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Abdalkader M, Nguyen TN, Sahoo A, Qureshi MM, Ong CJ, Klein P, Miller MI, Mian AZ, Kaesmacher J, Mujanovic A, Hu W, Chen HS, Setty BN. Contrast Staining in Noninfarcted Tissue after Endovascular Treatment of Acute Ischemic Stroke. AJNR Am J Neuroradiol 2024; 45:701-707. [PMID: 38697792 PMCID: PMC11288587 DOI: 10.3174/ajnr.a8222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 02/03/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND PURPOSE Contrast staining is a common finding after endovascular treatment of acute ischemic stroke. It typically occurs in infarcted tissue and is considered an indicator of irreversible brain damage. Contrast staining in noninfarcted tissue has not been systematically investigated. We sought to assess the incidence, risk factors, and clinical significance of contrast staining in noninfarcted tissue after endovascular treatment. MATERIALS AND METHODS We conducted a retrospective review of consecutive patients who underwent endovascular treatment for anterior circulation large-vessel occlusion acute ischemic stroke. Contrast staining, defined as new hyperdensity on CT after endovascular treatment, was categorized as either contrast staining in infarcted tissue if the stained region demonstrated restricted diffusion on follow-up MR imaging or contrast staining in noninfarcted tissue if the stained region demonstrated no restricted diffusion. Baseline differences between patients with and without contrast staining in noninfarcted tissue were compared. Logistic regression was used to identify independent associations for contrast staining in noninfarcted tissue after endovascular treatment. RESULTS Among 194 patients who underwent endovascular treatment for large-vessel occlusion acute ischemic stroke and met the inclusion criteria, contrast staining in infarcted tissue was noted in 52/194 (26.8%) patients; contrast staining in noninfarcted tissue, in 26 (13.4%) patients. Both contrast staining in infarcted tissue and contrast staining in noninfarcted tissue were noted in 5.6% (11/194). Patients with contrast staining in noninfarcted tissue were found to have a higher likelihood of having an ASPECTS of 8-10, to be associated with contrast staining in infarcted tissue, and to achieve successful reperfusion compared with those without contrast staining in noninfarcted tissue. In contrast staining in noninfarcted tissue regions, the average attenuation was 40 HU, significantly lower than the contrast staining in infarcted tissue regions (53 HU). None of the patients with contrast staining in noninfarcted tissue had clinical worsening during their hospital stay. The median discharge mRS was significantly lower in patients with contrast staining in noninfarcted tissue than in those without (3 versus 4; P = .018). No independent predictors of contrast staining in noninfarcted tissue were found. CONCLUSIONS Contrast staining can be seen outside the infarcted tissue after endovascular treatment of acute ischemic stroke, likely attributable to the reversible disruption of the BBB in ischemic but not infarcted tissue. While generally benign, understanding its characteristics is important because it may mimic pathologic conditions such as infarcted tissue and cerebral edema.
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Affiliation(s)
- Mohamad Abdalkader
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Thanh N Nguyen
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- Department of Neurology (T.N.N., C.J.O.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Anurag Sahoo
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Muhammad M Qureshi
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Charlene J Ong
- Department of Neurology (T.N.N., C.J.O.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- Department of Neurology (C.J.O.), Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Piers Klein
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Matthew I Miller
- Department of Medicine (M.I.M.), Cambridge Health Alliance, Cambridge, Massachusetts
| | - Asim Z Mian
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology (J.K., A.M.), Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology (J.K., A.M.), Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Wei Hu
- Department of Neurology and Stroke Center (W.H.), Division of Life Sciences and Medicine, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, Anhui, China
| | - Hui Sheng Chen
- Department of Neurology (H.S.C.), General Hospital of Northern Theater Command, Shenyang, China
| | - Bindu N Setty
