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Xu M, Yan P, Zhao Y, Wang H, Sun Q, Du Y. Neurosonological Parameters May Predict the Risk of Cerebral Hyperperfusion Syndrome After Carotid Artery Stenting. World Neurosurg 2024; 187:e77-e85. [PMID: 38593913 DOI: 10.1016/j.wneu.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Cerebral hyperperfusion syndrome (CHS) is a critical complication in patients who underwent carotid artery stenting (CAS). We sought to explore neurosonological parameters and additional risk factors associated with CHS in patients following CAS and further to develop a prediction model for CHS after CAS. METHODS A total of 197 patients who underwent CAS were included in this observational study. All patients were divided into CHS and non-CHS groups. Demographic, clinical, treatment, and laboratory data were extracted from electronic medical records. Logistic regression analysis and nomogram listing were used to build a CHS prediction model. Machine learning algorithms with five-fold cross-validation were used to further validate the CHS prediction model. RESULTS Twenty-two patients had clinically manifested CHS. Four parameters were detected as risk factors associated with CHS, including effective collateral circulation (P = 0.046), asymmetry ratio of peak systolic velocity of the middle cerebral artery (P = 0.001), severe stenosis or occlusion of the contralateral carotid artery (P = 0.010), and low-density lipoprotein cholesterol (P = 0.025). The area under the curve for the prediction model of CHS in the cohort was 0.835 (95% confidence interval 0.760-0.909). CONCLUSIONS In this study, CHS following CAS was associated with effective collateral circulation, ARP, contralateral ICA severe stenosis or occlusion, as well as low-density lipoprotein cholesterol. Subsequently, the CHS prediction model for CAS was built, which has the potential to facilitate tailored and precise management as well as treatment strategies for patients at high risk of CHS.
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Affiliation(s)
- Min Xu
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China; Neurointensive Care Unit, Shengli Oilfield Central Hospital, Dongying, Shandong, P.R. China; Medical School, Tianjin University, Tianjin, P.R. China
| | - Peng Yan
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Yuanyuan Zhao
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Hailing Wang
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Qinjian Sun
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Yifeng Du
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Jinan, Shandong, P.R. China; Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China.
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Shimohigoshi W, Akimoto T, Ozaki S, Fushimi S, Takagi R, Kawasaki T, Uramaru K, Tatezuki J, Manaka H, Nakai Y, Sakata K, Yamamoto T. Safety and Risk Factors of Carotid Artery Stenting with Simple Distal Filter Protection: A Single-Center Retrospective Study. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:155-163. [PMID: 38911486 PMCID: PMC11189783 DOI: 10.5797/jnet.oa.2023-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/09/2024] [Indexed: 06/25/2024]
Abstract
Objective Carotid artery stenting embolic protection devices offer various options, among which distal filter protection is the simplest and easiest to handle. However, compared to balloon protection systems, distal filter protection has more embolic complications. Therefore, we explored the risk factors of distal filter protection, intending to achieve a safer carotid artery stenting. This retrospective study was conducted to identify prognostic factors following carotid artery stenting with only distal filter protection from July 2010 to June 2021. Methods Information on patient background, procedures and devices, and complications was collected using medical records. The data pertaining to 187 patients were analyzed after excluding the data of patients in whom other protection devices (8 cases) were used. We used FilterWire EZ as the first choice for embolic protection device and SpiderFX when the patients had difficult-to-cross lesions. Results The patients' mean age was 71.9 ± 6.9 years, and 72 (38.5%) were symptomatic. Symptomatic (odds ratio: 2.02, p = 0.035) and difficult-to-cross lesions (odds ratio: 3.63, p = 0.0013) were factors independently associated with symptomatic complications. Conclusion This retrospective single-center study established independent prognostic factors for carotid artery stenting with distal filter protection. For patients with symptomatic lesions and severe stenosis or bends that are difficult to pass through, it is necessary to be careful when performing carotid artery stenting with distal filter protection.
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Affiliation(s)
- Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Shuto Fushimi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ryosuke Takagi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takafumi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Koichi Uramaru
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Junya Tatezuki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Ozaki S, Akimoto T, Iida Y, Miyake S, Suzuki R, Shimohigoshi W, Hori S, Suenaga J, Shimizu N, Nakai Y, Sakata K, Yamamoto T. Complications and outcomes of carotid artery stenting in high-risk cases. J Stroke Cerebrovasc Dis 2023; 32:107329. [PMID: 37657401 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/21/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk. MATERIALS AND METHODS We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing. RESULTS The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications. CONCLUSIONS This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.
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Affiliation(s)
- So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Satoshi Hori
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Jun Suenaga
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan; Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
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Fukuma K, Tanaka T, Takaya S, Tojima M, Kobayashi K, Shimotake A, Morita Y, Nishimura K, Koga M, Toyoda K, Matsumoto R, Takahashi R, Ikeda A, Ihara M. Developing an Asymmetry Method for Detecting Postictal Hyperperfusion in Poststroke Epilepsy. Front Neurol 2022; 13:877386. [PMID: 35911879 PMCID: PMC9334132 DOI: 10.3389/fneur.2022.877386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Using dual single-photon emission computed tomography (SPECT) scanning, we recently found the postictal-interictal (P-I) subtraction method frequently detects prolonged postictal hyperperfusion in poststroke epilepsy (PSE) and thus may be valuable for auxiliary diagnosis. This study aimed to determine if the asymmetry method can localize hyperperfusion to reflect epileptic activity in PSE using a single postictal SPECT scan. Sixty-four patients with PSE who had undergone perfusion SPECT two times (postictal and interictal) were enrolled. We formulated a novel asymmetry method (subtraction analysis of reversed postictal SPECT from postictal SPECT, co-registered to magnetic resonance imaging) to identify paradoxical asymmetric increase, defined as a higher perfusion area adjacent to stroke lesions compared to the contralateral side. The postictal hyperperfusion area and detection rates were determined by the asymmetry and P-I subtraction methods independently. We subsequently calculated the sensitivity and specificity of the asymmetry method, compared to the gold standard P-I subtraction method. We also evaluated lateralization concordance between the asymmetry method and other clinical findings. Among 64 patients (median age, 75 years), prolonged postictal hyperperfusion was detected in 43 (67%) by the asymmetry, and 54 (84%) the P-I, method. The asymmetry method had high sensitivity (80%) and specificity (100%) in detecting postictal hyperperfusion, showing high lateralization concordance with seizure semiology (97%) and epileptiform electroencephalography findings (interictal/ictal epileptiform discharges or periodic discharges) (100%). The present study demonstrated the advantages of the objective asymmetry method for detecting prolonged hyperperfusion through using one postictal SPECT scan in PSE.
