Correlation Between the Integrity of the Circle of Willis and the Severity of Initial Noncardiac Cerebral Infarction and Clinical Prognosis

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Abstract

The quality of collateral circulation affects the severity and prognosis of stroke patients. The effect of the circle of Willis, which is the primary collateral circulation, on ischemic stroke has attracted significant attention. This study was designed to investigate the effect of different circles of Willis types on stroke severity and prognosis in patients with noncardiac stroke.

A total of 376 patients with noncardiac ischemic stroke, who were treated by the specialty team of cerebrovascular diseases at the First Affiliated Hospital of Sun Yat-sen Hospital, were successively enrolled in this study. The detailed clinical characteristics of the patients were recorded upon admission, including risk factors of vascular disease and National Institutes of Health Stroke Scale (NIHSS) scores. The patients were divided into groups of different circles of Willis types based on magnetic resonance angiography (MRA) that was performed within 3 days of admission—type I: complete circle of Willis; type II: complete anterior half of the circle of Willis and incomplete posterior half of the circle of Willis; type III: incomplete anterior half of the circle of Willis and complete posterior half of the circle of Willis; and type IV: incomplete anterior and posterior halves of the circle of Willis. Patients were re-evaluated for NIHSS scores at discharge and after discharge. The modified Rankin score (mRS) was recorded for 90 days, and stroke recurrence and death after 90 days were also recorded until the end of the study.

The 376 patients were divided into 4 groups based on the MRA—type I group: 92 patients (24.5%); type II group: 215 patients (57.2%); type III group: 12 patients (3.2%), and type IV group: 57 patients (15.2%). NIHSS scores at admission and discharge were significantly lower for the type I group compared with those for the type II and type IV groups ( P < 0.05). NIHSS scores were higher in the groups with an incomplete circle of Willis compared with the group with a complete circle of Willis. A poor recovery rate was highest for the type IV group, whereas a good recovery rate was highest for the type I group. The logistic regression analysis showed that a complete circle of Willis was one of the predictors of suitable recovery (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.554–0.906).

Circle of Willis type was associated with stroke severity and patient prognosis, whereas an incomplete circle of Willis was associated with more severe conditions and a higher 90-day poor diagnosis rate. A complete circle of Willis was an independent predictor of good prognosis.

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Most cited references 25

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Collateral circulation.

David Liebeskind (2003)

The collateral circulation plays a pivotal role in the pathophysiology of cerebral ischemia. Current knowledge of the collateral circulation remains sparse, largely because of prior limitations in methods for evaluation of these diminutive routes of cerebral blood flow. Anatomic descriptions of the collateral circulation often focus on more proximal anastomoses at the circle of Willis, neglecting secondary collateral pathways provided by leptomeningeal vessels. Pathophysiological recruitment of collateral vessels likely depends on the temporal course of numerous compensatory hemodynamic, metabolic, and neural mechanisms. Subsequent endurance of these protective vascular pathways may determine the severity of ischemic injury. Characterization of the collateral circulation with advanced neuroimaging modalities that provide angiographic information and perfusion data may elucidate critical determinants of collateral blood flow. Such information on the status of the collateral circulation may be used to guide therapeutic interventions. Prognostication and risk stratification may also be improved by routine evaluation of collateral blood flow. Contemporary understanding of the collateral circulation may be greatly enhanced through further refinement of neuroimaging modalities that correlate angiographic findings with perfusion status, providing the basis for future therapeutic and prognostic applications.

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Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms.

M J Krabbe-Hartkamp, J van der Grond, F E de Leeuw … (1998)

To establish normal reference values for the presence of the anatomic variants of the circle of Willis and average diameters for its component vessels by using three-dimensional time-of-flight magnetic resonance (MR) angiography and to determine whether age- or sex-related differences exist in the circle's anatomy. One hundred fifty volunteers were grouped according to age: those aged 20-25 years (n = 50) and those aged 60-88 years (n = 100). All subjects underwent three-dimensional time-of-flight MR angiography of the arterial circle at 1.5 T. The anatomic variants of the anterior and posterior parts of the circle were determined separately, the completeness of the entire circle was assessed, and the diameters of all component vessels were measured. On MR angiograms, 111 (74%) subjects demonstrated a complete anterior part of the circle, 78 (52%) demonstrated a complete posterior part of the circle, and 63 (42%) demonstrated an entirely complete circle of Willis (complete anterior and posterior parts of the circle combined). The presence of an entirely complete circle of Willis was slightly higher in younger persons and in women. Most vessel diameters were smaller in women, except for the diameter of the posterior communicating artery. Statistically significant differences were found in vessel diameters between the younger and the older age groups. The authors determined normal reference values for morphologic variants and diameter measurements of the circle of Willis specific to three dimensional time-of-flight MR angiography.

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The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction.

N Pelc, M Marks, Pauline M. Ross … (1994)

After the occlusion of an internal carotid artery the principal source of collateral flow is through the arteries of the circle of Willis, but the size and patency of these arteries are quite variable. Study of the anatomy of the collateral pathways in patients with internal-carotid-artery occlusion with or without infarction in the watershed area of the deep white matter may identify patterns that afford protection from ischemic infarction. Using conventional magnetic resonance imaging and three-dimensional phase-contrast magnetic resonance angiography, we evaluated 29 consecutive patients (32 hemispheres at risk) with angiographically proved occlusion of the internal carotid artery. Four collateral pathways to the occluded vessel were evaluated: the proximal segment of the anterior cerebral artery, the posterior communicating artery, the ophthalmic artery, and leptomeningeal collateral vessels from the posterior cerebral artery. Only features of the ipsilateral posterior communicating artery were related to the risk of watershed infarction. The presence of posterior communicating arteries measuring at least 1 mm in diameter was associated with the absence of watershed infarction (13 hemispheres, no infarcts; P < 0.001). Conversely, there were 4 watershed infarcts in the 6 hemispheres with posterior communicating arteries measuring less than 1 mm in diameter and 10 infarcts in the 13 hemispheres with no detectable flow in the ipsilateral posterior communicating artery. A small (< 1 mm in diameter) or absent ipsilateral posterior communicating artery is a risk factor for ischemic cerebral infarction in patients with internal-carotid-artery occlusion.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: March 2016

Publication date (Electronic): 11 March 2016

Volume: 95

Issue: 10

Electronic Location Identifier: e2892

Affiliations

From the Department of Neurology (HZ, XJ, JL, ST, JZ, YF), First Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department, National Key Discipline, Guangzhou; Department of Neurology (HZ), Shantou Central Hospital, China; and Department of Clinical Research (JS), State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.

Author notes

Correspondence: Yu-Hua Fan, Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department, National Key Discipline, Guangzhou, China (e-mail: fansusan@ 123456126.com ).

Article

Accession ID: 02892

DOI: 10.1097/MD.0000000000002892

PMC ID: 4998866

PubMed ID: 26962785

SO-VID: cd88e678-5667-4ece-bef1-f4950b8c8927

License:

This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0

History

Date received : 9 October 2015

Date revision received : 16 December 2015

Date accepted : 9 January 2016

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