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Taira N, Hara S, Namba A, Tanaka Y, Maehara T. Spatial coefficient of variation of arterial spin labeling magnetic resonance imaging can predict decreased cerebrovascular reactivity measured by acetazolamide challenge single-photon emission tomography. Neuroradiology 2024; 66:1693-1703. [PMID: 39042167 DOI: 10.1007/s00234-024-03431-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE The aim of this study was to investigate whether the spatial coefficient of variation of arterial spin labeling (ASL-CoV) acquired in clinical settings can be used to estimate decreased cerebrovascular reactivity (CVR) measured with single-photon emission computed tomography (SPECT) and acetazolamide challenge in patients with atherosclerotic stenosis of intra- or extracranial arteries. METHODS We evaluated the data of 27 atherosclerotic stenosis patients who underwent pseudocontinuous ASL and SPECT. After spatial normalization, regional values were measured using the distributed middle cerebral artery territorial atlas of each patient. We performed comparisons, correlations, and receiver operating characteristic (ROC) curve analyses between ASL-cerebral blood blow (CBF), ASL-CoV, SPECT-CBF and SPECT-CVR. RESULTS Although the ASL-CBF values were positively correlated with SPECT-CBF values (r = 0.48, 95% confidence interval (CI) = 0.28-0.64), no significant difference in ASL-CBF values was detected between regions with and without decreased CVR. However, regions with decreased CVR had significantly greater ASL-CoV values than regions without decreased CVR. SPECT-CVR was negatively correlated with ASL-CoV (ρ = -0.29, 95% CI = -0.49 - -0.06). The area under the ROC curve of ASL-CoV in predicting decreased CVR (0.66, 95% CI = 0.51-0.81) was greater than that of ASL-CBF (0.51, 95% CI = 0.34-0.68). An ASL-CoV threshold value of 42% achieved a high specificity of 0.93 (sensitivity = 0.42, positive predictive value = 0.77, and negative predictive value = 0.75). CONCLUSION ASL-CoV acquired by single postlabeling delay without an acetazolamide challenge may aid in the identification of patients with decreased CVR on SPECT.
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Affiliation(s)
- Naoki Taira
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Aya Namba
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Fan X, Zuo Z, Lin T, Lai Z, You H, Qu J, Wei J, Liu B, Feng F. Arterial transit artifacts on arterial spin labeling MRI can predict cerebral hyperperfusion after carotid endarterectomy: an initial study. Eur Radiol 2022; 32:6145-6157. [PMID: 35394182 DOI: 10.1007/s00330-022-08755-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/28/2022] [Accepted: 03/19/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether preoperative arterial spin labeling (ASL) MRI can predict cerebral hyperperfusion after carotid endarterectomy (CEA) in patients with carotid stenosis. METHODS Consecutive patients with carotid stenosis who underwent CEA between May 2015 and July 2021 were included. For each patient, a cerebral blood flow ratio (rCBF) map was obtained by dividing postoperative CBF with preoperative CBF images from two pseudo-continuous ASL scans. Hyperperfusion regions with rCBF > 2 were extracted and weighted with rCBF to calculate the hyperperfusion index. According to the distribution of the hyperperfusion index, patients were divided into hyperperfusion and non-hyperperfusion groups. Preoperative ASL images were scored based on the presence of arterial transit artifacts (ATAs) in 10 regions of interest corresponding to the Alberta Stroke Programme Early Computed Tomography Score methodology. The degree of stenosis and primary and secondary collaterals were evaluated to correlate with the ASL score. Logistic regression and receiver operating characteristic curve analyses were performed to assess the predictive ability of the ASL score for cerebral hyperperfusion. RESULTS Of 86 patients included, cerebral hyperperfusion was present in 17 (19.8%) patients. Carotid near occlusion, opening of posterior communicating arteries with incomplete anterior semicircle, and leptomeningeal collaterals were associated with lower ASL scores (p < 0.05). The preoperative ASL score was an independent predictor of cerebral hyperperfusion (OR = 0.48 [95% CI [0.33-0.71]], p < 0.001) with the optimal cutoff value of 25 points (AUC = 0.98, 94.1% sensitivity, 88.4% specificity). CONCLUSIONS Based on the presence of ATAs, ASL can non-invasively predict cerebral hyperperfusion after CEA in patients with carotid stenosis. KEY POINTS • Carotid near occlusion, opening of posterior communicating arteries with incomplete anterior semicircle, and leptomeningeal collaterals were associated with lower ASL scores. • The ASL score performed better than the degree of stenosis, type of CoW, and leptomeningeal collaterals, as well as the combination of the three factors for the prediction of cerebral hyperperfusion. • For patients with carotid stenosis, preoperative ASL can non-invasively identify patients at high risk of cerebral hyperperfusion after carotid endarterectomy without complex post-processing steps.
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Affiliation(s)
- Xiaoyuan Fan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhentao Zuo
- State Key Laboratory of Brain and Cognitive Science, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China.,Sino-Danish College, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Beijing, China
| | - Tianye Lin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhichao Lai
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China.
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Jianxun Qu
- GE Healthcare, MR Research China, Beijing, China
| | - Juan Wei
- GE Healthcare, MR Research China, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China. .,State Key Laboratory of Difficult, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Validity of the γ-Ray Evaluation with iodoamphetamine for Cerebral Blood Flow Assessment (REICA) method for quantification of cerebral blood flow including acetazolamide challenge test. Ann Nucl Med 2022; 36:279-284. [PMID: 34973145 PMCID: PMC8897379 DOI: 10.1007/s12149-021-01700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022]
Abstract
Objective The γ-Ray Evaluation with iodoamphetamine for Cerebral Blood Flow Assessment (REICA) is a new method for quantifying cerebral blood flow (CBF) using single-photon emission computed tomography (SPECT) and [123I]N-isopropyl-p-iodoamphetamine (123I-IMP). The present study aimed to validate the REICA method using data including acetazolamide challenge test. Methods The REICA and Graph-Plot (GP) methods were used to calculate mean CBF (mCBF) for 92 acquisitions (rest: 57, stress: 35) and cerebrovascular reactivity (CVR) in 33 patients. To obtain stress data, 15 mg/kg of acetazolamide was injected intravenously 10 min before the administration of 123I-IMP, and blood samples were collected under the same conditions as rest data. The reference standard was the Autoradiograph (ARG) method using arterial blood sampling, and the accuracy of the REICA method was analyzed by comparing it with each method. Results For mCBF, the correlation coefficients (r) were 0.792 for the REICA method and 0.636 for the GP method. For CVR, r values were 0.660 for the REICA method and 0.578 for the GP method. In both acquisitions, the REICA method had a stronger correlation with the ARG method than the GP method. For mCBF, there was a significant difference in the correlation coefficient between the two correlation coefficients (p < 0.01). Conclusions The REICA method was more accurate than the GP method in quantifying CBF and closer to the ARG method. The REICA method, which is a noninvasive method of cerebral blood flow quantification using 123I-IMP, has great medical usefulness.
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Miura S, Imahori T, Sugihara M, Mizobe T, Aihara H, Fukase K, Matsumori M, Murakami H, Hosoda K, Sasayama T, Kohmura E. Subarachnoid hemorrhage associated with cerebral hyperperfusion syndrome after simultaneous carotid endarterectomy and coronary artery bypass grafting procedures: A case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Endo H, Fujimura M, Saito A, Endo T, Ootomo K, Tominaga T. Efficacy of arterial spin labeling magnetic resonance imaging with multiple post-labeling delays to predict postoperative cerebral hyperperfusion in carotid endarterectomy. Neurol Res 2020; 43:252-258. [PMID: 33190623 DOI: 10.1080/01616412.2020.1847529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Cerebral hyperperfusion (CHP) syndrome is one of the most deleterious complications after carotid endarterectomy (CEA). Arterial spin labeling (ASL) is a promising non-invasive method to evaluate various hemodynamic parameters in cerebrovascular diseases. The aim of this study was to clarify whether ASL with multiple post-labeling delays (PLDs) can predict postoperative CHP after CEA. Methods: Sixty-one patients with carotid artery stenosis treated by CEA were retrospectively analyzed. The asymmetry index of the preoperative CBF was obtained from ASL using 3 PLDs (1525 ms, 2025 ms, and 2525 ms) and single-photon emission computed tomography (SPECT). Cerebrovascular reactivity (CVR) was measured from SPECT with acetazolamide challenge. The slope of the regression line obtained from the asymmetry index of three PLDs was defined as the slope index. Results: The CHP phenomenon was observed in seven patients (11.5%), one of whom developed CHP syndrome (1.6%). Using the CHP phenomenon as a reference standard, the area under the receiver operating characteristics (ROC) was 0.68 for the asymmetry index of the preoperative SPECT, 0.71 for the asymmetry index of the preoperative ASL,0.73 for CVR, and 0.78 for the slope index. Using the cutoff value obtained by ROC analysis, the slope index demonstrated a sensitivity of 85%, specificity of 74%, positive predictive value of 30% and the negative predictive value of 98% for predicting CHP. Conclusions: The slope index calculated by ASL with multiple PLDs is a useful screening tool to predict postoperative CHP after CEA.
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Affiliation(s)
- Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital , Sendai, Japan.,Department of Neurosurgery, Tohoku University Graduate School of Medicine , Sendai, Japan.,Department of Neurosurgery, National Hospital Organization Sendai Medical Center , Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital , Sendai, Japan.,Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine , Sendai, Japan
| | - Atsushi Saito
- Department of Neurosurgery, Kohnan Hospital , Sendai, Japan.,Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine , Sendai, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Kohnan Hospital , Sendai, Japan.,Department of Neurosurgery, Tohoku University Graduate School of Medicine , Sendai, Japan
| | | | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine , Sendai, Japan
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Chen Z, Chen L, Shirakawa M, Liu W, Ortega D, Chen J, Balu N, Trouard T, Hatsukami TS, Zhou W, Yuan C. Intracranial vascular feature changes in time of flight MR angiography in patients undergoing carotid revascularization surgery. Magn Reson Imaging 2020; 75:45-50. [PMID: 33068670 DOI: 10.1016/j.mri.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE To characterize the intracranial vascular features extracted from time of flight (TOF) images and their changes from baseline to follow-up in patients undergoing carotid revascularization, using arterial spin labeling (ASL) cerebral blood flow (CBF) measurement as a reference. METHODS In this retrospective study, brain TOF and ASL images of 99 subjects, acquired before, within 48 h, and/or 6 months after, carotid revascularization surgery were analyzed. TOF images were analyzed using a custom software (iCafe) to quantify intracranial vascular features, including total vessel length, total vessel volume, and number of branches. Mean whole-brain CBF was calculated from ASL images. ASL scans showing low ASL signal in the entire flow territory of an internal carotid artery (ICA), which may be caused by labeling failure, were excluded. Changes and correlations between time points were analyzed separately for TOF intracranial vascular features and ASL CBF. RESULTS Similar to ASL CBF, TOF vascular features (i.e. total vessel length, total vessel volume and number of branches) increased dramatically from baseline to post-surgery, then returned to a level slightly higher than the baseline in long-term follow-up (All P < 0.05). Correlation between time points was observed for all three TOF vascular features but not for ASL CBF. CONCLUSION Intracranial vascular features, including total vessel length, total vessel volume and number of branches, extracted from TOF images are useful in detecting brain blood flow changes induced by carotid revascularization surgery.
