1
|
Intagliata A, Rountree K, Bath J. Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR. Vascular 2023; 31:694-698. [PMID: 35226570 DOI: 10.1177/17085381221080002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). METHODS We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. RESULTS TCAR was undertaken for a 58 year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10 months of follow-up. CONCLUSION This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.
Collapse
Affiliation(s)
| | - Kaitlyn Rountree
- Division of Vascular Surgery, University of Missouri, Columbia, MO, USA
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO, USA
| |
Collapse
|
2
|
Bhardwaj S, Craven BA, Sever JE, Costanzo F, Simon SD, Manning KB. Modeling flow in an in vitro anatomical cerebrovascular model with experimental validation. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1130201. [PMID: 36908295 PMCID: PMC9996037 DOI: 10.3389/fmedt.2023.1130201] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/09/2023] [Indexed: 02/25/2023] Open
Abstract
Acute ischemic stroke (AIS) is a leading cause of mortality that occurs when an embolus becomes lodged in the cerebral vasculature and obstructs blood flow in the brain. The severity of AIS is determined by the location and how extensively emboli become lodged, which are dictated in large part by the cerebral flow and the dynamics of embolus migration which are difficult to measure in vivo in AIS patients. Computational fluid dynamics (CFD) can be used to predict the patient-specific hemodynamics and embolus migration and lodging in the cerebral vasculature to better understand the underlying mechanics of AIS. To be relied upon, however, the computational simulations must be verified and validated. In this study, a realistic in vitro experimental model and a corresponding computational model of the cerebral vasculature are established that can be used to investigate flow and embolus migration and lodging in the brain. First, the in vitro anatomical model is described, including how the flow distribution in the model is tuned to match physiological measurements from the literature. Measurements of pressure and flow rate for both normal and stroke conditions were acquired and corresponding CFD simulations were performed and compared with the experiments to validate the flow predictions. Overall, the CFD simulations were in relatively close agreement with the experiments, to within ±7% of the mean experimental data with many of the CFD predictions within the uncertainty of the experimental measurement. This work provides an in vitro benchmark data set for flow in a realistic cerebrovascular model and is a first step towards validating a computational model of AIS.
Collapse
Affiliation(s)
- Saurabh Bhardwaj
- Department of Biomedical Engineering, Pennsylvania State University, University Park, PA, United States
| | - Brent A. Craven
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Jacob E. Sever
- Department of Biomedical Engineering, Pennsylvania State University, University Park, PA, United States
| | - Francesco Costanzo
- Department of Biomedical Engineering, Pennsylvania State University, University Park, PA, United States
- Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA, United States
| | - Scott D. Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States
| | - Keefe B. Manning
- Department of Biomedical Engineering, Pennsylvania State University, University Park, PA, United States
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, United States
| |
Collapse
|
3
|
Quiroga A, Novi S, Martins G, Bortoletto LF, Avelar W, Guillaumon AT, Li LM, Cendes F, Mesquita RC. Quantification of the Tissue Oxygenation Delay Induced by Breath-Holding in Patients with Carotid Atherosclerosis. Metabolites 2022; 12:metabo12111156. [PMID: 36422296 PMCID: PMC9697605 DOI: 10.3390/metabo12111156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/16/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Carotid artery stenosis (CAS) is a common vascular disease with long-term consequences for the brain. Although CAS is strongly associated with impaired cerebral hemodynamics and neurodegeneration, the mechanisms underlying hemodynamic impairment in the microvasculature remain unknown. In this work, we employed functional near-infrared spectroscopy (fNIRS) to introduce a methodological approach for quantifying the temporal delay of the evoked hemodynamic response. The method was validated during a vasodilatory task (breath-holding) in 50 CAS patients and 20 controls. Our results suggest that the hemodynamic response to breath-holding can be delayed by up to 6 s in the most severe patients, a significant increase from the median 4 s measured for the control group (p = 0.01). In addition, the fraction of brain regions that responded to the task decreased as the CAS severity increased, from a median of 90% in controls to 73% in the most severe CAS group (p = 0.04). The presence of collateral circulation increases the response to breath-holding and decreases the average time delays across the brain, although the number of communicating arteries alone cannot predict these fNIRS-based hemodynamic variables (p > 0.09). Overall, this work proposes a method to quantitatively assess impaired cerebral hemodynamics in CAS patients.
Collapse
Affiliation(s)
- Andrés Quiroga
- “Gleb Wataghin” Institute of Physics, University of Campinas, Campinas 13083-859, SP, Brazil
- Correspondence: (A.Q.); (R.C.M.)
| | - Sergio Novi
- “Gleb Wataghin” Institute of Physics, University of Campinas, Campinas 13083-859, SP, Brazil
| | - Giovani Martins
- “Gleb Wataghin” Institute of Physics, University of Campinas, Campinas 13083-859, SP, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
| | - Luis Felipe Bortoletto
- “Gleb Wataghin” Institute of Physics, University of Campinas, Campinas 13083-859, SP, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
| | - Wagner Avelar
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
- Clinical Hospital, University of Campinas, Campinas 13083-888, SP, Brazil
- Faculty of Medical Sciences, University of Campinas, Campinas 13083-894, SP, Brazil
| | - Ana Terezinha Guillaumon
- Clinical Hospital, University of Campinas, Campinas 13083-888, SP, Brazil
- Faculty of Medical Sciences, University of Campinas, Campinas 13083-894, SP, Brazil
| | - Li Min Li
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
- Clinical Hospital, University of Campinas, Campinas 13083-888, SP, Brazil
- Faculty of Medical Sciences, University of Campinas, Campinas 13083-894, SP, Brazil
| | - Fernando Cendes
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
- Clinical Hospital, University of Campinas, Campinas 13083-888, SP, Brazil
- Faculty of Medical Sciences, University of Campinas, Campinas 13083-894, SP, Brazil
| | - Rickson Coelho Mesquita
- “Gleb Wataghin” Institute of Physics, University of Campinas, Campinas 13083-859, SP, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas 13083-970, SP, Brazil
- Correspondence: (A.Q.); (R.C.M.)
| |
Collapse
|
4
|
Fan JL, Brassard P, Rickards CA, Nogueira RC, Nasr N, McBryde FD, Fisher JP, Tzeng YC. Integrative cerebral blood flow regulation in ischemic stroke. J Cereb Blood Flow Metab 2022; 42:387-403. [PMID: 34259070 PMCID: PMC8985438 DOI: 10.1177/0271678x211032029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Optimizing cerebral perfusion is key to rescuing salvageable ischemic brain tissue. Despite being an important determinant of cerebral perfusion, there are no effective guidelines for blood pressure (BP) management in acute stroke. The control of cerebral blood flow (CBF) involves a myriad of complex pathways which are largely unaccounted for in stroke management. Due to its unique anatomy and physiology, the cerebrovascular circulation is often treated as a stand-alone system rather than an integral component of the cardiovascular system. In order to optimize the strategies for BP management in acute ischemic stroke, a critical reappraisal of the mechanisms involved in CBF control is needed. In this review, we highlight the important role of collateral circulation and re-examine the pathophysiology of CBF control, namely the determinants of cerebral perfusion pressure gradient and resistance, in the context of stroke. Finally, we summarize the state of our knowledge regarding cardiovascular and cerebrovascular interaction and explore some potential avenues for future research in ischemic stroke.
Collapse
Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, Canada.,Research Center of the Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Fiona D McBryde
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - James P Fisher
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.,Department of Surgery & Anaesthesia, Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| |
Collapse
|
5
|
Wang J, Guo L, Holdefer RN, Zhang Y, Liu Q, Gai Q, Zhang W. Intraoperative Neurophysiology and Transcranial Doppler for Detection of Cerebral Ischemia and Hyperperfusion During Carotid Endarterectomy. World Neurosurg 2021; 154:e245-e253. [PMID: 34271149 DOI: 10.1016/j.wneu.2021.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate and compare efficacy of intraoperative neurophysiological monitoring (IONM) and intraoperative transcranial Doppler (TCD) techniques for identification of hypoperfusion during carotid artery clamp and hyperperfusion after release of occlusion during carotid endarterectomy. METHODS This was a retrospective, consecutive case series of 152 patients undergoing carotid endarterectomy between June 2018 and March 2020. Somatosensory evoked potentials, motor evoked potentials, electroencephalogram, and TCD were obtained. RESULTS Three patient cohorts were observed after clamping the carotid artery: A, in 132 of 152 patients (87%), TCD blood flow velocity decreased by <50% and there were no changes in IONM; B, in 5 of 152 (3%) patients, TCD blood flow rate was reduced 50%-100% with no changes in IONM; C, in 15 patients (10%), blood flow velocity was reduced by 50%-100% and all IONM modalities met warning criteria. With increased blood pressure, IONM and blood flow velocities improved to less than warning criteria in 8 of 15 patients. In 6 of the 7 remaining patients, IONM modalities recovered to baseline immediately after clamps were removed from the carotid artery. The 1 patient with persistent motor evoked potential deterioration experienced postoperative proximal muscle weakness, which recovered 48 hours later. In 22 patients, TCD detected hyperperfusion at the moment of clamp release. CONCLUSIONS TCD blood flow velocity is correlated with motor evoked potential and somatosensory evoked potential amplitude changes after clamping. After declamping, TCD can detect hyperperfusion and help regulate blood pressure to prevent hyperperfusion.
