Preoperative MRA flow quantification in CEA patients: flow differences between patients who develop cerebral ischemia and patients who do not develop cerebral ischemia during cross-clamping of the carotid artery

Diagnostic Accuracy of Preoperative Quantitative Susceptibility Mapping for Detecting Histologic Intraplaque Hemorrhage in Cervical ICA Stenosis in Patients Undergoing Carotid Endarterectomy

BACKGROUND AND PURPOSE

Quantitative susceptibility mapping has been proposed to assess intraplaque hemorrhage (IPH) in the carotid artery. The purpose of this study was to compare the diagnostic accuracy of preoperative quantitative susceptibility mapping with that of the conventional T1-weighed 3D-FSE sequence for detecting IPH in cervical ICA stenosis in patients undergoing carotid endarterectomy by using histology as the reference standard.

MATERIALS AND METHODS

Carotid T1-weighted 3D-FSE and QSM images were obtained from 16 patients with cervical ICA stenosis before carotid endarterectomy. Relative signal intensity and susceptibility of the ICA were measured on 3 axial images, including the location of most severe stenosis on T1-weighted 3D-FSE and quantitative susceptibility mapping images, respectively. Three transverse sections of carotid plaques excised by carotid endarterectomy, which corresponded with images on MR imaging, were stained with H&E, antibody against glycophorin A, and Prussian blue, and the relative area of histologic IPH was calculated.

RESULTS

The correlation coefficient was significantly greater between susceptibility and relative area-histologic IPH (ρ = 0.691) than between relative signal intensity and relative area-histologic IPH (ρ = 0.413; P = .0259). The areas under the receiver operating characteristic curves for detecting histologic sections consisting primarily of IPH (relative area-histologic IPH > 40.7%) tended to be greater for susceptibility (0.964) than for T1WI FSE-relative signal intensity (0.811). Marginal homogeneity was observed between susceptibility and histologic sections consisting primarily of IPH (P = .0412), but not between T1-weighted FSE-relative signal intensity and histologic sections consisting primarily of IPH (P = .1824).

CONCLUSIONS

Pre-carotid endarterectomy quantitative susceptibility mapping detects histologic IPH in cervical ICA stenosis more accurately than preoperative T1-weighted 3D-FSE imaging.

Association between preoperative white matter hyperintensities and postoperative new ischemic lesions on magnetic resonance imaging in patients with cognitive decline after carotid endarterectomy

Although cognitive decline after carotid endarterectomy (CEA) is mainly related to postoperative cerebral hyperperfusion, approximately 30% of patients with cognitive decline do not have postoperative cerebral hyperperfusion. In patients with acute ischemic events, the development of cognitive decline after such events is associated with the presence of chronic cerebral white matter hyperintensities (WMHs). The present prospective observational study aimed to determine whether preoperative WMHs and postoperative new ischemic lesions (PNILs) are associated with cognitive decline after CEA in patients without cerebral hyperperfusion after CEA. Brain magnetic resonance imaging (MRI) was performed preoperatively, and WMHs were graded according to the Fazekas scale in patients undergoing CEA for severe stenosis of the ipsilateral internal carotid. Diffusion-weighted MRI was performed before and after CEA to determine the development of PNILs. Neuropsychological testing was performed preoperatively and at 2 months postoperatively to determine the development of postoperative cognitive decline (PCD). In 142 patients without postoperative cerebral hyperperfusion, logistic regression analysis revealed that preoperative Fazekas scale of periventricular WMHs (PVWMHs) (95% confidence interval [CI]: 1.78-28.10; P = 0.0055) and PNILs in the eloquent areas (95% CI: 7.42-571.89; P = 0.0002) were significantly associated with PCD. The specificity and positive-predictive value for the prediction of PCD were significantly greater for the combination of preoperative Fazekas scale 2 or 3 of PVWMHs and PNILs in the eloquent areas than for each individually. Preoperative PVWMHs, PNILs in the eloquent areas, and the combination of both were associated with PCD in patients without cerebral hyperperfusion after CEA.

Prediction of cerebral hyperperfusion following carotid endarterectomy using intravoxel incoherent motion magnetic resonance imaging

OBJECTIVES

One of the risk factors for cerebral hyperperfusion following carotid endarterectomy (CEA) is a chronic reduction in cerebral perfusion pressure due to internal carotid artery (ICA) stenosis, which is clinically detected as increased cerebral blood volume (CBV). The perfusion fraction (f) is one of the intra-voxel incoherent motion (IVIM) parameters obtained using magnetic resonance (MR) imaging that theoretically reflects CBV. The present study aimed to determine whether preoperative IVIM-f on MR imaging predicts development of cerebral hyperperfusion following CEA.

MATERIALS AND METHODS

Sixty-eight patients with unilateral ICA stenosis (≥ 70%) underwent preoperative diffusion-weighted 3-T MR imaging, and IVIM-f maps were generated from these data. Quantitative brain perfusion single-photon emission computed tomography (SPECT) was performed before and immediately after CEA. Regions-of-interest (ROIs) were automatically placed in the bilateral middle cerebral artery territories in all images using a three-dimensional stereotactic ROI template, and affected-to-contralateral ratios in the ROIs were calculated on IVIM-f maps.

RESULTS

Nine patients (13%) exhibited postoperative hyperperfusion (cerebral blood flow increases of ≥ 100% compared with preoperative values in the ROIs on brain perfusion SPECT). Only high IVIM-f ratios were significantly associated with the occurrence of postoperative hyperperfusion (95% confidence interval, 253.8-6774.2; p = 0.0031) on logistic regression analysis. The sensitivity, specificity, and positive and negative predictive values of the IVIM-f ratio to predict the occurrence of postoperative hyperperfusion were 100%, 81%, 45%, and 100%, respectively.

CONCLUSIONS

Preoperative IVIM-f on MR imaging can predict development of cerebral hyperperfusion following CEA.

Development of a Flow Phantom for Transcranial Doppler Ultrasound Quality Assurance

Anecdotal evidence was recently brought to our attention suggesting a potential difference in velocity estimates between transcranial Doppler (TCD) systems when measuring high velocities (∼200 cm/s) close to the threshold for sickle cell disease stroke prevention. As we were unable to identify a suitable commercial TCD phantom, a middle cerebral artery (MCA) flow phantom was developed to evaluate velocity estimates from different devices under controlled conditions. Time-averaged velocity estimates were obtained using two TCD devices: a Spencer Technologies ST³ Doppler system (ST³ PMD150, Spencer Technologies, Seattle, WA, USA) and a DWL Dopplerbox (DWL Compumedics, SN-300947, Singen, Germany). These were compared with velocity estimates obtained using a Zonare duplex scanner (Zonare Medical Systems, Mountain View, CA, USA), with timed collection of fluid as the gold standard. Bland-Altman analysis was performed to compare measurements between devices. Our tests confirmed that velocities measured with the DWL TCD system were +4.1 cm/s (+3.7%; limits of agreement [LoA]: 2%, 5%; p = 0.03) higher than the Spencer system when measuring a velocity 110 cm/s and +12 cm/s higher (+5.7 %; LoA: 4.8%, 6.6%; p = 0.03) when measuring velocities of 210 cm/s, close to the diagnostic threshold for stroke intervention. We found our MCA phantom to be a valuable tool for systematically quantifying differences in TCD velocity estimates between devices, confirming that the DWL system gave consistently higher readings than the Spencer ST³ system. Differences become more pronounced at high velocities, which explains why they were not identified earlier. Our findings have clinical implications for centers using TCD to monitor patients with sickle cell disease, as extra care may be needed to adjust for bias between manufacturers when making treatment decisions about children with sickle cell with velocities close to the diagnostic threshold.