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Affiliation(s)
- Zhensen Chen
- Department of Radiology, University of Washington, Seattle, WA, USA.
| | - Li Chen
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA
| | - Manabu Shirakawa
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Wenjin Liu
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Dakota Ortega
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Jinmei Chen
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Niranjan Balu
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Theodore Trouard
- Department of Biomedical Engineering, The University of Arizona, Tuscon, AZ, USA
| | | | - Wei Zhou
- Department of Surgery, The University of Arizona, Tuscon, AZ, USA
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
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Huo R, Xu H, Yang D, Qiao H, Li J, Han H, Liu Y, Wang T, Yuan H, Zhao X. Associations Between Carotid Plaque Characteristics and Improvement of Cerebral Blood Perfusion in Patients With Moderate to Severe Carotid Stenosis Undergoing Carotid Endarterectomy. J Magn Reson Imaging 2020; 53:613-625. [PMID: 33037860 DOI: 10.1002/jmri.27365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The relationship between plaque characteristics and their predictive value for perioperative cerebral blood flow (CBF) are unknown. PURPOSE To investigate the relationship between carotid plaque characteristics and perioperative CBF utilizing MRI. STUDY TYPE Prospective. POPULATION In all, 131 patients with carotid moderate-to-severe stenosis referred for carotid endarterectomy (CEA). FIELD STRENGTH/SEQUENCE 3T, black-blood T1 - and T2 -weighted, 3D time-of-flight, and simultaneous noncontrast angiography intraplaque hemorrhage. ASSESSMENT The relative CBF (rCBF = CBFindex-hemisphere /CBFcontralateral-hemisphere ) and the CBF difference ratio (DRCBF = [CBFpost-CEA - CBFpre-CEA ]/CBFpre-CEA ) in the middle cerebral artery territory were measured. The pre- and post-CEA CTP data were used as the assessment standard for CBF change. Carotid lipid-rich necrotic core (LRNC), intraplaque hemorrhage, calcification, fibrous cap rupture, maximum wall thickness, normalized wall index (NWI), and stenosis were determined. STATISTICAL TESTS Pearson or Spearman correlation, Mann-Whitney U-test, and linear regression. RESULTS Patients with LRNC had higher rCBFpre-CEA than those without (1.0 ± 0.1 vs. 0.9 ± 0.1, P < 0.05). NWI was weakly correlated with rCBFpre-CEA (r = -0.213, P < 0.05) and DRCBF (r = 0.185, P < 0.05) and marginally correlated with rCBFpost-CEA (r = 0.166, P = 0.057). LRNC was weakly correlated with rCBFpre-CEA (r = 0.179, P < 0.05). NWI was associated with rCBFpre-CEA (β = -0.035; 95% confidence interval [CI] [-0.064, -0.006]; P < 0.05), rCBFpost-CEA (β = 0.042; 95% CI [0.002, 0.081]; P < 0.05) and DRCBF (β = 0.105; 95% CI [0.026, 0.185]; P < 0.05). After adjusting for confounding factors, associations of NWI with rCBFpost-CEA (β = 0.059; 95% CI [0.016, 0.103]; P < 0.05) and DRCBF (β = 0.110; 95% CI [0.021, 0.199]; P < 0.05) remained statistically significant, while the association between NWI and rCBFpre-CEA was no longer significant (β = -0.026; 95% CI [-0.058, 0.006]; P = 0.112).The associations of LRNC with rCBFpre-CEA (β = 0.057; 95% CI [-0.0006, 0.114]; P = 0.052) and DRCBF (β = -0.157; 95% CI [-0.314, 0.001]; P = 0.051) were close to statistical significance. After adjusting for confounding factors, these associations were statistically significant (of LRNC vs. rCBFpre-CEA : β = 0.060; 95% CI [0.003, 0.118]; P < 0.05; LRNC vs. DRCBF : β = -0.205; 95% CI [-0.375, -0.036]; P < 0.05). DATA CONCLUSION Carotid plaque burden and components, particularly LRNC, might be effective indicators for CBF change following CEA. Level of Evidence 1 Technical Efficacy Stage 5.
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Affiliation(s)
- Ran Huo
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Huimin Xu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Dandan Yang
- Center for Brain Disorders Research, Capital Medical University and Beijing Institute for Brain Disorders, Beijing, China.,Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Huiyu Qiao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Jin Li
- Department of Radiology, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Hualu Han
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Ying Liu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
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Manojlovic V, Budakov N, Budinski S, Milosevic D, Nikolic D, Manojlovic V. Cerebrovacular Reserve Predicts the Cerebral Hyperperfusion Syndrome After Carotid Endarterectomy. J Stroke Cerebrovasc Dis 2020; 29:105318. [PMID: 32992180 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Cerebral hyperperfusion syndrome is a rare but potentially severe complication of carotid artery revascularisation that develops under conditions of resistant postoperative hypertension and impaired cerebrovascular autoregulation. OBJECTIVE Was to determine which preoperative and operative factors affect the development of cerebral hyperperfusion syndrome after carotid endarterectomy. METHODS This prospective observational study enrolled 93 asymptomatic patients who underwent carotid endarterectomy. Cerebral hyperperfusion was registered in patients who had 100% postoperative increase in mean flow in middle cerebral artery registered by Transcranial Doppler ultrasound. Cerebral hyperperfusion syndrome was diagnosed in patients with cerebral hyperperfusion who postoperatively developed at least one of the symptoms. Pre-operative and operative risk factors for cerebral hyperperfusion syndrome were analysed by multivariate binary logistic regression. RESULTS Out of 93 operated patients, cerebral hyperperfusion was registered in 23 and cerebral hyperperfusion syndrome in 18 patients. Risk factors for cerebral hyperperfusion syndrome were included in the binary logistic regression model. Incomplete Circle of Willis morphology on 3D TOF magnetic resonance image (p = 0.002), Breath holding index below the 0.69 cut-off (p = 0.006), positive criteria for insufficient collateral flow through circle of Willis registered by TCD (p = 0.03), and poorly controlled hypertension (p = 0.023) showed statistically significant independent predictive value for cerebral hyperperfusion syndrome. The model was statistically significant (p = 0.012) and correctly classified 90.3 % of patients. CONCLUSIONS Incomplete circle of Willis and insufficient collateral flow, low cerebrovascular reserve, and poorly regulated hypertension are significant predictors of post- carotid endarterectomy hyperperfusion development.
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Affiliation(s)
- Vladimir Manojlovic
- Faculty of medicine, University of Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Novi Sad, Serbia.
| | - Nebojsa Budakov
- Faculty of medicine, University of Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Novi Sad, Serbia
| | - Slavko Budinski
- Faculty of medicine, University of Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Novi Sad, Serbia.
| | - Djordje Milosevic
- Faculty of medicine, University of Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Novi Sad, Serbia.
| | - Dragan Nikolic
- Faculty of medicine, University of Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Novi Sad, Serbia
| | - Vladimir Manojlovic
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; Clinic for vascular and endovascular surgery, Clinical centre of Vojvodina, Hajduk Veljkova 3, 21000 Novi Sad, Serbia.
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Mo D, Jia B, Shi H, Sun Y, Liu Q, Fan C, Deng J, Yuan J, Wu W, Jiang C, Zhang G, Du H, Ma N, Gao F, Sun X, Song L, Liu L, Peng G, Wang Y, Wang Y, Miao Z. Staged angioplasty versus regular carotid artery stenting in patients with carotid artery stenosis at high risk of hyperperfusion: a randomised clinical trial. Stroke Vasc Neurol 2020; 6:95-102. [PMID: 32973113 PMCID: PMC8005890 DOI: 10.1136/svn-2020-000391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Hyperperfusion (HP) is a devastating complication associated with carotid artery stenting (CAS) or endarterectomy. The efficacy and safety of staged angioplasty (SAP) in patients with CAS at high risk of HP remains unclear. We sought to determine whether SAP is superior to regular CAS in patients with high risk of HP. Methods A randomised, multicentre open-label clinical trial with blinded outcome assessment (STEP) was conducted. Patients with severe carotid stenosis at high risk of HP were randomly assigned (1:1) to the SAP or regular CAS group. The primary endpoint was hyperperfusion syndrome (HPS) and intracerebral haemorrhage (ICH) within 30 days after the procedure. Results From November 2014 to January 2017, a total of 64 patients were enrolled in 11 centres. 33 patients were allocated to the SAP group and 31 to the regular CAS group. At 30 days, the rate of primary endpoint was 0.0% (0/33) in the SAP group and 9.7% (3/31) in the regular CAS group (absolute risk reduction (ARR), 9.7%; 95% CI −20.1% to 0.7%; p=0.11). As one of the secondary endpoints, the incidence of HP phenomenon (HPP) was lower in the SAP group than the regular CAS group (0.0% vs 22.6%, ARR,−22.6%; 95% CI −36.8% to −10.2%; p=0.04). Conclusion The rate of HPS and ICH was not significantly lower in SAP group; the extended secondary endpoint of HPP, however, significantly reduced, which suggested that SAP may be a safe and effective carotid revascularisation procedure to prevent HP. Trial registration number NCT02224209.
