Circle of Willis Centerline Graphs: A Dataset and Baseline Algorithm

Will this be enough for your competent? doctor to verify a complete Circle of Willis and thus prevent an unneeded endarterectomy and stents.

 I would never do a carotid endarterectomy with all its' risks. I'm still of the opinion that you determine if the Circle of Willis is complete then you just close up the artery. I'm not medically trained so that opinion is obviously not worth listening to. I had a completely closed carotid artery for over 10 years with no problems with blood supply to the brain and I didn't have to worry about clots breaking off. 

Here is why your doctor needs to guarantee NO complications from endarterectomy!

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries.

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021) 

The latest here:

 Circle of Willis Centerline Graphs: A Dataset and Baseline Algorithm

Fabio Musioa,b, Norman Juchlera, Kaiyuan Yangb, Suprosanna Shitb, Chinmay Prabhakarb, Bjoern Menzeb, Sven Hirscha {fabio.musio, sven.hirsch}@zhaw.ch 

 a Institute of Computational Life Sciences, Zurich University of Applied Sciences, Waedenswil, Switzerland arXiv:2510.13720v1 [cs.CV] 15 Oct 2025 

  bDepartment of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland 

 Abstract 

 The Circle of Willis (CoW) is a critical network of arteries in the brain, often implicated in cerebrovascular pathologies. Voxel-level segmentation is an important first step toward an automated CoW assessment, but a full quantitative analysis requires centerline representations. However, conventional skeletonization techniques often struggle to extract reliable centerlines due to the CoW’s complex geometry, and publicly available centerline datasets remain scarce. To address these challenges, we used a thinning-based skeletonization algorithm to extract and curate centerline graphs and morphometric features from the TopCoW dataset, which includes 200 stroke patients, each imaged with magnetic resonance angiography (MRA) and computed tomography angiography (CTA). The curated graphs were used to develop a baseline algorithm for centerline and feature extraction, combining U-Net-based skeletonization with A* graph connection. Performance was evaluated on a held-out test set, focusing on anatomical accuracy and feature robustness. Further, we used the extracted features to predict the frequency of fetal PCA variants, confirm theoretical bifurcation optimality relations, and detect subtle modality differences between MRA and CTA. The baseline algorithm consistently reconstructed graph topology with high accuracy (F1 = 1), and the average Euclidean node distance between refer ence and predicted graphs was below one voxel. Features such as segment radius, length, and bifurcation ratios showed strong robustness, with median relative errors below 5% and Pearson correlations above 0.95. Our results demonstrate the utility of learning-based skeletonization combined with graph connection for anatomically plausible centerline extraction. We emphasize the importance of going beyond simple voxel-based measures by evaluating anatomical accuracy and feature robustness. The dataset and baseline algorithm have been released to support fur ther method development and clinical research. 

Rethinking stroke prevention for patients with mild carotid narrowing

 I would never do a carotid endarterectomy with all its' risks. I'm still of the opinion that you determine if the Circle of Willis is complete then you just close up the artery. I'm not medically trained so that opinion is obviously not worth listening to. 

Here is why your doctor needs to guarantee NO complications from endarterectomy!

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries.

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021) 

The latest here:

Rethinking stroke prevention for patients with mild carotid narrowing 

• Download PDF Copy

 Reviewed

University of ToyamaApr 24 2025

Ischemic stroke remains one of the leading causes of death and long-term disability worldwide, with narrowing of the carotid artery due to atherosclerosis contributing to up to 30% of all cases. For decades, medical practitioners have primarily relied on the degree of carotid narrowing (stenosis) to assess the risk of stroke and determine the best treatment options. However, mounting evidence suggests that this approach may be insufficient for patients with mild but symptomatic carotid stenosis.

Despite being classified as 'low-risk' due to having less than 50% carotid artery narrowing, a significant number of patients with mild carotid stenosis continue to experience recurrent ischemic events, even when receiving appropriate medical therapy. This implies that factors beyond the degree of stenosis may play a crucial role in determining stroke risk for this patient population.