Collapse
Affiliation(s)
- Jinfeng Wang
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Lanjun Guo
- Surgical Neuromonitoring Service, University of California San Francisco, San Francisco, California, USA.
| | - Robert N Holdefer
- Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Yansheng Zhang
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Qin Liu
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Qing Gai
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Wengao Zhang
- Department of Neurosurgery, Cangzhou Central Hospital, Cangzhou, China
| |
Collapse
|
6
|
Zarrinkoob L, Wåhlin A, Ambarki K, Birgander R, Eklund A, Malm J. Blood Flow Lateralization and Collateral Compensatory Mechanisms in Patients With Carotid Artery Stenosis. Stroke 2020; 50:1081-1088. [PMID: 30943887 PMCID: PMC6485302 DOI: 10.1161/strokeaha.119.024757] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background and Purpose- Four-dimensional phase-contrast magnetic resonance imaging enables quantification of blood flow rate (BFR; mL/min) in multiple cerebral arteries simultaneously, making it a promising technique for hemodynamic investigation in patients with stroke. The aim of this study was to quantify the hemodynamic disturbance and the compensatory pattern of collateral flow in patients with symptomatic carotid stenosis. Methods- Thirty-eight patients (mean, 72 years; 27 men) with symptomatic carotid stenosis (≥50%) or occlusion were investigated using 4-dimensional phase-contrast magnetic resonance imaging. For each patient, BFR was measured in 19 arteries/locations. The ipsilateral side to the symptomatic carotid stenosis was compared with the contralateral side. Results- Internal carotid artery BFR was lower on the ipsilateral side (134±87 versus 261±95 mL/min; P<0.001). BFR in anterior cerebral artery (A1 segment) was lower on ipsilateral side (35±58 versus 119±72 mL/min; P<0.001). Anterior cerebral artery territory bilaterally was primarily supplied by contralateral internal carotid artery. The ipsilateral internal carotid artery mainly supplied the ipsilateral middle cerebral artery (MCA) territory. MCA was also supplied by a reversed BFR found in the ophthalmic and the posterior communicating artery routes on the ipsilateral side (-5±28 versus 10±28 mL/min, P=0.001, and -2±12 versus 6±6 mL/min, P=0.03, respectively). Despite these compensations, BFR in MCA was lower on the ipsilateral side, and this laterality was more pronounced in patients with severe carotid stenosis (≥70%). Although comparing ipsilateral MCA BFR between stenosis groups (<70% and ≥70%), there was no difference ( P=0.95). Conclusions- With a novel approach using 4-dimensional phase-contrast magnetic resonance imaging, we could simultaneously quantify and rank the importance of collateral routes in patients with carotid stenosis. An important observation was that contralateral internal carotid artery mainly secured the bilateral anterior cerebral artery territory. Because of the collateral recruitment, compromised BFR in MCA is not necessarily related to the degree of carotid stenosis. These findings highlight the importance of simultaneous investigation of the hemodynamics of the entire cerebral arterial tree.
Collapse
Affiliation(s)
- Laleh Zarrinkoob
- From the Department of Pharmacology and Clinical Neuroscience, Umeå, Sweden (L.Z., J.M.).,Department of Surgical and Perioperative Sciences, Umeå, Sweden (L.Z.)
| | - Anders Wåhlin
- Department of Radiation Science, Umeå, Sweden (A.W., K.A., R.B., A.E.).,Centre for Biomedical Engineering and Physics, Umeå, Sweden (A.W., K.A., A.E.).,Umeå Center for Functional Brain Imaging, Sweden (A.W., A.E.)
| | - Khalid Ambarki
- Department of Radiation Science, Umeå, Sweden (A.W., K.A., R.B., A.E.).,Centre for Biomedical Engineering and Physics, Umeå, Sweden (A.W., K.A., A.E.)
| | - Richard Birgander
- Department of Radiation Science, Umeå, Sweden (A.W., K.A., R.B., A.E.)
| | - Anders Eklund
- Department of Radiation Science, Umeå, Sweden (A.W., K.A., R.B., A.E.).,Centre for Biomedical Engineering and Physics, Umeå, Sweden (A.W., K.A., A.E.).,Umeå Center for Functional Brain Imaging, Sweden (A.W., A.E.)
| | - Jan Malm
- From the Department of Pharmacology and Clinical Neuroscience, Umeå, Sweden (L.Z., J.M.)
| |
Collapse
|
7
|
Nas ÖF, Demir AB, Bakar M, Özkaya G, Kaçar E, Hakyemez B. Impact of Stent-Assisted Recanalization of Carotid Artery Stenosis on Brain Volume Changes. JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2016. [DOI: 10.5799/jcei.328500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
8
|
Roach BA, Donahue MJ, Davis LT, Faraco CC, Arteaga D, Chen SC, Ladner TR, Scott AO, Strother MK. Interrogating the Functional Correlates of Collateralization in Patients with Intracranial Stenosis Using Multimodal Hemodynamic Imaging. AJNR Am J Neuroradiol 2016; 37:1132-8. [PMID: 27056428 DOI: 10.3174/ajnr.a4758] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 11/28/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE The importance of collateralization for maintaining adequate cerebral perfusion is increasingly recognized. However, measuring collateral flow noninvasively has proved elusive. The aim of this study was to assess correlations among baseline perfusion and arterial transit time artifacts, cerebrovascular reactivity, and the presence of collateral vessels on digital subtraction angiography. MATERIALS AND METHODS The relationship between the presence of collateral vessels on arterial spin-labeling MR imaging and DSA was compared with blood oxygen level-dependent MR imaging measures of hypercapnic cerebrovascular reactivity in patients with symptomatic intracranial stenosis (n = 18). DSA maps were reviewed by a neuroradiologist and assigned the following scores: 1, collaterals to the periphery of the ischemic site; 2, complete irrigation of the ischemic bed via collateral flow; and 3, normal antegrade flow. Arterial spin-labeling maps were scored according to the following: 0, low signal; 1, moderate signal with arterial transit artifacts; 2, high signal with arterial transit artifacts; and 3, normal signal. RESULTS In regions with normal-to-high signal on arterial spin-labeling, collateral vessel presence on DSA strongly correlated with declines in cerebrovascular reactivity (as measured on blood oxygen level-dependent MR imaging, P < .001), most notably in patients with nonatherosclerotic disease. There was a trend toward increasing cerebrovascular reactivity with increases in the degree of collateralization on DSA (P = .082). CONCLUSIONS Collateral vessels may have fundamentally different vasoreactivity properties from healthy vessels, a finding that is observed most prominently in nonatherosclerotic disease and, to a lesser extent, in atherosclerotic disease.
Collapse
Affiliation(s)
- B A Roach
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - M J Donahue
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.) Neurology (M.J.D.) Psychiatry (M.J.D.)
| | - L T Davis
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - C C Faraco
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - D Arteaga
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - S-C Chen
- the Vanderbilt Center for Quantitative Sciences (S.-C.C.), Vanderbilt Medical Center, Nashville, Tennessee
| | - T R Ladner
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - A O Scott
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| | - M K Strother
- From the Departments of Radiology and Radiological Sciences (B.A.R., M.J.D., L.T.D., C.C.F., D.A., T.R.L., A.O.S., M.K.S.)
| |
Collapse
|
9
|
Chin SC, Chang CH, Chang TY, Huang KL, Wu TC, Lin JR, Chang YJ, Lee TH. Brain computed tomography perfusion may help to detect hemodynamic reconstitution and predict intracerebral hemorrhage after carotid stenting. J Vasc Surg 2012; 56:1281-90. [DOI: 10.1016/j.jvs.2012.04.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/16/2012] [Accepted: 04/17/2012] [Indexed: 10/28/2022]
|
10
|
Chang CH, Chang TY, Chang YJ, Huang KL, Chin SC, Ryu SJ, Yang TC, Lee TH. The role of perfusion computed tomography in the prediction of cerebral hyperperfusion syndrome. PLoS One 2011; 6:e19886. [PMID: 21625479 PMCID: PMC3098834 DOI: 10.1371/journal.pone.0019886] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 04/20/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hyperperfusion syndrome (HPS) following carotid angioplasty with stenting (CAS) is associated with significant morbidity and mortality. At present, there are no reliable parameters to predict HPS. The aim of this study was to clarify whether perfusion computed tomography (CT) is a feasible and reliable tool in predicting HPS after CAS. METHODOLOGY/PRINCIPAL FINDINGS We performed a retrospective case-control study of 54 patients (11 HPS patients and 43 non-HPS) with unilateral severe stenosis of the carotid artery who underwent CAS. We compared the prevalence of vascular risk factors and perfusion CT parameters including regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and time to peak (TTP) within seven days prior to CAS. Demographic information, risk factors for atherosclerosis, and perfusion CT parameters were evaluated by multivariable logistic regression analysis. The rCBV index was calculated as [(ipsilateral rCBV - contralateral rCBV)/contralateral rCBV], and indices of rCBF and TTP were similarly calculated. We found that eleven patients had HPS, including five with intracranial hemorrhages (ICHs) of whom three died. After a comparison with non-HPS control subjects, independent predictors of HPS included the severity of ipsilateral carotid artery stenosis, 3-hour mean systolic blood pressure (3 h SBP) after CAS, pre-stenting rCBV index >0.15 and TTP index >0.22. CONCLUSIONS/SIGNIFICANCE The combination of severe ipsilateral carotid stenosis, 3 h SBP after CAS, rCBV index and TTP index provides a potential screening tool for predicting HPS in patients with unilateral carotid stenosis receiving CAS. In addition, adequate management of post-stenting blood pressure is the most important treatable factor in preventing HPS in these high risk patients.