Prediction of cross-clamp-induced cerebral ischemia during carotid endarterectomy using arterial blood flow assessment

BACKGROUND

Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter.

METHODS

The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases.

RESULTS

Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the two groups (p=0.011). The direct-ABF ratio ≤0.58 was predictive of cerebral ischemia during CEA.

CONCLUSIONS

Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

Pre-operative Cerebral Small Vessel Disease on MR Imaging Is Associated With Cerebral Hyperperfusion After Carotid Endarterectomy

Objectives: To determine whether pre-operative cerebral small vessel disease is associated with cerebral hyperperfusion (CH) after carotid endarterectomy (CEA). Methods: Seventy-seven patients (mean age of 66 years and 58% male) undergoing CEA for carotid stenosis were investigated using brain MRI before and after surgery. CH was defined as an increase in cerebral blood flow > 100% compared with pre-operative values on arterial spin labeling MR images. The grade or the number of four cerebral small vessel disease markers (white matter hyperintensities, lacunes, perivascular spaces, and cerebral microbleeds) were evaluated based on pre-operative MRI. Cerebral small vessel disease markers were correlated with CH by using multivariate logistic regression analysis. The cutoff values of cerebral small vessel disease markers for predicting CH were assessed by receiver-operating characteristic curve analysis. Results: CH after CEA was observed in 16 patients (20.78%). Logistic regression analysis revealed that white matter hyperintensities (OR 3.09, 95% CI 1.72-5.54; p < 0.001) and lacunes (OR 1.37, 95% CI 1.06-1.76; p = 0.014) were independently associated with post-operative CH. Receiver-operating characteristic curve analysis showed that Fazekas score of white matter hyperintensities ≥3 points [area under the curve (AUC) = 0.84, sensitivity = 81.3%, specificity = 73.8%, positive predictive value (PPV) = 44.8% and negative predictive value (NPV) = 93.8%] and number of lacunes ≥ 2 (AUC = 0.73, sensitivity = 68.8%, specificity = 78.7%, PPV = 45.8% and NPV = 90.6%) were the optimal cutoff values for predicting CH. Conclusion: In patients with carotid stenosis, white matter hyperintensities and lacunes adversely affect CH after CEA. Based on the NPVs, pre-operative MR imaging can help identify patients who are not at risk of CH.

Role of Doppler Ultrasound Analysis of Blood Flow Through the Ophthalmic and Intracranial Arteries in Predicting Neurologic Symptoms During Carotid Endarterectomy

OBJECTIVES

Carotid endarterectomy (CEA) is frequently performed under locoregional anesthesia. The intraoperative clamping of the internal carotid artery (ICA) leads to cerebral hypoperfusion, which may in some patients result in the development of neurologic symptoms (NS). The objective of our study was to investigate whether there is an association between the preoperative ultrasound (US) Doppler flow in the ophthalmic artery (OA) and intracranial artery and the occurrence of these intraoperative NS.

METHODS

We compared 50 patients with NS and 150 patients without NS during CEA. We analyzed their preoperative blood flow characteristics by Doppler US and their clinical and demographic characteristics.

RESULTS

The contralateral ICA occlusion increased the likelihood of intraoperative NS (odds ratio [OR], 8.4; P < .001). Abnormal contralateral OA flow also increased the likelihood of NS (OR, 1.84; P < .001), whereas ipsilateral abnormal OA flow reduced it (OR, 0.73; P = .06). Increased flow in the ipsilateral anterior cerebral artery (ACA) increased the likelihood of NS (OR, 3.3), whereas reversed flow decreased it (OR, 0.1; P = .03). Inverse flow in the contralateral ACA increased the risk (OR, 5.4), whereas increased flow reduced it (OR, 0.2; P = .02). Male patients had a higher risk of NS (P = .09) as well as older patients (P = .05). Eight percent of the patients with NS developed a transient ischemic attack or stroke.

CONCLUSIONS

Doppler US analysis of the OA and ACA in combination with analysis of ICA stenosis may be a promising predictor of NS during ICA clamping. This, in turn, may warn the patient and the surgeon of an increased risk during surgery.

Development of cerebral microbleeds in patients with cerebral hyperperfusion following carotid endarterectomy and its relation to postoperative cognitive decline

OBJECTIVE

A primary cause of cognitive decline after carotid endarterectomy (CEA) is cerebral injury due to cerebral hyperperfusion. However, the mechanisms of how cerebral hyperperfusion induces cerebral cortex and white matter injury are not known. The presence of cerebral microbleeds (CMBs) on susceptibility-weighted imaging (SWI) is independently associated with a decline in global cognitive function. The purpose of this prospective observational study was to determine whether cerebral hyperperfusion following CEA leads to the development of CMBs and if postoperative cognitive decline is related to these developed CMBs.

METHODS

During the 27-month study period, patients who underwent CEA for ipsilateral internal carotid artery stenosis (≥ 70%) also underwent SWI and neuropsychological testing before and 2 months after surgery, as well as quantitative brain perfusion SPECT prior to and immediately after surgery.

RESULTS

According to quantitative brain perfusion SPECT and SWI before and after surgery, 12 (16%) and 7 (9%) of 75 patients exhibited postoperative cerebral hyperperfusion and increased CMBs in the cerebral hemisphere ipsilateral to surgery, respectively. Cerebral hyperperfusion was associated with an increase in CMBs after surgery (logistic regression analysis, 95% CI 5.08-31.25, p < 0.0001). According to neuropsychological assessments before and after surgery, 10 patients (13%) showed postoperative cognitive decline. Increased CMBs were associated with cognitive decline after surgery (logistic regression analysis, 95% CI 6.80-66.67, p < 0.0001). Among the patients with cerebral hyperperfusion after surgery, the incidence of postoperative cognitive decline was higher in those with increased CMBs (100%) than in those without (20%; p = 0.0101).

CONCLUSIONS

Cerebral hyperperfusion following CEA leads to the development of CMBs, and postoperative cognitive decline is related to these developed CMBs.

Quantitative Assessment of the Intracranial Vasculature of Infants and Adults Using iCafe (Intracranial Artery Feature Extraction)

Comprehensive quantification of intracranial artery features may help to assess and understand regional variations of blood supply during early brain development and aging. We analyzed vasculature features of 27 healthy infants during natural sleep, 13 infants at 7-months (7.3 ± 1.0 month), and 14 infants at 12-months (11.7 ± 0.4 month), and 13 older healthy, awake adults (62.8 ± 8.7 years) to investigate age-related vascular differences as a preliminary study of vascular changes associated with brain development. 3D time-of-flight (TOF) magnetic resonance angiography (MRA) acquisitions were processed in iCafe, a technique to quantify arterial features (http://icafe.clatfd.cn), to characterize intracranial vasculature. Overall, adult subjects were found to have increased ACA length, tortuosity, and vasculature density compared to both 7-month-old and 12-month-old infants, as well as MCA length compared to 7-month-old infants. No brain laterality differences were observed for any vascular measures in either infant or adult age groups. Reduced skull and brain sharpness, indicative of increased head motion and brain/vascular pulsation, respectively, were observed in infants but not correlated with length, tortuosity, or vasculature density measures. Quantitative analysis of TOF MRA using iCafe may provide an objective approach for systematic study of infant brain vascular development and for clinical assessment of adult and pediatric brain vascular diseases.