To address this gap, a team including Lecturer Daina Kashiwazaki and Dr. Satoshi Kuroda from Toyama University, Japan, aimed to tackle this knowledge gap via their 'Mild but Unstable Stenosis of Internal Carotid Artery (MUSIC)' study. This multicenter prospective cohort study, which was published online on February 21, 2025, in the Journal of Neurosurgery, investigated the clinical features, radiological findings, and treatment outcomes of patients with symptomatic mild carotid stenosis.

The researchers enrolled 124 patients who had experienced cerebrovascular or retinal ischemic events ipsilateral (same side) to mild carotid stenosis. While all participants received the best medical therapy (BMT) for their condition, carotid endarterectomy (CEA)-the surgical removal of plaque-or carotid artery stenting (CAS) was performed in 63 patients. Patients were followed up for two years, with the primary endpoint being the occurrence of ipsilateral ischemic stroke.

The findings were quite striking: approximately 81% of patients had radiologically unstable plaque, with 59.5% exhibiting intraplaque hemorrhage (IPH). This type of plaque composition was associated with a significantly higher risk of both primary and secondary endpoints, the latter of which included ocular symptoms, any type of stroke, and plaque progression requiring CEA. Additionally, the incidence of ipsilateral ischemic stroke was markedly higher in the group receiving only BMT compared to those who also underwent CEA (15.1% vs. 1.7%). "The distinctive clinical and radiological features in high-risk patients strongly indicate that plaque composition, namely IPH, but not degree of stenosis, plays a key role in subsequent ischemic events in patients with symptomatic mild carotid stenosis," explains Kashiwazaki.

Clot-Busting Ultrasound Gives Carotid Endarterectomy a Step Up

 

I still don't understand why you would medically need to treat a carotid artery at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

Before you go down either route ask your doctor to GUARANTEE NO STROKE from either procedure. If it was me I would ask my doctor to see if the Circle of Willis was complete; if yes, then have the doctor close up the offending artery. My right carotid artery completely closed up for 14 years before collaterals grew around it. I have had no dizziness or cognitive issues with only 3 arteries feeding the Circle of Willis.

Here is why your doctor needs to guarantee NO complications from endarterectomy!

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries.

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

Clot-Busting Ultrasound Gives Carotid Endarterectomy a Step Up

      Strokes down after surgery for internal carotid artery stenosis

by Nicole Lou, Senior Staff Writer, MedPage Today March 19, 2025

Key Takeaways

• Sonolysis, an application of therapeutic ultrasound, reduced periprocedural cerebrovascular events during carotid endarterectomy.
• The safety profile of sonolysis was supported by a reported lack of intracranial bleeds.
• Questions remain regarding the internal validity of the trial results, sonolysis' mechanism of benefit, and its cost-effectiveness.

There were clinical benefits to putting patients under a steady ultrasound beam during carotid endarterectomy, the phase III sham-controlled SONOBIRDIE trial found.

Applied during the surgery for people averaging 80% internal carotid artery stenosis, sonolysis resulted in reductions in 30-day:

• Combined ischemic stroke, transient ischemic attack (TIA), and death (2.2% vs 7.6%; risk ratio [RR] 0.28, 95% CI 0.15-0.54)
• Ischemic stroke (1.4% vs 5.4%; RR 0.25, 95% CI 0.11-0.56)
• TIA (0.6% vs 2.6%; RR 0.23, 95% CI 0.07-0.73)

Although there were no significant between-group differences in mortality at 30 days or 1 year, the other clinical benefits were supported by the finding of fewer new ischemic lesions among study participants who had follow-up brain MRI (8.5% vs 17.4%, P=0.004), according to researchers led by David Školoudík, PhD, of the University of Ostrava in Czech Republic.