Collapse
Affiliation(s)
- Chien Hung Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Ting Yu Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Yeu Jhy Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Kuo Lun Huang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Shy Chyi Chin
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Shan Jin Ryu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Tao Chieh Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
| | - Tsong Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Kueishan, Taoyuan, Taiwan
- * E-mail:
| |
Collapse
|
11
|
Abstract
Haemodynamic stroke is a type of ischaemic stroke that is caused by hypoperfusion rather than by embolism or local vasculopathy. It can be caused by systemic diseases such as heart failure or hypotension, but also by severe obstruction of the carotid or vertebral arteries. Patients with haemodynamic stroke or transient ischaemic attack might show specific clinical features that distinguish them from patients with embolism or local small-vessel disease. Ancillary investigations of cerebral perfusion can show whether blood flow to the brain is compromised and provide important prognostic information. Management of patients who have hypoperfusion as the major cause of ischaemic stroke or as a contributing factor is hampered by the lack of clinical trials. Treatment aimed at increasing cerebral blood flow might be considered in selected patients on the basis of information from case series. Further research is needed to define criteria for the diagnosis of haemodynamic stroke and to investigate treatment options in controlled studies.
Collapse
Affiliation(s)
- Catharina J M Klijn
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, Netherlands.
| | | |
Collapse
|
12
|
Clinical implication and prognosis of normal baseline cerebral blood flow with impaired vascular reserve in patients with major cerebral artery occlusive disease. Ann Nucl Med 2010; 24:371-7. [DOI: 10.1007/s12149-010-0367-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
|
13
|
Ursino M, Giannessi M. A Model of Cerebrovascular Reactivity Including the Circle of Willis and Cortical Anastomoses. Ann Biomed Eng 2010; 38:955-74. [DOI: 10.1007/s10439-010-9923-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 01/07/2010] [Indexed: 01/26/2023]
|
14
|
Przybylski GJ, Yonas H, Smith HA. Reduced stroke risk in patients with compromised cerebral blood flow reactivity treated with superficial temporal artery to distal middle cerebral artery bypass surgery. J Stroke Cerebrovasc Dis 2009; 7:302-9. [PMID: 17895105 DOI: 10.1016/s1052-3057(98)80047-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/1997] [Accepted: 04/22/1998] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED Extracranial-to-intracranial (EC-IC) bypass surgery for the prevention of stroke in patients with symptomatic carotid artery occlusion has nearly ended after a randomized trial showed no benefit of the procedure. Although an EC-IC bypass might benefit patients with compromised cerebrovascular hemodynamics, the randomized trial did not differentiate patients with hemodynamic from embolic etiologies. However, subsequent investigators have identified a subgroup of patients at increased stroke risk from hemodynamic compromise. METHODS We examined the subsequent stroke rate of 42 patients with symptomatic carotid occlusion at high risk for stroke identified as having a baseline cerebral blood flow (CBF)<45 mL/100 g/min and a >5% CBF reduction in one vascular territory after a vasodilatory challenge from 1 g of intravenous acetazolamide on stable xenon-computed tomography (CT) CBF imaging. RESULTS Thirty patients (group 1) treated medically were a subgroup with carotid occlusion from our long-term natural history study. During a median follow-up of 12 months, 9 patients (30%) had a new stroke within a median of 5 months. Twelve patients (group 2) had recurrent, disabling cerebral ischemic symptoms, with 8 progressing to mild fixed neurological deficits from deep white matter infarction identified on CT. All were treated with superficial temporal artery to distal middle cerebral artery (STA-MCA) bypass with restoration of cerebrovascular reserve postoperatively; none had a stroke during the 18-month minimum follow-up (P=.041). Perioperative morbidity included subendocardial infarction in one and a small, asymptomatic left frontal hemorrhage in another patient. Early postoperative and delayed xenon/CT CBF studies obtained a median of 5 months postoperatively showed maintenance of cerebrovascular reserve. CONCLUSION STA-MCA bypass surgery can restore cerebrovascular reserve in high-risk patients with symptomatic internal carotid artery occlusion. This was achieved with minimal perioperative complications, resulting in a subsequent reduction of stroke frequency. We suggest that the efficacy of STA-MCA bypass surgery for symptomatic carotid occlusion be re-examined prospectively using hemodynamic selection criteria.
Collapse
Affiliation(s)
- G J Przybylski
- Department of Neurological Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | |
Collapse
|
15
|
Expression of a latent ophthalmic artery collateral circulation after extracranial–intracranial bypass. Clin Neurol Neurosurg 2009; 111:274-7. [DOI: 10.1016/j.clineuro.2008.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Revised: 09/03/2008] [Accepted: 09/04/2008] [Indexed: 11/21/2022]
|
16
|
Garrett MC, Komotar RJ, Starke RM, Merkow MB, Otten ML, Connolly ES. Radiographic and clinical predictors of hemodynamic insufficiency in patients with athero-occlusive disease. J Stroke Cerebrovasc Dis 2009; 17:340-3. [PMID: 18984424 DOI: 10.1016/j.jstrokecerebrovasdis.2008.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 03/04/2008] [Accepted: 04/21/2008] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Recent studies have shown that patients with increased oxygen extraction fraction (OEF) as measured by positron emission tomography (PET) have a substantially increased risk of stroke as a result of hemodynamic insufficiency. These patients appear to be ideal candidates for extracranial (EC)-intracranial (IC) bypass. The feasibility of this screening protocol, however, is controversial given PET's limited availability and high expense. A better understanding of the clinical factors that identify patients with potential hemodynamic insufficiency would streamline screening and improve cost-efficiency. METHODS We performed a MEDLINE (1985-2007) database search for studies identifying clinical and radiographic predictors of hemodynamic failure and increased OEF on PET. We used the following key words, singly and in combination: "EC-IC bypass," "hemodynamic failure," and "misery perfusion." Additional studies were identified manually by scrutinizing references from manuscripts, major neurosurgical journals and texts, and personal files. Each study was reviewed for methodology, clinical criteria, and correlation with subsequent PET findings and stroke rates. A consensus was determined regarding the predictive value of each marker. RESULTS Our literature search revealed 5 clinical and radiographic markers that have been used to identify patients with hemodynamic failure: orthostatic limb shaking, blurry vision on exposure to heat, leptomeningeal and ophthalmic collateral circulation on angiography, watershed infarction, and impaired vasodilatory response to acetazolamide. Orthostatic limb shaking is a rare finding but is predictive of hemodynamic failure and is associated with increased stroke risk. Blurry vision on exposure to heat is not predictive of increased stroke risk. Leptomeningeal and ophthalmic collateral circulation is a sensitive but not specific marker. Watershed infarction is highly sensitive and impaired vasodilatory response to acetazolamide is associated with increased OEF but may not be interchangeable. CONCLUSIONS Orthostatic limb shaking, watershed infarction, collateral circulation, and impaired vasoreactivity to acetazolamide in patients with athero-occlusive disease may predict hemodynamic failure, increased OEF on PET, and high stroke rates. Recognition of these predictive markers may improve patient selection for surgical intervention, as such individuals appear to benefit from EC-IC bypass.
Collapse
Affiliation(s)
- Matthew C Garrett
- Department of Neurosurgery, Columbia University, New York, New York 10032, USA
| | | | | | | | | | | |
Collapse
|
17
|
KUNZ ALEXANDER, IADECOLA COSTANTINO. Cerebral vascular dysregulation in the ischemic brain. HANDBOOK OF CLINICAL NEUROLOGY 2009; 92:283-305. [PMID: 18790280 PMCID: PMC3982865 DOI: 10.1016/s0072-9752(08)01914-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
18
|
Bokkers RPH, van Laar PJ, van de Ven KCC, Kapelle LJ, Klijn CJM, Hendrikse J. Arterial spin-labeling MR imaging measurements of timing parameters in patients with a carotid artery occlusion. AJNR Am J Neuroradiol 2008; 29:1698-703. [PMID: 18701581 DOI: 10.3174/ajnr.a1232] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Arterial spin-labeling (ASL) with image acquisition at multiple delay times can be exploited in perfusion MR imaging to visualize and quantify the temporal dynamics of arterial blood inflow. In this study, we investigated the consequences of an internal carotid artery (ICA) occlusion and collateral blood flow on regional timing parameters. MATERIALS AND METHODS Seventeen functionally independent patients with a symptomatic ICA occlusion (15 men, 2 women; mean age, 57 years) and 29 sex- and age-matched control subjects were investigated. ASL at multiple delay times was used to quantify regional cerebral blood flow (CBF) and the transit and trailing edge times (arterial timing parameters) reflecting, respectively, the beginning and end of the labeled bolus. Intra-arterial digital subtraction angiography and MR angiography were used to grade collaterals. RESULTS In the hemisphere ipsilateral to the ICA occlusion, the CBF was lower in the anterior frontal (31 +/- 4 versus 47 +/- 3 mL/min/100 g, P < .01), posterior frontal (39 +/- 4 versus 55 +/- 2 mL/min/100 g, P < .01), and frontal parietal region (49 +/- 3 versus 61 +/- 3 mL/min/100 g, P = .04) than that in control subjects. The trailing edge of the frontal-parietal region was longer in the hemisphere ipsilateral to the ICA occlusion compared with that in control subjects (2225 +/- 167 versus 1593 +/- 35 ms, P < .01). In patients with leptomeningeal collateral flow, the trailing edge was longer in the anterior frontal region (2436 +/- 275 versus 1648 +/- 201 ms, P = .03) and shorter in the occipital region (1815 +/- 128 versus 2388 +/- 203 ms, P = .04), compared with patients without leptomeningeal collaterals. CONCLUSION Regional assessment of timing parameters with ASL may provide valuable information on the cerebral hemodynamic status. In patients with leptomeningeal collaterals, the most impaired territory was found in the frontal lobe.