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Affiliation(s)
- Dapeng Mo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Huaizhang Shi
- Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yaxuan Sun
- Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Qingan Liu
- Neurosurgery, Harbin Medical University Fourth Hospital, Harbin, China
| | - Chengzhe Fan
- Neurology, Beijing An Zhen Hospital, Beijing, China
| | - Jianping Deng
- Neurosurgery, Tangdu Hospital, The Second Affiliated Hospital, Fourth Military Medical University, Xi'an, China
| | - Jinglin Yuan
- Neurology, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Wei Wu
- Neurology, Shandong University Qilu Hospital, Jinan, China
| | | | - Guilian Zhang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, China
| | - Hanjun Du
- Neurology, Peking University Shougang Hospital, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Lian Liu
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Guangge Peng
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China.,Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China.,Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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11
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Cerebral hemodynamics associated with fluid-attenuated inversion recovery hyperintense vessels in patients with extracranial carotid artery stenosis. Neuroradiology 2020; 62:677-684. [PMID: 32152648 DOI: 10.1007/s00234-020-02385-0] [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: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Fluid-attenuated inversion recovery hyperintense vessels (FHVs) are linked to sluggish or disordered blood flow. The purpose of this study is to compare FHVs with digital subtraction angiography (DSA) findings and cerebral hemodynamic changes on acetazolamide challenge SPECT and to determine the clinical and imaging metrics associated with FHVs in patients with extracranial carotid artery stenosis (ECAS). METHODS The subjects were patients with chronic ECAS who underwent carotid artery stenting in our department between March 2011 and October 2018. Relationships of FHVs with age, sex, medical history, cerebral angiographic findings using DSA, and quantitative values of cerebral blood flow (CBF) were examined. The resting CBF (rCBF) and cerebrovascular reactivity (CVR) in the middle cerebral artery territory were measured quantitatively using SPECT with acetazolamide challenge. We used multivariate logistic regression analysis to identify independent predictors of FHVs. RESULTS Of 173 patients included, 92 (53.2%) had FHVs. Patients with FHVs had more severe stenosis (P < 0.01) and more leptomeningeal collateral vessels (P < 0.01). FHV-positive cases had significantly reduced CVR compared with FHV-negative cases (P < 0.01), although there was no significant difference in rCBF between FHV-positive and FHV-negative cases. Logistic regression analysis showed that ipsilateral rCBF and ipsilateral CVR were significant predictors for FHVs (P < 0.01). CONCLUSION In patients with ECAS, cerebral hemodynamic metrics, especially ipsilateral rCBF and ipsilateral CVR, are associated with the presence of FHVs.
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12
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Matsumura H, Ito Y, Uemura K, Nakai Y, Komatsu Y, Ishikawa E, Matsumaru Y, Matsumura A. Prediction of the Cerebral Hyperperfusion Phenomenon after Carotid Endarterectomy Using a Transit Time Flowmeter. Neurol Med Chir (Tokyo) 2020; 60:94-100. [PMID: 31866664 PMCID: PMC7040430 DOI: 10.2176/nmc.oa.2019-0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to investigate the relationship between the cerebral hyperperfusion phenomenon (CHP) and carotid artery flow volume as measured by a transit time flowmeter during carotid endarterectomy (CEA). We retrospectively investigated 74 patients who underwent both transit time flowmetry and single photon emission computed tomography (SPECT). The flow volumes of the internal carotid artery (ICA) before and after the endarterectomy were recorded during surgery as the pre- and the post-ICA (mL/min), respectively. We defined the difference between the pre- and the post-ICA as the ΔIC (mL/min). Two independent board-certified neurosurgeons analyzed the asymmetry index (affected side/contralateral side) of regional qualitative cerebral blood flow before and after the CEA respectively. We defined the CHP as an excessive increase in this asymmetry index between preoperative and postoperative SPECT. The CHP was observed in five of the 74 patients (6.8%). The pre-ICA of the CHP cases was significantly lower than that of the non-CHP cases (in mL/min, median 29 vs. 97; P = 0.01). The ΔIC of the CHP cases was significantly higher than that of the non-CHP cases (in mL/min, median 154 vs. 50; P = 0.002). The cut-off value of the ΔIC was 81 mL/min (sensitivity 100%, specificity 78.3%, area under the curve 0.912). The findings of this study suggest that the ΔIC is associated with the CHP. The transit time flowmeter is useful to predict the CHP during surgery.
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Affiliation(s)
| | - Yoshiro Ito
- Department of Neurosurgery, University of Tsukuba
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital
| | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital
| | - Yoji Komatsu
- Department of Neurosurgery, Hitachi Medical Education and Research Center, University of Tsukuba Hospital
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13
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Hayakawa M, Sugiu K, Yoshimura S, Hishikawa T, Yamagami H, Fukuda-Doi M, Sakai N, Iihara K, Ogasawara K, Oishi H, Ito Y, Matsumaru Y. Effectiveness of staged angioplasty for avoidance of cerebral hyperperfusion syndrome after carotid revascularization. J Neurosurg 2020; 132:51-61. [PMID: 30660130 DOI: 10.3171/2018.8.jns18887] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 08/24/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid artery stenting (CAS). Staged angioplasty (SAP)-i.e., angioplasty followed by delayed CAS-has been reported as a potential CHS-avoiding procedure. The purpose of this study was to clarify the effectiveness of SAP in avoiding CHS after carotid revascularization for patients at high risk for this complication. METHODS The authors retrospectively studied cases involving patients at high risk for CHS from 44 Japanese centers who were scheduled for SAP, regular CAS, angioplasty, or staged procedures other than SAP between October 2007 and March 2014. They investigated the rate of CHS in the population scheduled for SAP or regular CAS, and for safety analysis, the composite rate of transient ischemic attack (TIA) and ischemic stroke in the population eventually receiving SAP or regular CAS. RESULTS Data from a total of 525 patients (532 lesions, mean age 72.5 ± 7.5 years, 74 women ) were analyzed. Scheduled procedures included SAP for 113 lesions and regular CAS for 419 lesions. The rate of CHS was lower in the SAP group than in the regular CAS group (4.4% vs 10.5%, p = 0.047). Multivariate analysis showed that SAP was negatively related to CHS (OR 0.315; 95% CI 0.120-0.828). In the population eventually receiving SAP (102 lesions) or regular CAS (428 lesions), the composite rate of TIA and ischemic stroke was comparable between the SAP group and the regular CAS group (9.8% vs 9.3%). CONCLUSIONS SAP may be an effective and safe carotid revascularization procedure to avoid CHS.
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Affiliation(s)
- Mikito Hayakawa
- Departments of1Cerebrovascular Medicine and
- 2Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kenji Sugiu
- 3Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama
| | | | - Tomohito Hishikawa
- 3Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama
| | - Hiroshi Yamagami
- 5Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita
| | | | - Nobuyuki Sakai
- 7Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe
| | - Koji Iihara
- 8Department of Neurosurgery, Graduate School of Medical Sciences Kyusyu University, Fukuoka
| | | | - Hidenori Oishi
- 10Department of Neurosurgery/Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo
| | - Yasushi Ito
- 11Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata; and
| | - Yuji Matsumaru
- 2Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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14
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Effect of Unilateral Carotid Artery Stenting on Cognitive Function in Patients with Severe Bilateral Stenosis. World Neurosurg 2019; 135:188-191. [PMID: 31863885 DOI: 10.1016/j.wneu.2019.12.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 11/23/2022]
Abstract
CASE DESCRIPTION An 82-year-old man with dementia, gait disturbance, and a small cerebral infarction owing to severe bilateral carotid artery stenosis was successfully treated with carotid artery stenting (CAS). Preoperative cerebral vascular reactivity was reduced in the bilateral cerebral hemispheres. We performed CAS to treat right internal carotid artery stenosis. Following CAS, cerebral vascular reactivity showed an increase in the bilateral cerebral hemispheres. Memory, fluency, and attention also showed improvement. CONCLUSIONS This case illustrates the potential benefit of single-stage CAS for cognitive function in severe bilateral carotid artery stenosis without hyperperfusion syndrome.
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15
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Soman S, Dai W, Dong L, Hitchner E, Lee K, Baughman BD, Holdsworth SJ, Massaband P, Bhat JV, Moseley ME, Rosen A, Zhou W, Zaharchuk G. Identifying cardiovascular risk factors that impact cerebrovascular reactivity: An ASL MRI study. J Magn Reson Imaging 2019; 51:734-747. [PMID: 31294898 DOI: 10.1002/jmri.26862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To maintain cerebral blood flow (CBF), cerebral blood vessels dilate and contract in response to blood supply through cerebrovascular reactivity (CR). PURPOSE Cardiovascular (CV) disease is associated with increased stroke risk, but which risk factors specifically impact CR is unknown. STUDY TYPE Prospective longitudinal. SUBJECTS Fifty-three subjects undergoing carotid endarterectomy or stenting. FIELD STRENGTH/SEQUENCE 3T, 3D pseudo-continuous arterial spin labeling (PCASL) ASL, and T1 3D fast spoiled gradient echo (FSPGR). ASSESSMENT We evaluated group differences in CBF changes for multiple cardiovascular risk factors in patients undergoing carotid revascularization surgery. STATISTICAL TESTS PRE (baseline), POST (48-hour postop), and 6MO (6 months postop) whole-brain CBF measurements, as 129 CBF maps from 53 subjects were modeled as within-subject analysis of variance (ANOVA). To identify CV risk factors associated with CBF change, the CBF change from PRE to POST, POST to 6MO, and PRE to 6MO were modeled as multiple linear regression with each CV risk factor as an independent variable. Statistical models were performed controlling for age on a voxel-by-voxel basis using SPM8. Significant clusters were reported if familywise error (FWE)-corrected cluster-level was P < 0.05, while the voxel-level significance threshold was set for P < 0.001. RESULTS The entire group showed significant (cluster-level P < 0.001) CBF increase from PRE to POST, decrease from POST to 6MO, and no significant difference (all voxels with P > 0.001) from PRE to 6MO. Of multiple CV risk factors evaluated, only elevated systolic blood pressure (SBP, P = 0.001), chronic renal insufficiency (CRI, P = 0.026), and history of prior stroke (CVA, P < 0.001) predicted lower increases in CBF PRE to POST. Over POST to 6MO, obesity predicted lower (P > 0.001) and cholesterol greater CBF decrease (P > 0.001). DATA CONCLUSION The CV risk factors of higher SBP, CRI, CVA, BMI, and cholesterol may indicate altered CR, and may warrant different stroke risk mitigation and special consideration for CBF change evaluation. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:734-747.
