to compare the performance of the 3D exoscope in bypass surgery with the gold standard operative microscope. METHODS: All direct STA-MCA bypass procedures performed at a single university hospital for MMD between 2015 and 2023 were considered for inclusion. Data were retrospectively collected from patient files and surgical video material. From 2020 onwards, bypass procedures were exclusively performed using a digital three-dimensional exoscope as visualization device. Results were compared with a microsurgical bypass control group (2015-2019). The primary endpoint was defined as total duration of surgery, duration of completing the vascular anastomosis (ischemia time), bypass patency, number of stiches to perform the anastomosis, added stiches after leakage testing of the anastomosis and the Glasgow outcome scale (GOS) at last follow-up as secondary outcome parameter. RESULTS: A total of 16 consecutive moyamoya patients underwent 21 STA-MCA bypass procedures. Thereof, six patients were operated using a microscope and ten patients using an exoscope (ORBEYE® n = 1; AEOS® n = 9). Total duration of surgery was comparable between devices (microscope: 313 min. ± 116 vs. exoscope: 279 min. ± 42; p = 0.647). Ischemia time also proved similar between groups (microscope: 43 min. ± 19 vs. exoscope: 41 min. ± 7; p = 0.701). No differences were noted in bypass patency rates. The number of stiches per anastomosis was similar between visualization devices (microscope: 17 ± 4 vs. exoscope: 17 ± 2; p = 0.887). In contrast, more additional stiches were needed in microscopic anastomoses after leakage testing the bypass (p = 0.035). CONCLUSION: Taking into account the small sample size, end-to-side bypass surgery for moyamoya disease using a foot switch-operated 3D exoscope was not associated with more complications and led to comparable clinical and radiological results as microscopic bypass surgery.

A Pediatric Case of Middle Cerebral Artery Dissection With Delayed Morphological Changes.

Middle cerebral artery dissection (MCAD) is a rare condition with no consensus on its treatment strategy and prognosis. This report describes a case of MCAD with perforating artery infarction in which radiographic findings progressed despite a lack of symptoms following maintenance infusion without antithrombotic therapy. A five-year-old boy presented to our hospital with right hemiplegia. Magnetic resonance imaging revealed diffusion restriction in the left basal ganglia. Additionally, magnetic resonance angiography (MRA) revealed irregular walls in the horizontal portion of the left middle cerebral artery. MRA performed three months after admission revealed progressive stenosis but no new ischemic lesions. MCAD can be associated with long-term morphological changes in the vessel walls. Intracranial artery dissection (IAD) in pediatric patients often presents without headache or neck pain, and serial imaging helps monitor disease progression. In conclusion, the morphology of the vessels can change over several months. Especially in pediatric patients, IAD often presents without headache or neck pain, and serial imaging evaluations help monitor disease progression.

Neuroprotective Effect and Mechanism of Tanreqing Injection on Ischemic Stroke: Insights from Network Pharmacology and in vivo Experiments.

OBJECTIVE: To explore the neuroprotective effects and mechanism of Tanreqing Injection (TRQ) on treating ischemic stroke based on network pharmacology and in vivo experimental validation. METHODS: The chemical compounds of TRQ were retrieved based on published data, with targets retrieved from PubChem, Therapeutic Target Database and DrugBank. Network visualization and analysis were performed using Cytoscape, with protein-protein interaction networks derived from the STRING database. Enrichment analysis was performed using Kyoto Encyclopedia of Genes Genomes pathway and Gene Ontology analysis. In in vivo experiments, the middle cerebral artery occlusion (MCAO) model was used. Infarct volume was determined by 2,3,5-triphenyltetrazolium hydrochloride staining and protein expressions were analyzed by Western blot. Molecular docking was performed to predict ligand-receptor interactions. RESULTS: We screened 81 chemical compounds in TRQ and retrieved their therapeutic targets. Of the targets, 116 were therapeutic targets for stroke. The enrichment analysis showed that the apelin signaling pathway was a key pathway for ischemic stroke. Furthermore, in in vivo experiment we found that administering with intraperitoneal injection of 2.5 mL/kg TRQ every 6 h could significantly reduce the infarct volume of MCAO rats (P<0.05). In addition, protein levels of the apelin receptor (APJ)/phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) pathway were increased by TRQ (P<0.05). In addition, 41 chemical compounds in TRQ could bind to APJ. CONCLUSIONS: The neuroprotective effect of TRQ may be related to the APJ/PI3K/AKT signaling pathway. However, further studies are needed to confirm the findings.