Collapse
Affiliation(s)
- R P H Bokkers
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | | | | | | | | |
Collapse
|
19
|
Waaijer A, van Leeuwen MS, van der Worp HB, Verhagen HJM, Mali WPTM, Velthuis BK. Anatomic Variations in the Circle of Willis in Patients with Symptomatic Carotid Artery Stenosis Assessed with Multidetector Row CT Angiography. Cerebrovasc Dis 2006; 23:267-74. [PMID: 17199084 DOI: 10.1159/000098326] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 09/01/2006] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To assess the presence of anterior and posterior collateral pathways in the circle of Willis in patients with symptomatic carotid artery stenosis (SCAS) and to compare this to patients without carotid artery stenosis. MATERIALS AND METHODS Multislice CT angiography was performed in 91 patients and 91 control subjects. Using consensus reading, 2 observers evaluated the presence and diameter of the anterior communicating artery (AcomA), the A1 segments of the anterior cerebral arteries, the posterior communicating arteries (PcomA) and the P1 segments of the posterior cerebral arteries. Anterior or posterior pathways were assumed to be present if the diameter of continuous arterial segments was >1 mm; both A1 segments and AcomA anterior, and ipsilateral P1 segment and PcomA posterior. Comparison between patients and controls was performed using the chi(2) test. RESULTS In the patients we found significantly more hypoplastic (<1 mm) or invisible A1 segments (16 and 14 vs. 4 and 1, respectively, p < 0.01). The AcomA was invisible in 4 patients versus 1 control. An isolated compromised anterior pathway and a combined compromised anterior and posterior pathway occurred more frequently in the patients as compared to the controls; 9 versus 1% (p < 0.01) and 26 versus 4% (p < 0.01). CONCLUSION A compromised anterior collateral pathway, usually combined with a compromised posterior pathway, occurs more frequently in patients with SCAS as compared to controls, which suggests a relation between symptomatic carotid stenosis and an incomplete circle of Willis.
Collapse
Affiliation(s)
- A Waaijer
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | | | | | | | | |
Collapse
|
20
|
de Boorder MJ, van der Grond J, van Dongen AJ, Klijn CJM, Jaap Kappelle L, Van Rijk PP, Hendrikse J. Spect measurements of regional cerebral perfusion and carbondioxide reactivity: correlation with cerebral collaterals in internal carotid artery occlusive disease. J Neurol 2006; 253:1285-91. [PMID: 17063318 DOI: 10.1007/s00415-006-0192-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2005] [Accepted: 12/13/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of the present study was to assess the regional variation in cerebral perfusion, vasomotor reactivity (VMR) and the role of cerebral collaterals in patients with symptomatic internal carotid artery (ICA). METHODS Seventeen functionally independent patients (60+/-9 years, mean+/-SD) with a unilateral symptomatic internal carotid artery occlusion and a <30% contralateral ICA stenosis were investigated. (99 m) Tc-hexamethyl propyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) was performed to study cerebral blood flow in rest and during a CO(2) challenge in the cerebellum, temporal lobe, occipital lobe, basal ganglia, frontal lobe and parietal lobe. Time of flight and phase contrast MRA were used to study collateral flow via circle of Willis. RESULTS In rest, cerebral perfusion on the side ipsilateral to the ICA occlusion was decreased compared with the contralateral side in the basal ganglia (p<0.05), frontal lobe (p<0.01) and parietal lobe (p<0.01). During a CO(2) challenge only the ipsilateral frontal lobe demonstrated a perfusion decrease compared with the contralateral frontal lobe (p<0.05). Furthermore, in patients without collateral flow via the anterior circle of Willis the perfusion of the ipsilateral frontal lobe was significantly decreased (p<0.01) during the CO(2) challenge and crossed cerebellar diaschisis with a decreased perfusion on the contralateral cerebellar hemisphere was detected (p<0.05). No cerebral blood flow (CBF) differences were found for present/absent collateral flow via the posterior communicating artery. CONCLUSION Regional assessment of cerebral perfusion and VMR with SPECT demonstrated the heterogeneity of cerebral hemodynamics and the importance of collateral flow via the anterior circle of Willis.
Collapse
|
21
|
Okazawa H, Tsuchida T, Kobayashi M, Arai Y, Pagani M, Isozaki M, Yonekura Y. Can the detection of misery perfusion in chronic cerebrovascular disease be based on reductions in baseline CBF and vasoreactivity? Eur J Nucl Med Mol Imaging 2006; 34:121-9. [PMID: 16896662 DOI: 10.1007/s00259-006-0192-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 05/02/2006] [Accepted: 06/09/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to clarify whether decreases in baseline regional cerebral blood flow (rCBF) and in residual cerebral vasoreactivity (CVR), assessed by the acetazolamide (ACZ) challenge, can detect misery perfusion in patients with chronic cerebrovascular disease (CVD). METHODS Oxygen extraction fraction (OEF) and other haemodynamic parameters were measured in 115 patients (64+/-9 years old) with unilateral cerebrovascular steno-occlusive disease (>70% stenosis) using (15)O-gas and water PET. A significant elevation of OEF, by greater than the mean+2SD compared with healthy controls, was defined as misery perfusion. CBF, CVR determined by percent change in CBF after ACZ administration, OEF and other haemodynamic parameters in the territories of the bilateral middle cerebral arteries were analysed. Diagnostic accuracy for the detection of misery perfusion using the criteria determined by baseline CBF and CVR was evaluated in all patients and in only those patients with occlusive lesions. RESULTS Ten of 24 patients with misery perfusion showed a significant reduction in CVR. Using criteria determined by significant decreases in CVR and baseline CBF, misery perfusion was detected with a sensitivity of 42% and a specificity of 95% in all patients. In patients with occlusive lesions (n=50), sensitivity was higher but specificity was slightly lower. The diagnostic accuracy of the threshold determined by baseline CBF alone was similar in all patients and in only those patients with occlusive lesions, and was higher than that achieved using the asymmetry index of OEF. CONCLUSION Reductions in CVR and baseline CBF in the ACZ challenge for CVD would detect misery perfusion with high specificity. Reduction in baseline rCBF is more accurate than reduction in CVR alone for the detection of misery perfusion.
Collapse
Affiliation(s)
- Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, 23-3 Shimoaizuki, Matcuoka-cho, Fukui, 910-1193, Japan.
| | | | | | | | | | | | | |
Collapse
|
22
|
Hendrikse J, van Osch MJP, Rutgers DR, Bakker CJG, Kappelle LJ, Golay X, van der Grond J. Internal Carotid Artery Occlusion Assessed at Pulsed Arterial Spin-labeling Perfusion MR Imaging at Multiple Delay Times. Radiology 2004; 233:899-904. [PMID: 15486211 DOI: 10.1148/radiol.2333031276] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Magnetic resonance (MR) imaging with pulsed arterial spin labeling (ASL) was performed at six different inversion times in nine patients with internal carotid artery (ICA) occlusion and in 11 control subjects. The hospital's commission on scientific research on human subjects approved the study protocol, and all study subjects gave informed consent. Cerebral blood flow (CBF) in the middle cerebral artery territories was calculated from the combined signal intensities measured with ASL at the multiple inversion times. In the patients with ICA occlusion, mean CBF values were decreased in the gray matter of the hemisphere ipsilateral to the occlusion, as compared with values in the gray matter of the contralateral hemisphere (P < .05) and with values in the gray matter of the control subjects (P < .05). Quantification of CBF with ASL at multiple inversion times can compensate for the blood transit delays in patients with ICA occlusion.
Collapse
Affiliation(s)
- Jeroen Hendrikse
- Department of Radiology (Hp E 01.132), University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
| | | | | | | | | | | | | |
Collapse
|
23
|
Yamauchi H, Kudoh T, Sugimoto K, Takahashi M, Kishibe Y, Okazawa H. Pattern of collaterals, type of infarcts, and haemodynamic impairment in carotid artery occlusion. J Neurol Neurosurg Psychiatry 2004; 75:1697-701. [PMID: 15548485 PMCID: PMC1738852 DOI: 10.1136/jnnp.2004.040261] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In internal carotid artery (ICA) occlusion, increased oxygen extraction fraction (OEF) indicates inadequate collateral blood flow distal to the occlusion, which may be caused by poor function of collateral pathways. In ICA occlusion, the circle of Willis may be the major collateral pathway, while the collaterals through the ophthalmic artery and leptomeningeal vessels may be recruited when collateral flow through the circle of Willis is inadequate. Conversely, ischaemic lesions may affect the adequacy of collateral blood flow by reducing the metabolic demand of the brain. OBJECTIVE To determine whether the pattern of collateral pathways and the type of infarcts are independent predictors of OEF in ICA occlusion. METHODS We studied 42 patients with symptomatic ICA occlusion. The presence of Willisian, ophthalmic, or leptomeningeal collaterals was evaluated by conventional four vessel angiography. The infarcts on magnetic resonance imaging were categorised as territorial, border zone (external or internal), striatocapsular, lacunar, and other white matter infarcts. The value of OEF in the affected hemisphere was measured with positron emission tomography as an index of haemodynamic impairment. RESULTS Using multivariate analysis, the presence of any ophthalmic or leptomeningeal collaterals and the absence of striatocapsular infarcts were significant and independent predictors of increased OEF. CONCLUSIONS In patients with symptomatic ICA occlusion, the supply of collateral flow, which is affected by the pattern of collateral pathways, and the metabolic demand of the brain, which is affected by the type of infarct, may be important factors determining the severity of haemodynamic impairment.