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Affiliation(s)
- Salil Soman
- The Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Weiying Dai
- Department of Computer Science, State University of New York at Binghamton, Binghamton, New York, USA
| | - Lucy Dong
- University of California Los Angeles, Los Angeles, California, USA
| | - Elizabeth Hitchner
- Department of Pediatrics, Stanford University School of Medicine, Los Altos Hills, California, USA
| | - Kyuwon Lee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittanie D Baughman
- Palo Alto Veterans Affairs Health Care System, Palo Alto VAHCS, Palo Alto, California, USA
| | - Samantha J Holdsworth
- Faculty of Medical and Health Sciences, Division of Medical Science, University of Auckland, Auckland, New Zealand
| | - Payam Massaband
- Stanford University School of Medicine, Department of Radiology, Palo Alto, California, USA
| | - Jyoti V Bhat
- Palo Alto Veterans Affairs Health Care System, Palo Alto VAHCS, Palo Alto, California, USA
| | - Michael E Moseley
- Stanford University, Department of Radiology, Lucas Center for MR Spectroscopy and Imaging, Stanford, California, USA
| | - Allyson Rosen
- Department of Behavioral Science and Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Arizona, USA
| | - Greg Zaharchuk
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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16
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Hussain MA, Alali AS, Mamdani M, Tu JV, Saposnik G, Salata K, Nathens AB, de Mestral C, Bhatt DL, Verma S, Al-Omran M. Risk of intracranial hemorrhage after carotid artery stenting versus endarterectomy: a population-based study. J Neurosurg 2018; 129:1522-1529. [PMID: 29393758 DOI: 10.3171/2017.8.jns171142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/02/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIntracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome is a rare but major complication of carotid artery revascularization. The objective of this study was to compare the rate of ICH after carotid artery stenting (CAS) with that after endarterectomy (CEA).METHODSThe authors performed a retrospective population-based cohort study of patients who underwent carotid artery revascularization in the province of Ontario, Canada, between 2002 and 2015. The primary outcome was the rate of ICH that occurred within 90 days after carotid artery intervention among patients who underwent CAS versus that of those who underwent CEA. The authors used inverse probability of treatment weighting and propensity scores to account for selection bias. In sensitivity analyses, patients who had postprocedure ischemic stroke were excluded, and the following subgroups were examined: patients with symptomatic and asymptomatic carotid artery stenosis, patients treated between 2010 and 2015, and patients aged ≥ 66 years (to account for antiplatelet and anticoagulant use).RESULTSA total of 16,688 patients underwent carotid artery revascularization (14% CAS, 86% CEA). Patients with more comorbid illnesses, symptomatic carotid artery stenosis, or cardiac disease and those who were taking antiplatelet agents or warfarin before surgery were more likely to undergo CAS. Among the overall cohort, 80 (0.48%) patients developed ICH within 90 days (0.85% after CAS, 0.42% after CEA). The 180-day mortality rate after ICH in the overall cohort was 2.7%, whereas the 180-day mortality rate among patients who suffered ICH was 42.5% (40% for CAS-treated patients, 43.3% for CEA-treated patients). In the adjusted analysis, patients who underwent CAS were significantly more likely to have ICH than those who underwent CEA (adjusted OR 1.77; 95% CI 1.32-2.36; p < 0.001). These results were consistent after excluding patients who developed postprocedure ischemic stroke (adjusted OR 1.90; 95% CI 1.41-2.56) and consistent among symptomatic (adjusted OR 1.74; 95% CI 1.16-2.63) and asymptomatic (adjusted OR 1.75; 95% CI 1.16-2.63) patients with carotid artery stenosis, among patients treated between 2010 and 2015 (adjusted OR 2.21; 95% CI 1.45-3.38), and among the subgroup of patients aged ≥ 66 years (adjusted OR 1.53; 95% CI 1.05-2.24) after adjusting for medication use.CONCLUSIONSCAS is associated with a rare but higher risk of ICH relative to CEA. Future research is needed to devise strategies that minimize the risk of this serious complication after carotid artery revascularization.
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Affiliation(s)
| | - Aziz S Alali
- 3Sunnybrook Research Institute
- 4Interdepartmental Division of Critical Care, and
| | - Muhammad Mamdani
- 5Li Ka Shing Knowledge Institute, and
- 6Institute of Health Policy, Management, and Evaluation
- 7King Saud University-Li Ka Shing Collaborative Research Program and
- 8Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- 9Department of Medicine, University of Toronto
| | - Jack V Tu
- 3Sunnybrook Research Institute
- 6Institute of Health Policy, Management, and Evaluation
- 8Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- 9Department of Medicine, University of Toronto
- 10Division of Cardiology, and
| | - Gustavo Saposnik
- 5Li Ka Shing Knowledge Institute, and
- 6Institute of Health Policy, Management, and Evaluation
- 8Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- 9Department of Medicine, University of Toronto
- Divisions of11Neurology and
| | | | - Avery B Nathens
- 2Department of Surgery
- 3Sunnybrook Research Institute
- 6Institute of Health Policy, Management, and Evaluation
- 8Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- 12Department of Surgery, Sunnybrook Health Sciences Centre
| | - Charles de Mestral
- 1Division of Vascular Surgery
- 2Department of Surgery
- 5Li Ka Shing Knowledge Institute, and
| | - Deepak L Bhatt
- 13Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Subodh Verma
- 2Department of Surgery
- 5Li Ka Shing Knowledge Institute, and
- 7King Saud University-Li Ka Shing Collaborative Research Program and
- 14Cardiac Surgery, St. Michael's Hospital
| | - Mohammed Al-Omran
- 1Division of Vascular Surgery
- 2Department of Surgery
- 5Li Ka Shing Knowledge Institute, and
- 7King Saud University-Li Ka Shing Collaborative Research Program and
- 15Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia; and
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17
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Kobayashi M, Yoshida K, Kojima D, Oshida S, Fujiwara S, Kubo Y, Ogasawara K. 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. J Vasc Surg 2018; 69:454-461. [PMID: 29960793 DOI: 10.1016/j.jvs.2018.03.437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/10/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Daigo Kojima
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Sotaro Oshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yoshitada Kubo
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.
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ITO Y, TSURUTA W, NAKAI Y, TAKIGAWA T, MARUSHIMA A, MASUMOTO T, MATSUMARU Y, ISHIKAWA E, MATSUMURA A. Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis. Neurol Med Chir (Tokyo) 2018; 58:191-198. [PMID: 29503393 PMCID: PMC5958040 DOI: 10.2176/nmc.oa.2017-0228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/07/2018] [Indexed: 12/13/2022] Open
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.
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Affiliation(s)
- Yoshiro ITO
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Wataro TSURUTA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasunobu NAKAI
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Tomoji TAKIGAWA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Aiki MARUSHIMA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tomohiko MASUMOTO
- Department of Radiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji MATSUMARU
- Division for Stroke, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi ISHIKAWA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akira MATSUMURA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Tanaka H, Watanabe Y, Nakamura H, Takahashi H, Arisawa A, Fujiwara T, Matsuo C, Tomiyama N. Multiple blood flow measurements before and after carotid artery stenting via phase-contrast magnetic resonance imaging: An observational study. PLoS One 2018; 13:e0195099. [PMID: 29641548 PMCID: PMC5895018 DOI: 10.1371/journal.pone.0195099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 03/18/2018] [Indexed: 11/19/2022] Open
Abstract
After carotid artery stenting, the procurement of information about blood flow redistribution among brain-feeding arteries and its time trend is essential to understanding a patient’s physiological background and to determine their care regimen. Cerebral blood flow has been measured twice following carotid artery stenting in few previous studies, with some discrepancies in the results. The purpose of this study was to measure cerebral blood flow at multiple time points after carotid artery stenting, and to elucidate the time trend of cerebral blood flow and redistribution among arteries. Blood flow rates in 11 subjects were measured preoperatively, at one day, one week, and about three months, respectively after carotid artery stenting by using phase-contrast magnetic resonance imaging. The target vessels were the bilateral internal carotid arteries, the basilar artery, and the bilateral middle cerebral arteries. Lumen was semi-automatically defined using an algorithm utilizing pulsatility. The results showed that blood flow rates in the stented internal carotid artery and the ipsilateral middle cerebral artery increased following carotid artery stenting. Blood flow rates in the contralateral internal carotid artery and the basilar artery gradually declined, and they were lower than the preoperative values at three months after stenting. The sum of blood flow rates of the bilateral internal carotid arteries and the basilar artery increased after carotid artery stenting, and then decreased over the next three months. There was no significant change in the blood flow rate in the contralateral middle cerebral artery. From these results, it was concluded that redistribution among the bilateral internal carotid arteries and the basilar artery occurs after carotid artery stenting, and that it takes months thereafter to reach another equilibrium.
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Affiliation(s)
- Hisashi Tanaka
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
| | - Yoshiyuki Watanabe
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroto Takahashi
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Atsuko Arisawa
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuya Fujiwara
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Chisato Matsuo
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Noriyuki Tomiyama
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Maier IL, Tsogkas I, Behme D, Bähr M, Knauth M, Psychogios MN, Liman J. High Systolic Blood Pressure after Successful Endovascular Treatment Affects Early Functional Outcome in Acute Ischemic Stroke. Cerebrovasc Dis 2017; 45:18-25. [PMID: 29176326 DOI: 10.1159/000484720] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/25/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endovascular treatment (EVT) has been shown to significantly improve functional outcome in patients with acute large cerebral vessel occlusions. To date, no evidence-based recommendations on blood pressure management after successful EVT exist. Previous studies showed an association between high pre-EVT systolic blood pressure (SBP) and functional outcome, but do not answer the question on how to manage blood pressure after successful recanalization. The purpose of this study was to determine the role of blood pressure measurements as a predictor for early functional outcome in patients with successful EVT. METHODS Prospectively derived data from patients with acute large vessel occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Mean systolic- and maximum SBP as well as SBP-peaks have been obtained for the first 24 h after successful EVT. Predictive value of SBP for discharge modified Rankin Scale (mRS) ≤2 has been investigated using logistic regression models. RESULTS From 168 patients with successful EVT, 74 (44%) had a favorable outcome with an mRS ≤2. Mean- (127 vs. 131 mm Hg, p = 0.035) and maximum SBP (157 vs. 169 mm Hg, p < 0.001) as well as the number of SBP-peaks (0 vs. 1.5, p = 0.004) were lower in patients with favorable outcomes. Multivariable logistic regression showed high mean- and maximum SBP to predict unfavorable outcomes. Cutoff mean SBP was 141 mm Hg and maximum SBP 159 mm Hg. CONCLUSIONS High SBP in the first 24 h after recanalization of acute anterior cerebral vessel occlusions is associated with unfavorable functional outcome. Interventional studies are needed to determine the role of SBP management as a modifiable parameter in the early phase after successful EVT.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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Kunieda T, Miyake K, Sakamoto H, Iwasaki Y, Iida S, Morise S, Fujita K, Nakamura M, Kaneko S, Kusaka H. Leptomeningeal Collaterals Strongly Correlate with Reduced Cerebrovascular Reactivity Measured by Acetazolamide-challenged Single-photon Emission Computed Tomography Using a Stereotactic Extraction Estimation Analysis in Patients with Unilateral Internal Carotid Artery Stenosis. Intern Med 2017; 56:2857-2863. [PMID: 28943539 PMCID: PMC5709627 DOI: 10.2169/internalmedicine.8397-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To assess the correlation between the angiographic appearance of cerebral collateral pathways or the degree of internal carotid artery stenosis (ICAS) and reduced cerebrovascular reactivity (CVR) estimated by single-photon emission computed tomography (SPECT) image analysis in patients with unilateral ICAS. Methods A retrospective analysis was performed in 42 patients with unilateral ICAS who underwent cerebral angiography and acetazolamide-challenged SPECT of the brain. Cerebral blood flow quantitation was performed using the quantitative SPECT/dual-table autoradiography method. The CVR in the middle cerebral artery (MCA) territory was evaluated using the stereotactic extraction estimation based on the Japanese extracranial-intracranial bypass trial (SEE-JET) program and classified as reduced (<18.4%) or non-reduced (≥18.4%). Angiographic collateralization was classified as circle of Willis (type 1), extracranial-intracranial (type 2), and leptomeningeal (type 3). The degree of ICAS was defined as severe (≥70% stenosis) or non-severe (<70%). Results Eight patients showed reduced CVR, including 6 (46%) of 13 with type 3 collaterals and 2 (7%) of 29 without type 3 collaterals (p=0.006). In contrast, type 1 and type 2 collaterals and severe ICAS were not significantly associated with reduced CVR. Conclusion In patients with unilateral ICAS, leptomeningeal collaterals are strongly correlated with reduced CVR in the MCA territory, which presumably increases the risk of cerebral hyperperfusion after carotid artery stenting (CAS). Therefore, these findings may be clinically applicable to the perioperative management of CAS.