"The results of the SONOBIRDIE trial suggest that sonolysis should be used to reduce the risk of periprocedural cerebrovascular events during carotid endarterectomy in all patients with sufficient temporal bone window for transcranial Doppler," they wrote in The BMJ. "It has the potential to make carotid endarterectomy safer with a higher benefit for patients with carotid stenosis compared with the best medical treatment, especially in patients with asymptomatic carotid stenosis."

Notably, the SONOBIRDIE trial had been stopped early for effectiveness and its main results were previously reported at the European Stroke Organisation Conference in 2023.

As for safety in the trial, sonolysis did not result in any intracranial bleeds. Approximately 95% of patients in the sonolysis group were free from serious adverse events 30 days after the procedure; there was one reported case of intracerebral bleeding/subarachnoid hemorrhage in one sonolysis patient (0.2%) and none in the control group.

Sonolysis is the continuous application of a low-intensity pulsed wave ultrasound beam using a standard ultrasound machine and a transcranial Doppler probe. The procedure is thought to reduce thromboembolic risk by activating fibrinolytic enzymes in tandem with a direct mechanical breaking of existing clots -- though the exact mechanism of benefit remains unknown.

For carotid endarterectomy in SONOBIRDIE, sonolysis was started before the first skin incision and stopped after the last suturing of the skin at the end of surgery (up to 2 hours).

"These findings represent a potentially significant innovation in the application of ultrasound from its historical diagnostic role to now also as a therapeutic intervention," noted Jesse Columbo, MD, of Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, in an accompanying editorial. "Given the well documented low risk of stroke associated with asymptomatic carotid endarterectomy, the observed absolute risk reduction of 5.4% seems to represent a substantial additive advance in carotid endarterectomy care."

However, Columbo laid out his concerns about the internal validity of the results, citing the whopping 6.9% incidence of the primary composite outcome in asymptomatic patients in the study and the fact that symptom status seemed to have no bearing on event rates.

"Resolution of the above concerns, along with a cost effectiveness calculation, can then inform whether this exciting new application of an established technology can improve care for patients undergoing carotid endarterectomy," he wrote.

The SONOBIRDIE trial was conducted in Czech Republic, Slovakia, and Austria among 1,004 patients with ≥70% symptomatic or asymptomatic internal carotid artery stenosis who were randomized to sonolysis or a sham procedure.

Mean age was 68 years, 31% were women, and 45% had symptomatic carotid stenosis. Over 80% were on statins, about 90% were on antiplatelets, and over 10% were on anticoagulants.

Školoudík's group reported that baseline characteristics were comparable between groups.

Based on the 45.8% of patients who underwent brain MRI before and 1 day after carotid endarterectomy, all ischemic lesions after surgery were ipsilateral to the intervened internal carotid artery.

The investigators acknowledged that the sonographer on each case was not blinded to the assigned treatment, but patients and the rest of their care team were blinded.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The study was partially funded by grants from the Czech Health Research Council.

Školoudík and colleagues declared no competing personal interests.

Columbo reported support from the NIH/National Heart, Lung, and Blood Institute and the Society for Vascular Surgery.

Primary Source

The BMJ

Source Reference: Školoudík D, et al "Sonolysis during carotid endarterectomy: randomised controlled trial" BMJ 2025; DOI: 10.1136/bmj-2024-082750.

Secondary Source

The BMJ

Source Reference: Columbo JA "Therapeutic ultrasound during carotid endarterectomy" BMJ 2025; DOI: 10.1136/bmj.r385.

Stroke Risk Reduction Similar With Carotid Stenting and Endarterectomy

 To me, they are mimimizing the stroke risks of the procedures. I would prefer just verifying that the Circle of Willis is complete and then just close up the offending artery. I'm not medically trained so your doctor will not even know about that solution.

Stroke Risk Reduction Similar With Carotid Stenting and Endarterectomy

 

By Walter Alexander

VIRTUAL -- September 2, 2021 -- For patients with a severely narrowed carotid artery, stenting and surgery have similar effects on the chance of having a disabling or fatal stroke, according to a study presented at the Virtual 2021 European Society of Cardiology (ESC) Congress.

