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Original research
Circle of Willis integrity in acute middle cerebral artery occlusion: does the posterior communicating artery matter?
  1. Udi Sadeh-Gonik1,
  2. Anatoly Budylev1,
  3. David Krivitzky2,
  4. Jeremy Molad2,
  5. Hen Halevi2,3,4,
  6. Tali Jonas-Kimchi1,
  7. Hila Yashar1,
  8. Einor Ben Assayag2,3,4,
  9. Estelle Seyman2,4
  1. 1 Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  2. 2 Department of Stroke and Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  3. 3 Sagol School of Neuroscience Tel Aviv University, Tel-Aviv, Israel
  4. 4 The Faculty of Medicine,Tel Aviv University, Tel-Aviv, Israel
  1. Correspondence to Dr Estelle Seyman; seyman.estelle{at}gmail.com

Abstract

Background Collateral circulation is an important determinant of outcome in people with acute ischemic stroke due to large vessel occlusion (LVO).

Objective To explore the impact of the circle of Willis (CW) anatomical characteristics ipsilateral to the occlusion site, particularly the posterior communicating artery (PComA) and the A1-portion of the anterior cerebral artery (A1-ACA), on stroke outcomes in a cohort of patients with LVO and middle cerebral artery (MCA) occlusion, undergoing endovascular thrombectomy (EVT).

Methods This is a retrospective cohort study performed in a comprehensive tertiary stroke center. The study population consisted of consecutive patients with LVO with proximal MCA occlusion (M1) between June 2016 and April 2021, undergoing EVT. Demographic, clinical, and imaging information was extracted from patient files. Patency and diameters of ipsilateral A1-ACA and PComA were manually measured on admission CT angiography images in the core laboratory.

Results One hundred and five patients with LVO comprised the study cohort, mean age 72.3 years, 43.8% were male, mean National Institutes of Health Stroke Scale score at admission 15.2. The cohort was grouped according to CW vessel characteristics. On univariate analysis, a well-developed PComA was associated with lower rates of hemorrhagic transformation (1.8% vs 14.3%, P=0.01) and a trend towards lower mortality rates (8.9% vs 20.4%, P=0.08).On multivariable regression analysis a well-developed PComA emerged as an independent predictor for survival (aOR=0.09, 95% CI 0.01 to 0.4 for survival at discharge, P=0.009, aOR=0.22, 95% CI 0.05 to 0.8 for survival at 90 days, P=0.02).

Conclusions In a cohort of patients with LVO due to M1 occlusion undergoing EVT, a well-developed PComA was associated with significantly lower hemorrhagic transformation rates, a trend towards better functional outcomes, and independently predicted survival. Larger studies are needed to understand the differential effect of CW collateral conduits on stroke outcome and evaluate the practicality of incorporating such factors in the clinical decision-making process prior to EVT.

  • Thrombectomy
  • Stroke
  • Blood Flow
  • CT Angiography

Data availability statement

Data are available upon reasonable request. All data are available upon reasonable request from corresponding author.

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Data availability statement

Data are available upon reasonable request. All data are available upon reasonable request from corresponding author.

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Footnotes

  • US-G and AB contributed equally.

  • Contributors US-G: methodology investigation, validation, writing original draft, review and editing of final draft. AB: methodology and software, image analysis, investigation, writing original draft, review and editing of final draft. These authors contributed equally to the manuscript. DK, HY: data analysis, investigation. JM, HH, TJ-K: conceptualization, methodology, review and editing of final draft. EB-A: writing original draft, review and editing of final draft. ES:

    guarantor, conceptualization, methodology, supervision, investigation, validation, supervision, writing original draft, review and editing of final draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.