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Affiliation(s)
| | - Kosuke Miyake
- Department of Neurology, Kansai Medical University, Japan
| | | | - Yuko Iwasaki
- Department of Neurology, Kansai Medical University, Japan
| | - Shin Iida
- Department of Neurology, Kansai Medical University, Japan
| | - Satoshi Morise
- Department of Neurology, Kansai Medical University, Japan
| | - Kengo Fujita
- Department of Neurology, Kansai Medical University, Japan
| | | | - Satoshi Kaneko
- Department of Neurology, Kansai Medical University, Japan
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Abreu P, Nogueira J, Rodrigues FB, Nascimento A, Carvalho M, Marreiros A, Nzwalo H. Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysis. Acta Neurochir (Wien) 2017; 159:2089-2097. [PMID: 28916863 DOI: 10.1007/s00701-017-3328-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 09/05/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization. METHODS We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol. RESULTS Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis. CONCLUSIONS ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.
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Affiliation(s)
- Pedro Abreu
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Filipe Brogueira Rodrigues
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Huntington's Disease Centre, Institute of Neurology, University College London, London, UK
| | - Ana Nascimento
- Department of Neurology, Centro Hospitalar do Algarve, Faro, Portugal
| | - Mariana Carvalho
- Department of Neurology, Centro Hospitalar do Algarve, Faro, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Hipólito Nzwalo
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal.
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Nomura JI, Uwano I, Sasaki M, Kudo K, Yamashita F, Ito K, Fujiwara S, Kobayashi M, Ogasawara K. Preoperative Cerebral Oxygen Extraction Fraction Imaging Generated from 7T MR Quantitative Susceptibility Mapping Predicts Development of Cerebral Hyperperfusion following Carotid Endarterectomy. AJNR Am J Neuroradiol 2017; 38:2327-2333. [PMID: 28982786 DOI: 10.3174/ajnr.a5390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 07/18/2017] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- J-I Nomura
- From the Department of Neurosurgery (J.-i.N., S.F., M.K., K.O.)
| | - I Uwano
- Division of Ultrahigh Field MRI (I.U., M.S., F.Y., K.I), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Morioka, Japan
| | - M Sasaki
- Division of Ultrahigh Field MRI (I.U., M.S., F.Y., K.I), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Morioka, Japan
| | - K Kudo
- Department of Diagnostic and Interventional Radiology (K.K.), Hokkaido University School of Medicine, Sappro, Japan
| | - F Yamashita
- Division of Ultrahigh Field MRI (I.U., M.S., F.Y., K.I), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Morioka, Japan
| | - K Ito
- Division of Ultrahigh Field MRI (I.U., M.S., F.Y., K.I), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Morioka, Japan
| | - S Fujiwara
- From the Department of Neurosurgery (J.-i.N., S.F., M.K., K.O.)
| | - M Kobayashi
- From the Department of Neurosurgery (J.-i.N., S.F., M.K., K.O.)
| | - K Ogasawara
- From the Department of Neurosurgery (J.-i.N., S.F., M.K., K.O.)
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The Pathophysiology of Watershed Infarction: A Three-Dimensional Time-of-Flight Magnetic Resonance Angiography Study. J Stroke Cerebrovasc Dis 2017; 26:1966-1973. [PMID: 28694111 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/08/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most of the time, watershed infarcts (WIs) involve steno-occlusive carotid disease. The pathophysiological mechanism could be predicted by their pattern: internal WIs (IWIs) are thought to be due to hemodynamic impairment in contrast to cortical WIs (CWIs), which are more likely to be caused by microembolic phenomena. We used a 3D time-of-flight (TOF) magnetic resonance angiography (MRA) study to assess this hypothesis. METHODS In 45 consecutive patients with a recent WI and ipsilateral cervical carotid stenosis, clinical and radiological data were obtained retrospectively. 3D TOF MRA were analyzed both qualitatively and quantitatively (internal carotid and anterior, middle and posterior cerebral arteries). Then, 2 groups were determined depending on their radiological patterns: WIs with (IWI+) or without (IWI-) an internal watershed. RESULTS Thirty-two of the 45 patients (71%) had IWIs that were or were not associated with CWIs (IWI+), while 13 patients (29%) had only CWIs (IWI-). There was no significant relationship between the radiological pattern and the demographic data, the cardiovascular risk factors, or the degree of stenosis. However, IWI+ patients more frequently had motor weakness (P = .03) than CWI patients. An ipsilateral reduced middle cerebral artery intensity on 3D TOF MRA in both qualitative and quantitative analyses was significantly associated with IWI+. Instead within IWI-, no significantly reduced signal intensity was found. CONCLUSION These findings originally support the view that IWIs are mainly caused by a hemodynamic impairment related to carotid stenosis, whereas CWIs are mostly due to a microembolic mechanism. 3D TOF MRA, which gives pertinent information on pathophysiology on IWIs, can help in decision making.
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Perioperative Changes in Cerebral Perfusion Territories Assessed by Arterial Spin Labeling Magnetic Resonance Imaging Are Associated with Postoperative Increases in Cerebral Blood Flow in Patients with Carotid Stenosis. World Neurosurg 2017; 102:477-486. [DOI: 10.1016/j.wneu.2017.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/17/2022]
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26
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Kobayashi S, Morita A. The History of Neuroscience and Neurosurgery in Japan. ACTA ACUST UNITED AC 2017. [DOI: 10.17795/inj867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Shigeaki Kobayashi
- Medical Research and Education Center, Stroke and Brain Center, Aizawa Hospital, Matsumoto , Japan
| | - Akio Morita
- Medical Research and Education Center, Stroke and Brain Center, Aizawa Hospital, Matsumoto , Japan
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27
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Shimogawa T, Morioka T, Sayama T, Haga S, Akiyama T, Murao K, Kanazawa Y, Furuta Y, Sakata A, Arakawa S. Signal changes on magnetic resonance perfusion images with arterial spin labeling after carotid endarterectomy. Surg Neurol Int 2016; 7:S1031-S1040. [PMID: 28144479 PMCID: PMC5234294 DOI: 10.4103/2152-7806.196322] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/23/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cerebral hyperperfusion after carotid endarterectomy (CEA) is defined as an increase in ipsilateral cerebral blood flow (CBF). Practically, however, prompt and precise assessment of cerebral hyperperfusion is difficult because of limitations in the methodology of CBF measurement during the perioperative period. Arterial spin labeling (ASL) is a completely noninvasive and repeatable magnetic resonance perfusion imaging technique that uses magnetically-labelled blood water as an endogenous tracer. To clarify the usefulness of ASL in the management of cerebral hyperperfusion, we investigated signal changes by ASL with a single 1.5-s post-labeling delay on visual inspection. METHODS Thirty-two consecutive patients who underwent CEA were enrolled in this retrospective study. RESULTS On postoperative day 1, 22 (68.8%) and 4 (12.5%) patients exhibited increased ASL signals bilaterally (Group A) and on the operated side (Group B), respectively. Follow-up ASL showed improvement in these findings. Six (18.8%) patients showed no change (Group C). There was no apparent correlation between ASL signals on postoperative day 1 and the preoperative hemodynamic state, including the cerebrovascular reserve (P = 0.2062). Three (9.4%) patients developed cerebral hyperperfusion syndrome (two in Group A and one in Group B). Coincidence in the localization of increased ASL signals and electroencephalographic abnormalities was noted in these patients. CONCLUSION Visual analysis of ASL with a single post-labeling delay overestimates CBF and cannot identify patients at risk of cerebral hyperperfusion syndrome probably because of the strong effect of the shortened arterial transit time immediately after CEA. However, ASL may be used as for screening.
