The Paramount Role of the Anterior Communicating Artery in the Collateral Cerebral Circulation

Abstract

Clinical manifestation of carotid occlusive disease is largely dependent on the severity of stenosis and the capability of collateral circulation. However, due to the complexity and difficulty in evaluation, cerebral collateral circulation has, so far, remained underappreciated. We report a patient with advanced extracranial arterial disease (including the right subclavian steal, occlusion of the right external carotid artery, and severe stenosis of the left vertebral artery), who underwent transient right internal carotid artery occlusion during carotid intervention. Throughout the occlusion, the flow into the right hemisphere (monitored by transcranial Doppler ultrasound in the right middle cerebral artery) was sufficient despite almost totally dependent on the anterior communicating artery, which highlights its role as the most potent collateral pathway.

Keywords

carotid occlusion - transcranial Doppler - cerebrovascular reserve - collateral circulation

• References

• 1 Meier B, Frank B, Wahl A, Diener HC. Secondary stroke prevention: patent foramen ovale, aortic plaque, and carotid stenosis. Eur Heart J 2012; 33 (6) 705-713 , 713a, 713b
• 2 Sfyroeras G, Karkos CD, Liasidis C , et al. The impact of carotid stenting on the hemodynamic parameters and cerebrovascular reactivity of the ipsilateral middle cerebral artery. J Vasc Surg 2006; 44 (5) 1016-1022, discussion 1022
• 3 Silvestrini M, Vernieri F, Pasqualetti P , et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 2000; 283 (16) 2122-2127
• 4 Hedera P, Bujdáková J, Traubner P. Effect of collateral flow patterns on outcome of carotid occlusion. Eur Neurol 1995; 35 (4) 212-216
• 5 Romero JR, Pikula A, Nguyen TN, Nien YL, Norbash A, Babikian VL. Cerebral collateral circulation in carotid artery disease. Curr Cardiol Rev 2009; 5 (4) 279-288
• 6 Visser GH, Wieneke GH, van Huffelen AC, Eikelboom BC. The use of preoperative transcranial Doppler variables to predict which patients do not need a shunt during carotid endarterectomy. Eur J Vasc Endovasc Surg 2000; 19 (3) 226-232
• 7 Doblar DD, Plyushcheva NV, Jordan W, McDowell H. Predicting the effect of carotid artery occlusion during carotid endarterectomy: comparing transcranial Doppler measurements and cerebral angiography. Stroke 1998; 29 (10) 2038-2042
• 8 Chuang YM, Liu CY, Pan PJ, Lin CP. Posterior communicating artery hypoplasia as a risk factor for acute ischemic stroke in the absence of carotid artery occlusion. J Clin Neurosci 2008; 15 (12) 1376-1381
• 9 Hoksbergen AW, Fülesdi B, Legemate DA, Csiba L. Collateral configuration of the circle of Willis: transcranial color-coded duplex ultrasonography and comparison with postmortem anatomy. Stroke 2000; 31 (6) 1346-1351
• 10 Liebeskind DS. Collateral circulation. Stroke 2003; 34 (9) 2279-2284
• 11 Cremonesi A, Rigattieri S, Liso A , et al. Proximal protection in carotid artery stenting: rationale and recent findings. EuroIntervention 2007; 3 (2) 269-274
• 12 Moran KT, Zide RS, Persson AV, Jewell ER. Natural history of subclavian steal syndrome. Am Surg 1988; 54 (11) 643-644
• 13 Mozersky DJ, Barnes RW, Sumner DS, Strandness Jr DE. Hemodynamics of innominate artery occlusion. Ann Surg 1973; 178 (2) 123-127
• 14 Tyagi S, Girish MP, Gupta MD. Endovascular revascularization of bald aortic arch for severe cerebral ischemia. Catheter Cardiovasc Interv 2013; 81 (7) 1213-1216
• 15 Filis K, Toufektzian L, Sigala F , et al. Right subclavian double steal syndrome: a case report. J Med Case Reports 2008; 2: 392
• 16 Muñoz R, Pulido L, Gállego J. Asymptomatic subclavian-carotid double steal phenomenon due to innominate artery stenosis. Neurology 2012; 78 (20) e125