Neurally adjusted ventilatory assist preserves cerebral blood flow velocity in patients recovering from acute brain injury

Neurally adjusted ventilatory assist (NAVA) has never been applied in patients recovering from acute brain injury (ABI) because neural respiratory drive could be affected by intracranial disease with detrimental effects on cerebral blood flow (CBF) velocity. Our primary aim was to assess the impact of NAVA and pressure support ventilation (PSV) on CBF velocity. In fifteen adult patients recovering from ABI and undergoing invasive assisted ventilation, PSV and NAVA were applied over 30-min-lasting trials, in the following sequence: PSV₁, NAVA, and PSV₂. While PSV was set to deliver a tidal volume ranging between 6 and 8 ml kg⁻¹ of predicted body weight, in NAVA the level of assistance was chosen to achieve the same inspiratory peak airway pressure as PSV. At the end of each trial, a sonographic evaluation of CBF mean velocity was bilaterally obtained on the middle cerebral artery and an arterial blood gas sample was taken for analysis. CBF mean velocity was 51.8 [41.9,75.2] cm  s⁻¹ at baseline, 51.9 [43.4,71.0] cm s⁻¹ in PSV₁, 53.6 [40.7,67.7] cm s⁻¹ in NAVA, and 49.5 [42.1,70.8] cm s⁻¹ in PSV₂ (p = 0.0514) on the left and 50.2 [38.0,77.7] cm s⁻¹ at baseline, 47.8 [41.7,68.2] cm s⁻¹ in PSV₁, 53.9 [40.1,78.5] cm s⁻¹ in NAVA, and 55.6 [35.9,74.1] cm s⁻¹ in PSV₂ (p = 0.8240) on the right side. No differences were detected for pH (p = 0.0551), arterial carbon dioxide tension (p = 0.8142), and oxygenation (p = 0.0928) over the entire study duration. NAVA and PSV preserved CBF velocity in patients recovering from ABI.

Trial registration: The present trial was prospectively registered at www.clinicatrials.gov (NCT03721354) on October 18th, 2018.

Limitations of median nerve somatosensory evoked potential monitoring during carotid endarterectomy

OBJECTIVE

Hypoperfusion during carotid artery cross-clamping (CC) for carotid endarterectomy (CEA) may result in the major complication of perioperative stroke. Median nerve somatosensory evoked potential (MNSSEP) monitoring, which is an established method for the prediction of cerebral ischemia, has low sensitivity in detecting such hypoperfusion. In this study the authors sought to explore the limitations of MNSSEP monitoring compared to tibial nerve somatosensory evoked potential (TNSSEP) monitoring for the detection of CC-related hypoperfusion.

METHODS

The authors retrospectively analyzed data from patients who underwent unilateral CEA with routine shunt use. All patients underwent preoperative magnetic resonance angiography and were monitored for intraoperative cerebral ischemia by using MNSSEP, TNSSEP, and carotid stump pressure during CC. First, the frequency of MNSSEP and TNSSEP changes during CC were analyzed. Subsequently, variables related to stump pressure were determined by using linear analysis and those related to each of the somatosensory evoked potential (SSEP) changes were determined by using logistic regression analysis.

RESULTS

A total of 94 patients (mean age 74 years) were included in the study. TNSSEP identified a greater number of SSEP changes during CC than MNSSEP (20.2% vs 11.7%; p < 0.05). Linear regression analysis demonstrated that hypoplasia of the contralateral proximal segment of the anterior cerebral artery (A1 hypoplasia) (p < 0.01) and hypoplasia of the ipsilateral precommunicating segment of the posterior cerebral artery (P1 hypoplasia) (p = 0.02) independently and negatively correlated with stump pressure. Both contralateral A1 hypoplasia (OR 26.25, 95% CI 4.52-152.51) and ipsilateral P1 hypoplasia (OR 8.75, 95% CI 1.83-41.94) were independently related to the TNSSEP changes. However, only ipsilateral P1 hypoplasia (OR 8.76, 95% CI 1.61-47.67) was independently related to MNSSEP changes.

CONCLUSIONS

TNSSEP monitoring appears to be superior to MNSSEP in detecting CC-related hypoperfusion. Correlation with stump pressure and SSEP changes indicates that TNSSEP, and not MNSSEP monitoring, is a reliable indicator of cerebral ischemia in the territory of the anterior cerebral artery.

Incorporation of Transcranial Doppler into the ED for the neurocritical care patient

INTRODUCTION

In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD).

OBJECTIVE

This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided.

DISCUSSION

Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided.

CONCLUSIONS

With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.

Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions

OBJECTIVE

The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions.

METHODS

This was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery.

RESULTS

There were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively.

CONCLUSIONS

ECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.

Preoperative brain temperature imaging on proton magnetic resonance spectroscopy predicts hemispheric ischemia during carotid endarterectomy for unilateral carotid stenosis with inadequate collateral blood flow

Objective Preoperative magnetic resonance (MR) angiography sometimes shows the absence of collateral flow via the circle of Willis. This study examined whether brain temperature (BT) imaging on multi-voxel proton MR spectroscopy after this finding increases the accuracy of predicting hemispheric ischemia during internal carotid artery (ICA) clamping during endarterectomy for patients with symptomatic unilateral carotid stenosis. Methods In 52 patients with ICA stenosis (≥70%) and absence of collateral blood flow via the circle of Willis on preoperative MR angiography, BT imaging was displayed using proton multi-voxel MR spectroscopy. The difference between BTs in the affected and contralateral hemispheres (BT_{affected hemisphere} - BT_{contralateral hemisphere}) in the deep white matter of the centrum semiovale was calculated and defined as hemispheric ΔBT. Development of cerebral hemispheric ischemia during ICA clamping was determined from intraoperative electroencephalography (EEG). Results Multivariate analysis revealed that high preoperative hemispheric ΔBT was significantly associated with development of EEG-defined hemispheric ischemia (95% confidence intervals [CIs], 5.376-15.452; p = 0.006). The positive-predictive value for development of EEG-defined hemispheric ischemia was significantly greater for preoperative hemispheric ΔBT following preoperative MR angiography (95%CI, 42-87%) than for preoperative MR angiography alone (95%CI, 13-37%). Conclusions For patients without collateral flow via the circle of Willis, BT imaging increases the predictive accuracy for development of hemispheric ischemia during ICA clamping during CEA.

Preoperative Cerebral Oxygen Extraction Fraction Imaging Generated from 7T MR Quantitative Susceptibility Mapping Predicts Development of Cerebral Hyperperfusion following Carotid Endarterectomy

BACKGROUND AND PURPOSE

Preoperative hemodynamic impairment in the affected cerebral hemisphere is associated with the development of cerebral hyperperfusion following carotid endarterectomy. Cerebral oxygen extraction fraction images generated from 7T MR quantitative susceptibility mapping correlate with oxygen extraction fraction images on positron-emission tomography. The present study aimed to determine whether preoperative oxygen extraction fraction imaging generated from 7T MR quantitative susceptibility mapping could identify patients at risk for cerebral hyperperfusion following carotid endarterectomy.