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Affiliation(s)
- Takafumi Shimogawa
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Tetsuro Sayama
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Sei Haga
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Tomoaki Akiyama
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Kei Murao
- Department of Cerebrovascular Disease, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Yuka Kanazawa
- Department of Cerebrovascular Disease, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Yoshihiko Furuta
- Department of Cerebrovascular Disease, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Ayumi Sakata
- Department of Clinical Chemistry and Laboratory Medicine, Kyusyu University Hospital, Fukuoka, Japan
| | - Shuji Arakawa
- Department of Cerebrovascular Disease, Kyushu Rosai Hospital, Kitakyushu, Japan
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Evaluation of Cerebral Hyperperfusion After Carotid Artery Stenting Using C‑Arm CT Measurements of Cerebral Blood Volume. Clin Neuroradiol 2016; 28:253-260. [PMID: 27942771 DOI: 10.1007/s00062-016-0552-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Hyperperfusion syndrome (HPS) after carotid artery stenting (CAS) causes serious symptoms; therefore, early evaluation after CAS is considered to be important. Measurement of cerebral blood volume using C‑arm computed tomography (C-arm CBV) has recently become possible. Here, the usefulness of C‑arm CBV for the evaluation of hyperperfusion was investigated. METHODS C-arm CBV was measured before and immediately after CAS in 30 patients. The regions of interest (ROI) were set in the bilateral middle cerebral artery perfused regions, and the affected/healthy side ratio of measured C‑arm CBV (CBV ratios) was determined to evaluate cerebral perfusion. For comparing values before and after CAS, the CBV ratio increase rate (postoperative CBV ratios/preoperative CBV ratios) was also determined. RESULTS C-arm CBV was successfully measured in 30 patients. Intracerebral hemorrhage (ICH) was detected in 3 patients, and no other patient had hyperperfusion syndrome. In the patients who developed ICH, postoperative C‑arm CBV on the affected side was high, and a marked increase was confirmed in the postoperative CBV ratios. Postoperative CBV ratios were 1.03 ± 0.40 and 1.45 ± 0.68 in the non-ICH and ICH groups, and CBV ratio increase rates were 2.7 ± 24.0% and 28.5 ± 26.7% in the non-ICH and ICH groups, respectively; these differences were statistically significant (P < 0.01). CONCLUSION C-arm CT allows CBV measurements immediately after CAS without requiring transport of the patient out of the angiography room, and it may enable the evaluation of hyperperfusion before and after CAS.
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Cerebral hyperperfusion syndrome resulting in subarachnoid hemorrhage after carotid artery stenting. Ann Nucl Med 2016; 30:669-674. [PMID: 27485406 DOI: 10.1007/s12149-016-1108-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
A 64-year-old, right-handed man underwent endovascular treatment for internal carotid artery stenosis after experiencing a left-hemispheric transient ischemic attack. 15O-gas and H 215 O positron emission tomography revealed slightly reduced cerebral blood flow (CBF), elevated cerebral blood volume, and severely reduced cerebral vasoreactivity in the ipsilateral hemisphere as determined by an acetazolamide challenge test. The patient underwent left carotid artery stenting (CAS) via a prefemoral approach under local anesthesia without any complications. Follow-up examinations performed 20 h postoperatively showed subarachnoid hemorrhage (SAH) and cerebral hyperperfusion syndrome (CHS) in the left frontal lobe. Although it is a relatively rare phenomenon, SAH resulting from CHS was determined to be specifically caused by CAS. In this case, the causes of SAH may have been related to multiple factors including increased regional CBF, loss of cerebrovascular autoregulation, contrast agent-mediated disruption of major cerebral vessels, and strong antiplatelet therapy.
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Maltezos C, Papanas N, Papas T, Georgiadis G, Dragoumanis C, Marakis J, Maltezos E, Lazarides M. Changes in Blood Flow of Anterior and Middle Cerebral Arteries Following Carotid Endarterectomy: A Transcranial Doppler Study. Vasc Endovascular Surg 2016; 41:389-96. [DOI: 10.1177/1538574407302850] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim: The aim of the present study was to evaluate the changes in blood flow of anterior and middle cerebral arteries following carotid endarterectomy, using transcranial Doppler (TCD) flow studies. Patients and methods: This study included 100 patients (72 men, mean age 65 years) who underwent carotid endarterectomy because of high-grade carotid stenosis or symptoms of ischemic stroke. Endarterectomy was performed by a distal shunt between the common carotid and internal carotid arteries. Blood flow in the anterior and middle cerebral arteries was assessed by TCD preoperatively and also in the postoperative period (1st and 4th day; 1st, 6th, and 12th month). Collateral circulation in the Willis circle was evaluated by common carotid compression. Results: Patients with bilateral carotid stenosis ≥70% exhibited a significantly increased flow velocity in the ipsilateral anterior cerebral artery (ACA), middle cerebral artery (MCA), and in the contralateral ACA. Patients with entirely occluded contralateral internal carotid artery showed the most pronounced changes in cerebral hemodynamics. Blood flow velocities returned to the preoperative values at 1 to 12 months following endarterectomy. Hyperperfusion syndrome was manifested in 14 patients, who exhibited significantly higher flow velocities in the ipsilateral MCA compared with asymptomatic patients. Conclusions: A transient bilateral increase of blood flow velocity in the anterior part of the Willis circle may often occur in the immediate postoperative period following carotid endarterectomy. Although its clinical significance is not entirely understood, this increase may be associated with cerebral hyperperfusion syndrome.
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Affiliation(s)
- C.K. Maltezos
- Department of Vascular Surgery, General Hospital “Georgios Gennimatas,” Athens, Greece
| | - N. Papanas
- Second Department of Internal Medicine, papanasnikos@ yahoo.gr
| | - T.T. Papas
- Department of Vascular Surgery, General Hospital “Georgios Gennimatas,” Athens, Greece, Department of Vascular Surgery
| | | | - C.K. Dragoumanis
- Department of Anaesthesiology, Democritus University, Alexndroupolis, Greece
| | - J. Marakis
- Department of Vascular Surgery, General Hospital “Georgios Gennimatas,” Athens, Greece
| | | | - M.K. Lazarides
- Department of Vascular Surgery, General Hospital “Georgios Gennimatas,” Athens, Greece, Department of Vascular Surgery
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Fujimoto K, Matsumoto Y, Oikawa K, Nomura JI, Shimada Y, Fujiwara S, Terasaki K, Kobayashi M, Yoshida K, Ogasawara K. 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. Int J Mol Sci 2016; 17:ijms17081261. [PMID: 27527146 PMCID: PMC5000659 DOI: 10.3390/ijms17081261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Kentaro Fujimoto
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Yoshiyasu Matsumoto
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Kohki Oikawa
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Jun-Ichi Nomura
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Yasuyoshi Shimada
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Shunrou Fujiwara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Kazunori Terasaki
- Cyclotron Research Center, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
| | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, 19-1 Uchmaru, 020-8505 Morioka, Japan.
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Matsumoto N, Enatsu R, Matsui Y, Ikeda H, Yamana N, Oda M, Saiki M, Narumi O. Perioperative Evaluation of Cerebral Blood Flow Using (123)I-labeled N-isopropyl-p-iodoamphetamine Single-Photon Emission Computed Tomography without Blood Sampling in Patients Who Underwent Carotid Artery Stenting. Chin Med J (Engl) 2016; 129:1616-8. [PMID: 27364800 PMCID: PMC4931270 DOI: 10.4103/0366-6999.184473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Naoki Matsumoto
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Rei Enatsu
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Yasuzumi Matsui
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Norikazu Yamana
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Masashi Oda
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Masaaki Saiki
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
| | - Osamu Narumi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji 670-8520, Hyogo, Japan
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Fantini S, Sassaroli A, Tgavalekos KT, Kornbluth J. Cerebral blood flow and autoregulation: current measurement techniques and prospects for noninvasive optical methods. NEUROPHOTONICS 2016; 3:031411. [PMID: 27403447 PMCID: PMC4914489 DOI: 10.1117/1.nph.3.3.031411] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/10/2016] [Indexed: 05/23/2023]
Abstract
Cerebral blood flow (CBF) and cerebral autoregulation (CA) are critically important to maintain proper brain perfusion and supply the brain with the necessary oxygen and energy substrates. Adequate brain perfusion is required to support normal brain function, to achieve successful aging, and to navigate acute and chronic medical conditions. We review the general principles of CBF measurements and the current techniques to measure CBF based on direct intravascular measurements, nuclear medicine, X-ray imaging, magnetic resonance imaging, ultrasound techniques, thermal diffusion, and optical methods. We also review techniques for arterial blood pressure measurements as well as theoretical and experimental methods for the assessment of CA, including recent approaches based on optical techniques. The assessment of cerebral perfusion in the clinical practice is also presented. The comprehensive description of principles, methods, and clinical requirements of CBF and CA measurements highlights the potentially important role that noninvasive optical methods can play in the assessment of neurovascular health. In fact, optical techniques have the ability to provide a noninvasive, quantitative, and continuous monitor of CBF and autoregulation.
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Affiliation(s)
- Sergio Fantini
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Angelo Sassaroli
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Kristen T. Tgavalekos
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Joshua Kornbluth
- Tufts University School of Medicine, Department of Neurology, Division of Neurocritical Care, 800 Washington Street, Box #314, Boston, Massachusetts 02111, United States
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Lin CJ, Guo WY, Chang FC, Hung SC, Chen KK, Yu DZ, Wu CHF, Liou JKA. Using Flat-Panel Perfusion Imaging to Measure Cerebral Hemodynamics: A Pilot Feasibility Study in Patients With Carotid Stenosis. Medicine (Baltimore) 2016; 95:e3529. [PMID: 27196456 PMCID: PMC4902398 DOI: 10.1097/md.0000000000003529] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Flat-detector CT perfusion (FD-CTP) imaging has demonstrated efficacy in qualitatively accessing the penumbra in acute stroke equivalent to that of magnetic resonance perfusion (MRP). The aim of our study was to evaluate the feasibility of quantifying oligemia in the brain in patients with carotid stenosis.Ten patients with unilateral carotid stenosis of >70% were included. All MRPs and FD-CTPs were performed before stenting. Region-of-interests (ROIs) including middle cerebral artery territory at basal ganglia level on both stenotic and contralateral sides were used for quantitative analysis. Relative time to peak (rTTP) was defined as TTP of the stenotic side divided by TTP of the contralateral side, and so as relative cerebral blood volume (rCBV), relative mean transit time (rMTT), and relative cerebral blood flow (rCBF). Absolute and relative TTP, CBV, MTT, CBF between two modalities were compared.For absolute quantitative analysis, the correlation of TTP was highest (r = 0.56), followed by CBV (r = 0.47), MTT (r = 0.47), and CBF (r = 0.43); for relative quantitative analysis, rCBF was the highest (r = 0.79), followed by rTTP (r = 0.75) and rCBV (r = 0.50).We confirmed that relative quantitative assessment of FD-CTP is feasible in chronic ischemic disease. Absolute quantitative measurements between MRP and FD-CTP only expressed moderate correlations. Optimization of acquisitions and algorithms is warranted to achieve better quantification.