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Affiliation(s)
- Kazuki Fukuma
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
- *Correspondence: Kazuki Fukuma
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shigetoshi Takaya
- Department of Neurology, Senri Rehabilitation Hospital, Osaka, Japan
- Department of Rehabilitation Medicine, Senri Rehabilitation Hospital, Osaka, Japan
| | - Maya Tojima
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Shimotake
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kunihiro Nishimura
- Departments of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
- Masafumi Ihara
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Nishimoto T, Oka F, Okazaki K, Ishihara H. Relationship between cerebral hyperperfusion syndrome and the immediate change of cerebral blood flow after carotid artery stenting evaluated by single-photon emission computed tomography. Neuroradiology 2022; 64:1157-1164. [PMID: 34812919 DOI: 10.1007/s00234-021-02822-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/17/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Cerebral hyperperfusion syndrome (CHS) is a critical complication after carotid artery stenting (CAS). However, few CAS studies have evaluated immediate and temporary changes in ipsilateral cerebral blood flow (CBF) quantitatively. The study was performed to evaluate immediate changes in CBF after CAS and subsequent CBF changes in patients with cerebral hyperperfusion (HP) using 123I-IMP SPECT. METHODS The subjects were 223 patients with chronic extracranial carotid artery stenosis who underwent CAS in our department between March 2010 and March 2020. Quantitative CBF and cerebrovascular reactivity to acetazolamide in the middle cerebral artery were assessed before CAS by 123I-IMP SPECT. CBF was also measured immediately after CAS by 123I-IMP SPECT. When HP was detected, CBF was measured again 3 and 7 days after CAS. RESULTS The median (interquartile range) ipsilateral quantitative CBF change after CAS was - 0.1% (- 9.5-8.2%), and the upper value of the 95% CI of the quantitative CBF change was 48.2%. Thus, we defined HP after CAS as an increase in quantitative CBF of > 48.2% compared with the preoperative value. Of 223 patients, 5 (2.2%) had HP, and 4 of these patients (80%) developed CHS. In the CHS patients, HP was maintained for about 3 days and improved after about 7 days. CONCLUSION An immediate CBF increase of > 48.2% after CAS may lead to development of CHS. In CHS after CAS, HP persisted for about 1 week and postoperative management may be required for at least 1 week.
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Affiliation(s)
- Takuma Nishimoto
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Fumiaki Oka
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Koki Okazaki
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
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Chen JY, Tu XK. Research Progress on Postoperative Transient Neurological Dysfunction in Pediatric and Adult Patients with Moyamoya Disease after Revascularization Surgery. Clin Neurol Neurosurg 2022; 217:107254. [DOI: 10.1016/j.clineuro.2022.107254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
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Efficacy of pretreatment with the free radical scavenger, edaravone, for prevention of cerebral hyperperfusion after carotid artery stenting: A single-center randomized controlled trial. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Mori T, Yoshioka K, Tanno Y, Kasakura S. Intentional Stent Stenosis to Prevent Hyperperfusion Syndrome after Carotid Artery Stenting for Extremely High-Grade Stenosis. AJNR Am J Neuroradiol 2021; 42:132-137. [PMID: 33184067 DOI: 10.3174/ajnr.a6853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/14/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage due to hyperperfusion syndrome is a severe carotid artery stent placement complication of extremely high-grade stenosis, causing hemodynamic insufficiency. To prevent hyperperfusion syndrome, we attempted intentional residual stent stenosis and implemented "gentle" carotid artery stent placement, defined as carotid artery stent placement using a closed-cell stent coupled with slight balloon predilation, without balloon postdilation. Gradual stent expansion was expected. We investigated the incidence of hyperperfusion syndrome and long-term outcomes after gentle carotid artery stent placement. MATERIALS AND METHODS We included patients who underwent carotid artery stent placement for extremely high-grade stenosis from January 2015 to March 2019. We defined extremely high-grade stenosis as carotid stenosis with conventional angiographic "slow flow" and a reduced MCA signal intensity on MRA. A reduced MCA signal intensity was defined as MCA with a relative signal intensity of <0.9 in the ipsilateral compared with the contralateral MCA. We evaluated the stent diameter, CBF on SPECT, hyperperfusion syndrome, and intracranial hemorrhage. We defined hyperperfusion syndrome as a triad of ipsilateral headache, seizure, and hemiparesis. RESULTS Twenty-eight of the 191 patients met our inclusion criteria. After carotid artery stent placement, their median minimal stent diameter was 2.9 mm, which expanded to 3.9 mm at 4 months. Neither cerebral hyperperfusion syndrome nor intracranial hemorrhage occurred. CONCLUSIONS The gentle carotid artery stent placement strategy for intentional residual stent stenosis may prevent hyperperfusion syndrome in high-risk patients. Stents spontaneously dilated in 4 months.
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Affiliation(s)
- T Mori
- From the Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Japan.
| | - K Yoshioka
- From the Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Y Tanno
- From the Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Japan
| | - S Kasakura
- From the Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Japan
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Bonatti G, Iannuzzi F, Amodio S, Mandelli M, Nogas S, Sottano M, Brunetti I, Battaglini D, Pelosi P, Robba C. Neuromonitoring during general anesthesia in non-neurologic surgery. Best Pract Res Clin Anaesthesiol 2020; 35:255-266. [PMID: 34030809 DOI: 10.1016/j.bpa.2020.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022]
Abstract
Cerebral complications are common in perioperative settings even in non-neurosurgical procedures. These include postoperative cognitive dysfunction or delirium as well as cerebrovascular accidents. During surgery, it is essential to ensure an adequate degree of sedation and analgesia, and at the same time, to provide hemodynamic and respiratory stability in order to minimize neurological complications. In this context, the role of neuromonitoring in the operating room is gaining interest, even in the non-neurolosurgical population. The use of multimodal neuromonitoring can potentially reduce the occurrence of adverse effects during and after surgery, and optimize the administration of anesthetic drugs. In addition to the traditional focus on monitoring hemodynamic and respiratory systems during general anesthesia, the ability to constantly monitor the activity and maintenance of brain homeostasis, creating evidence-based protocols, should also become part of the standard of care: in this challenge, neuromonitoring comes to our aid. In this review, we aim to describe the role of the main types of noninvasive neuromonitoring such as those based on electroencephalography (EEG) waves (EEG, Entropy module, Bispectral Index, Narcotrend Monitor), near-infrared spectroscopy (NIRS) based on noninvasive measurement of cerebral regional oxygenation, and Transcranial Doppler used in the perioperative settings in non-neurosurgical intervention. We also describe the advantages, disadvantage, and limitation of each monitoring technique.