MATERIALS AND METHODS

Seventy-seven patients with unilateral internal carotid artery stenosis (≥70%) underwent preoperative 3D T2*-weighted imaging using a multiple dipole-inversion algorithm with a 7T MR imager. Quantitative susceptibility mapping images were then obtained, and oxygen extraction fraction maps were generated. Quantitative brain perfusion single-photon emission CT was also performed before and immediately after carotid endarterectomy. ROIs were automatically placed in the bilateral middle cerebral artery territories in all images using a 3D stereotactic ROI template, and affected-to-contralateral ratios in the ROIs were calculated on quantitative susceptibility mapping-oxygen extraction fraction images.

RESULTS

Ten patients (13%) showed post-carotid endarterectomy hyperperfusion (cerebral blood flow increases of ≥100% compared with preoperative values in the ROIs on brain perfusion SPECT). Multivariate analysis showed that a high quantitative susceptibility mapping-oxygen extraction fraction ratio was significantly associated with the development of post-carotid endarterectomy hyperperfusion (95% confidence interval, 33.5-249.7; P = .002). Sensitivity, specificity, and positive- and negative-predictive values of the quantitative susceptibility mapping-oxygen extraction fraction ratio for the prediction of the development of post-carotid endarterectomy hyperperfusion were 90%, 84%, 45%, and 98%, respectively.

CONCLUSIONS

Preoperative oxygen extraction fraction imaging generated from 7T MR quantitative susceptibility mapping identifies patients at risk for cerebral hyperperfusion following carotid endarterectomy.

Effective collateral circulation may indicate improved perfusion territory restoration after carotid endarterectomy

OBJECTIVES

To investigate the relationship between the level of collateral circulation and perfusion territory normalisation after carotid endarterectomy (CEA).

METHODS

This study enrolled 22 patients with severe carotid stenosis that underwent CEA and 54 volunteers without significant carotid stenosis. All patients were scanned with ASL and t-ASL within 1 month before and 1 week after CEA. Collateral circulation was assessed on preoperative ASL images based on the presence of ATA. The postoperative flow territories were considered as back to normal if they conformed to the perfusion territory map in a healthy population. Neuropsychological tests were performed on patients before and within 7 days after surgery.

RESULTS

ATA-based collateral score assessed on preoperative ASL was significantly higher in the flow territory normalisation group (n=11, 50 %) after CEA (P < 0.0001). The MMSE (mean change=1.36±0.96) and MOCA (mean change=1.18±0.95) test scores showed a significant postoperative (7 days after CEA) improvement in the flow territory normalisation group [>mean differences+2SD among control (MMSE=1.35, MOCA=1.02)].

CONCLUSIONS

This study demonstrated that effective collateral flow in carotid stenosis patients was associated with normalisation of t-ASL perfusion territory after CEA. The perfusion territory normalisation group tends to have more cognitive improvement after CEA.

KEY POINTS

• Evaluation of collaterals before CEA is helpful for avoiding ischaemia during clamping. • There was good agreement on ATA-based ASL collateral grading. • Perfusion territories in carotid stenosis patients are altered. • Patients have better collateral circulation with perfusion territory back to normal. • MMSE and MOCA test scores improved more in the territory normalisation group.

Cerebral Hyperperfusion after Revascularization Inhibits Development of Cerebral Ischemic Lesions Due to Artery-to-Artery Emboli during Carotid Exposure in Endarterectomy for Patients with Preoperative Cerebral Hemodynamic Insufficiency: Revisiting the "Impaired Clearance of Emboli" Concept

The purpose of the present study was to determine whether cerebral hyperperfusion after revascularization inhibits development of cerebral ischemic lesions due to artery-to-artery emboli during exposure of the carotid arteries in carotid endarterectomy (CEA). In patients undergoing CEA for internal carotid artery stenosis (≥70%), cerebral blood flow (CBF) was measured using single-photon emission computed tomography (SPECT) before and immediately after CEA. Microembolic signals (MES) were identified using transcranial Doppler during carotid exposure. Diffusion-weighted magnetic resonance imaging (DWI) was performed within 24 h after surgery. Of 32 patients with a combination of reduced cerebrovascular reactivity to acetazolamide on preoperative brain perfusion SPECT and MES during carotid exposure, 14 (44%) showed cerebral hyperperfusion (defined as postoperative CBF increase ≥100% compared with preoperative values), and 16 (50%) developed DWI-characterized postoperative cerebral ischemic lesions. Postoperative cerebral hyperperfusion was significantly associated with the absence of DWI-characterized postoperative cerebral ischemic lesions (95% confidence interval, 0.001–0.179; p = 0.0009). These data suggest that cerebral hyperperfusion after revascularization inhibits development of cerebral ischemic lesions due to artery-to-artery emboli during carotid exposure in CEA, supporting the “impaired clearance of emboli” concept. Blood pressure elevation following carotid declamping would be effective when embolism not accompanied by cerebral hyperperfusion occurs during CEA.

Preoperative prediction of cerebral hyperperfusion after carotid endarterectomy using middle cerebral artery signal intensity in 1.5-tesla magnetic resonance angiography followed by cerebrovascular reactivity to acetazolamide using brain perfusion single-photon emission computed tomography

OBJECTIVE

The purpose of the present study was to determine whether the signal intensity of the middle cerebral artery (MCA) on preoperative 1.5-T magnetic resonance angiography (MRA) could identify patients at risk for hyperperfusion following carotid endarterectomy (CEA) as a clinical screening test and whether an additional measurement of preoperative cerebrovascular reactivity (CVR) to acetazolamide on brain perfusion single-photon emission computed tomography (SPECT) could increase the predictive accuracy for the development of hyperperfusion.

METHODS

In 301 patients, the signal intensity of the MCA ipsilateral to CEA on MRA was preoperatively graded according to the ability to visualize the MCA. For patients with reduced MCA signal intensity on the MRA study, CVR to acetazolamide was subsequently assessed using brain perfusion SPECT. Cerebral hyperperfusion was determined intraoperatively using transcranial regional cerebral oxygen saturation monitoring with near-infrared spectroscopy.

RESULTS

Preoperative reduced MCA signal intensity was significantly associated with the development of cerebral hyperperfusion (95% CI, 1.188-3.965; p = 0.0352). While the sensitivity and negative predictive value were 100% both for the preoperative MCA signal intensity alone and in combination with subsequent preoperative CVR to acetazolamide, the specificity and positive predictive value were significantly greater for the latter than for the former (p < 0.05).

CONCLUSIONS

Signal intensity of the MCA on preoperative 1.5-T MRA identifies patients at risk for hyperperfusion following CEA as a clinical screening test. An additional measurement of preoperative CVR to acetazolamide increases the predictive accuracy for the development of hyperperfusion.

Pre-operative methods to predict need for shunting during carotid endarterectomy

OBJECTIVES

To establish whether pre-operative investigations are able to predict cerebral tolerance to carotid cross clamping during carotid endarterectomy (CEA).

METHODS

A search of the MEDLINE database from 1950 to 2015 was made in combination with manual cross-referencing using the search strategy: ("carotid" [all fields] AND "endarterectomy" [all fields]) AND "preoperative" [all fields]) AND "clamping" [all fields]) AND ("MRA" [all fields] OR "MRI" [all fields] OR "CT" [all fields] OR "CTA" [all fields] OR "EEG" [all fields] OR "Doppler" [all fields] OR "angiography" [all fields]). A total of 20 studies were identified as eligible for inclusion.

RESULTS

3D Time of Flight MRA and acetazolomide stress SPECT imaging have been reported to have a negative predictive value of 96% and 94% respectively for the need for intraoperative shunting during carotid endarterectomy.