The second asymptomatic carotid surgery trial (ACST-2) was conducted to address uncertainty as to whether the benefits demonstrated in clinical trials of endarterectomy (50% reduced stroke over 5 years) extend to carotid stenting.

“Both doctors and patients are substantially uncertain as to which to prefer,” stated Alison Halliday, MD, University of Oxford, Oxford, United Kingdom.

ACST-2 included 3,625 patients with severe carotid artery narrowing (≥60% on ultrasound) found by chance and without recent stroke or other related neurological symptoms. The patients were randomised 1:1 to endarterectomy or carotid stenting and followed for an average of 5 years.

The primary outcome measure was 5-year nonprocedural stroke. Procedural stroke risks, such as morbidity and mortality within 1 month after the procedure, were also tallied.

Fatal or disabling stroke occurred at the same rate in both groups (2.5%), with a rate ratio (RR) for carotid stenting versus endarterectomy of 0.98 (95% confidence interval [CI], 0.64-1.48; P = .91). Nonprocedural stroke rates were 5.3% in the carotid stenting group and 4.5% in the endarterectomy group (RR = 1.16; 95% CI, 0.86-1.57; P = .33); when data were included in a meta-analysis of major trials of carotid stenting versus endarterectomy, the difference was similarly nonsignificant for any stroke (RR = 1.11; 95% CI, 0.91-1.32; P = .21).

In regard to procedural risks, Dr. Halliday said that 1% of patients in both groups had a disabling stroke or died within 30 days (15 stented group and 18 endarterectomy group), and 2% had a non-disabling stroke (48 and 29 patients, respectively).(This is why I would never do these procedures. I had a completely closed carotid artery for 13 years and had no effects from that.)

ACST-2 is the largest trial to compare long-term stroke with carotid stenting versus endarterectomy in stroke-naive asymptomatic patients with a severely narrowed carotid artery. It showed that carotid stenting and endarterectomy involve similar risks and benefits and, when competently performed, involve about a 1% risk of causing disabling stroke or death. Both interventions reduced future stroke risk in half.

“Patients should all be given good medical treatment to reduce stroke risk, but adding carotid stenting or endarterectomy may also be appropriate,” Dr. Halliday concluded.

[Presentation title: Carotid Artery Surgery and Stenting Have Similar Long-Term Effects on Stroke]

 

Up-to-date perspective on the treatment of cervical carotid high-degree stenosis, DEBATE: treat or not to treat?

I don't know how to get the full presentation but this pretty much matches my thoughts on carotid stenting and endarterectomy.

 

Before you go down either route ask your doctor to GUARANTEE NO STROKE from either procedure. If it was me I would ask my doctor to see if the Circle of Willis was complete; if yes, then have the doctor close up the offending artery. My right carotid artery completely closed up for 14 years before collaterals grew around it. I have had no dizziness or cognitive issues with only 3 arteries feeding the Circle of Willis.

Problems to consider:

1.  Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries.

2. You might want to prevent stent placement complications per European Society of Cardiology

A - Minor complications

• Carotid artery spasm

• Sustained hypotension / bradycardia

• Carotid artery dissection

• Contrast encephalopathy (very rare)

• Minor embolic neurological events (TIAs)

B - Major complications

• Major embolic stroke

• Intracranial hemorrhage

• Hyperperfusion syndrome

• Carotid perforation (very rare)

• Acute stent thrombosis (very rare)

• Complications at the site of the vascular access

  The latest here:

Up-to-date perspective on the treatment of cervical carotid high-degree stenosis, DEBATE: treat or not to treat?

 

Registry: More Options for Blocked Carotids Mean Better Outcomes

In my opinion being not medically trained they missed the most important option.

1. Determine if the Circle of Willis is complete.

2. If yes, then completely close up the offending artery.

3. Your other three arteries supplying the Circle of Willis provide enough blood for you to function just fine. 

4. This is why I would never consider a carotid endarterectomy as long as the Circle of Willis is complete.
   

5. Cognitive Dysfunction and Mortality After Carotid Endarterectomy

6. Risks of TCAR are here: Transcarotid Artery Revascularization,  you don't want them to happen and they put a stent in besides.