- From the Department of Radiology (M.A., T.N.N., A.S., M.M.Q., P.K., A.Z.M., B.N.S.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Binder NF, El Amki M, Glück C, Middleham W, Reuss AM, Bertolo A, Thurner P, Deffieux T, Lambride C, Epp R, Handelsmann HL, Baumgartner P, Orset C, Bethge P, Kulcsar Z, Aguzzi A, Tanter M, Schmid F, Vivien D, Wyss MT, Luft A, Weller M, Weber B, Wegener S. Leptomeningeal collaterals regulate reperfusion in ischemic stroke and rescue the brain from futile recanalization. Neuron 2024; 112:1456-1472.e6. [PMID: 38412858 DOI: 10.1016/j.neuron.2024.01.031] [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: 05/03/2023] [Revised: 11/18/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
Recanalization is the mainstay of ischemic stroke treatment. However, even with timely clot removal, many stroke patients recover poorly. Leptomeningeal collaterals (LMCs) are pial anastomotic vessels with yet-unknown functions. We applied laser speckle imaging, ultrafast ultrasound, and two-photon microscopy in a thrombin-based mouse model of stroke and fibrinolytic treatment to show that LMCs maintain cerebral autoregulation and allow for gradual reperfusion, resulting in small infarcts. In mice with poor LMCs, distal arterial segments collapse, and deleterious hyperemia causes hemorrhage and mortality after recanalization. In silico analyses confirm the relevance of LMCs for preserving perfusion in the ischemic region. Accordingly, in stroke patients with poor collaterals undergoing thrombectomy, rapid reperfusion resulted in hemorrhagic transformation and unfavorable recovery. Thus, we identify LMCs as key components regulating reperfusion and preventing futile recanalization after stroke. Future therapeutic interventions should aim to enhance collateral function, allowing for beneficial reperfusion after stroke.
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Affiliation(s)
- Nadine Felizitas Binder
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Mohamad El Amki
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Chaim Glück
- Institute of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057 Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - William Middleham
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Anna Maria Reuss
- Institute of Neuropathology, University Hospital Zurich, University of Zurich, Schmelzbergstrasse 12, 8091 Zurich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Adrien Bertolo
- Iconeus, 6 rue Jean Calvin, Paris, France; Physics for Medicine, INSERM U1273, ESPCI Paris, CNRS UMR 8063, PSL Research University, 17 rue Moreau, Paris, France
| | - Patrick Thurner
- Department of Neuroradiology, University Hospital and University of Zurich, Zürich, France
| | - Thomas Deffieux
- Physics for Medicine, INSERM U1273, ESPCI Paris, CNRS UMR 8063, PSL Research University, 17 rue Moreau, Paris, France
| | - Chryso Lambride
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Robert Epp
- Institute of Fluid Dynamics, ETH Zurich, Zurich, Switzerland
| | - Hannah-Lea Handelsmann
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland
| | - Philipp Baumgartner
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland
| | - Cyrille Orset
- Normandie University, UNICAEN, INSERM, Unité Mixte de Recherche-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institute Blood and Brain @ Caen Normandie, GIP Cyceron, Caen, France
| | - Philipp Bethge
- Brain Research Institute, University of Zurich, 8057 Zurich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital and University of Zurich, Zürich, France
| | - Adriano Aguzzi
- Institute of Neuropathology, University Hospital Zurich, University of Zurich, Schmelzbergstrasse 12, 8091 Zurich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Mickael Tanter
- Physics for Medicine, INSERM U1273, ESPCI Paris, CNRS UMR 8063, PSL Research University, 17 rue Moreau, Paris, France
| | - Franca Schmid
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM, Unité Mixte de Recherche-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institute Blood and Brain @ Caen Normandie, GIP Cyceron, Caen, France; Department of Clinical Research, Caen Normandie University Hospital, Caen, France
| | - Matthias Tasso Wyss
- Institute of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057 Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Bruno Weber
- Institute of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057 Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zürich, Switzerland; Neuroscience Center Zurich, University of Zurich, ETH Zurich, Zurich, Switzerland.