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Affiliation(s)
- Giulia Bonatti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Sara Amodio
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Maura Mandelli
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Stefano Nogas
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Marco Sottano
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Iole Brunetti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
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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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Wan Y, Wang H, Wang D, Tian H, Zuo J, Fang Q. The safety and efficacy of staged angioplasty for treating carotid stenosis with a high risk of hyperperfusion: A single-center retrospective study. Interv Neuroradiol 2020; 26:637-642. [PMID: 32772622 DOI: 10.1177/1591019920946507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Hyperperfusion syndrome (HPS) following carotid artery stenting (CAS) is a rare but life-threatening complication. Staged angioplasty (SAP) is an alternative method that prevents HPS by preventing a sudden increase in cerebral blood flow. In this study, we investigated the safety and efficacy of SAP. METHODS A total of 114 patients with carotid stenosis underwent CAS treatment in our hospital between September 2014 and September 2019. Patients with severe stenosis and poor collateral circulation shown on digital subtraction angiography (DSA) and hypoperfusion of the ipsilateral diseased blood vessel shown on computed tomography perfusion (CTP) imaging were subjected to SAP treatment (the SAP group), and other patients received regular CAS treatment (the RS group). RESULTS Twenty-two patients (19.3%) with a high risk of HPS underwent SAP treatment, 1 of whom had carotid dissection after stage I balloon angioplasty and underwent regular CAS. This patient had HPS after surgery. None of the other patients in either group had HPS. One patient in the SAP group (4.5%) had hyperperfusion phenomenon (HPP) after stage II stenting, and 2 patients in the RS group (2.2%) had HPP. One patient in the SAP group (4.5%) and 4 patients in the RS group (4.3%) had symptomatic ischemic complications postoperatively. None of the differences between the 2 groups were statistically significant. Three patients had reduced modified Rankin Scale (mRS) scores at 90 days after discharge. CONCLUSION This research suggests that SAP appears to be an effective method to prevent HPS for patients with a high risk of HPS.
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Affiliation(s)
- Yue Wan
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China.,Department of Neurology, The Third Hospital of Hubei Province, Wuhan, P.R. China
| | - Hui Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
| | - Dapeng Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
| | - Hao Tian
- Department of Neurology, The Third Hospital of Hubei Province, Wuhan, P.R. China
| | - Jing Zuo
- Department of Neurology, The Third Hospital of Hubei Province, Wuhan, P.R. China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
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12
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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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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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Terakado T, Marushima A, Koyama Y, Tsuruta W, Takigawa T, Ito Y, Hino T, Sato M, Hayakawa M, Ishikawa E, Inoue Y, Matsumaru Y, Matsumura A. Effectiveness of Near-Infrared Spectroscopy (NIRO-200NX, Pulse Mode) for Risk Management in Carotid Artery Stenting. World Neurosurg 2019; 131:e425-e432. [DOI: 10.1016/j.wneu.2019.07.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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15
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Iwata T. Initial Experience of a Novel Sheath Guide Specifically Designed for Transradial Approach for Carotid Artery Stenting. World Neurosurg 2019; 130:e760-e764. [DOI: 10.1016/j.wneu.2019.06.215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
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16
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Chu WF, Lee HJ, Lin CJ, Chang FC, Guo WY, Chen LW, Lin YY, Luo CB. Fluoroscopic angiography quantifies delay in cerebral circulation time and requires less radiation in carotid stenosis patients: A pilot study. J Chin Med Assoc 2019; 82:396-400. [PMID: 30893249 DOI: 10.1097/jcma.0000000000000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Quantitative digital subtraction angiography (DSA) facilitates in-room assessment of flow changes in various cerebrovascular diseases and improves patient safety. The purpose of this study was to compare the diagnostic accuracy of quantitative fluoroscopic angiography (FA) and DSA. METHODS Twenty-two patients with >70% carotid stenosis according to NASCET criteria were prospectively included in the study. All patients received DSA and FA (ArtisZee, Siemens Healthcare, Forchheim, Germany) before and after carotid stenting in the same angiosuite. The regions of interest (ROIs) included the extracranial internal carotid artery (eICA), first segment of the middle cerebral artery (MCA1), and sigmoid sinus in the anterior-posterior view; cavernous portion of the ICA (cICA), parietal vein, and jugular vein in the lateral views. The time-to-peak (TTP) for all ROIs and cerebral circulation time (CCT) were measured from FA and DSA scans. TTP, CCT, and radiation doses from DSA were compared with those from FA. RESULTS The mean age of the patients were 69 ± 9.5 years old. The average stenosis was 89.7% ± 7.8% before stenting and 31% ± 3.6% after stenting. No patient suffered from periprocedural stroke. The intermethod correlation for TTP for all ROIs except the eICA and cICA ranged from 0.46 to 0.65 before stenting and 0.57 to 0.73 after stenting, and that for CCT was 0.65 before stenting and 0.57 after stenting. The radiation doses were significantly lower for FA than for DSA regardless of views or periprocedural timing (p < 0.001). CONCLUSION Stenosis facilitated the creation of a bolus by manual injection and therefore increased the accuracy of cerebral flow quantification in FA. Cerebral hemodynamic assessment by FA is quicker and associated with less radiation.
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Affiliation(s)
- Wei-Fa Chu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Han-Jui Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Liang-Wei Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Yang Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chao-Bao Luo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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17
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ASL perfusion features and type of circle of Willis as imaging markers for cerebral hyperperfusion after carotid revascularization: a preliminary study. Eur Radiol 2018; 29:2651-2658. [PMID: 30443757 DOI: 10.1007/s00330-018-5816-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/29/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Cerebral hyperperfusion (CH) could be a disastrous outcome causing complication after carotid revascularization if not managed properly and timely. The aim of this study was to investigate the association between preoperative arterial spin labelling (ASL) perfusion features and circle of Willis (CoW) pattern with CH. METHODS Forty-eight consecutive carotid stenosis patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were enrolled. All patients had single post-labelling delay (PLD) ASL, territory-ASL, and 3-dimensional time-of-flight MR angiography (3D TOF MRA) within 2 weeks before surgery and within 3 days after surgery. Spatial coefficient of variation (CoV) of cerebral blood flow (CBF), whole brain, and territory perfusion volume ratio were calculated from ASL and territory-ASL. Postoperative CoW was classified into two groups based on patency of the first segment of the anterior cerebral arteries (A1) and anterior communicating artery (AcomA). ASL perfusion features, type of CoW, and clinical characteristics were analyzed between CH group and non-CH group to identify CH risk factors. RESULTS Higher CoV (p = 0.005) of CBF, lower whole brain perfusion volume ratio (p = 0.012), missing any of A1 or AcomA in CoW (p = 0.002 for postoperative MRA and p = 0.004 for preoperative MRA), and large artery stroke history (p = 0.028) were significantly associated with higher risk of CH. Two cases with cerebral hyperperfusion syndrome (CHS) were also discussed, and their perfusion and angiographic features were shown. CONCLUSIONS Single-PLD ASL and MRA might be useful and non-invasive imaging tools to identify patients with higher risk of CH after carotid revascularization. KEY POINTS • Cerebral hyperperfusion is a critical complication after carotid endarterectomy or carotid artery stenting. • ASL and MRA can be used to identify patients at higher risk of cerebral hyperperfusion • Pattern of circle of Willis, ASL perfusion features, and whole brain perfusion volume ratio are potential predicting markers for hyperperfusion after carotid revascularization.
