The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles

Objectives: During unilateral selective cerebral perfusion (uSCP), with right axillary artery or brachiocephalic trunk cannulation, the brain receives blood only via the right common carotid artery and right vertebral artery (VA). The left hemisphere is perfused mainly through the circle of Willis (CW). However, at least 50% of individuals have some variation in the CW. The aim of the present work was to study the variations in CW and VA that could have an impact on haemodynamics during uSCP.

Methods: From May 2005 to March 2012, a total number of 250 circles obtained via routine dissection for medico-legal reasons were examined. The external diameters of all CW segments and both VAs were measured. From January 2008 to March 2012, a total number of 250 patients subjected to computed tomographic angiography of the CW were also examined.

Results: Nine evident configurations of the CW that could cause hypoperfusion during uSCP were observed. They were subdivided in to seven types, according to location and the number of major vessels at risk of hypoperfusion. Type IA: hypo/aplasia of left posterior communicating artery (PComA), found in 35.6% of cases; Type IB: hypo/aplasia of anterior communicating artery (AComA), found in 2% of cases; Type IIA: hypo/aplasia of both left PComA and AComA, found in 4.8% of cases; Type IIB: hypo/aplasia of precommunicating (P1) segment of left posterior cerebral artery or right VA, found in 9.2% of cases; Type IIIA: hypo/aplasia of precommunicating (A1) segment of right anterior cerebral artery, found in 6% of cases; Type IIIB: hypo/aplasia of both right VA and AComA, found in 0.2% of cases; Type IV: hypo/aplasia of both right A1 and right VA or both right A1 and left P1, found in 0.8% of cases. All types were present in 58.6% of all examined CWs.

Conclusions: Our results show that CW variations are present in a significant number of patients. Our data support the need for extensive preoperative examination and meticulous intraoperative monitoring of cerebral perfusion during uSCP. Finally, our data support the superiority of bilateral SCP over uSCP, because most of the variations reported do not have haemodynamic significance during bilateral SCP.