7. And this problem tied to stents:Plaque Protrusion Tied to Stroke in Carotid Stenting 3% rate

 

 The latest here:

Registry: More Options for Blocked Carotids Mean Better Outcomes

 

Adoption of TCAR may be good for carotid revascularization in general

by Nicole Lou, Staff Writer, MedPage Today February 22, 2021

Centers adding transcarotid artery revascularization (TCAR) to their treatment options had improved perioperative outcomes for patients with carotid artery stenosis, according to the Vascular Quality Initiative (VQI) registry.

Major adverse cardiovascular event (MACE) rates -- counting in-hospital stroke, MI, and death at 30 days -- were similar between patients undergoing TCAR and those getting surgical carotid endarterectomy (CEA; 2.3% vs 2.4%, P=0.91), reported a group led by Jesse Columbo, MD, MS, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

Despite such similar results, VQI centers had 10% less MACE in their overall carotid revascularization programs in the year after adopting TCAR than if they had stuck with the surgical option alone (OR 0.90, 95% CI 0.81-0.99), according to a difference-in-difference analysis by Columbo's group, published online in JAMA Open Network.

"This finding suggests that this new technology may have allowed proceduralists to select patients for whom TCAR may be superior to CEA, while still performing CEA on patients for whom that procedure was appropriate," study authors said.

"Overall, while observational in nature, these data imply that both TCAR and CEA may be reasonable treatment choices for patients undergoing carotid revascularization and providers may be able to choose the modality they feel best aligns with the patient's clinical presentation and anatomy," they concluded.

Moreover, the observed 10% MACE reduction, already "impressive," may in fact be an underestimation of the benefits of TCAR adoption, because the study included only VQI hospitals, which record only 10% of the CEAs performed in the U.S., commented Peter Groeneveld, MD, of the University of Pennsylvania in Philadelphia, in an invited commentary.

In contrast, device sales records indicate that the registry captures more than 95% of TCAR procedures.

TCAR was introduced to the U.S. market with the 2015 FDA approval of the Enroute stent system from Silk Road Medical.

The carotid procedure is designed to be a lower-risk alternative to surgery for patients at high risk due to anatomic or medical challenges. It is also designed with no need to traverse the aortic arch and carotid lesion prior to embolic protection, unlike transfemoral carotid stenting.

Whether TCAR is truly noninferior to CEA has not been proven in a randomized controlled trial. Transfemoral carotid stenting has been linked to more periprocedural events but no difference in outcomes at 10 years compared with surgery.

"An ongoing challenge for cardiovascular surgeons and interventionalists is to ascertain whether new therapeutic options for patients with a severe cardiovascular disease improve clinical outcomes across the full spectrum of patients with the disease. There are no guarantees that new therapies will produce net benefits across broad populations," Groeneveld cautioned.

He cited the examples of percutaneous coronary intervention, which may have "inappropriately shifted numerous patients away from the better treatment option" of coronary artery bypass grafting, and transcatheter aortic valve replacement, which conversely increased the accessibility of treatment while "potentially improving outcomes across the full spectrum of patients with aortic valve disease."

In general, better clinical outcomes for heart procedure recipients will require a "collective learning process" that harnesses data collection and judicious interpretation of statistical analyses, according to Groeneveld.

The study was a retrospective analysis of a national quality improvement registry maintained by the Society for Vascular Surgery. Included were people who underwent carotid procedures in 2015-2019. Those who got transfemoral carotid stenting were excluded.

A total of 86,027 patients at 469 participating VQI centers constituted the study cohort. Although only 8.9% got TCAR, TCAR procedures had jumped from 0.7% of all carotid procedures in 2015 to 17.0% in 2019. Accordingly, adoption of TCAR rose from 15 VQI centers in 2015 to 247 in 2019.