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Pascual JSG, Guo E, Yang R, Langdon KD, Lama S, Sutherland GR. Ruptured pial-pial collateral aneurysm associated with left internal carotid artery occlusion: nuances of surgical management. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 7:CASE2454. [PMID: 38498919 PMCID: PMC10953998 DOI: 10.3171/case2454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/07/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Carotid occlusion often leads to the formation of a collateral network. On rare occasions, due to hemodynamic influence, aneurysms can occur. Here, the authors describe a 69-year-old male presenting with intracerebral hemorrhage secondary to a ruptured aneurysm within such a network. OBSERVATIONS The patient presented to the emergency department with an altered level of consciousness. Imaging showed a left temporal lobe hemorrhage extending into the ventricle, subdural hematoma, and evidence of contrast extravasation. Digital subtraction angiography revealed an occluded left internal carotid artery with the left middle cerebral artery territory reconstituted by flow through an external carotid artery-internal carotid artery anastomosis. The latter was formed by the superficial temporal artery-superior orbital artery, as well as pial-pial collaterals from the posterior temporal artery. Notably, a 4-mm aneurysm arising from the pial-pial collateral network was identified. Surgical intervention involved a left temporal craniectomy and aneurysm excision, with special attention paid to preserving the anastomotic flow through the superficial temporal artery. LESSONS This case underscores the importance of recognizing and preserving collateral vascular pathways in cases of carotid occlusion with an associated aneurysm. It emphasizes the necessary balance between managing aneurysm risk and maintaining cerebral perfusion, highlighting the need for careful preoperative planning and intraoperative caution.
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Affiliation(s)
- Juan Silvestre G Pascual
- 1Department of Clinical Neurosciences, Project NeuroArm, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- 2Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada; and
| | - Eddie Guo
- 1Department of Clinical Neurosciences, Project NeuroArm, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Runze Yang
- 2Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada; and
| | - Kristopher D Langdon
- 3Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanju Lama
- 1Department of Clinical Neurosciences, Project NeuroArm, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- 2Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada; and
| | - Garnette R Sutherland
- 1Department of Clinical Neurosciences, Project NeuroArm, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- 2Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada; and
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Zavriyev AI, Kaya K, Wu KC, Pierce ET, Franceschini MA, Robinson MB. Measuring pulsatile cortical blood flow and volume during carotid endarterectomy. BIOMEDICAL OPTICS EXPRESS 2024; 15:1355-1369. [PMID: 38495722 PMCID: PMC10942688 DOI: 10.1364/boe.507730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 03/19/2024]
Abstract
Carotid endarterectomy (CEA) involves removal of plaque in the carotid artery to reduce the risk of stroke and improve cerebral perfusion. This study aimed to investigate the utility of assessing pulsatile blood volume and flow during CEA. Using a combined near-infrared spectroscopy/diffuse correlation spectroscopy instrument, pulsatile hemodynamics were assessed in 12 patients undergoing CEA. Alterations to pulsatile amplitude, pulse transit time, and beat morphology were observed in measurements ipsilateral to the surgical side. The additional information provided through analysis of pulsatile hemodynamic signals has the potential to enable the discovery of non-invasive biomarkers related to cortical perfusion.
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Affiliation(s)
- Alexander I. Zavriyev
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kutlu Kaya
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kuan Cheng Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric T. Pierce
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Angela Franceschini
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell B. Robinson
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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5
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Bhandari A, Feridooni T, Pikula A, Styra R, Mikulis DJ, Howe KL. Evaluating the influence of altered cerebral hemodynamics on cognitive performance in asymptomatic carotid artery stenosis: A systematic review. J Vasc Surg 2024; 79:436-447. [PMID: 37619916 DOI: 10.1016/j.jvs.2023.08.111] [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: 04/11/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Substantial controversy exists regarding asymptomatic carotid stenosis (ACS) and its potential role in the pathophysiology of cognitive impairment. If proven, this hypothesis may suggest an additional definition for symptomatic carotid disease that would alter current management. This study aimed to synthesize the literature evaluating the relationship between impaired cerebral hemodynamics and cognition in patients with ACS. METHODS A literature search was performed using MEDLINE, Embase, and EBM Reviews through May 2022. We included prospective case-control studies that used validated, objective measure(s) of either global cognition or one or more domains of cognitive function and assessed cerebrovascular reserve (CVR). RESULTS Five studies were included, comprising a total of 782 patients with moderate (50%-69%) to severe (70%-99%) ACS. Patients with ACS and impaired ipsilateral CVR demonstrated significant cognitive impairment compared with controls. Patients with unilateral or bilateral ACS and normal CVR had cognitive scores similar to controls. Those with bilateral CVR impairment demonstrated the lowest cognitive scores. CONCLUSIONS This review lends support to the claim that cognitive impairment, likely the result of impaired cerebral hemodynamics, is an under-recognized morbidity in patients with ACS. CVR may serve as an additional tool to determine whether patients are in fact symptomatic from their carotid stenosis and warrant consideration for intervention.