Maternal rest improves growth in small-for-gestational-age fetuses (<10th percentile).

BACKGROUND: Optimal management of fetuses diagnosed as small for gestational age based on an estimated fetal weight of <10th percentile represents a major clinical problem. The standard approach is to increase fetal surveillance with serial biometry and antepartum testing to assess fetal well-being and timing of delivery. Observational studies have indicated that maternal rest in the left lateral position improves maternal cardiac output and uterine blood flow. However, maternal bed rest has not been recommended based on the results of a randomized clinical trial that showed that maternal rest does not improve fetal growth in small-for-gestational-age fetuses. This study was conducted to revisit this question. OBJECTIVE: This study aimed to determine whether maternal bed rest was associated with an increase in the fetal biometric parameters that reflect growth after the diagnosis of a small-for-gestational-age fetus. STUDY DESIGN: A retrospective study was conducted on fetuses who were diagnosed as small for gestational age because of an estimated fetal weight of <10th percentile for gestational age. The mothers were asked to rest in the left lateral recumbent position. Fetal biometry was performed 2 weeks after the diagnosis. All fetuses before entry into the study had a previous ultrasound that demonstrated an estimated fetal weight of >10th percentile. To assess the response to bed rest, the change in fetal biometric parameters (estimated fetal weight, head circumference, abdominal circumference, and femur length) after the recommendation of bed rest was computed for 2 periods: (1) before the diagnosis of a weight of <10th percentile vs at the time of diagnosis of a weight of <10th percentile and (2) at the time of diagnosis of a weight of <10th percentile vs 2 weeks after maternal bed rest. For repeated measures, proportions were compared using the McNemar test, and percentile values were compared using the Kruskal-Wallis test. A P value of <.05 was considered significant. To describe changes in the estimated fetal weight without bed rest, 2 control groups in which the mothers were not placed on bed rest after the diagnosis of a small-for-gestational-age fetus were included. RESULTS: A total of 265 fetuses were observed before and after maternal bed rest. The following were observed in this study: (1) after 2 weeks of maternal rest, 199 of 265 fetuses (75%) had a fetal weight of >10th percentile; (2) the median fetal weight percentile increased from 6.8 (interquartile range, 4.4-8.4) to 18.0 (interquartile range, 9.5-29.5) after 2 weeks of bed rest; (3) similar trends were noted for the head circumference, abdominal circumference, and femur length. In the groups of patients who were not asked to be on bed rest, a reassignment to a weight of >10th percentile at a follow-up examination only occurred in 7 of 37 patients (19%) in the Texas-Michigan group and 13 of 111 patients (12%) in the Colorado group compared with the bed rest group (199/265 [75%]) (P<.001). CONCLUSION: Patients who were prescribed 2 weeks of bed rest after the diagnosis of a fetal weight of <10th percentile had an increase in weight of >10th percentile in 199 of 265 fetuses (75%). This increase in fetal weight was significantly higher than that in the 2 control groups in which bed rest was not prescribed. This observation suggests that bed rest improves fetal growth in a subset of patients.

A Long-term outcome of symptomatic middle cerebral artery undergoing intracranial angioplasty or stenting.

PURPOSE: For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period. METHODS: A set of 41 individuals with symptomatic stenosis in the central cerebral artery (MCA) who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed. RESULTS: A total of 41 individuals successfully underwent stenting , respectively. After stenting, the extent of stenosis was decreased from 71.8 percent (56 -87.8%) to 24.9 percent (0-45 percent). The mean of follow period is 36.9 ± 13.68 months (range , 11-67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CTA was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively. CONCLUSION: In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty & stenting are demonstrated to be technically feasible and safe. Its early & long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny.