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18
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Nagashima H, Hongo K, Nagm A. Change in Cerebral Blood Flow after Palliative Percutaneous Angioplasty and Timing of Second Stage Carotid Artery Stenting in Staged Angioplasty. Neurol Med Chir (Tokyo) 2018; 58:254-259. [PMID: 29760312 PMCID: PMC6002678 DOI: 10.2176/nmc.oa.2018-0027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to elucidate the hemodynamic changes after palliative angioplasty and the timing of second stage carotid artery stenting (CAS) in staged angioplasty for patients with severe hemodynamically compromised carotid artery stenosis. Among consecutive 111 patients with carotid artery stenosis, chronological changes in the cerebral blood flow of all 11 hemodynamically compromised patients treated with CAS were evaluated with single photon emission computed tomogram (SPECT) in each stage of the treatment. Ten of these 11 patients underwent staged angioplasty and one was treated with single-stage CAS. All the 10 patients who underwent staged angioplasty showed improved cerebral vascular reactivity (CVR) on SPECT after the first stage palliative angioplasty. Only one patient treated with staged angioplasty with 4-week interval before the CAS showed restenosis of the lesion. Cerebral hyperperfusion syndrome (CHS) was not observed in nine of 10 patients with staged angioplasty. One patient of staged angioplasty (who presented restenosis at the time of elective CAS) and another patient in whom we could not apply staged angioplasty (for his renal dysfunction) showed CHS after CAS. In conclusion, restoration of CVR could be achieved within a few days following palliative angioplasty, and 1–2-week interval is enough for staged angioplasty.
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Affiliation(s)
- Hisashi Nagashima
- Clinical Safety and Quality Management Section, University of Toyama Hospital
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine
| | - Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine.,Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr city
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19
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Staged carotid artery stenting in patients with severe carotid stenosis: Multicenter experience. J Clin Neurosci 2018; 53:74-78. [PMID: 29685407 DOI: 10.1016/j.jocn.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/08/2018] [Indexed: 11/24/2022]
Abstract
Cerebral hyperperfusion syndrome (CHS) is serious complication after carotid artery stenting (CAS) caused by decreased cerebral vasoreactivity (CVR) due to long standing hypoperfusion of the brain. We hypothesized that partial dilatation of carotid stenosis would allow the recovery of CVR, and prevent CHS when definitive angioplasty with stent is performed afterward. In this study, we aimed to evaluate the safety and efficacy of staged CAS in patients with severe carotid artery stenosis with evident hemodynamic compromise in regard to preventing hyperperfusion syndrome. From January 2005 to February 2016, 53 patients with 55 severe carotid artery stenosis lesions showing decreased CVR and/or cerebral basal flow at the perfusion studies underwent staged CAS in three institutes. The procedure consisted of initial partial balloon angioplasty (BA), recovery period, and delayed definitive stenting (DS). We analyzed immediate results, complications, recoil and CHS related to staged CAS. We experienced no symptomatic manifestation of CHS except self-limited headache after the procedures. The median of intervals between BA and DS stages were 10 days. There was no case of severe recoil during the interval between BA and DS stage. Where perfusion imaging data was available, hyperperfusion was present in three and one patients after BA and DS stage, respectively, with no clinical symptom of CHS. In conclusion, staged CAS was feasible in patients with severe carotid artery stenosis and hemodynamic compromise, without inducing severe complication of CHS such as intracranial hemorrhage.
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20
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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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Andereggen L, Amin-Hanjani S, El-Koussy M, Verma RK, Yuki K, Schoeni D, Hsieh K, Gralla J, Schroth G, Beck J, Raabe A, Arnold M, Reinert M, Andres RH. Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study. J Neurosurg 2018; 128:1006-1014. [DOI: 10.3171/2016.11.jns161033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVECerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.METHODSIn this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.RESULTSTwenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.CONCLUSIONSCerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.
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Affiliation(s)
- Lukas Andereggen
- Departments of 1Neurosurgery,
- 4Department of Neurosurgery and F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Kenya Yuki
- 4Department of Neurosurgery and F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Marcel Arnold
- 3Neurology, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Michael Reinert
- Departments of 1Neurosurgery,
- 6Department of Neurosurgery, Neurocenter Lugano, Lugano, Switzerland
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22
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Misaki K, Uchiyama N, Inaki A, Kinuya S, Nambu I, Kamide T, Mohri M, Hayashi Y, Nakada M. Objective evaluation of cerebrovascular reactivity for acetazolamide predicts cerebral hyperperfusion after carotid artery stenting: Comparison with region of interest methods. J Neuroradiol 2018. [PMID: 29524498 DOI: 10.1016/j.neurad.2018.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Hemodynamic impairments are considered risk factors of cerebral hyperperfusion after carotid artery stenting (CAS); measurement by Single-photon emission computed tomography (SPECT) using a subjective region of interest (ROI) method lacks consistency and reproducibility. MATERIALS AND METHODS The present study compared objective perfusion analysis (stereotactic extraction estimation [SEE] method) with the ROI method for preoperative SPECT to predict the hyperperfusion phenomenon (HPP) after CAS. Preoperative resting asymmetry index (cerebral blood flow [CBF] ratio from the affected to unaffected hemisphere) and cerebrovascular reactivity (CVR) to acetazolamide were measured by N-isopropyl-p-[123I]-iodoamphetamine SPECT using the SEE and ROI method in 84 patients. CBF was also measured the day after CAS. Perfusion data with the highest area under the curve (AUC) by receiver-operating characteristic (ROC) analysis was considered a perfusion risk factor of HPP. Multivariate analyses for clinical characteristics and perfusion risk factors were performed to determine predictors of HPP. RESULTS The HPP was observed in 10 patients (11.9%). Female sex, contralateral stenosis, and degree of stenosis were significantly associated with HPP development on univariate analysis, and symptomatic stenosis was not found to be a significant factor. On SPECT analysis, CVR in the MCA area by SEE method had the highest AUC (0.981). Multivariate analysis showed that CVR in the MCA area was a significant predictor of HPP (P=0.041). To predict hyperperfusion, the ROC curve of the CVR showed a cutoff value of -0.60%, sensitivity of 94.6%, and specificity of 100% (P<0.001). CONCLUSIONS Objective SEE method had better a predictive capability than ROI method to identify risk of hyperperfusion after CAS.
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Affiliation(s)
- Kouichi Misaki
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan.