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Affiliation(s)
- Chung-Jung Lin
- From the Department of Radiology (C-JL, W-YG, F-CC, S-CH, J-KAL), Taipei Veterans General Hospital; School of Medicine (C-JL, W-YG, F-CC, S-CH), National Yang-Ming University; Department of Biomedical Imaging and Radiological Sciences (S-CH, K-KC, J-KAL), School of Biomedical Science of Engineering, National Yang-Ming University; Siemens Healthcare GmbH (D-ZY), Advanced Therapies, Forchheim, Germany; Siemens Healthcare Ltd. (C-HFW), Advanced Therapies, Taipei, Taiwan
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Yoshida J, Ogasawara K, Chida K, Oikawa K, Matsumoto Y, Nomura JI, Ogasawara Y, Fujiwara S, Kobayashi M, Yoshida K, Terasaki K, Ogawa A. 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. Neurol Res 2016; 38:1-9. [PMID: 26896025 DOI: 10.1080/01616412.2015.1114291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Jun Yoshida
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Kuniaki Ogasawara
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Kohei Chida
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Kohki Oikawa
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | | | - Jun-Ichi Nomura
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Yasushi Ogasawara
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Shunro Fujiwara
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Masakazu Kobayashi
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Kenji Yoshida
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
| | - Kazunori Terasaki
- b School of Medicine , Cyclotron Research Center, Iwate Medical University , Morioka , Japan
| | - Akira Ogawa
- a Department of Neurosurgery , Iwate Medical University , Morioka , Japan
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Prediction of cerebral hyperperfusion syndrome after carotid artery stenting by CT perfusion imaging with acetazolamide challenge. Neuroradiology 2015; 58:253-9. [DOI: 10.1007/s00234-015-1623-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/17/2015] [Indexed: 11/26/2022]
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Yoshida K, Ogasawara K, Saura H, Saito H, Kobayashi M, Yoshida K, Terasaki K, Fujiwara S, Ogawa A. Post-carotid endarterectomy changes in cerebral glucose metabolism on 18F-fluorodeoxyglucose positron emission tomography associated with postoperative improvement or impairment in cognitive function. J Neurosurg 2015; 123:1546-54. [DOI: 10.3171/2014.12.jns142339] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Cognitive function is often improved or impaired after carotid endarterectomy (CEA) for patients with cerebral hemodynamic impairment. Cerebral glucose metabolism measured using positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) correlates with cognitive function in patients with neurodegenerative diseases. The present study aimed to determine whether postoperative changes in cerebral glucose metabolism are associated with cognitive changes after CEA.
METHODS
In patients who were scheduled to undergo CEA for ipsilateral internal carotid artery (ICA) stenosis (≥ 70% narrowing), cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide were assessed preoperatively using brain perfusion single-photon emission computed tomography (SPECT). CBF measurement using SPECT was also performed immediately after CEA. For patients with reduced preoperative CVR to acetazolamide in the cerebral hemisphere ipsilateral to surgery, cerebral glucose metabolism was assessed using FDG-PET before surgery and 3 months after surgery and was analyzed using 3D stereotactic surface projection. Neuropsychological testing was also performed preoperatively and 3 months postoperatively.
RESULTS
Twenty-two patients with reduced preoperative CVR to acetazolamide successfully underwent FDG-PET studies and neuropsychological testing before and after CEA. Seven, 9, and 6 patients were defined as showing improved, unchanged, and impaired postoperative cognition, respectively, based on the neuropsychological assessments. The cortical area with increased postoperative glucose metabolism was greater in patients with improved postoperative cognition than in those with unchanged (p < 0.001) or impaired (p < 0.001) postoperative cognition. The cortical area with decreased postoperative glucose metabolism was greater in patients with impaired postoperative cognition than in those with improved (p < 0.001) or unchanged (p < 0.001) postoperative cognition. All 7 patients with improved cognition exhibited postoperative hemispheric increases in glucose metabolism, while 5 of the 6 patients with impaired cognition exhibited postoperative hemispheric decreases in glucose metabolism. Brain perfusion SPECT revealed that the latter 6 patients experienced postoperative cerebral hyperperfusion, and 2 of the 6 patients exhibited cerebral hyperperfusion syndrome. The cortical area with decreased postoperative glucose metabolism in these 2 patients was greater than that in other patients.
CONCLUSIONS
Postoperative changes in cerebral glucose metabolism, as measured using FDG-PET, are associated with cognitive improvement and impairment after CEA.
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Affiliation(s)
- Koji Yoshida
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kuniaki Ogasawara
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Hiroaki Saura
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Hideo Saito
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Masakazu Kobayashi
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | | | - Kazunori Terasaki
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
| | | | - Akira Ogawa
- 1Department of Neurosurgery
- 2Cyclotron Research Center, School of Medicine, Iwate Medical University, Iwate, Japan
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Hosoda K. The Significance of Cerebral Hemodynamics Imaging in Carotid Endarterectomy: A Brief Review. Neurol Med Chir (Tokyo) 2015; 55:782-8. [PMID: 26369874 PMCID: PMC4663027 DOI: 10.2176/nmc.ra.2015-0090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The indication of carotid endarterectomy (CEA) is principally determined by the presence or absence of symptoms and the degree of stenosis. However, the results of recent studies have implicated the usefulness of cerebral hemodynamics imaging for perioperative assessments. Many studies using single-photon emission computed tomography (SPECT) have demonstrated that cerebral hemodynamics imaging assessments are useful in the prediction and assessment of post-CEA hyperperfusion. In studies using transcranial Doppler ultrasonography, SPECT, or positron-emission tomography (PET), cerebral hemodynamic impairment is highly likely to increase the risk of cerebral infarction in patients with asymptomatic carotid artery stenosis. In other studies using the same modalities, cerebral hemodynamic impairment might be related to cognitive impairment in carotid artery stenosis, and this cognitive impairment might be improved with CEA. Nuclear medicine techniques involve the injection of radioactive tracers. Arterial spin labeling (ASL) is an emerging technique of perfusion magnetic resonance imaging (MRI) for the noninvasive measurement of cerebral perfusion. ASL could detect pathologic states such as hypoperfusion, impaired vasoreactivity, and postoperative hyperperfusion activities that are equivalent to SPECT. In addition, regional perfusion imaging visualizes cerebral perfusion territories by selective ASL. In conclusion, cerebral hemodynamic imaging would be useful for the perioperative assessment of CEA. However, there is a lack of sufficient scientific evidence to confirm the benefits, necessitating further study.
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Affiliation(s)
- Kohkichi Hosoda
- Department of Neurosurgery, Kobe University Graduate School of Medicine
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Vanpeteghem C, Moerman A, De Hert S. Perioperative Hemodynamic Management of Carotid Artery Surgery. J Cardiothorac Vasc Anesth 2015; 30:491-500. [PMID: 26597466 DOI: 10.1053/j.jvca.2015.07.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Indexed: 01/21/2023]
Affiliation(s)
| | - Anneliese Moerman
- Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium
| | - Stefan De Hert
- Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium
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Abstract
PURPOSE This study aimed to define hyperperfusion in carotid stenting patients without excluding patients with stenosis on the contralateral side. MATERIALS AND METHODS A total of 32 patients were enrolled. Prestent computed tomography perfusions were performed within 1 week before stenting, poststent perfusions 3 days after stenting. Prestent relative cerebral blood volume, relative cerebral blood flow, and relative mean transient time (rMTT) were calculated by dividing measurements from ipsilateral stent sides to contralateral sides and prestent difference mean transit time (dMTT) by subtracting contralateral mean transient time (MTT) from ipsilateral MTT. Poststent values were calculated similarly. For differences between prestent and poststent values, independent t test was used between groups and paired sample t test within the groups. RESULTS Of the 31 patients, 4 showed poststent clinical hyperperfusion syndrome. Six showed poststent radiologic hyperperfusion with increased cerebral blood flow, increased or spared cerebral blood volume, and shortened MTT values, but only 1 demonstrated clinical hyperperfusion. Between normal and hyperperfused groups, only appreciable difference was noted in prestent and poststent dMTT without statistical significance. Within the groups, only statistical difference (P < 0.001) was noted in rMTT and dMTT in normal groups and no significant difference in the hyperperfused group. CONCLUSIONS Radiologic hyperperfusion does not match clinical hyperperfusion. Normal group responded to stenting with statistically significant changes of rMTT and dMTT. Hyperperfusion mostly occurred in the contralateral critically stenosed patients. The hyperperfused group, due to similar MTT of both hemispheres and ipsilateral internal carotid artery being the main feeder of both hemispheres, did not show significant changes in their rMTT and dMTT values after stenting. This shows that reduced hemodynamic reserve is the main reason behind the hyperperfusion after carotid stenting.
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Oshida S, Ogasawara K, Saura H, Yoshida K, Fujiwara S, Kojima D, Kobayashi M, Yoshida K, Kubo Y, Ogawa A. 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. Neurol Med Chir (Tokyo) 2015; 55:141-8. [PMID: 25746308 PMCID: PMC4533404 DOI: 10.2176/nmc.oa.2014-0269] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Sotaro Oshida
- Department of Neurosurgery, Iwate Medical University
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Lin CJ, Chang FC, Tsai FY, Guo WY, Hung SC, Chen DYT, Lin CH, Chang CY. Stenotic transverse sinus predisposes to poststenting hyperperfusion syndrome as evidenced by quantitative analysis of peritherapeutic cerebral circulation time. AJNR Am J Neuroradiol 2014; 35:1132-6. [PMID: 24436346 DOI: 10.3174/ajnr.a3838] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hyperperfusion syndrome is a devastating complication of carotid stent placement. The shortening of cerebral circulation time after stent placement is seen as a good indicator of the development of hyperperfusion syndrome. The purpose of our study was to evaluate whether patients with ipsilateral transverse sinus stenosis are prone to having shortened cerebral circulation time after stent placement, subsequently leading to the possible development of hyperperfusion syndrome. MATERIALS AND METHODS Forty-nine patients with >70% unilateral carotid stenosis undergoing stent placement were recruited for analysis. Group A consisted of patients with a stenotic ipsilateral transverse sinus >50% greater than the diameter of the contralateral transverse sinus; the remaining patients were in group B. Quantitative DSA was used to calculate cerebral circulation time. Cerebral circulation time was defined as the time difference between the relative time to maximal intensity of ROIs in the proximal internal carotid artery and the internal jugular vein. ΔCCT was defined as cerebral circulation time before stent placement minus cerebral circulation time after stent placement. ΔCCT, white matter hyperintensity signals, and sulcal effacement in MR imaging were compared between the 2 groups. RESULTS ΔCCT was significantly shorter in group A (0.65 ± 1.3) than in group B (-0.12 ± 1.4). Three patients had white matter hyperintensity signals in group A, and 1 developed hyperperfusion syndrome. Group B showed no MR imaging signs of hyperperfusion syndrome. CONCLUSIONS Ipsilateral hypoplastic transverse sinus was associated with prolonged cerebral circulation time before stent placement and greatly shortened cerebral circulation time after stent placement. Inadequate venous drainage might play a role in impaired cerebral autoregulation and might influence the development of poststenting hyperperfusion syndrome.