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Affiliation(s)
- Apoorva Bhandari
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tiam Feridooni
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Aleksandra Pikula
- Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Rima Styra
- Department of Psychiatry, University of Toronto, University Health Network, Toronto, ON, Canada
| | - David J Mikulis
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada.
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Roopnarinesingh R, Leppert M, Mukherjee D. Evidence and Mechanisms for Embolic Stroke in Contralateral Hemispheres From Carotid Artery Sources. J Am Heart Assoc 2023; 12:e030792. [PMID: 38014680 PMCID: PMC10727331 DOI: 10.1161/jaha.123.030792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Disambiguation of embolus pathogenesis in embolic strokes is often a clinical challenge. One common source of embolic stroke is the carotid arteries, with emboli originating due to plaque buildup or perioperatively during revascularization procedures. Although it is commonly thought that thromboemboli from carotid sources travel to cerebral arteries ipsilaterally, there are existing reports of contralateral embolic events that complicate embolus source destination relationship for carotid sources. Here, we hypothesize that emboli from carotid sources can travel to contralateral hemispheres and that embolus interactions with collateral hemodynamics in the circle of Willis influence this process. METHODS AND RESULTS We use a patient-specific computational embolus-hemodynamics interaction model developed in prior works to conduct an in silico experiment spanning 4 patient vascular models, 6 circle of Willis anastomosis variants, and 3 different thromboembolus sizes released from left and right carotid artery sites. This led to a total of 144 different experiments, estimating trajectories and distribution of approximately 1.728 million embolus samples. Across all cases considered, emboli from left and right carotid sources showed nonzero contralateral transport (P value <-0.05). Contralateral movement revealed a size dependence, with smaller emboli traveling more contralaterally. Detailed analysis of embolus dynamics revealed that collateral flow routes in the circle of Willis played a role in routing emboli, and transhemispheric movement occurred through the anterior and posterior communicating arteries in the circle of Willis. CONCLUSIONS We generated quantitative data demonstrating the complex dynamics of finite size thromboembolus particles as they interact with pulsatile arterial hemodynamics and traverse the vascular network of the circle of Willis. This leads to a nonintuitive source-destination relationship for emboli originating from carotid artery sites, and emboli from carotid sources can potentially travel to cerebral arteries on contralateral hemispheres.
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Affiliation(s)
| | - Michelle Leppert
- Department of NeurologyUniversity of Colorado Anschutz Medical CampusAuroraCO
| | - Debanjan Mukherjee
- Paul M Rady Department of Mechanical EngineeringUniversity of Colorado BoulderBolderCO
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Roopnarinesingh R, Leppert M, Mukherjee D. Evidence And Mechanisms For Embolic Stroke In Contralateral Hemispheres From Carotid Artery Sources. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.20.23288892. [PMID: 37162897 PMCID: PMC10168406 DOI: 10.1101/2023.04.20.23288892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Disambiguation of embolus etiology in embolic strokes is often a clinical challenge. One common source of embolic stroke is the carotid arteries, with emboli originating due to plaque build up, or perioperatively during revascularization procedures. While it is commonly thought that thromboemboli from carotid sources travel to cerebral arteries ipsilaterally, there are existing reports of contralateral embolic events which complicate embolus source destination relationship for carotid sources. Here, we hypothesize that emboli from carotid sources can travel to contralateral hemispheres, and that embolus interactions with collateral hemodynamics in the Circle of Willis influences this process. We use a patient-specific computational embolus-hemodynamics interaction model developed in prior works to conduct an in silico experiment spanning 4 patient vascular models, 6 Circle of Willis anastomosis variants, and 3 different thromboembolus sizes released from left and right carotid artery sites. This led to a total of 144 different experiments, estimating trajectories and distribution of approximately 1.728 million embolus samples. Across all cases considered, emboli from left and right carotid sources showed non-zero contralateral transport (p value < 0.05). Contralateral movement revealed a size-dependence, with smaller emboli traveling more contralaterally. Detailed analysis of embolus dynamics revealed that collateral flow routes in Circle of Willis played a role in routing emboli, and transhemispheric movement occurred through the anterior and posterior communicating arteries in the Circle of Willis. We generated quantitative data demonstrating the complex dynamics of finite size thromboembolus particles as they interact with pulsatile arterial hemodynamics, and traverse the vascular network of the Circle of Willis. This leads to a non-intuitive source-destination relationship for emboli originating from carotid artery sites, and emboli from carotid sources can potentially travel to cerebral arteries on contralateral hemispheres.