The TCAR group was significantly older on average (73.1 vs 70.6 years) and included fewer women (36.4% vs 39.5%) than the CEA group.

Unobserved confounding was a major potential limitation to the study.

"The primary threat to this study's validity is whether TCAR adoption by a hospital was associated with other concurrent quality-of-care initiatives that were the actual effectors of lower MACE rates. For example, it would not be surprising if TCAR-adopting hospitals were on a different trajectory for surgical quality than hospitals that did not adopt TCAR or did so slowly," according to Groeneveld.

A randomized trial "is likely the only way to dispel any lingering doubts regarding TCAR's comparative effectiveness" against surgery, but the "preponderance of existing observational data and evidence from single-group trials certainly supports TCAR's noninferiority to CEA," the editorialist acknowledged.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Columbo and Groeneveld had no disclosures.

Study coauthors reported ties to the NIH, the Patient-Centered Outcomes Research Institute, and Silk Road Medical.

Primary Source

JAMA Open Network

Source Reference: Columbo JA, et al "Association of adoption of transcarotid artery revascularization with center-level perioperative outcomes" JAMA Network Open 2021; DOI: 10.1001/jamanetworkopen.2020.37885.

Secondary Source

JAMA Open Network

Source Reference: Groeneveld PW "Assessing the outcomes of procedural innovation" JAMA Network Open 2021; DOI: 10.1001/jamanetworkopen.2021.0328.

Occupational Rehabilitation of Patients with Posterior Cerebral Artery Stroke and Anatomical Variations of the Circle of Willis

 I do wonder how you tell the variation in the Circle of Willis and with that  you should be able to tell if it is complete which would tell you if you should just close up blocked carotid arteries rather than stent them or do an endarterectomy with their attendant risks.

Occupational Rehabilitation of Patients with Posterior Cerebral Artery Stroke and Anatomical Variations of the Circle of Willis

Ana-Maria Dumitrescu1, Carmen Valerica Ripa2, Ioan Gotcă3, Irina-Luciana Gurzu4, Gica Avram Lehaci5, Roxana Gabriela Cobzaru6*, Ana-Maria Slanina7 and Anca Sava81 Occupational Health, Rehabilitation Clinical Hospital of Iasi, Romania, PhD student in Anatomy, “GrigoreT.Popa” University of Medicine and Pharmacy, Iasi, Romania2 Department of Microbiology, “GrigoreT.Popa” University of Medicine and Pharmacy, Iasi, Romania3 Clinical Psychologist ,"Dr. Ghelerter" Centre for Mental Health, Iasi, Romania4 Department of Preventive Medicine, “GrigoreT.Popa” University of Medicine and Pharmacy, Iasi, Romania5 "Grigore T.Popa” University of Medicine and Pharmacy, Iasi, Romania6 Department of Microbiology, “GrigoreT.Popa” University of Medicine and Pharmacy, Iasi, Romania7 Department of Family Medicine, “Grigore.T.Popa” University of Medicine and Pharmacy, Iasi, Romania8 Department of Morpho-functional Sciences I, “GrigoreT.Popa” University of Medicine and Pharmacy, Iasi, Romania*Corresponding author: Roxana-Gabriela Cobzaru

Abstract 

Aim and background: 

Considering its great importance in connecting the internal carotid with the vertebrobasilar system, the circle of Willis, a major anastomotic arterial system located at the base of the brain, may present various anatomical configurations that become possible triggers for certain cerebrovascular diseases such as strokes or aneurysms. The present study wants to highlight the importance of clinical findings related to anatomical variations in the circle of Willis that could lay at the basis of the development of posterior cerebral artery stroke (PCA stroke), interconnecting them with occupational rehabilitation of such patients. 

Material and methods: 

We did a research of data published over the last 1 years, from several international medical libraries and databases such as Pubmed, Google Scholar, Cambridge Core, using the following specific keywords combination: “circle of Willis, anatomical variants, posterior cerebral artery stroke, cognitive and language disorder”, and “posterior cerebral artery stroke, occupational therapy, occupational rehabilitation”. A descriptive review was realized describing several types of occupational rehabilitation techniques involved in the case of patients with PCA stroke, considered as a consequence of variations of the circle of Willis. 