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Anri Inaki
- Department of Nuclear Medicine, Kanazawa University, Kanazawa, Japan
| | - Seigo Kinuya
- Department of Nuclear Medicine, Kanazawa University, Kanazawa, Japan
| | - Iku Nambu
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Tomoya Kamide
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Masanao Mohri
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Yasuhiko Hayashi
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
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Iwata T, Mori T, Tanno Y, Kasakura S, Yoshioka K. Measurement of oxygen extraction fraction by blood sampling to estimate severe cerebral hemodynamic failure and anticipate cerebral hyperperfusion syndrome following carotid artery stenting. J Neurointerv Surg 2018; 10:1063-1066. [PMID: 29511115 DOI: 10.1136/neurintsurg-2018-013748] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS) is likely to occur after carotid revascularization in patients with stage 2 hemodynamic failure (st2HF), in whom the oxygen extraction fraction (OEF) increases. OBJECTIVE The purpose of our study was to investigate whether measurement of the global cerebral OEF (gcOEF) by blood sampling can be used to estimate st2HF and anticipate CHS following carotid artery stenting (CAS). METHODS The OEF was calculated by blood sampling just before and after elective CAS. Data were collected prospectively. Patients who underwent elective CAS and gcOEF calculation were included in the study. Patients' baseline features, pre-CAS gcOEF, post-CAS gcOEF, and incidence of CHS (defined as headache, seizure, focal neurologic deficits, and/or restlessness) were evaluated. RESULTS 141 patients met the inclusion criteria and 134 patients were analyzed. Median pre-CAS gcOEF and post-CAS gcOEF were 0.41 and 0.42, respectively. Nine patients developed CHS. Median pre-CAS gcOEF was higher in patients with than in those without CHS (Mann-Whitney U test, P<0.05), but median post-CAS gcOEF was not significantly higher in patients with CHS (P=0.058). Scattergrams of patients with and without CHS showed that the cut-off values of the pre-CAS gcOEF and post-CAS gcOEF for anticipation of CHS were 0.46 (P<0.01) and 0.49 (P<0.001), respectively. CONCLUSION Elevation of the pre-CAS or post-CAS gcOEF by blood sampling allowed for anticipation of CHS following CAS. Elevation of the pre-CAS gcOEF might be associated with st2HF.
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Affiliation(s)
- Tomonori Iwata
- Department of Vascular Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan.,Department of Internal Medicine, Nayutanomori Hospital, Saga, Japan
| | - Takahisa Mori
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Kamakura, Japan
| | - Yuhei Tanno
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Kamakura, Japan
| | - Shigen Kasakura
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Kamakura, Japan
| | - Kazuhiro Yoshioka
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Kamakura, Japan
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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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Lee HJ, Hong JS, Lin CJ, Kao YH, Chang FC, Luo CB, Chu WF. Automatic flow analysis of digital subtraction angiography using independent component analysis in patients with carotid stenosis. PLoS One 2017; 12:e0185330. [PMID: 28949999 PMCID: PMC5614569 DOI: 10.1371/journal.pone.0185330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/11/2017] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Current time-density curve analysis of digital subtraction angiography (DSA) provides intravascular flow information but requires manual vasculature selection. We developed an angiographic marker that represents cerebral perfusion by using automatic independent component analysis. MATERIALS AND METHODS We retrospectively analyzed the data of 44 patients with unilateral carotid stenosis higher than 70% according to North American Symptomatic Carotid Endarterectomy Trial criteria. For all patients, magnetic resonance perfusion (MRP) was performed one day before DSA. Fixed contrast injection protocols and DSA acquisition parameters were used before stenting. The cerebral circulation time (CCT) was defined as the difference in the time to peak between the parietal vein and cavernous internal carotid artery in a lateral angiogram. Both anterior-posterior and lateral DSA views were processed using independent component analysis, and the capillary angiogram was extracted automatically. The full width at half maximum of the time-density curve in the capillary phase in the anterior-posterior and lateral DSA views was defined as the angiographic mean transient time (aMTT; i.e., aMTTAP and aMTTLat). The correlations between the degree of stenosis, CCT, aMTTAP and aMTTLat, and MRP parameters were evaluated. RESULTS The degree of stenosis showed no correlation with CCT, aMTTAP, aMTTLat, or any MRP parameter. CCT showed a strong correlation with aMTTAP (r = 0.67) and aMTTLat (r = 0.72). Among the MRP parameters, CCT showed only a moderate correlation with MTT (r = 0.67) and Tmax (r = 0.40). aMTTAP showed a moderate correlation with Tmax (r = 0.42) and a strong correlation with MTT (r = 0.77). aMTTLat also showed similar correlations with Tmax (r = 0.59) and MTT (r = 0.73). CONCLUSION Apart from vascular anatomy, aMTT estimates brain parenchyma hemodynamics from DSA and is concordant with MRP. This process is completely automatic and provides immediate measurement of quantitative peritherapeutic brain parenchyma changes during stenting.
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Affiliation(s)
- Han-Jui Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jia-Sheng Hong
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Hsuan Kao
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Fa Chu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Ohta T, Nakahara I, Matsumoto S, Ishibashi R, Miyata H, Nishi H, Watanabe S, Nagata I. Prediction of Cerebral Hyperperfusion After Carotid Artery Stenting by Cerebral Angiography and Single-Photon Emission Computed Tomography Without Acetazolamide Challenge. Neurosurgery 2017; 81:512-519. [DOI: 10.1093/neuros/nyx041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/17/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Center, Kochi City, Kochi Prefecture, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake City, Aichi Prefecture, Japan
| | - Shoji Matsumoto
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Haruka Miyata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Hidehisa Nishi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake City, Aichi Prefecture, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
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Park HS, Nakagawa I, Yokoyama S, Motoyama Y, Park YS, Wada T, Kichikawa K, Nakase H. Amplitude of Tissue Oxygenation Index Change Predicts Cerebral Hyperperfusion Syndrome During Carotid Artery Stenting. World Neurosurg 2017; 99:548-555. [DOI: 10.1016/j.wneu.2016.12.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
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Mo D, Luo G, Wang B, Ma N, Gao F, Sun X, Xu X, Miao Z. Staged carotid artery angioplasty and stenting for patients with high-grade carotid stenosis with high risk of developing hyperperfusion injury: a retrospective analysis of 44 cases. Stroke Vasc Neurol 2016; 1:147-153. [PMID: 28959477 PMCID: PMC5435210 DOI: 10.1136/svn-2016-000024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 10/27/2016] [Accepted: 11/04/2016] [Indexed: 11/17/2022] Open
Abstract
Background Hyperperfusion syndrome (HPS) is a rare but potentially a life-threatening complication after carotid artery angioplasty and stenting (CAS). Staged CAS has been an alternative to prevent HPS. Materials and methods 44 of 908 patients with high-grade internal carotid artery stenosis or near occlusion were at risk of HPS because of poor collateral flow and impaired cerebral blood flow (CBF). They were treated with first (stage 1), followed by a full CAS (stage 2) 1 month later. Their 30-day outcomes were tabulated and analysed. Results During follow-up, 1 of the 44 (2.2%) patients developed HPS immediately, 3 (7%) had postprocedural HPS (ie, transcranial Doppler (TCD) >120%) without clinical symptoms and 3 (7%) required stenting at stage 1 for carotid dissections. After stage 1, there were significant improvement between the preprocedural and postprocedural CBF (0.98±0.06 vs 0.85±0.05, p<0.05), mean transit time (MTT; 1.05±0.05 vs 1.15±0.05, p<0.05), time to peak (TTP; 1.04±0.06 vs 1.20±0.06, p<0.05) on CT perfusion (CTP), and CBF (66.41±7.41 vs 44.44±6.43, p<0.05) on TCD. After stage 2, improvement was seen in CBF (1.01±0.07 vs 0.98±0.06, p<0.05), MTT (1.01±0.05 vs 1.05±0.05, p<0.05), TTP (0.99±0.06 vs 1.04±0.06, p<0.05) on CTP and CBF (66.41±7.41 vs 93.78±18.81, p<0.05) on TCD. 2 had postoperative increase of middle cerebral artery mean flow velocity of 120% after stage 2 without clinical symptoms. Conclusion Staged carotid artery stenting probably decreased the chance of developing HPS in this group of selected patients. Although requiring a 2-step intervention, staged CAS may be a safe and effective alternative.