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Affiliation(s)
- C-J Lin
- From the Department of Radiology (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), Taipei Veterans General Hospital, Taipei, TaiwanSchool of Medicine (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), National Yang Ming University, Taipei, Taiwan
| | - F-C Chang
- From the Department of Radiology (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), Taipei Veterans General Hospital, Taipei, TaiwanSchool of Medicine (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), National Yang Ming University, Taipei, Taiwan
| | - F-Y Tsai
- Imaging Research Center (F.-Y.T., D.Y.-T.C.), Taipei Medical University, Taipei, Taiwan
| | - W-Y Guo
- From the Department of Radiology (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), Taipei Veterans General Hospital, Taipei, TaiwanSchool of Medicine (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), National Yang Ming University, Taipei, Taiwan
| | - S-C Hung
- From the Department of Radiology (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), Taipei Veterans General Hospital, Taipei, TaiwanSchool of Medicine (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), National Yang Ming University, Taipei, Taiwan
| | - D Y-T Chen
- Imaging Research Center (F.-Y.T., D.Y.-T.C.), Taipei Medical University, Taipei, TaiwanDepartment of Medical Imaging (D.Y.-T.C.), Shuang-Ho Hospital, New Taipei City, Taiwan
| | - C-H Lin
- Graduate Institute of Epidemiology and Preventive Medicine (C.-H.L.), National Taiwan University, Taipei, Taiwan
| | - C-Y Chang
- From the Department of Radiology (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), Taipei Veterans General Hospital, Taipei, TaiwanSchool of Medicine (C.-J.L., F.-C.C., W.-Y.G., S.-C.H., C.-Y.C.), National Yang Ming University, Taipei, Taiwan
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Reply: To PMID 23891492. J Vasc Surg 2014; 59:571. [PMID: 24461873 DOI: 10.1016/j.jvs.2013.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 11/20/2022]
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Oka F, Ishihara H, Kato S, Oku T, Yamane A, Kunitugu I, Suzuki M. Cerebral hemodynamic benefits after carotid artery stenting in patients with near occlusion. J Vasc Surg 2013; 58:1512-7. [DOI: 10.1016/j.jvs.2013.05.103] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 05/21/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
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Kawai N, Hatakeyama T, Okauchi M, Kawanishi M, Shindo A, Kudomi N, Yamamoto Y, Nishiyama Y, Tamiya T. Cerebral blood flow and oxygen metabolism measurements using positron emission tomography on the first day after carotid artery stenting. J Stroke Cerebrovasc Dis 2013; 23:e55-64. [PMID: 24119366 DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 06/16/2013] [Accepted: 08/14/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The aim of the present study is the characterization of hemodynamics to predict hyperperfusion syndrome (HPS) after carotid artery stenting (CAS) with positron emission tomography (PET) obtained before and on the first day after the treatment. METHODS Cerebral perfusion and oxygen metabolism were evaluated by (15)O-gas PET in 18 patients with symptomatic internal carotid artery (ICA) stenosis before and on the first day after CAS. Regional cerebral blood flow (CBF), oxygen extraction fraction (OEF), cerebral metabolic rate of oxygen (CMRO2), and cerebral blood volume (CBV) were measured in the ipsilateral and contralateral middle cerebral artery territories and compared between before and after CAS. RESULTS CBF increased in 16 of 18 patients on the first day after CAS and postoperative CBF was significantly higher than preoperative CBF bilaterally. OEF decreased in 15 of 18 patients on the first day after CAS and postoperative OEF was significantly lower than preoperative OEF in the ipsilateral hemisphere. CMRO2 and CBV did not change significantly. None of the patients showed HPS after CAS. All patients who had preoperative OEF of 53% or more (misery perfusion) in the ipsilateral hemisphere showed 50% or more increase in CBF postoperatively. The preoperative OEF value significantly correlated with the rate of postoperative increase in CBF bilaterally. CONCLUSIONS CAS increases cerebral perfusion and improves hemodynamic compromise in patients with symptomatic ICA stenosis. Although we could not clarify the usefulness of PET before and on the first day after CAS in predicting HPS, a high preoperative OEF is related to postoperative marked CBF increase and might be used as a predictor of HPS. Patients with greater hemodynamic compromise with a high preoperative OEF should be managed carefully to prevent HPS, but they have a greater chance of CBF increase after CAS.
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Affiliation(s)
- Nobuyuki Kawai
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.
| | - Tetsuhiro Hatakeyama
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Masanobu Okauchi
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Masahiko Kawanishi
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Atsushi Shindo
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Nobuyuki Kudomi
- Department of Medical Physics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yuka Yamamoto
- Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshihiro Nishiyama
- Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Tamiya
- Department of Neurological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
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48
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Kim KH, Lee CH, Son YJ, Yang HJ, Chung YS, Lee SH. Post-carotid endarterectomy cerebral hyperperfusion syndrome : is it preventable by strict blood pressure control? J Korean Neurosurg Soc 2013; 54:159-63. [PMID: 24278642 PMCID: PMC3836920 DOI: 10.3340/jkns.2013.54.3.159] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 06/11/2013] [Accepted: 09/08/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid endarterectomy (CEA). However, the prevalence of CHS has decreased as techniques have improved. This study evaluates the role of strict blood pressure (BP) control for the prevention of CHS. Methods All 18 patients who received CEA from February 2009 through November 2012 were retrospectively reviewed. All patients were routinely managed in an intensive care unit by a same protocol. The cerebral perfusion state was evaluated on the basis of the regional cerebral blood flow (rCBF) study by perfusion computed tomography (pCT) and mean velocity by transcranial doppler (TCD). BP was strictly controlled (<140/90 mm Hg) for 7 days. When either post-CEA hyperperfusion (>100% increase in the rCBF by pCT or in the mean velocity by TCD compared with preoperative values) or CHS was detected, BP was maintained below 120/80 mm Hg. Results TCD and pCT data on the patients were analyzed. Ipsilateral rCBF was significantly increased after CEA in the pCT (p=0.049). Post-CEA hyperperfusion was observed in 3 patients (18.7%) in the pCT and 2 patients (12.5%) in the TCD study. No patients developed clinical CHS for one month after CEA. Furthermore, no patients developed additional neurological deficits related to postoperative cerebrovascular complications. Conclusion Intensive care with strict BP control (<140/90 mm Hg) achieved a low prevalence of post-CEA hyperperfusion and prevented CHS. This study suggests that intensive care with strict BP control can prevent the prevalence of post-CEA CHS.
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Affiliation(s)
- Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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49
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Chang TY, Kuan WC, Huang KL, Chang CH, Chang YJ, Wong HF, Lee TH, Liu HL. Heterogeneous cerebral vasoreactivity dynamics in patients with carotid stenosis. PLoS One 2013; 8:e76072. [PMID: 24086687 PMCID: PMC3785420 DOI: 10.1371/journal.pone.0076072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 08/20/2013] [Indexed: 11/19/2022] Open
Abstract
Cerebral vasoreactivity (CVR) can be assessed by functional MRI (fMRI) using hypercapnia challenges. In normal subjects, studies have shown temporal variability of CVR blood oxygenation level-dependent responses among different brain regions. In the current study, we analyzed the variability of BOLD CVR dynamics by fMRI with a breath-holding task in 17 subjects with unilateral carotid stenosis before they received carotid stenting. Great heterogeneity of CVR dynamics was observed when comparing BOLD responses between ipsilateral and contralateral hemispheres in each patient, especially in middle cerebral artery (MCA) territories. While some subjects (n=12) had similar CVR responses between either hemisphere, the others (n=5) had a poorly correlated pattern of BOLD changes between ipsilateral and contralateral hemispheres. In the latter group, defined as impaired CVR, post-stenting perfusion tended to be more significantly increased. Our data provides the first observation of divergent temporal BOLD responses during breath holding in patients with carotid stenosis. The development of collateral circulation and the derangement of cerebral hemodynamics can be detected through this novel analysis of the different patterns of BOLD changes. The results also help in prediction of robust increase of perfusion or hyperperfusion after carotid stenting.
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Affiliation(s)
- Ting-Yu Chang
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wan-Chun Kuan
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Lun Huang
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ho-Fai Wong
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (HLL); (THL)
| | - Ho-Ling Liu
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (HLL); (THL)
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50
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Sato K, Kurata A, Oka H, Kan S, Inoue Y, Asano Y, Fujii K. Signal intensity changes for the middle cerebral artery on 3-dimensional time-of-flight magnetic resonance angiography indicate acute hemodynamic changes after carotid endarterectomy. J Stroke Cerebrovasc Dis 2013; 22:e511-5. [PMID: 23810351 DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/08/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND For 3-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA), the signal intensity (SI) loss depends on the flow velocity. In this study, we aimed to evaluate whether 3D-TOF-MRA could be used as an alternative to single-photon emission computed tomography (SPECT) for assessing the increase in the regional cerebral blood flow (rCBF) after carotid endarterectomy (CEA). To do this, we compared the SI of the middle cerebral artery (MCA) on magnetic resonance angiography (MRA) and the rCBF on SPECT. METHODS We enrolled 30 patients with internal carotid artery stenosis. SPECT and MRA were performed before and 3-4 days after CEA. rCBF was assessed using SPECT, and the SI of the MCA was assessed using single-slab 3D-TOF-MRA. Regions of interest were placed in the bilateral middle M1 portions of the MCA on MRA, and their mean SI was measured. The increase ratio of the rCBF on SPECT and the increase ratio of the SI of the MCA on MRA were calculated using the formula: (post-CEA ipsilateral/post-CEA contralateral)/(pre-CEA ipsilateral/pre-CEA contralateral). RESULTS A significant correlation was observed between the increase ratio of the rCBF on SPECT and the increase ratio of the SI of the MCA on MRA (r=.894, y=.4863+.5184x, P<.001). All values obtained by MRA were greater than or equal to the SPECT values, indicating that MRA tends to overestimate the post-CEA rCBF increase. CONCLUSION Because MRA identified increased rCBF after CEA, we recommend that patients first be screened using MRA.
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Affiliation(s)
- Kimitoshi Sato
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
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