Results: 

There are taken into consideration the connections between PCA stroke and specific clinical pathologies represented mainly by cognitive, behavioral, visual and language disorders and the rehabilitation in these cases, which has been little investigated in the specialty literature, with a focus on occupational therapy procedures. 

Conclusion: 

A correct knowledge upon the clinical consequences of anatomical variants of the circle of Willis, in this case, related to PCA stroke would be very useful not only to surgeons, pathologists and anatomists, but also to bedside clinicians. 

Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2

Don't listen to what I have to say, I'm not medically trained.

Instead of doing a carotid endarterectomy with its attendant risks, why not glue it up?

1. Verify that the Circle of Willis is complete. Mine obviously is since one carotid artery is completely blocked and I am having no cognitive issues(arrogance is not one of my issues).

2. Glue the offending artery shut, No risky surgery.

 I guess this is why gluing is not done for brain work:
FDA issues warning about Covidien brain device that has killed nine - Onyx glue

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries. Don't listen to me, but ask your doctor plenty of questions.   Ask for a guarantee of no stroke due to any procedure.  

The latest here:

 

Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2

Show all authors

T Reiff, HH Eckstein, U Mansmann, ...

First Published March 15, 2019 Research Article Find in PubMed 

https://doi.org/10.1177/1747493019833017

Article information

 

Abstract

Background

Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria.

Methods

SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported.

Findings

It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates.

Interpretation

The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.

Keywords Asymptomatic carotid artery stenosis, stroke, primary prevention, carotid endarterectomy, carotid artery stenting, best medical treatment, disease-free survival, epidemiology, prospective study

Introduction

The prevalence of asymptomatic carotid artery stenosis (ACS) >50% is about 1%–2% in the general population^1,2 (US/European or Korean population) and increases with age ≥70 years up to 12.5% in men and 6.9% in women.³ Choice of treatment for patients with ACS still varies considerably among and within countries⁴ and is a matter of debate.^5,6 Two interventional methods such as carotid endarterectomy (CEA) and carotid artery stenting (CAS) compete with best medical treatment (BMT) alone. Guidelines recommending interventional treatment of ACS refer to data of two large randomized trials (Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial 1 (ACST-1)) having compared CEA with conservatively treated control groups more than 15 years ago. ACAS⁷ showed in 1995 an annual risk of ipsilateral stroke in medically treated patients of 2.2% and ACST-1⁸ in 2004 a risk of about 1%.

Since then a decline in stroke risk has been shown^9,10 and an increasing number of retrospective analyses indicates quite low annual stroke rates of about 1% or less under modern intensive BMT.^11–15 On the other hand, publications with low stroke rates of ACS under BMT have been criticized for mixing patients with low-grade (50%–69%) and high-grade (≥70%) stenosis, having small patient numbers, not reporting adherence to BMT, neglecting transient ischemic attack (TIA)/high-risk plaque morphology and consecutive carotid revascularization (therefore preventing stroke), or discriminating insufficiently between ipsilateral and contralateral events.¹⁶ Furthermore, two independent studies showed much higher annual rates of ipsilateral ischemic events in BMT (2.9% in a group of 1121 patients¹⁷ and 2.4% in a group of 794 patients¹⁸). However, in ACST-1, lipid-lowering therapy showed lower rates of long-term stroke in both groups,¹⁹ indicating that stroke risk decreases with intensive medical therapy including statin medication⁹ by plaque stabilization and consecutive reduction of microembolization.^20–23

