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Original Investigation
January 2019

Mapping the Supratentorial Cerebral Arterial Territories Using 1160 Large Artery Infarcts

Author Affiliations
  • 1Department of Neurology, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
  • 2Korean Brain MRI Data Center, Dongguk University Ilsan Hospital, Goyang, Korea
  • 3Department of Neurology, Myongji Hospital Hanyang University College of Medicine, Goyang, Korea
  • 4Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston
  • 5Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston
  • 6Department of Neurology, Dongtan Sacred Heart Hospital, Hwaseong, Korea
  • 7Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Korea
  • 8Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
  • 9Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
  • 10Department of Neurology, Yeungnam University Hospital, Daegu, Korea
  • 11Department of Neurology, Dong-A University Hospital, Busan, Korea
  • 12Department of Neurology, Eulji University Hospital, Daejeon, Korea
  • 13Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
  • 14Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
  • 15Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
  • 16Department of Neurology, Seoul Medical Center, Seoul, Korea
  • 17Department of Neurology, Soonchunhyang University Hospital, Bucheon, Korea
  • 18Daium Inc, Busan, Korea
  • 19Department of Computer Science, Inje University, Gimhae, Korea
  • 20Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
JAMA Neurol. 2019;76(1):72-80. doi:10.1001/jamaneurol.2018.2808
Key Points

Question  Are there ways to overcome major weakness of the current vascular territorial maps (high variability, particularly of border zones, and maps that were derived from small sample size data)?

Findings  In this cross-sectional study, statistically rigorous maps were generated to delineate territorial border zones using diffusion-weighted magnetic resonance imaging of 1160 consecutive patients with acute supratentorial infarction owing to atherosclerotic intracranial large artery steno-occlusion. Border zones could be defined using either relative infarct frequencies or the Certainty Index that reflects the likelihood of a voxel being a member of a specific vascular territory.

Meaning  This new topographic brain atlas can be used to objectively define the supratentorial arterial territories and their borders.

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.

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