CONCLUSIONS

There is some evidence to suggest that pre-operative imaging investigations can reliably identify which patients undergoing CEA will not require carotid shunting for neurological protection. However, this evidence is limited and there is a need for more rigorous studies to be conducted.

Does preoperative measurement of cerebral blood flow with acetazolamide challenge in addition to preoperative measurement of cerebral blood flow at the resting state increase the predictive accuracy of development of cerebral hyperperfusion after carotid endarterectomy? Results from 500 cases with brain perfusion single-photon emission computed tomography study

The purpose of the present study was to determine whether preoperative measurement of cerebral blood flow (CBF) with acetazolamide in addition to preoperative measurement of CBF at the resting state increases the predictive accuracy of development of cerebral hyperperfusion after carotid endarterectomy (CEA). CBF at the resting state and cerebrovascular reactivity (CVR) to acetazolamide were quantitatively assessed using N-isopropyl-p-[¹²³I]-iodoamphetamine (IMP)-autoradiography method with single-photon emission computed tomography (SPECT) before CEA in 500 patients with ipsilateral internal carotid artery stenosis (≥ 70%). CBF measurement using ¹²³I-IMP SPECT was also performed immediately and 3 days after CEA. A region of interest (ROI) was automatically placed in the middle cerebral artery territory in the affected cerebral hemisphere using a three-dimensional stereotactic ROI template. Preoperative decreases in CBF at the resting state [95% confidence intervals (CIs), 0.855 to 0.967; P = 0.0023] and preoperative decreases in CVR to acetazolamide (95% CIs, 0.844 to 0.912; P < 0.0001) were significant independent predictors of post-CEA hyperperfusion. The area under the receiver operating characteristic curve for prediction of the development of post-CEA hyperperfusion was significantly greater for CVR to acetazolamide than for CBF at the resting state (difference between areas, 0.173; P < 0.0001). Sensitivity, specificity, and positive- and negative-predictive values for the prediction of the development of post-CEA hyperperfusion were significantly greater for CVR to acetazolamide than for CBF at the resting state (P < 0.05, respectively). The present study demonstrated that preoperative measurement of CBF with acetazolamide in addition to preoperative measurement of CBF at the resting state increases the predictive accuracy of the development of post-CEA hyperperfusion.

A 3D numerical study of the collateral capacity of the Circle of Willis with anatomical variation in the posterior circulation

Background

The Circle of Willis (CoW) is the most important collateral pathway of the cerebral artery. The present study aims to investigate the collateral capacity of CoW with anatomical variation when unilateral internalcarotid artery (ICA) is occluded.

Methods

Basing on MRI data, we have reconstructed eight 3D models with variations in the posterior circulation of the CoW and set four different degrees of stenosis in the right ICA, namely 24%, 43%, 64% and 79%, respectively. Finally, a total of 40 models are performed with computational fluid dynamics simulations. All of the simulations share the same boundary condition with static pressure and the volume flow rate (VFR) are obtained to evaluate their collateral capacity.

Results

As for the middle cerebral artery (MCA) and the anterior cerebral artery (ACA), the transitional-type model possesses the best collateral capacity. But for the posterior cerebral artery (PCA), unilateral stenosis of ICA has the weakest influence on the unilateral posterior communicating artery (PCoA) absent model. We also find that the full fetal-type posterior circle of Willis is an utmost dangerous variation which must be paid more attention.

Conclusion

The results demonstrate that different models have different collateral capacities in coping stenosis of unilateral ICA and these differences can be reflected by different outlets. The study could be used as a reference for neurosurgeon in choosing the best treatment strategy.

Importance of dynamic aortic evaluation in planning TEVAR

Dynamic aortic evaluation in planning thoracic endovascular aortic repair (TEVAR) is important to provide optimal stent graft sizing. Static imaging protocols do not consider normal aortic dynamics and may lead to stent graft to aorta mismatch, causing stent graft related complications, such as type I endoleak and stent graft migration. Dynamic imaging can assist in accurate stent graft selection and sizing preoperatively, and evaluate stent graft performance during follow-up. To create new imaging technologies, integration of knowledge between diverse scientific fields is essential (i.e., engineering, informatics and medicine). Different dynamic imaging modalities, such as electrocardiographic-gated computed tomography angiography (ECG-gated CTA) and four-dimensional phase-contrast MRI (4D PC-MRI), are progressively investigated and implemented into clinical practice as important instruments in preoperative planning for TEVAR. In time, further application of dynamic imaging tools for preoperative screening and follow-up after TEVAR might lead to better outcomes for patients. The advances in dynamic imaging for evaluation of the thoracic aorta using new imaging modalities and their future perspectives are addressed in this manuscript.

In vitro study of hemodynamic treatment improvement: Hunterian ligation of a fenestrated basilar artery aneurysm after coiling

Hunterian ligation affecting hemodynamics in vessels was proposed to avoid rebleeding in a case of a fenestrated basilar artery aneurysm after incomplete coil occlusion. We studied the hemodynamics in vitro to predict the hemodynamic changes near the aneurysm remnant caused by Hunterian ligation. A transparent model was fabricated based on three-dimensional rotational angiography imaging. Arteries were segmented and reconstructed. Pulsatile flow in the artery segments near the partially occluded (coiled) aneurysm was investigated by means of particle image velocimetry. The hemodynamic situation was investigated before and after Hunterian ligation of either the left or the right vertebral artery (LVA/RVA). Since post-ligation flow rate in the basilar artery was unknown, reduced and retained flow rates were simulated for both ligation options. Flow in the RVA and in the corresponding fenestra vessel is characterized by a vortex at the vertebrobasilar junction, whereas the LVA exhibits undisturbed laminar flow. Both options (RVA or LVA ligation) cause a significant flow reduction near the aneurysm remnant with a retained flow rate. The impact of RVA ligation is, however, significantly higher. This in vitro case study shows that flow reduction near the aneurysm remnant can be achieved by Hunterian ligation and that this effect depends largely on the selection of the ligated vessel. Thus the ability of the proposed in vitro pipe-line to improve hemodynamic impact of the proposed therapy was successfully proved.

Cerebrovascular reactivity by quantitative magnetic resonance angiography with a Co₂ challenge. Validation as a new imaging biomarker

Assessment of cerebrovascular reactivity (CVR) is essential in cerebrovascular diseases, as exhausted CVR may enhance the risk of cerebral ischemic events. Transcranial Doppler (TCD) with a vasodilatory stimulus is currently used for CVR evaluation. Scanty data are available for Quantitative Magnetic Resonance Angiography (QMRA), which supplies higher spatial resolution and quantitative cerebral blood flow values. Aims of our pilot study were: (a) to assess safety and feasibility of CO2 administration during QMRA, (b) evaluation of CVR under QMRA compared to TCD, and (c) quantitative evaluation of blood flow from the major intracranial arterial vessels both at rest and after CO2. CVR during 5% CO2 air breathing was measured with TCD as a reference method and compared with QMRA. Fifteen healthy subjects (age 60.47 ± 2.24; male 11/15) were evaluated at rest and during CO2 challenge. Feasibility and safety of QMRA under CO2 were ensured in all subjects. CVR from middle cerebral artery territory was not statistically different between TCD and MRI (p>0.05). Mean arterial pressure (MAP) and heart rate (HR) increased during QMRA and TCD (MAP p=0.007 and p=0.001; HR p=0.043 and p=0.068, respectively). Blood flow values from all intracranial vessels increased after CO2 inhalation (p<0.001). CO2 administration during QMRA sessions is safe and feasible. Good correlation in terms of CVR was obtained comparing TCD and QMRA. Blood flow values significantly increased from all intracranial arterial vessels after CO2. Studies regarding CVR in physiopathological conditions might consider the utilization of QMRA both in routine clinical settings and in research projects.