Collapse
Affiliation(s)
- H Yamauchi
- Research Institute, Shiga Medical Center, Moriyama City, Shiga, Japan.
| | | | | | | | | | | |
Collapse
|
24
|
Risks of Stroke and Current Indications for Cerebral Revascularization in Patients with Carotid Occlusion. Neurosurg Clin N Am 2001. [DOI: 10.1016/s1042-3680(18)30037-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
25
|
Vernieri F, Pasqualetti P, Diomedi M, Giacomini P, Rossini PM, Caltagirone C, Silvestrini M. Cerebral hemodynamics in patients with carotid artery occlusion and contralateral moderate or severe internal carotid artery stenosis. J Neurosurg 2001; 94:559-64. [PMID: 11302653 DOI: 10.3171/jns.2001.94.4.0559] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to evaluate cerebral hemodynamics in patients suffering from occlusion of the carotid artery (CA) and contralateral CA stenosis. METHODS Using transcranial Doppler ultrasonography, the cerebrovascular reactivity to hypercapnia in the middle cerebral arteries was evaluated by calculating the breath-holding index (BHI) of 69 symptomatic patients suffering from internal CA (ICA) occlusion and moderate or severe contralateral ICA stenosis. To evaluate which variables influenced BHIs ipsilateral to the site of ICA occlusion, a multiple stepwise linear regression analysis was performed that included the following factors: patient age, percentage of contralateral ICA stenosis, contralateral BHI, number of collateral pathways, and presence of hypertension, diabetes, smoking, and hyperlipidemia. An analysis of variance was conducted to evaluate the impact of the type of collateral vessels on the BHI. A regression analysis showed that the BHI ipsilateral to the site of ICA occlusion could be accounted for by the contralateral BHI (which was entered at the first step of the analysis, p < 0.001) and by the number of collateral pathways (which was entered at the second step, p = 0.033). Neither the degree of contralateral ICA stenosis nor the other variables could be added to improve the model. The analysis demonstrated that the absence of collateral pathways and the presence of the anterior communicating artery (ACoA) alone were associated with lower BHI values than those found in the presence of two or three collateral vessels, regardless of the presence of an anterior collateral pathway. CONCLUSIONS On the basis of these data one can infer that the cerebral hemodynamic status of patients with occlusive disease of the CA is influenced by individual anatomical and functional characteristics. Because improvement in contralateral hemodynamics after surgical correction of an ICA stenosis can only be expected in the presence of an ACoA, the planning of strategies for influencing cerebral blood flow distal to an ICA occlusion and, in particular, the consideration of a contralateral carotid endarterectomy, should be preceded by a careful evaluation of the intracranial hemodynamic adaptive status of the patient. Particular attention should be paid to cerebrovascular reactivity and the number and type of collateral vessels that are present.
Collapse
Affiliation(s)
- F Vernieri
- Department of Neuroscience, Fatebenefratelli Hospital, Rome, Italy
| | | | | | | | | | | | | |
Collapse
|
26
|
Nagata K, Kondoh Y, Atchison R, Sato M, Satoh Y, Watahiki Y, Hirata Y, Yokoyama E. Vascular and metabolic reserve in Alzheimer's disease. Neurobiol Aging 2000; 21:301-7. [PMID: 10867215 DOI: 10.1016/s0197-4580(00)00130-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Vascular and metabolic reserve were analyzed in probable Alzheimer's disease (AD) and vascular dementia (VaD). Cerebral blood flow (CBF), cerebral blood volume (CBV), cerebral metabolic rate of oxygen (CMRO(2)), and oxygen extraction fraction (OEF) were measured quantitatively with positron emission tomography (PET). Vascular reactivity (VR) was also calculated by comparing the CBF during 5% CO(2) inhalation with the CBF during normal breathing. Vascular transit time (VTT) that was calculated as a ratio of CBV/CBF and VR reflect vasodilating capacity of the small resistance vessels, whereas OEF designates metabolic (oxygen-extraction) reserve in threatening brain ischemia. Significant increase in OEF was seen in the parieto-temporal cortex and both VTT and VR were preserved in AD patients. By constrast, there was no significant increase in OEF whereas VTT was prolonged and VR was markedly depressed in VaD patients. The increase of OEF and preserved VTT and VR seen in AD patients indicate the possible participation of vascular factors in the pathogenesis of AD perhaps at the capillary level.
Collapse
Affiliation(s)
- K Nagata
- Department of Neurology, Research Institute for Brain and Blood Vessels, 6-10 Senshu-Kubota-Machi, 010-0874, Akita, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Feldmann E, Skolnick BE. Cerebral hemodynamics, autoregulation, and blood pressure management. J Stroke Cerebrovasc Dis 1999; 8:176-82. [PMID: 17895161 DOI: 10.1016/s1052-3057(99)80024-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- E Feldmann
- Department of Neurology, Brown University, Providence, RI, USA; Penn Neurological Institute at Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | | |
Collapse
|
28
|
Micieli G, Bosone D, Zappoli F, Marcheselli S, Argenteri A, Nappi G. Vasomotor response to CO2 and L-Arginine in patients with severe internal carotid artery stenosis; pre- and post-surgical evaluation with transcranial Doppler. J Neurol Sci 1999; 163:153-8. [PMID: 10371076 DOI: 10.1016/s0022-510x(99)00027-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM Carotid artery disease may cause both thromboembolism and cerebral blood flow disturbances, particularly in subjects with impaired hemodynamic compensatory mechanisms. The aim of this study was to evaluate by transcranial Doppler (TCD) the hemodynamic changes induced by CO2 and L-Arginine stimulation in a selected population with severe unilateral carotid stenosis (70-80%), before and after carotid endarterectomy, in order to determine the effect of surgery in the vascular hemodynamics of these patients. METHODS We studied 20 subjects (mean age 66.4 years) consecutively admitted to our institute with ischemia and unilateral severe internal carotid artery stenosis (70-80%) detected by Color Doppler. All patients underwent arterial digital subtraction angiography to confirm the ultrasonographic evaluation. TCD was performed bilaterally; blood flow velocity was monitored during CO2 and L-Arginine stimulation both in basal conditions and three months after surgery. RESULTS After endarterectomy, mean velocity increased in response to both stimuli with a trend toward statistical significance. A significantly lower reactivity to L-Arginine on the stenotic side was found in the pre-operative phase: this asymmetrical reactivity was no longer observable after carotid endarterectomy. CONCLUSIONS We found a statistically significant difference in L-Arginine reactivity in the stenotic side of patients with severe unilateral internal carotid stenosis. This is probably related to an alteration of the endothelium function due to the carotid pathology, since the abnormalities disappeared three months after endarterectomy.
Collapse
MESH Headings
- Aged
- Arginine/pharmacology
- Blood Flow Velocity
- Brain/diagnostic imaging
- Carbon Dioxide/pharmacology
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/drug effects
- Carotid Artery, Internal/physiopathology
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/physiopathology
- Carotid Stenosis/surgery
- Cerebrovascular Circulation
- Endarterectomy, Carotid
- Female
- Functional Laterality
- Hemodynamics/drug effects
- Hemodynamics/physiology
- Humans
- Male
- Middle Aged
- Muscle, Smooth, Vascular/diagnostic imaging
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/physiopathology
- Postoperative Period
- Regression Analysis
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Transcranial
Collapse
Affiliation(s)
- G Micieli
- Fondazione C. Mondino, Neurovascular Unit, University of Pavia, Italy.
| | | | | | | | | | | |
Collapse
|
29
|
Inao S, Tadokoro M, Nishino M, Mizutani N, Terada K, Bundo M, Kuchiwaki H, Yoshida J. Neural activation of the brain with hemodynamic insufficiency. J Cereb Blood Flow Metab 1998; 18:960-7. [PMID: 9740099 DOI: 10.1097/00004647-199809000-00005] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about how ischemia affects hemodynamic responses to neural activation in the brain. We compare the effects of a motor activation task and a cerebral vasodilating agent, acetazolamide (ACZ), on regional cerebral blood flow (rCBF) in primary sensorimotor cortex (PSM) in six patients with major cerebral artery steno-occlusive lesions without paresis of the upper extremities. Quantitative rCBF was measured in all patients using H2(15)O autoradiographic method and positron emission tomography. The CBF was determined at rest, during a bimanual motor activation task, and 10 minutes after ACZ administration. With bimanual motor activation, rCBF increased significantly in both PSM compared with at rest (P < 0.01 on lesion side, and P < 0.02 on contralateral side). However, rCBF did not increase after ACZ injection in the PSM on the lesion side, whereas rCBF increased significantly in the contralateral PSM after ACZ injection compared with the level at rest. This result suggests that despite a decreased hemodynamic reserve, there is a nearly normal flow response to neural activation, indicating that the mechanism of vasodilation responsible for perfusion change is different for acetazolamide and neural activation. The relations among neural activation, hemodynamic status, and cerebral metabolism in the ischemic stroke patients are discussed.
Collapse
Affiliation(s)
- S Inao
- Department of Neurosurgery, Nagoya University School of Medicine, Japan
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Hulshof MC, Rehmann CJ, Booij J, van Royen EA, Bosch DA, González González D. Lack of perfusion enhancement after administration of nicotinamide and carbogen in patients with glioblastoma: a 99mTc-HMPAO SPECT study. Radiother Oncol 1998; 48:135-42. [PMID: 9783884 DOI: 10.1016/s0167-8140(98)00053-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Nicotinamide (NAM) and carbogen both have been shown to enhance the radiation effect in rodent tumour models and are currently being tested in clinical trials. These agents have demonstrated to act against hypoxia and one of their underlying mechanisms could be an increase of tumour blood perfusion. PURPOSE To analyse the effect of both agents on normal brain perfusion and tumour perfusion in patients with glioblastoma. MATERIALS AND METHODS Nineteen patients with glioblastoma were studied with 99mtechnetium-hexamethylpropyleneamine oxime single photon emission computed tomography (99mTc-HMPAO SPECT) before and after administration of carbogen and/or NAM. Another six patients were studied with the same procedure but without any flow modulator and were used as controls. RESULTS Although the variations between patients were large, no significant enhancement in mean tumour and normal brain perfusion could be demonstrated with NAM or carbogen compared to the control patients. Also no consistent changes in the mean perfusion ratio between tumour and surrounding normal brain were found, suggesting an absence of a selective perfusion effect. CONCLUSIONS No significant influence of carbogen and/or NAM on tumour perfusion and normal brain perfusion could be detected with SPECT in patients with glioblastoma.