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Affiliation(s)
- Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Bo Wang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xiaotong Xu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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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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Iwata T, Mori T, Miyazaki Y, Tanno Y, Kasakura S, Aoyagi Y. Global oxygen extraction fraction by blood sampling to anticipate cerebral hyperperfusion phenomenon after carotid artery stenting. Neurosurgery 2015; 75:546-51; discussion 551. [PMID: 24991711 DOI: 10.1227/neu.0000000000000485] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebral hyperperfusion syndrome sometimes occurs after carotid revascularization in patients with severe hemodynamic failure. To prevent cerebral hyperperfusion syndrome, cerebral hyperperfusion phenomenon (CHP) must be detected early. Single-photon emission computed tomography (SPECT) is useful for detecting CHP, but it is impractical on a daily basis. A tool with high availability to find CHP is desired. OBJECTIVE To investigate whether global oxygen extraction fraction (OEF) by a blood sampling method is useful for indicating CHP after carotid artery stenting (CAS). METHODS When patients underwent elective CAS from September 2010 to August 2012, we performed blood sampling for OEF calculation and SPECT before and immediately after elective CAS. Data were collected prospectively. OEF was calculated from the cerebral arteriovenous oxygen difference. Cerebral blood flow was measured in the affected middle cerebral artery (MCA) territory and in the ipsilateral cerebellum by SPECT. The ratio of MCA to cerebellar activity was defined as cerebral blood flow in the affected MCA territory divided by cerebral blood flow in the ipsilateral cerebellar hemisphere. Probable CHP was defined as ≥10% increase in the ratio of MCA to cerebellar activity after CAS. The relationship between peri-CAS OEF and probable CHP was evaluated. RESULTS Of the 96 patients enrolled, 92 patients were analyzed. Probable CHP occurred in 17 patients. Post-CAS OEF was related to probable CHP (P < .01), but pre-CAS OEF was not. The receiver-operating characteristic curve showed that the cutoff value was 45% for probable CHP (P < .001). CONCLUSION An increase in blood sampling OEF immediately after CAS was related to probable CHP; then the oxygen demand should be reduced.
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Affiliation(s)
- Tomonori Iwata
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Kamakura City, Kanagawa, Japan
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Lai ZC, Liu B, Chen Y, Ni L, Liu CW. Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index. Chin Med J (Engl) 2015; 128:1611-7. [PMID: 26063363 PMCID: PMC4733740 DOI: 10.4103/0366-6999.158317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy (CEA). An >100% increase in middle cerebral artery velocity (MCAV) after CEA is used to predict the cerebral hyperperfusion syndrome (CHS) development, but the accuracy is limited. The increase in blood pressure (BP) after surgery is a risk factor of CHS, but no study uses it to predict CHS. This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA. Methods: Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively; 30 min postoperatively. The new parameter velocity BP index (VBI) was calculated from the postoperative increase ratios of MCAV and BP. The prediction powers of VBI and the increase ratio of MCAV (velocity ratio [VR]) were compared for predicting CHS occurrence. Results: Totally, 6/185 cases suffered CHS. The best-fit cut-off point of 2.0 for VBI was identified, which had 83.3% sensitivity, 98.3% specificity, 62.5% positive predictive value and 99.4% negative predictive value for CHS development. This result is significantly better than VR (33.3%, 97.2%, 28.6% and 97.8%). The area under the curve (AUC) of receiver operating characteristic: AUCVBI= 0.981, 95% confidence interval [CI] 0.949–0.995; AUCVR= 0.935, 95% CI 0.890–0.966, P = 0.02. Conclusions: The new parameter VBI can more accurately predict patients at risk of CHS after CEA. This observation needs to be validated by larger studies.
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Affiliation(s)
| | | | | | | | - Chang-Wei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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Kaneda S, Takemura N, Yoshimura R. [Prediction of hyperperfusion after carotid artery stenting based on preoperative estimation of the cerebral blood flow (according to the Kuroda grading system) by single photon emission computed tomography]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2015; 71:208-215. [PMID: 25797663 DOI: 10.6009/jjrt.2015_jsrt_71.3.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This study was conducted to investigate whether preoperative estimation of the cerebral blood flow (CBF) by single photon emission computed tomography (SPECT) can allow identification of patients at risk for hyperperfusion (HP) after carotid artery stenting (CAS). In 40 patients scheduled to undergo CAS, the CBF and cerebral vascular reserve (CVR) were measured prior to the intervention by resting and acetazolamide loading SPECT. The SPECT findings were classified into 4 types: Type 1, normal CBF in the resting state (CBFrest) and normal CVR; Type 2, normal CBFrest and reduced CVR; Type 3, reduced CBFrest and reduced CVR; and Type 4, reduced CBFrest and normal CVR. Four patients presented with HP after CAS. Patients with high proportions of Type 2 and Type 3 had high risk of HP after CAS. (ROC analysis: AUC=0.94, cutoff value of 75.8% had PPV of 75.0%, NPV of 97.2% and odds ratio of 105.0). The proportions of Type 2 and Type 3 in preoperative SPECT may identify patients at risk for the development of HP.