Feasibility of 4D flow MR imaging of the brain with either Cartesian y-z radial sampling or k-t SENSE: comparison with 4D Flow MR imaging using SENSE

PURPOSE

A drawback of time-resolved 3-dimensional phase contrast magnetic resonance (4D Flow MR) imaging is its lengthy scan time for clinical application in the brain. We assessed the feasibility for flow measurement and visualization of 4D Flow MR imaging using Cartesian y-z radial sampling and that using k-t sensitivity encoding (k-t SENSE) by comparison with the standard scan using SENSE.

MATERIALS AND METHODS

Sixteen volunteers underwent 3 types of 4D Flow MR imaging of the brain using a 3.0-tesla scanner. As the standard scan, 4D Flow MR imaging with SENSE was performed first and then followed by 2 types of acceleration scan-with Cartesian y-z radial sampling and with k-t SENSE. We measured peak systolic velocity (PSV) and blood flow volume (BFV) in 9 arteries, and the percentage of particles arriving from the emitter plane at the target plane in 3 arteries, visually graded image quality in 9 arteries, and compared these quantitative and visual data between the standard scan and each acceleration scan.

RESULTS

4D Flow MR imaging examinations were completed in all but one volunteer, who did not undergo the last examination because of headache. Each acceleration scan reduced scan time by 50% compared with the standard scan. The k-t SENSE imaging underestimated PSV and BFV (P < 0.05). There were significant correlations for PSV and BFV between the standard scan and each acceleration scan (P < 0.01). The percentage of particles reaching the target plane did not differ between the standard scan and each acceleration scan. For visual assessment, y-z radial sampling deteriorated the image quality of the 3 arteries.

CONCLUSION

Cartesian y-z radial sampling is feasible for measuring flow, and k-t SENSE offers sufficient flow visualization; both allow acquisition of 4D Flow MR imaging with shorter scan time.

Preoperative magnetic resonance angiography as a predictive test for cerebral ischemia during carotid endarterectomy

BACKGROUND

To evaluate whether the preoperative magnetic resonance angiography (MRA) can predict the risk of cerebral ischemia associated with the carotid endarterectomy (CEA).

METHODS

Between January 2004 and December 2010, 382 consecutive patients (mean age: 56.6 years; range: 45-78 years) were identified to have undergone preoperative MRA and the CEA under regional anesthesia. It was determined that the patient needs shunting during the CEA by intraoperative monitoring of patient's neurology. All patients were divided into two subgroups: shunt group or no-shunt group. Imaging findings on preoperative MRA were correlated to shunting using univariate and multivariate logistic regression analyses combined with patient's demographic and clinical features to identify predictors of cerebral ischemia during the CEA.

RESULTS

In 37 of 382 CEA cases (9.7%), shunting had been performed intraoperatively because the patient had a neurologic deficit. At multivariate analysis, preoperative MRA findings such as the absence of patent communicating arteries (odds ratio [OR], 5.56; 95% confidence interval [CI], 3.05-9.69; p = 0.013) and the increase of intracranial arteries which were not patent in the contralateral hemisphere (OR, 4.277; 95% CI, 2.575 to 7.104; p < 0.0001) were significantly associated with shunting.

CONCLUSIONS

Preoperative MRA is valuable when predicting cerebral ischemia leading to an inevitable shunting during CEA. Therefore, if there are preoperative MRA findings such as multiple occlusive intracranial arteries in the contralateral hemisphere or the absence of patent communicating arteries, it is recommended that CEA be performed under general anesthesia with routine shunting to avoid a serious shunt-related complication.

[Non-invasive evaluation of intracranial pressure: how and for whom?]

The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.

Comorbid intracranial vertebral artery asymmetry as a risk factor for severe vestibular neuronitis

BACKGROUND

Our previous study had demonstrated that verterbral artery hypoplasia (VAH) contribute to ipsilateral vestibular dysfunction. The aim of this study was to test if VAH contributes to prognosis of vestibular neuronitis (VN) through presumed regional malperfusion.

METHODS

We performed a prospective magnetic resonance angiographic registry in patients with acute vestibular neuritis in which were then assigned to VAH (n=29) and control group (n=40). Vestibular function was determined by caloric irrigation, with the use of the vestibular paresis formula (to measure the extent of unilateral caloric paresis) within 3 days after the onset of symptoms and 12 months afterward.

RESULTS

The baseline vestibular paresis was higher (56.8 ± 15.9%) in the VAH VN subjects (n=29), than in VN subjects without VAH (n=40) (37.4 ± 17.7%) (p=0.01). Analysis of variance showed a less percentage of the VAH group return to normal at 4th and 12th week visit.

CONCLUSION

Our results suggested that comorbid VAH may predispose to severe VN at acute stage.

Correlation of intraoperative collateral perfusion pressure during carotid endarterectomy and status of the contralateral carotid artery and collateral cerebral blood flow

BACKGROUND

The optimal method for predicting when carotid shunting is not necessary during carotid endarterectomy (CEA) is controversial. This study will analyze the correlation of collateral perfusion pressure and the status of contralateral carotid/cerebral collaterals and determine whether preoperative duplex ultrasound/cerebral angiography can predict when CEA can be done without shunting.

METHODS

Ninety-eight patients were randomized into routine shunting and 102 into selective shunting when the collateral perfusion pressure (systolic carotid stump pressure) was <40 mm Hg during CEA. All patients had preoperative carotid duplex ultrasound and 87 had angiography, the results of which were evaluated for the presence of collateral flow from the contralateral carotid artery or posterior circulation through the anterior and/or posterior communicating arteries.

RESULTS

The perioperative stroke rate was 1.5% for the entire group. There was no correlation between preoperative symptoms and the status of the contralateral carotid artery (normal, stenosed, or occluded). The mean collateral perfusion pressure was inversely related to the severity of the contralateral carotid stenosis: 60, 57, 55, 56, and 38 mm Hg for normal, <50% stenosed, 50-69% stenosed, 70-99% stenosed, and occluded arteries, respectively (p = 0.005). There was a direct relation between the number of patients with a collateral perfusion pressure of <40 mm Hg (shunted group) and the severity of the contralateral carotid stenosis: 6 of 62 (10%) for normal carotid, 7 of 43 (16%) for <50% stenosis (OR = 1.82), 12 of 69 (17%) for 50-69% stenosis (OR = 1.97), 3 of 10 (30%) for 70-99% stenosis (OR = 4, CI = 0.81-19.68), and 9 of 13 (70%) for occlusion (OR = 21, CI = 4.98-89.32) (p < 0.0001). None of the patients (0/56) with normal to <70% contralateral carotid stenosis with cross-filling had a collateral perfusion pressure of <40 mm Hg (no shunting was necessary). However, 9 of 17 (47%) patients with <70% contralateral carotid stenosis and no cross-filling had a collateral perfusion pressure of <40 mm Hg (p < 0.0001), whereas 6 of 7 (86%) patients with ≥70% contralateral carotid stenosis and cross-filling versus 2 of 7 (29%) with ≥70% contralateral carotid stenosis and no cross-filling had a collateral perfusion stump pressure of >40 mm Hg (p = 0.1026). Overall, 62 of 63 (98.4%) patients with cross-filling versus 10 of 24 (42%) without cross-filling had a collateral perfusion pressure of ≥40 mm Hg (p < 0.0001).