Collapse
Affiliation(s)
- M C Hulshof
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
31
|
van Everdingen KJ, Visser GH, Klijn CJ, Kappelle LJ, van der Grond J. Role of collateral flow on cerebral hemodynamics in patients with unilateral internal carotid artery occlusion. Ann Neurol 1998; 44:167-76. [PMID: 9708538 DOI: 10.1002/ana.410440206] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The objective of this study was to evaluate the role of collateral blood flow via the anterior and posterior communicating arteries (ACoA and PCoA) and via the ophthalmic artery (OphA) on cerebral hemodynamics, metabolism, and border zone infarcts in 57 patients with unilateral symptomatic occlusions of the internal carotid artery. Collateral flow via the ACoA and PCoA was determined with magnetic resonance angiography (MRA) and collateral flow via the OphA with transcranial Doppler (TCD). Volume flow was studied with MRA, metabolism with 1H MR spectroscopy, CO2 reactivity with TCD, and the incidence of border zone infarcts with MRI. Compared with controls, patients had deteriorated volume flow, metabolism, and CO2 reactivity. No differences were found between patients with and patients without collateral flow through the ACoA and/or PCoA, or between patients with or without collateral flow via the OphA. Patients without collateral flow via any of these collaterals had decreased volume flow in the middle cerebral artery, decreased N-acetylaspartate/choline, and increased lactate/N-acetylaspartate, compared with the other patients. Patients with symptomatic internal carotid artery occlusion have deteriorated cerebral hemodynamics and metabolism. Different collateral flow patterns via the ACoA, PCoA, or OphA have no effect on the hemodynamic and metabolic parameters, as long as one of these pathways is present.
Collapse
|
32
|
Minhas PS, Smielewski P, Czosnyka M, Kirkpatrick PJ. Preoperative carbon dioxide reactivity studies do not predict the hemodynamic changes seen during carotid endarterectomy after internal carotid artery clamping. J Stroke Cerebrovasc Dis 1998; 7:44-51. [PMID: 17895055 DOI: 10.1016/s1052-3057(98)80020-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/1997] [Accepted: 06/23/1997] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE A preoperative warning of progressive cerebral ischemia during surgery may be of use in planning carotid endarterectomy (CE). We have set out to determine whether preoperative cerebrovascular reactivity studies predict the late hemodynamic changes detected during the procedure. PATIENTS AND METHODS Sixty-seven patients awaiting CE for high-grade carotid stenosis underwent preoperative cerebral CO(2) reactivity assessment using standard transcranial Doppler (TCD) methods. During subsequent surgery, hemodynamic changes were monitored with TCD, near-infrared spectroscopy, and a cerebral function monitor. Signals of mean MCA flow velocity (FV) and of cerebral oxyhemoglobin and deoxyhemoglobin concentration were recorded continuously, and the mean values were measured at 5, 10, and 15 minutes after internal carotid clamping. For each variable, the maximum signal change was measured 5 minutes after clamp application (Max(5)), and in addition the spontaneous hemodynamic recovery over the next 10 minutes (I(rec)) was calculated. Scatterplots of Max(5) and I(rec) against preoperative CO(2) reactivity indices (ipsilateral, bihemispheric mean, and interhemispheric assymmetry) were generated for correlative analysis. RESULTS The Max(5) for oxyhemoglobin and deoxyhemoglobin were inversely related (r=-.302, P=.015). There was no relationship between ipsilateral preoperative CO(2) reactivity index and Max(5) for any intraoperative variable measured. In addition, the reactivity did not predict the hemodynamic recovery (I(rec)) observed during clamp application. However, the interhemispheric asymmetry did show a modest inverse correlation to Max(5) FV (r=-.256, P=.046). CONCLUSION Preoperative TCD cerebral CO(2) reactivity cannot be used clinically to predict the intraoperative hemodynamic changes seen during CE.
Collapse
Affiliation(s)
- P S Minhas
- Addenbrookes Hospital, Cambridge, England
| | | | | | | |
Collapse
|
33
|
Levine RL, Turski PA, Turnipseed WD, Dulli DA, Grist TM. Vasodilatory responses and magnetic resonance angiography. Extracranial and intracranial intravascular flow data. J Neuroimaging 1997; 7:152-8. [PMID: 9237434 DOI: 10.1111/jon199773152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
This study measured the responses of both extracranial (internal carotid arteries) and intracranial (middle cerebral/angular, basilar arteries) intravascular arterial volume flow rates to acetazolamide using phase-contrast magnetic resonance angiography. Twenty-eight newly studied patients were subdivided into four groups: Group I--Nonocclusive, asymptomatic (n = 7, or 14 carotid and middle cerebral/angular artery sides); Group II--unilateral carotid transient ischemic attacks, nonhemodynamic (embolic), varying stenoses (n = 11); Group III--unilateral carotid transient ischemic attacks, hemodynamic, varying stenoses (n = 5); and Group IV--unilateral carotid occlusion, asymptomatic (n = 5). The data were separated into nonischemic and ischemic sides so as to illustrate group differences based on vasodilatory responses to acetazolamide. For example, the percent change in volume flow rates over baseline values for the ischemic-side middle cerebral arteries of Group III was significantly the lowest of all of the vasodilatory responses (-25 +/- 11% vs 40 +/- 14% for group II ischemic middle cerebral/angular artery sides, p = 0.008). Group III patients also had significantly lower standing blood pressures (p = 0.012), higher number of transient ischemic attacks (p = 0.008), and shorter duration of events (p = 0.013). Determinations of volume flow rate continue to assist in determining the degree of hemodynamic compromise of a particular vascular territory.
Collapse
Affiliation(s)
- R L Levine
- Department of Neurology, Middleton Veteran's Hospital, Madison, WI, USA
| | | | | | | | | |
Collapse
|
34
|
Nagahama Y, Fukuyama H, Yamauchi H, Katsumi Y, Dong Y, Konishi J, Kimura J. Effect of nicardipine on cerebral blood flow in hypertensive patients with internal carotid artery occlusion: a PET study. J Stroke Cerebrovasc Dis 1997; 6:325-31. [PMID: 17895029 DOI: 10.1016/s1052-3057(97)80214-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/1996] [Accepted: 02/14/1997] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The objective of this study was to elucidate the effect of intravenous administration of nicardipine on the cerebral blood flow of hypertensive patients with internal carotid artery occlusion (ICAO). PATIENTS AND METHODS Six patients with ICAO and 10 normal individuals were examined by positron emission tomography. The cerebral blood flow (CBF), cerebral blood volume (CBV), cerebral metabolic rate of oxygen, oxygen extraction fraction (OEF) and CBF/CBV ratio were evaluated for each vascular territory and each hemisphere, and the interhemispheric asymmetry index of each parameter was also calculated. Nicardipine was administered intravenously to each patient, and the changes in CBF (DeltaCBF%) and in blood pressure (DeltaBP) were examined. RESULTS After the administration of nicardipine, the CBF was significantly increased in the patient hemisphere and was unchanged in the occluded hemisphere. Stepwise regression analysis disclosed that the DeltaBP and asymmetry index of OEF were significantly correlated with the DeltaCBF% in the occluded hemisphere. CONCLUSIONS These results suggest that CBF is unchanged or increased in ICAO patients after nicardipine administration, but that excessive reduction of blood pressure may lead to CBF decrease in the patients with marked hemodynamic imbalance between the occluded and patent hemispheres. These results suggest that it is advisable not to reduce blood pressure excessively in these patients in the treatment of perioperative or acute hypertension with calcium antagonist.
Collapse
Affiliation(s)
- Y Nagahama
- Department of Neurology, Kyoto University, Kyoto, Japan
| | | | | | | | | | | | | |
Collapse
|
35
|
Halatsch ME, Rustenbeck HH, Jansen J. Progression of arteriovenous malformation in moyamoya syndrome. Acta Neurochir (Wien) 1997; 139:82-5. [PMID: 9059717 DOI: 10.1007/bf01850873] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report a case of moyamoya disease (MMD) associated with arteriovenous malformation (AVM). The 30-year-old female patient presented with left-hemispheric transient ischaemic attacks (TIAs) involving dysphasia and right-sided hemiparesis. CT-scan and lumbar puncture showed no evidence of intracranial haemorrhage. Cerebral angiography revealed typical moyamoya vessels and occlusion of multiple cerebral arteries with consecutive collateral blood supply. Moreover, a left-parietal AVM with a diameter of approximately 2 cm was detected. An extra-intracranial arterial bypass (EIAB) connecting the left superficial temporal artery (STA) with a cortical branch of the left middle cerebral artery (MCA) was performed (STA-MCA anastomosis) and yielded subsequent resolution of the neurological deficit. Nine months post-operatively neurological deficits similar to those of the initial presentation recurred. Repeated angiography suggested comparatively increased AVM blood flow, and successful extirpation of the AVM gradually re-established almost full functional ability. However, deterioration of the neurological condition developed again. We herewith present the first European case of moyamoya disease associated with arteriovenous malformation and report the clinical course under an alternative neurosurgical treatment consisting of STA-MCA anastomosis and delayed extirpation of the AVM.