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Koyanagi M, Yoshida K, Kurosaki Y, Sadamasa N, Narumi O, Sato T, Chin M, Handa A, Yamagata S, Miyamoto S. Reduced cerebrovascular reserve is associated with an increased risk of postoperative ischemic lesions during carotid artery stenting. J Neurointerv Surg 2014; 8:576-80. [DOI: 10.1136/neurintsurg-2014-011163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 08/19/2014] [Indexed: 11/04/2022]
Abstract
BackgroundReduced cerebrovascular reserve (CVR) is associated with increased risk of ischemic events in carotid steno-occlusive diseases.ObjectiveTo determine whether pretreatment CVR can predict postoperative ischemic lesions after carotid artery stenting (CAS) by retrospective analysis.MethodsWe retrospectively reviewed the medical records of 46 patients (42 men; mean age 74.2±8.3 years) who underwent CAS and preprocedural cerebral blood flow measurement by quantitative single-photon emission CT. Ischemic lesions were evaluated by diffusion-weighted image (DWI) within 72 h after the intervention. We also evaluated plaque characteristics using black-blood MR plaque imaging.ResultsNew ipsilateral DWI-positive lesions were found in 11 cases (23.9%). Patients were classified into two groups based on the presence or absence of new DWI-positive lesions, and no significant differences in characteristics were found between the DWI-positive and DWI-negative groups, except for age and CVR of the ipsilateral middle cerebral artery (MCA) territory. The DWI-positive group was significantly older than the DWI-negative group (79.7±4.1 vs 72.5±8.6 years; p=0.0085) and had lower average regional CVR (1.4±18.2% vs 22.4±25.8%; p=0.016). MR plaque imaging showed no significant difference in relative overall plaque MR signal intensity between the two groups (1.53±0.37 vs 1.34±0.26; p=0.113). In multivariate logistic regression analysis, lower CVR of the ipsilateral MCA territory (<11%) was the only independent risk factor for new ischemic lesions following CAS (OR=6.99; 95% CI 1.17 to 41.80; p=0.033).ConclusionsImpaired pretreatment CVR was associated with increased incidence of new infarction after CAS.
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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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Buczek J, Karliński M, Kobayashi A, Białek P, Członkowska A. Hyperperfusion syndrome after carotid endarterectomy and carotid stenting. Cerebrovasc Dis 2013; 35:531-7. [PMID: 23817298 DOI: 10.1159/000350736] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/07/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hyperperfusion syndrome (HS) is a relatively rare but possibly serious complication of carotid revascularization procedures. Impaired cerebral autoregulation and postrevascularization changes in cerebral blood flow are the main mechanisms involved in the development of HS. Most up-to-date studies addressing this issue are retrospective and tend to concentrate on carotid endarterectomy (CEA), neglecting carotid stenting (CAS). Our aim was to compare the frequency of clinical signs of HS and hyperperfusion detected by transcranial Doppler (TCD) in patients undergoing CAS or CEA due to carotid stenosis. METHODS In this prospective observational study, we evaluated 61 patients scheduled for routine CAS or CEA. Each patient was examined by a neurologist before and after the revascularization procedure to assess the clinical status. Severe headache, ocular or facial pain, confusion, visual disturbances, epileptic seizures or any focal deficits not caused by cerebral ischemia were considered clinical signs of HS. Peak systolic velocity (PSV), end-diastolic velocity, mean velocity (MV), and pulsatility index were measured by TCD once before and twice after the intervention (within 6 h after and 2-5 days after the procedure). Hyperperfusion was defined as a >100% increase in the middle cerebral artery (MCA) blood velocity, evaluated separately for PSV and MV after the procedure compared with the baseline value. Cerebrovascular reactivity (CVR) was evaluated with a TCD acetazolamide test before the intervention. RESULTS CAS (n = 33) and CEA (n = 28) patients were included in the study. There was no difference between the groups in the frequency of clinical signs of HS (21.2 vs. 21.4%) and ratio of TCD hyperperfusion (12.1 vs. 14.3%). In the CAS group, ipsilateral MCA velocity significantly increased directly after the intervention and 2-5 days later, while it increased in the CEA group only 2-5 days after the intervention. The sensitivity and specificity of hyperperfusion, defined by MV, for HS signs were 38.5 and 93.8%, respectively, whereas those defined by PSV were 30.8 and 89.6%, respectively. The sensitivity and specificity of impaired CVR (<25%) for HS signs were 63.6 and 73.5%, respectively. CONCLUSIONS There is no difference in the frequency of HS clinical signs and hyperperfusion detected by TCD between patients after CAE and CAS. Clinical signs suggested HS does not always correspond with TCD hyperperfusion. However, both the CVR test and TCD measurements of MCA velocity can help identify patients at high risk for HS.
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Affiliation(s)
- Julia Buczek
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
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36
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Techniques for Optimizing Results in Carotid Stenting. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Katano H, Mase M, Sakurai K, Miyachi S, Yamada K. Revaluation of collateral pathways as escape routes from hyperemia/hyperperfusion following surgical treatment for carotid stenosis. Acta Neurochir (Wien) 2012; 154:2139-48; discussion 2148-9. [PMID: 22990629 DOI: 10.1007/s00701-012-1498-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 08/23/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although acetazolamide-challenged single-photon emission CT (SPECT) is recommended before carotid endarterectomy (CEA) and carotid artery stenting (CAS), given the relationship between preoperative decreased cerebrovascular reserve (CVR) and postoperative cerebral hyperperfusion syndrome (CHS), it is controversial whether all cases should be checked. METHODS I-IMP-SPECT at rest was performed for 65 operative cases of carotid stenoses. At preoperative MR angiography we classified cases into two groups: G, featuring an anterior communicating artery with bilateral A1 with/without posterior communicating arteries; and P, a poor-escape-route group which did not match these criteria. Postoperative rCBF patterns were divided into two types: B, bilateral rCBF increase; and I, ipsilateral rCBF increase. RESULTS Cases with high postoperative increase rate of rCBF were most frequently found in Group P and the Type I cases (p < 0.001). All four cases with hyperemia or hyperperfusion belonged to Group P. Only two out of 48 patients in Group G were Type I, both demonstrating a preoperative rCBF decrease rate more than 10 % as compared to the contralateral side. CONCLUSIONS From the present study, preliminary analysis of escape routes by preoperative MR angiography before surgical treatment of carotid stenosis is recommended and CVR investigation with acetazolamide-challenge SPECT should be considered for those relatively few cases with poor escape routes.
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Affiliation(s)
- Hiroyuki Katano
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi, Mizuho-cho, Mizuho-ku, Japan.