CONCLUSIONS

There was an inverse correlation between collateral perfusion pressure and severity of contralateral carotid stenosis, and patients with severe contralateral carotid stenosis/occlusion were more likely to be shunted. The presence of cross-filling with normal to <70% contralateral carotid stenosis was associated with a collateral perfusion stump pressure of ≥40 mm Hg in 100% of patients for whom shunting was not carried out in our series.

Noninvasive detection of the distinction between progressive and compensated hydrocephalus in infants: is it possible?

OBJECT

Clinical signs and symptoms of hydrocephalus can be clear and specific, but also subtle, nonspecific, or even absent. It may be difficult to decide whether shunt placement is indicated, especially in infants. Therefore, there is a need for the development of better noninvasive detection methods to distinguish between compensated and (slowly) progressive hydrocephalus. Early interference can reverse the cerebral damage, whereas the detection of a nonpathological state in infants with compensated hydrocephalus avoids the complications of unnecessary shunt procedures. Using MR imaging, the authors investigated cerebral blood flow (CBF) and apparent diffusion coefficients (ADCs) measured in infants with clinically compensated hydrocephalus.

METHODS

The diagnosis of compensated hydrocephalus was made on the basis of clinical criteria, consisting of no signs or symptoms of increased intracranial pressure (ICP), measurement of a normal ICP, and standard MR imaging showing enlarged ventricles. Flow measurements through both internal carotid arteries and the basilar artery were considered to represent the total CBF. In addition, ADC values were assessed in 5 different regions of interest in the brain parenchyma using diffusion weighted imaging. Brain volumetric measurement was performed to express CBF in ml/100 cm(3) brain/min, thus compensating for physiological CBF growth over time. Mean arterial blood pressure was manually measured to exclude this factor as a cause of a possible change in CBF. Intracranial pressure measurement was performed noninvasively using the Rotterdam Teletransducer.

RESULTS

Eighteen infants with clinically compensated hydrocephalus were included. The mean CBF was 53.5 ml/100 cm(3) of brain/min. The individual CBF values were graphically compared with age-related normal CBF values and fell in the normal range. Mean ADC value was 890.0 x10(-6) mm(2)/sec. Apparent diffusion coefficient values per region of interest were graphically compared with normal ADC values per region of interest and fell within the normal range.

CONCLUSIONS

In infants with hydrocephalus, normal CBF and low ADC values, as measured using MR imaging, are associated with compensated hydrocephalus and may support a conservative approach with respect to the decision on whether to place a shunt.

Associations between total cerebral blood flow and age related changes of the brain

Background and Purpose

Although total cerebral blood flow (tCBF) is known to be related to age, less is known regarding the associations between tCBF and the morphologic changes of the brain accompanying cerebral aging. The purpose of this study was to investigate whether total cerebral blood flow (tCBF) is related to white matter hyperintensity (WMH) volume and/or cerebral atrophy. Furthermore, we investigate whether tCBF should be expressed in mL/min, as was done in all previous MR studies, or in mL/100 mL/min, which yielded good results in precious SPECT, PET and perfusion MRI studies investigating regional cerebral blood flow.

Materials and Methods

Patients were included from the nested MRI sub-study of the PROSPER study. Dual fast spin echo and FLAIR images were obtained in all patients. In addition, single slice phase contrast MR angiography was used for flow measurements in the internal carotids and vertebral arteries. tCBF was expressed in both mL/min and mL/100 mL/min.

Results

We found a significant correlation between tCBF in mL/min and both age (r = −.124; p = p≤.001) and parenchymal volume (r = 0.430; p≤.001). We found no association between tCBF in mL/min and %-atrophy (r = −.077; p = .103) or total WMH volume (r = −.069; p = .148). When tCBF was expressed in mL/100 mL/min the correlation between tCBF and age was no longer found (r = −.001; p = .985). Multivariate regression analyses corrected for age showed a significant correlation between tCBF in mL/100 mL/min and WMH volume (r = −.106; p = .044). No significant association between tCBF in mL/100 mL/min and %-atrophy was found.

Conclusion

From this study we conclude that, when evaluating tCBF alterations due to various pathologies, tCBF should in mL/100 mL/min instead of mL/min. Furthermore, changes or differences in WMH volume should be accounted for.

Contralateral stroke during carotid endarterectomy due to abnormalities in the circle of Willis

Approximately 10-20% of patients will not tolerate cross-clamping of the common carotid artery for carotid endarterectomy procedures. The most frequent causes of neurological deficits are either embolization of particulate matter or cerebral hypoperfusion. Insufficient blood flow through primary collaterals of the circle of Willis is the main reason for hypoperfusion that requires immediate shunt placement. Although excessive preoperative imaging is not indicated in many patients undergoing disobliteration of a stenosed internal carotid artery, there are some patients with particular anatomic constellations who would benefit from a more detailed preoperative work-up. In these cases, the specific risk should be evaluated prior to surgery in order to make plans for appropriate intraoperative management regarding neurologic monitoring and shunt insertion. As regional anesthesia permits early detection of ischemic symptoms, it is advantageous in these patients. We report a case where regional anesthesia allowed early detection of rapidly progressing signs of bi-hemispheric brain ischemia in a patient with diabetes and with at that time unknown severe abnormalities of the circle of Willis. Lack of adequate collateralization was detected only after surgery, in a combined perfusion-magnetic resonance imaging study. In symptomatic diabetics with low-grade stenosis of the internal carotid artery, preoperative assessment of the function of the circle of Willis may therefore be helpful in predicting any increased risk for intraoperative cerebral ischemia.

Increased intravascular flow rate triggers cerebral arteriogenesis

Peripheral arteriogenesis is distinctly enhanced by increased fluid shear stress. Thus, the aim of this study was to investigate in the rat brain whether increased fluid shear stress can also stimulate cerebral arteriogenesis. To increase fluid shear stress in the cerebral circulation, we developed different shear stress models as the ligature of both common carotid arteries (Double-Ligature model), bilateral carotid ligature followed by creation of a unilateral arterio-venous fistula (two-stage protocol, Ligature-Shunt model), and unilateral arterio-venous fistula-creation alone (Solo-Shunt model). Blood flow changes were monitored in vivo by quantitative magnetic resonance imaging-analysis. Cerebral arteriogenesis was analyzed by magnetic resonance imaging and contrast agent-angiography. For proliferation and accumulation of mononuclear cells, immunohistochemistry was performed. During the 14 days-observation period, blood flow increased maximal by 5.5-fold in the A. basilaris and 10.3-fold in the fistula-sided A. cerebri posterior of the Ligature-Shunt model. Considerable vessel growth was found in all shear stress-stimulated arteries. Comparative analysis of vessel length and diameter versus blood flow indicated a correlation between the growth of cerebral collaterals and rising intravascular flow rates (R2=0.90/0.96). Immunohistochemistry showed the typical phases of arteriogenesis and accumulation of mononuclear cells. In conclusion, we provide evidence that fluid shear stress is not only the pivotal trigger of peripheral but also of cerebral arteriogenesis.

Cardiovascular applications of phase-contrast MRI

OBJECTIVE

The purpose of this study was to review and illustrate various clinical applications of phase-contrast MRI.

CONCLUSION

Cardiac MRI has emerged as a valuable noninvasive clinical tool for evaluation of the cardiovascular system. Phase-contrast MRI has a variety of established applications in quantifying blood flow and velocity and several emerging applications, such as evaluation of diastolic function and myocardial dyssynchrony.