Collapse
Affiliation(s)
- M E Halatsch
- Department of Neurosurgery, University of Göttingen, Federal Republic of Germany
| | | | | |
Collapse
|
36
|
Patrick JT, Fritz JV, Adamo JM, Dandonna P. Phase-contrast magnetic resonance angiography for the determination of cerebrovascular reserve. J Neuroimaging 1996; 6:137-43. [PMID: 8704287 DOI: 10.1111/jon199663137] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Cerebrovascular reserve (CVR) is the potential for cerebral arteriolar dilatation to occur, in response to decreased cerebral perfusion pressure, in order to maintain constant cerebral blood flow. Diminution or absence of CVR is considered a risk factor for stroke. Current methods for determining CVR include single-photon emission computed tomography, positron emission tomography and transcranial Doppler (TCD) ultrasonography. However, significant advantages could derive from the utilization of magnetic resonance angiography (MRA) based on the concurrent acquisition of hemodynamic information (CVR and collateral flow) with phase-contrast (PC) techniques and vascular morphology with three-dimensional, time-of-flight methods. With a 1.5-T scanner and acetazolamide (AZM), an arteriolar dilator, CVR was determined in 7 normal subjects. Mean flow velocity in the middle cerebral arteries was determined by PC MRA before and after AZM administration. For comparative purposes, mean flow velocities in the same middle cerebral arteries were determined by TCD before and after AZM administration. The mean flow velocities were as follows (mean +/- standard deviation, n = 7): 40 +/- 8 (PC MRA) versus 61 +/- 10 cm/sec (TCD) before AZM treatment and 58 +/- 11 (PC MRA) versus 85 +/- 15 cm/sec (TCD) after AZM administration. The increase in mean flow velocity (before vs after AZM), that is, the CVR, was 45 +/- 11% as shown by PC MRA and 39 +/- 14% as shown by TCD. Although significant differences were present between the mean flow velocities measured before and those after AZM administration, as determined by PC MRA and TCD, the CVR was not significantly different (45 vs 39%, respectively). These preliminary results suggest that PC MRA may be a method for determining CVR.
Collapse
Affiliation(s)
- J T Patrick
- Division of Neuroimaging Research, Lucy Dent Imaging Center Buffalo, NY, USA
| | | | | | | |
Collapse
|
37
|
Sorteberg A, Sorteberg W, Lindegaard KF, Nornes H. Cerebral haemodynamic considerations in obstructive carotid artery disease. Acta Neurochir (Wien) 1996; 138:68-75; discussion 75-6. [PMID: 8686528 DOI: 10.1007/bf01411727] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
46 subjects with obstructive carotid artery disease were investigated with transcranial Doppler ultrasonography. Their baseline blood velocities (V) in the middle, anterior and posterior cerebral artery (MCA, ACA and PCA) and in the extracranial internal carotid artery (ICA) were measured and the pulsatility index (PI) calculated for each vessel. Thereafter the vasomotor reserve in both MCAs was tested. Typical patterns of V, PI and vasomotor reactivity are presented. Arterial collaterals were recognized by their relatively increased velocities. We demonstrated a close association of the baseline variables V and PI and the total vasomotor reactivity (hypocapnic plus no, hypercapnic response) by calculating an index of Uhem related to the cerebrovascular tone. The Uhem index is expressed by: Uhem index = VMCA.PIMCA/VPCA.PIPCA The relationship between Uhem index and the total vasomotor reactivity seemed to correspond to a hyperbolic curve. The hyperbolic tangent of Uhem index and total vasomotor reactivity correlated highly significantly, r = 0.8203, p < 0.0001, n = 49, the best fit for the regression line was Y = -0.005 + Uhem index 51.3. On the 99% significance level an Uhem index > or = 0.94 indicated normal total cerebral vasomotor reactivity in contrast to an impaired reactivity when < or = 0.81. Findings in 20 patients investigated post hoc supported the validity of our concept.
Collapse
Affiliation(s)
- A Sorteberg
- Department of Neurosurgery, Rikshospitalet, University of Oslo, Norway
| | | | | | | |
Collapse
|
38
|
Touho H. Percutaneous transluminal angioplasty in the treatment of atherosclerotic disease of the anterior cerebral circulation and hemodynamic evaluation. J Neurosurg 1995; 82:953-60. [PMID: 7760197 DOI: 10.3171/jns.1995.82.6.0953] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Nineteen patients between 56 and 76 years of age with clinically symptomatic atherosclerotic stenotic lesions at or distal to the C-5 segment in the carotid arterial system underwent percutaneous transluminal angioplasty (PTA). The 19 patients had a total of 19 stenotic lesions, including two lesions in the C-5 segment, three in the C-4 segment, and three in the C-2 segment of the carotid artery, six in the M1 segment and three in the M2 segment of the middle cerebral artery, and two in the A2 segment of the anterior cerebral artery. Both prior to and more than 6 months after PTA, angiograms were performed and cerebral perfusion was measured using 99mTc-hexamethyl-propyleneamine-oxime single-photon emission computerized tomography, before and after the administration of 10 mg/kg acetazolamide. Percutaneous transluminal angioplasty could be performed in 13 (68.4%) of the 19 patients. The mean degree of stenosis (+/- standard deviation) was 83.1% +/- 8.6% before PTA, but only 35.8% +/- 17.3% on the follow-up angiograms. Restenosis was detected in follow-up angiograms in five (38.5%) of the 13 patients. Seven of the 13 patients exhibited improvement in their neurological condition after PTA and had shown subnormal cerebral perfusion and subnormal vasodilatory response to administration of acetazolamide prior to undergoing PTA. On the other hand, the remaining six patients exhibited no improvement in neurological condition after PTA, and four of these patients (66.7%) had shown normal perfusion and five (83.3%) had shown normal vasodilatory response to administration of acetazolamide prior to undergoing PTA. These findings suggest that PTA may be indicated for patients with atherosclerotic stenotic lesions in the anterior cerebral circulation who have subnormal cerebral perfusion and low vasodilatory response to administration of acetazolamide.
Collapse
Affiliation(s)
- H Touho
- Department of Neurosurgery, Osaka Neurological Institute, Japan
| |
Collapse
|
39
|
Jaggi JL, Noordergraaf A. Effect of non-steady-state perfusion on xenon-133 cerebral blood flow measurements: an analytical study. J Cereb Blood Flow Metab 1995; 15:321-8. [PMID: 7860665 DOI: 10.1038/jcbfm.1995.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Activation studies employing the noninvasive xenon-133 technique are widely used to investigate the cerebral circulation. Typical examples are the investigation of hemispheral specialization of higher cortical function with cognitive activation or the assessment of the hemodynamic reserve in occlusive cerebrovascular disease by CO2 inhalation. Traditionally, in studies using this technique, there is the requirement of a circulatory steady state during the measurement. Due to limitations in the duration of the stimulus or habituation to the stimulus, the basic assumption is often violated. In this study we investigated with the aid of a computer model to what extent blood flow measurement results are affected by non-steady-state blood flow. The findings indicate that cortical activation need not extend throughout the whole measurement to be detectable. Maintenance of activation for at least 5 min is sufficient for a successful measurement. In addition, the results show that the activation should be fully established when the measurement starts to achieve maximal sensitivity. Delay in activating the circulation will result in attenuated responses, especially if the stimulus is delayed beyond 2 min.
Collapse
Affiliation(s)
- J L Jaggi
- Department of Neurology, University of Pennsylvania, Philadelphia
| | | |
Collapse
|
40
|
Touho H, Takaoka M, Ohnishi H, Furuoka N, Karasawa J. Percutaneous transluminal angioplasty for severe stenosis of the posterior cerebral artery: case report. SURGICAL NEUROLOGY 1995; 43:42-7. [PMID: 7701422 DOI: 10.1016/0090-3019(95)80036-g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The Stealth dilation catheter was used for the intravascular treatment of a patient who had hemodynamically significant stenosis of the posterior cerebral artery and had a history of recurrent transient ischemic attacks associated with right hemiparesis and ipsilateral hemianopia dating from March 1993. Cerebral perfusion studies prior to and after the intravenous administration of acetazolamide demonstrated regions of moderately low perfusion and low hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. Cerebral angiograms demonstrated severe stenosis of the left posterior cerebral artery and occlusions of both middle cerebral arteries, which had leptomeningeal anastomoses with the posterior cerebral arteries. Percutaneous transluminal angioplasty (PTA) was performed using the Stealth catheter on the stenotic segment of the left posterior cerebral artery after left superficial temporal artery-middle cerebral artery anastomosis. The patient manifested marked improvement in her neurologic condition just after PTA, in association with marked increase in cerebral perfusion and hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. We have presented evidence that PTA can be used to treat patients with stenosis of the first segment of the posterior cerebral artery and hemodynamic compromise in the territory that artery supplies.
Collapse
Affiliation(s)
- H Touho
- Department of Neurosurgery, Osaka Neurological Institute, Japan
| | | | | | | | | |
Collapse
|
41
|
Smith HA, Thompson-Dobkin J, Yonas H, Flint E. Correlation of xenon-enhanced computed tomography-defined cerebral blood flow reactivity and collateral flow patterns. Stroke 1994; 25:1784-7. [PMID: 8073458 DOI: 10.1161/01.str.25.9.1784] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE A chronic compromise of cerebral hemodynamics has been shown to identify a group of patients at an increased risk for stroke. Because a "steal phenomenon" induced by a vasodilatory challenge has characterized the group at greatest risk, it was hypothesized that these individuals would also have a severe compromise of primary collaterals and an increased dependence on leptomeningeal collaterals. METHODS Twenty-three patients with symptomatic cerebrovascular disease underwent angiography and xenon-enhanced computed tomographic cerebral blood flow studies before and after 1 g IV acetazolamide within 6 months of each other. Cerebral blood flow vasoreactivity was classified by whether cerebral blood flow increased (> 5%) or was unchanged (+/- 5%) (group 1) or fell by > 5% (group 2) in any vascular territory. Angiographic collateralization was classified into four types: normal (type 1), willisian (type 2), ophthalmic (type 3), and leptomeningeal (type 4). RESULTS Twenty percent (2/10) of group 1 patients and 69% (9/13) of group 2 patients (P = .0009) had leptomeningeal collaterals. CONCLUSIONS A negative flow reactivity is significantly associated with a dependence on leptomeningeal collaterals and implies a state of maximal hemodynamic compromise.