To establish any benefit of interventional therapies over BMT alone, peri-interventional complications such as stroke, myocardial infarction, and death have to be taken into account. The peri-interventional risk of stroke within the first 30 days in the asymptomatic cohort of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) was reported with 1.4% for CEA and 2.5% for CAS.^24,25 In the Asymptomatic Carotid Trial (ACT-I), it was 1.4% for CEA and 2.8% for CAS.²⁶ Data collected outside randomized controlled trials indicate even higher stroke rates^27,28 Regarding composite endpoints including stroke, death, and myocardial infarction, the peri-interventional risk for patients with ACS partially exceeded 3%: Within the first 30 days from intervention, it amounted to 3.6% for CEA and 3.5% in CAS in CREST^24,25 and to 2.6% for CEA and to 3.3% for CAS in ACT-I.²⁶ Considering the low risk rate under modern pharmacotherapy, interventional therapies have to prove at least non-inferiority to BMT alone.²⁹

In order to attain a higher evidence level for treatment of ACS based upon optimal current treatment options, randomized controlled trials comparing CEA with CAS with a third medical arm were requested.^30–33 Up to now, no data of randomized controlled trials with a BMT arm have been published. The SPACE-2 trial was initiated in 2009 comparing both interventional methods to BMT alone. Due to low recruitment rates, further enrollment had to be stopped prematurely.³⁴ Data from the one-year follow-up examination are presented in this publication.

 

Adverse effects of pre-existing cerebral small vessel disease on cognitive improvement after carotid endarterectomy

 

Don't listen to what I have to say, I'm not medically trained.

Instead of doing a carotid endarterectomy with its attendant risks, why not glue it up?

1. Verify that the Circle of Willis is complete. Mine obviously is since one carotid artery is completely blocked and I am having no cognitive issues(arrogance is not one of my issues).

2. Glue the offending artery shut, No risky surgery.

 I guess this is why gluing is not done for brain work:
FDA issues warning about Covidien brain device that has killed nine - Onyx glue

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries. Don't listen to me, but ask your doctor plenty of questions.   Ask for a guarantee of no stroke due to any procedure.  

The latest here:

Adverse effects of pre-existing cerebral small vessel disease on cognitive improvement after carotid endarterectomy

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Jun Yoshida, Fumio Yamashita, Makoto Sasaki, ...

First Published September 9, 2019 Research Article Find in PubMed 

https://doi.org/10.1177/1747493019874732

Article information

   

Abstract

Background

Although patients with improved cognition after carotid endarterectomy usually exhibit postoperative restoration of cerebral blood flow, less than half of patients with such cerebral blood flow change have postoperatively improved cognition. Cerebral small vessel disease on magnetic resonance imaging is associated with irreversible cognitive impairment.

Aims

The purpose of the present prospective study was to determine whether pre-existing cerebral small vessel disease affects cognitive improvement after carotid endarterectomy.

Methods

Brain MR imaging was performed preoperatively, and the number or grade of each cerebral small vessel disease was determined in 80 patients undergoing carotid endarterectomy for ipsilateral internal carotid artery stenosis (≥70%). The volume of white matter hyperintensities relative to the intracranial volume was also calculated. Brain perfusion single-photon emission computed tomography and neuropsychological testing were performed preoperatively and two months postoperatively. Based on these data, a postoperative increase in cerebral blood flow and postoperative improved cognition, respectively, were determined.

Results

Logistic regression analysis using the sequential backward elimination approach revealed that a postoperative increase in cerebral blood flow (95% confidence interval [CI], 10.74–3730.00; P = 0.0004) and the relative volume of white matter hyperintensities (95% CI, 0.01–0.63; P = 0.0314) were significantly associated with postoperative improved cognition. Although eight of nine patients with postoperative improved cognition exhibited both a relative volume of white matter hyperintensities <0.65% and a postoperative increase in cerebral blood flow, none of patients with a relative volume of white matter hyperintensities ≥0.65% had postoperative improved cognition regardless of any postoperative change in cerebral blood flow.

Conclusion

Pre-existing cerebral white matter hyperintensities on magnetic resonance imaging adversely affect cognitive improvement after carotid endarterectomy.

Keywords Carotid endarterectomy, cognition, cerebral small vessel disease, cerebral white matter hyperintensity, cerebral blood flow

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