Magnetic resonance imaging for quantitative flow measurement in infants with hydrocephalus: a prospective study

OBJECT

Raised intracranial pressure (ICP) that is associated with hydrocephalus may lead to alterations in cerebral hemodynamics and ischemic changes in the brain. In infants with hydrocephalus, defining the right moment for surgical intervention based on clinical signs alone can sometimes be a difficult task. Clinical signs of raised ICP are known to be unreliable and sometimes even misleading. Furthermore, when sutures are closed, ICP does not always correlate with the size of the ventricles or with the clinical signs or symptoms. In this study the authors investigated whether cerebral blood flow (CBF) can be measured by using quantitative MR angiography in infants with progressive hydrocephalus. In addition, the authors investigated the relationship between CBF and ICP, before and after cerebrospinal fluid (CSF) diversion.

METHODS

Fifteen infants with progressive hydrocephalus (age range 1 day-7 months) were examined. All patients underwent anterior fontanel pressure measurement, MR angiography, and mean arterial blood pressure measurements before and after CSF diversion. Brain volume was measured to compensate for the physiological increase in CBF during brain maturation in infants.

RESULTS

The mean preoperative ICP was 19.1 +/- 8.4 cm H(2)O (+/- standard deviation). The mean postoperative ICP was 6.7 +/- 4.0 cm H(2)O (p < 0.005). The mean preoperative CBF was 25.7 +/- 11.3 ml/100 cm(3) brain/min. After CSF diversion, CBF increased to 50.1 +/- 12.1 ml/100 cm(3) brain/min (p < 0.005). The mean arterial blood pressure did not change after surgical intervention.

CONCLUSIONS

Magnetic resonance imaging can be used to measure CBF in infants with hydrocephalus. Raised ICP was related to a decrease in CBF. After CSF diversion, CBF and ICP improved to values within the normal range.

The Quantification of Cerebral Blood Flow by Phase Contrast MRA: Basics and Applications

Phase-contrast magnetic resonance (PCMRA) flow quantification can determine vascular velocities and volumetric flow rate (VFR) non-invasively for in vitro and in vivo studies. Recently, the increasing power of MR imaging units and the reduced time for data acquisition and post-processing have led to an increasing number of investigations on the use of phase-contrast flow measurements as an additional source of quantitative functional information in MR imaging. In addition, PCMRA can be added to morphologic MRI sequences, offering the option to correlate flow to morphology based on data generated during one examination. This review discusses the basics of phase-contrast imaging, describing the errors and avoiding methods associated with PCMRA, providing guidelines for flow measurement and data analysis, and presenting the current clinical cerebral applications.

Evaluation of extracranial-intracranial bypass using quantitative magnetic resonance angiography

OBJECT

To date, angiography has been the primary modality for assessing graft patency following extracranial-intracranial bypass. The utility of a noninvasive and quantitative method of assessing bypass function postoperatively was evaluated using quantitative magnetic resonance (MR) angiography.

METHODS

One hundred one cases of bypass surgery performed over a 5.5-year period at a single institution were reviewed. In 62 cases, both angiographic and quantitative MR angiographic data were available. Intraoperative flow measurements were available in 13 cases in which quantitative MR angiography was performed during the early postoperative period (within 48 hours after surgery). There was excellent correlation between quantitative MR angiographic flow and angiographic findings over the mean 10 months of imaging follow up. Occluded bypasses were consistently absent on quantitative MR angiograms (four cases). The flow rates were significantly lower in those bypasses that became stenotic or reduced in diameter as demonstrated by follow-up angiography (nine cases) than in those bypasses that remained fully patent (mean +/- standard error of the mean, 37 +/- 13 ml/minute compared with 105 +/- 7 ml/minute, p = 0.001). Flows were appreciably lower in poorly functioning bypasses for both vein and in situ arterial grafts. All angiographically poor bypasses (nine cases) were identifiable by absolute flows of less than 20 ml/minute or a reduction in flow greater than 30% within 3 months. Good correlation was seen between intraoperative flow measurements and early postoperative quantitative MR angiographic flow measurements (13 cases, Pearson correlation coefficient = 0.70, p = 0.02).

CONCLUSIONS

Bypass grafts can be assessed in a noninvasive fashion by using quantitative MR angiography. This imaging modality provides not only information regarding patency as shown by conventional angiography, but also a quantitative assessment of bypass function. In this study, a low or rapidly decreasing flow was indicative of a shrunken or stenotic graft. Quantitative MR angiography may provide an alternative to standard angiography for serial follow up of bypass grafts.

Anatomic Variations in the Circle of Willis in Patients with Symptomatic Carotid Artery Stenosis Assessed with Multidetector Row CT Angiography

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.

Cerebral Ischemia during Carotid Artery Cross-Clamping: Predictive Value of Phase-Contrast Magnetic Resonance Imaging

The goal of this prospective study was to determine the utility of preoperative cerebral magnetic resonance imaging (MRI) in predicting cerebral ischemia during carotid artery cross-clamping for endarterectomy. Between January 2000 and December 2003, a total of 121 patients (95 men, 26 women) underwent three-dimensional phase-contrast MRI to assess collateral function prior to carotid endarterectomy. During regional anesthesia, patients were monitored to detect ischemic events and their timing in relation to cross-clamping and to determine mean intraoperative arterial pressure. These findings were then correlated with the collateral variations observed in the circle of Willis on preoperative MRI. Patients were classified into three groups according to neurological tolerance: normal tolerance (n = 106), immediate severe deficit (n = 9), and late deficit associated with arterial hypotension (n = 6). In the second group, a significant correlation was found between the absence of collateral circulation and neurological deficit (p < .0001). These results indicated that three-dimensional phase-contrast MRI is useful for predicting cerebral ischemia during carotid cross-clamping and selecting indications for shunting. Absence of visible collaterals of the circle of Willis on MRI is significantly predictive of early ischemia and an indication for systematic shunt placement.

Hemodynamic effect of carotid stenting and carotid endarterectomy

BACKGROUND

Carotid angioplasty with stent placement (CAS) may offer an alternative treatment to carotid endarterectomy (CEA). However, in contrast to CEA, which has been shown to normalize impaired cerebral hemodynamics, the effects of CAS remain unclear. To investigate alterations in cerebral hemodynamics, we prospectively studied patients undergoing CAS and compared them with a group of similar patients undergoing CEA.

METHODS

Twenty-three patients undergoing CAS for recently symptomatic internal carotid artery (ICA) stenosis were prospectively studied. Volume flow in the ICAs and basilar artery (BA) were measured with magnetic resonance volume flow quantification before CAS and 1 month after. The results were compared with those in 13 similar patients undergoing CEA and 40 control subjects without ICA stenosis.

RESULTS

After CAS, volume flow in the ipsilateral ICA increased from 114 +/- 17 to 231 +/- 17 mL/min (P < .001), and total volume flow (ICAs plus BA) increased from 495 +/- 24 to 552 +/- 28 mL/min (P < .05). No significant changes were seen in the contralateral ICA and BA after CAS. Total volume flow and flow in the stenosed ICA normalized after CAS compared with control subjects. Volume flow values similarly improved after CEA.

CONCLUSIONS

CAS results in a normalization of impaired cerebral hemodynamics, as assessed by magnetic resonance volume flow measurements. The degree of improvement is similar to that seen after CEA.