Collapse
Affiliation(s)
- H A Smith
- Department of Neurological Surgery, University of Pittsburgh, PA, School of Medicine
| | | | | | | |
Collapse
|
42
|
|
43
|
Guidelines for the management of transient ischemic attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Stroke 1994; 25:1320-35. [PMID: 8203003 DOI: 10.1161/01.str.25.6.1320] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
44
|
Feinberg WM, Albers GW, Barnett HJ, Biller J, Caplan LR, Carter LP, Hart RG, Hobson RW, Kronmal RA, Moore WS. Guidelines for the management of transient ischemic attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Circulation 1994; 89:2950-65. [PMID: 8205721 DOI: 10.1161/01.cir.89.6.2950] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
45
|
Nariai T, Suzuki R, Matsushima Y, Ichimura K, Hirakawa K, Ishii K, Senda M. Surgically induced angiogenesis to compensate for hemodynamic cerebral ischemia. Stroke 1994; 25:1014-21. [PMID: 8165672 DOI: 10.1161/01.str.25.5.1014] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE The ischemic brain may stimulate angiogenesis to compensate for impaired circulation. We examined the conditions promoting such angiogenesis to provide the basis for surgical treatment. METHODS The degree of cerebral hemodynamic stress was studied in patients with moyamoya disease using the stable xenon-enhanced computed tomographic acetazolamide tolerance test and positron emission tomography. Patients were subjected to surgery in which scalp arteries were placed on the cerebral cortex without vessel-to-vessel anastomosis. Formation of the newly vascularized collateral network connecting the implanted artery to cortical arteries was assessed angiographically 12 to 17 months after surgery. RESULTS Preoperative average resting cerebral blood flow for cortex that developed revascularization of cortical arteries was not significantly different from that for cortex that did not. However, cortex that developed revascularization had an average preoperative increase of blood flow by acetazolamide treatment of -3.29 +/- 4.6 mL/min per 100 cm3 (n = 20), which was significantly less (P = .0034) than that of cortex that did not show revascularization (20.7 +/- 4.3 mL/min per 100 cm3; n = 9). Good revascularization developed when the cortex showed increase of blood flow by acetazolamide treatment of less than 0 (steal phenomenon). Preoperative positron emission tomography data indicated that revascularization developed when the cortex was under "misery perfusion." Postoperative hemodynamics were ameliorated by revascularization. CONCLUSIONS Angiogenesis to connect the implanted scalp arteries to the cerebral cortical arteries was selectively initiated when ischemia of hemodynamic origin existed.
Collapse
Affiliation(s)
- T Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, School of Medicine, Japan
| | | | | | | | | | | | | |
Collapse
|
46
|
Nighoghossian N, Trouillas P, Philippon B, Itti R, Adeleine P. Cerebral blood flow reserve assessment in symptomatic versus asymptomatic high-grade internal carotid artery stenosis. Stroke 1994; 25:1010-3. [PMID: 8165671 DOI: 10.1161/01.str.25.5.1010] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Thromboembolic stroke is likely to occur in patients with a restricted cerebral blood flow reserve. Our aims were to determine (1) whether symptomatic patients had any significant hemodynamic restriction ipsilateral to carotid occlusive disease compared with patients whose carotid stenosis is asymptomatic and (2) whether patients with carotid occlusive disease have impaired cerebral perfusion reserve compared with control subjects. METHODS We compared cerebral blood flow and collateral capacity using the 133Xe inhalation method and acetazolamide test in symptomatic (n = 10) and asymptomatic (n = 10) patients who had a high-grade internal carotid artery stenosis (range, 70% to 99%). Results were compared with those from 10 healthy control subjects. RESULTS Mean baseline cerebral blood flow was 40.29 +/- 1.38 mL/100 g per minute on the symptomatic side in symptomatic patients versus 45.20 +/- 2.53 mL/100 g per minute on the lesion side in asymptomatic patients (control subjects, 46.91 +/- 2.11 mL/100 g per minute in the right hemisphere versus 46.17 +/- 1.93 mL/100 g per minute in the left). There was no statistical difference between patients in symptomatic and asymptomatic groups versus control subjects (P > .10). Mean cerebral blood flow increase after acetazolamide was in the same range in symptomatic (52.89 +/- 2.54 mL/100 g per minute) and asymptomatic (56.22 +/- 3.35 mL/100 g per minute) patients (P > .10), and no difference was observed regarding control subjects (54.25 +/- 2.94 mL/100 g per minute; P > .10). Three asymptomatic and two symptomatic patients and three control subjects had no significant cerebral blood flow increase after acetazolamide. CONCLUSIONS An additional hemodynamic factor in thromboembolic ischemia related to severe unilateral carotid stenosis might be an unusual finding in patients without apparent hemodynamic induction of symptoms. The lack of significant variation in postacetazolamide cerebral blood flow in some patients and control subjects implies that this procedure may be inconsistent in assessing the cerebral perfusion reserve in the individual case.
Collapse
Affiliation(s)
- N Nighoghossian
- Department of Neurology Cerebrovascular Disease, Neurological Hospital, Lyon, France
| | | | | | | | | |
Collapse
|
47
|
Takayasu's disease: Ultrasonic evaluation of extracranial and intracranial hemodynamics. J Stroke Cerebrovasc Dis 1994; 4:130-6. [DOI: 10.1016/s1052-3057(10)80121-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
48
|
Esses GE, Babikian V, Cantelmo NL, Saint-Hilaire M, Pochay VE, Johnson WC. Hemodynamic considerations during carotid endarterectomy. J Stroke Cerebrovasc Dis 1994; 4:220-3. [DOI: 10.1016/s1052-3057(10)80094-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
49
|
Ringelstein EB, Weiller C, Weckesser M, Weckesser S. Cerebral vasomotor reactivity is significantly reduced in low-flow as compared to thromboembolic infarctions: the key role of the circle of Willis. J Neurol Sci 1994; 121:103-9. [PMID: 8133304 DOI: 10.1016/0022-510x(94)90163-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To test the hypothesis that cerebral vasomotor reactivity (CVMR) is significantly more reduced in patients with hemispheric low-flow infarctions than in brain infarctions due to arterio-arterial embolism, a series of 64 consecutive patients with internal carotid artery occlusions were studied. CVMR was calculated from relative changes of blood flow velocity within the middle cerebral artery (MCA) measured by transcranial Doppler ultrasonography (TCD) during hypo- and hypercapnia. The configuration of the circle of Willis (COW) was also determined by TCD using common carotid artery compression tests. Anterior, posterior or ophthalmic artery collateral flow, and absence or combinations of these, were differentiated. CT scans were categorized as showing either no infarction (group I; n = 20) or territorial (group II; n = 28), or low-flow infarctions (group III; n = 16). As compared to normal, CVMR was significantly reduced but equal in groups I and II, however, even more reduced in group III. CVMR was lowest, and low-flow infarctions were most frequent in patients whose collateral hemispheric blood supply was from the ophthalmic artery as opposed to patients with a complete or nearly complete COW. Our findings indicate that low-flow infarctions in extracranial ICA occlusions represent brain damage due to a critical reduction in cerebral perfusion pressure, as opposed to thromboembolically induced lesions. The configuration of the COW seems to play the key role. Our findings also support the view that the pattern of hemispheric infarction seen on CT indicates the pathogenesis of stroke.
Collapse
Affiliation(s)
- E B Ringelstein
- Department of Neurology, University Hospital, Münster, Germany
| | | | | | | |
Collapse
|
50
|
Yonas H, Smith HA, Durham SR, Pentheny SL, Johnson DW. Increased stroke risk predicted by compromised cerebral blood flow reactivity. J Neurosurg 1993; 79:483-9. [PMID: 8410214 DOI: 10.3171/jns.1993.79.4.0483] [Citation(s) in RCA: 346] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The authors sought to determine risk for stroke in individuals with symptomatic carotid stenosis or occlusion based upon an assessment of cerebral blood flow (CBF) reserves. Vascular reserve was assessed by two consecutive xenon/computerized tomography (Xe/CT) CBF studies with intravenous acetazolamide introduced 20 minutes prior to the second study. Patients were assigned to one of two vasoreactivity groups. Group 2 included individuals who experienced a CBF reduction of more than 5% in at least one vascular territory and had a baseline flow of 45 cc/100 gm/min or less. Group 1 included all other individuals. Any territory with volume loss on CT of more than 50% was eliminated from analysis. Sixty-eight individuals were followed at 6-month intervals for a mean of 24 months. In Group 1 two strokes were observed contralateral to the side with lowest reserve, for a stroke incidence of 4.4%; in Group 2 eight strokes were observed ipsilateral to the side with lowest reserve, for a stroke incidence of 36%. The latter group had a 12.6 times greater chance of stroke (p = 0.0007). History of stroke, history of transient ischemic attacks, baseline CBF, and degree of stenosis were not associated with an increased stroke rate. In this study, significantly compromised vascular reserves accompanied by relatively low initial flow identified individuals who subsequently demonstrated a significantly increased rate of ipsilateral stroke.
Collapse
Affiliation(s)
- H Yonas
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania
| | | | | | | | | |
Collapse
|