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38
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Incidence and Clinical Features of Symptomatic Cerebral Hyperperfusion Syndrome After Vascular Reconstruction. World Neurosurg 2012; 78:447-54. [DOI: 10.1016/j.wneu.2011.10.041] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 09/19/2011] [Accepted: 10/24/2011] [Indexed: 11/20/2022]
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40
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Revascularization and cerebral hyperperfusion: we know what but not why. World Neurosurg 2012; 78:413-4. [PMID: 22381283 DOI: 10.1016/j.wneu.2011.12.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 12/10/2011] [Indexed: 11/22/2022]
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Narita S, Aikawa H, Nagata SI, Tsutsumi M, Nii K, Yoshida H, Matsumoto Y, Hamaguchi S, Etoh H, Sakamoto K, Inoue R, Kazekawa K. Intraprocedural prediction of hemorrhagic cerebral hyperperfusion syndrome after carotid artery stenting. J Stroke Cerebrovasc Dis 2011; 22:615-9. [PMID: 22209646 DOI: 10.1016/j.jstrokecerebrovasdis.2011.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 10/03/2011] [Accepted: 10/27/2011] [Indexed: 10/14/2022] Open
Abstract
Hyperperfusion syndrome (HPS) is a rare but severe complication after carotid artery stenting (CAS). Reliable methods for predicting HPS remain to be developed. We aimed to establish a predictive value of hemorrhagic HPS after CAS. Our retrospective study included 136 consecutive patients who had undergone CAS. We determined the cerebral circulation time (CCT) by measuring the interval between the point of maximal opacification of the terminal portion of the internal carotid artery and the cortical vein. We calculated intraprocedural CCT changes (ΔCCT) by subtracting postprocedural CCT values from preprocedural CCT values. The mean ΔCCT was 0.9 ± 0.9 seconds; 3 patients (2.2%) with prolonged ΔCCT (2.7, 5.4, and 5.8 seconds) developed HPS. The cutoff time of 2.7 seconds predicted hemorrhagic HPS retrospectively with 100% sensitivity and 99% specificity. Our findings suggest that post-CAS HPS can be predicted by using the ΔCCT value obtained by intraprocedural digital subtraction angiography. Patients with a ΔCCT >2.7 seconds require careful intensive hemodynamic and neurologic monitoring after CAS.
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Affiliation(s)
- Sumito Narita
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
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McDonald RJ, Cloft HJ, Kallmes DF. Intracranial Hemorrhage Is Much More Common After Carotid Stenting Than After Endarterectomy. Stroke 2011; 42:2782-7. [DOI: 10.1161/strokeaha.111.618769] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intracranial hemorrhage (ICH) is a rare and devastating complication of carotid revascularization. We sought to determine the prevalence of, type of, and risk factors associated with ICH among recipients of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) within the National Inpatient Sample (NIS).
Methods—
Postoperative cases of ICH after CEA (International Classification of Disease 9
th
edition [ICD-9]: 38.12) or CAS (ICD-9: 00.63) were retrieved from the 2001 to 2008 NIS. Clinical presentation (asymptomatic versus symptomatic), discharge status, in-hospital mortality, demographics, and hospital characteristics were extracted from NIS data. Charlson indices of comorbidity were determined based on ICD-9 and clinical classification software codes. Multivariate regression was used to determine the impact of revascularization procedure type and symptom status on adverse outcomes, including ICH, in-hospital mortality, and unfavorable discharge status.
Results—
Among 57 663 486 NIS hospital admissions, 215 012 CEA and 13 884 CAS procedures were performed. Symptomatic presentations represented the minority of CEA (N=10 049; 5%) and CAS cases (N=1251; 10%). ICH occurred significantly more frequently after CAS than CEA in both symptomatic (4.4% versus 0.8%;
P
<0.0001) and asymptomatic presentations (0.5% versus 0.06%;
P
<0.0001). Multivariate regression suggested that symptomatic presentations (versus asymptomatic) and CAS procedures (versus CEA) were both independently predictive of 6-fold to 7-fold increases in the frequency of postoperative ICH. ICH was independently predictive in a 30-fold increased risk of mortality before discharge.
Conclusions—
CAS procedures are associated with elevated adverse outcomes, including ICH, in-hospital death, and unfavorable discharges, especially among symptomatic presentations.
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Affiliation(s)
- Robert J. McDonald
- From the Clinician Investigator Training Program (R.J.M.), Department of Radiology (R.J.M., H.J.C., D.F.K.), Department of Neurosurgery (H.J.C., D.F.K.), College of Medicine, Mayo Clinic, Rochester, MN
| | - Harry J. Cloft
- From the Clinician Investigator Training Program (R.J.M.), Department of Radiology (R.J.M., H.J.C., D.F.K.), Department of Neurosurgery (H.J.C., D.F.K.), College of Medicine, Mayo Clinic, Rochester, MN
| | - David F. Kallmes
- From the Clinician Investigator Training Program (R.J.M.), Department of Radiology (R.J.M., H.J.C., D.F.K.), Department of Neurosurgery (H.J.C., D.F.K.), College of Medicine, Mayo Clinic, Rochester, MN
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Iwata T, Mori T, Tajiri H, Miyazaki Y, Nakazaki M. Long-term Angiographic and Clinical Outcome Following Stenting by Flow Reversal Technique for Chronic Occlusions Older Than 3 Months of the Cervical Carotid or Vertebral Artery. Neurosurgery 2011; 70:82-90; discussion 90. [DOI: 10.1227/neu.0b013e31822e074c] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Long-term angiographic and clinical outcome following stenting by flow reversal technique (FRT) for chronic occlusions (COs) of the cervical internal carotid artery (ICA) or vertebral artery (VA) is unknown.
OBJECTIVE
The aim of our retrospective study was to investigate the feasibility, safety, and long-term outcome of stenting by FRT for COs of the cervical ICA or VA.
METHODS
Included for analysis were patients (1) who underwent stenting for COs of the ICA or VA older than 3 months by FRT, and (2) who finished at least 1-year follow-up angiographic and clinical investigation. Criteria of stenting for CO in the ICA or VA were patients (1) who experienced minor strokes, a transient ischemic attack, or transient symptoms probably due to hemodynamic compromise or insufficiency, (2) angiographic complete occlusion of the ICA or VA, and (3) occlusion limited in the cervical area of the affected artery.
RESULTS
During the study period, 6 patients underwent stenting by FRT for cervical COs successfully, ICAs in 4 cases and VAs in 2 cases. The prestenting angiographically estimated occlusion length ranged from 50 to 130 mm. Total length of the deployed stents ranged from 30 to 108 mm. No complications occurred during the periprocedural period. Neither transient ischemic events nor restenosis has occurred during the follow-up period.
CONCLUSION
COs of the cervical carotid or vertebral arteries older than 3 months can be opened safely with FRT, and 1-year angiographic and long-term clinical outcome is favorable.
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Affiliation(s)
- Tomonori Iwata
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Takahisa Mori
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Hiroyuki Tajiri
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yuichi Miyazaki
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Masahito Nakazaki
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kanagawa, Japan
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