Mapping the Supratentorial Cerebral Arterial Territories Using 1160 Large Artery Infarcts

Abstract

IMPORTANCE Cerebral vascular territories are of key clinical importance in patients with stroke, but available maps are highly variable and based on prior studies with small sample sizes. OBJECTIVE To update and improve the state of knowledge on the supratentorial vascular supply to the brain by using the natural experiment of large artery infarcts and to map out the variable anatomy of the anterior, middle, and posterior cerebral artery (ACA, MCA, and PCA) territories. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, digital maps of supratentorial infarcts were generated using diffusion-weighted magnetic resonance imaging (MRI) of 1160 patients with acute (<1-week) stroke recruited (May 2011 to February 2013) consecutively from 11 Korean stroke centers. All had supratentorial infarction associated with significant stenosis or occlusion of 1 of 3 large supratentorial cerebral arteries but with patent intracranial or extracranial carotid arteries. Data were analyzed between February 2016 and August 2017. MAIN OUTCOMES AND MEASURES The 3 vascular territories were mapped individually by affected vessel, generating 3 data sets for which infarct frequency is defined for each voxel in the data set. By mapping these 3 vascular territories collectively, we generated data sets showing the Certainty Index (CI) to reflect the likelihood of a voxel being a member of a specific vascular territory, calculated as either ACA, MCA, or PCA infarct frequency divided by total infarct frequency in that voxel. RESULTS Of the 1160 patients (mean [SD] age, 67.0 [13.3] years old), 623 were men (53.7%). When the cutoff CI was set as 90%, the volume of the MCA territory (approximately 54% of the supratentorial parenchymal brain volume) was about 4-fold bigger than the volumes of the ACA and PCA territories (each approximately 13%). Quantitative studies showed that the medial frontal gyrus, superior frontal gyrus, and anterior cingulate were involved mostly in ACA infarcts, whereas the middle frontal gyrus and caudate were involved mostly by MCA infarcts. The PCA infarct territory was smaller and narrower than traditionally shown. Border-zone maps could be defined by using either relative infarct frequencies or CI differences. CONCLUSIONS AND RELEVANCE We have generated statistically rigorous maps to delineate territorial border zones and lines. The new topographic brain atlas can be used in clinical care and in research to objectively define the supratentorial arterial territories and their borders.

Computer Modeling of Clot Retrieval—Circle of Willis

“…The collaterals described on computed tomography angiography after LVO are likely to be due to the work of the LA in conjunction with CoW (15,16). The contribution of this secondary collateral system has been observed in maps of infarct territory as relative sparing of the posterior and superior parts of the MCA territory (17,18) and in our earlier work on the computer model of the cerebral circulation (9).…”

Cortical ischaemic patterns in term partial-prolonged hypoxic-ischaemic injury—the inter-arterial watershed demonstrated through atrophy, ulegyria and signal change on delayed MRI scans in children with cerebral palsy

“…The inter-arterial watershed zone of the brain, also known as the inter-territorial border zone [21], is the portion of the brain that lies at the periphery of the supply of the main vessels of the brain, i.e. between the supply of the anterior cerebral artery (ACA), the posterior cerebral artery (PCA) and the middle cerebral artery (MCA).…”

“…1). In contrast, the watershed zone for adults has been outlined by mapping arterial infarctions from many patients [21].…”

Boundary and vulnerability estimation of the internal borderzone using ischemic stroke lesion mapping

“…These regions sustain many essential brain functions which contribute to critical symptomatology of acute stroke patients. They appear to be more frequently injured in the literature 4,8,9,13,[19][20][21][22][23][24] than any other brain areas. Several studies have connected the insula to stroke severity.…”

“…Probabilistic estimates of S, D and IBZ regions are of particular interest when considering the substantial spatial variability of the different vascular fields 24,37 . Lang et al 19 used the spatial distributions reported by van der Zwan et al 37 to study its impact on the topographical infarct characterization.…”