Microsurgical management of a ruptured intracranial mycotic aneurysm in infancy.

INTRODUCTION: During infancy, infectious aneurysms are uncommon and potentially fatal lesions with an imminent risk of intracranial hemorrhage development. CASE PRESENTATION: A 1-month-old infant presented with loss of consciousness and clonic movements of the right superior limb after a work-up for Hirschsprung's disease. His physical exam revealed stupor, miosis, anterior fontanelle swelling, and hyperreflexia of the right superior limb. Blood cultures were positive for Candida albicans. In addition, brain imaging revealed an intraparenchymal hematoma in the left temporal lobe and a saccular aneurysm at the M3 segment of the left middle cerebral artery. Upon careful discussion with the patient's family, he underwent evacuation of the hematoma and aneurysm repair. His postoperative clinical course was uneventful. At the 5-month follow-up, a brain MRI showed encephalomalacia in the area of prior hemorrhage. Furthermore, he had preserved motor function and adequate psychomotor development on subsequent pediatric evaluations. CONCLUSION: Microsurgical management of ruptured mycotic aneurysms demands a systematic work-up and nuanced appraisal of clinical and aneurysmal factors. Operating in a confined space and considering the fragile nature of aneurysms are of utmost relevance for effectively treating these lesions.

Triplicated middle cerebral arteries (duplicated and ipsilateral accessory) associated with triplicated anterior cerebral arteries (accessory) diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of duplicated middle cerebral artery (MCA) combined with ipsilateral accessory MCA, forming a triplicated MCA, associated with the accessory anterior cerebral artery (ACA), forming a triplicated A2 segment of the ACA detected incidentally on magnetic resonance (MR) angiography. METHODS: A 70-year-old woman with internal carotid artery (ICA) stenosis at the origin, which was detected by ultrasound, underwent cranial MR imaging and MR angiography of the intracranial region for an evaluation of brain and cerebral arterial lesions. The MR machine was a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. RESULTS: Multiple ischemic white matter lesions are observed. No significant stenotic lesions were observed in intracranial arteries. The right duplicated MCA was originated from right distal ICA. And main MCA was originated from right ICA bifurcation. Right accessory MCA was arisen from the A2 segment of the right ACA. Thus, the right MCA was triplicated. There was also an accessory ACA forming a triplicated ACA at its A2 segment. These findings were clearly identified on partial volume-rendering (VR) images. CONCLUSION: We herein report a case of triplicated MCA associated with triplicated ACA. MCA variations are relatively rare, and this is the third case of triplicated MCA reported in relevant English-language literature. To identify multiple cerebral arterial variations, creating partial VR images using MR angiographic source images is useful.

One-Stage Combined Open and Endovascular Treatment Using a Hybrid Operating Room is Safe and Effective for Distal Middle Cerebral Artery Aneurysms.

BACKGROUND: Aneurysms located in the distal middle cerebral artery (DMCA) are relatively rare and lack an established treatment strategy. For DMCA aneurysms, we performed a one-stage combined procedure of endovascular parent artery occlusion (PAO) with coils and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in a hybrid operating room (HOR). The aim of this study was to evaluate the safety and efficacy of this procedure. METHODS: Cases of unruptured DMCA aneurysms treated with the one-stage combined PAO and STA-MCA bypass in HOR were retrospectively examined, and patients' and aneurysmal backgrounds, surgical procedures, and treatment outcomes were analyzed. RESULTS: Six patients were included in the study. The average maximum diameter of the aneurysms was 14.4 mm. One aneurysm was located at M2 and five at M3. All aneurysms had a fusiform shape. No cases were associated with infection, trauma, or malignant tumors. In all 6 cases, the combined PAO and STA-MCA bypass was successfully completed. No postoperative hemorrhagic complications occurred. A symptomatic ischemic complication occurred in 1 case whose symptom disappeared in a week. Three months after surgery, complete obliteration of the aneurysm and patency of the bypass was confirmed in all cases. CONCLUSIONS: The one-stage combined PAO and STA-MCA bypass in the HOR is safe and effective for DMCA aneurysms, potentially serving as a treatment option for this complex aneurysm.