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8
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Mohimen A, Gupta A, Gill S, Sahu S, Anadure R. Correlation of CT perfusion with MRI brain in symptomatic carotid artery stenosis. Med J Armed Forces India 2023; 79:421-427. [PMID: 37441288 PMCID: PMC10334217 DOI: 10.1016/j.mjafi.2022.04.003] [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: 12/21/2021] [Accepted: 04/03/2022] [Indexed: 10/18/2022] Open
Abstract
Background Cerebral white matter disease and large vessel cerebral steno-occlusive are both associated with high incidence of strokes and mortality. There is a lack of literature correlating the cerebral perfusion downstream of a stenotic lesion with white matter changes in the cerebral hemispheres. The aim of this study was to correlate the white matter changes in magnetic resonance imaging (MRI) with computed tomography (CT) perfusion parameters in patients with symptomatic carotid stenosis. Methods A total of 50 patients with symptomatic carotid stenosis underwent MRI brain and CT Perfusion. Percentage differences in cerebral blood flow (CBF) and mean transit time (MTT) were correlated with symmetric and asymmetric small vessel ischemic disease (SVID) on MRI. Receiver operating characteristic (ROC) curve analysis was performed to determine sensitivity and specificity for different values of percentage CBF and MTT difference. Results A total of 17 patients with symmetrical SVID had a mean CBF difference of 6.58 (SD of 3.17) and mean MTT difference of 11.61 (SD of 4.32). 33 patients with asymmetrical SVID had a mean CBF difference of 34.73 (SD of 6.87) and mean MTT difference of 44.63 (SD of 9.12). ROC curve analysis showed percentage CBF and MTT differences of 12.5% and 26.5% respectively to be associated with 100% specificity and sensitivity. Conclusion In patients with symptomatic carotid stenosis, CT perfusion parameters correlate with MRI features of SVID.
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Affiliation(s)
- Aneesh Mohimen
- Professor (Radiology) & Interventional Radiologist, Command Hospital (Central Command), Lucknow, India
| | - Ayon Gupta
- Assistant Professor, Department of Community Medicine, Armed Forces Medical College, Pune, India
| | - Shaman Gill
- Associate Professor (Medicine) & Neurologist, Command Hospital (Central Command), Lucknow, India
| | - Samaresh Sahu
- Professor, Department of Radiology, Armed Forces Medical College, Pune, India
| | - Ravi Anadure
- Professor (Medicine) & Neurologist, Armed Forces Clinic, New Delhi, India
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Peerlings D, de Jong HWAM, Bennink E, Dankbaar JW, Velthuis BK, Emmer BJ, Majoie CBLM, Marquering HA. Spatial CT perfusion data helpful in automatically locating vessel occlusions for acute ischemic stroke patients. Front Neurol 2023; 14:1136232. [PMID: 37064186 PMCID: PMC10090274 DOI: 10.3389/fneur.2023.1136232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionLocating a vessel occlusion is important for clinical decision support in stroke healthcare. The advent of endovascular thrombectomy beyond proximal large vessel occlusions spurs alternative approaches to locate vessel occlusions. We explore whether CT perfusion (CTP) data can help to automatically locate vessel occlusions.MethodsWe composed an atlas with the downstream regions of particular vessel segments. Occlusion of these segments should result in the hypoperfusion of the corresponding downstream region. We differentiated between seven-vessel occlusion locations (ICA, proximal M1, distal M1, M2, M3, ACA, and posterior circulation). We included 596 patients from the DUtch acute STroke (DUST) multicenter study. Each patient CTP data set was processed with perfusion software to determine the hypoperfused region. The downstream region with the highest overlap with the hypoperfused region was considered to indicate the vessel occlusion location. We assessed the indications from CTP against expert annotations from CTA.ResultsOur atlas-based model had a mean accuracy of 86% and could achieve substantial agreement with the annotations from CTA according to Cohen's kappa coefficient (up to 0.68). In particular, anterior large vessel occlusions and occlusions in the posterior circulation could be located with an accuracy of 80 and 92%, respectively.ConclusionThe spatial layout of the hypoperfused region can help to automatically indicate the vessel occlusion location for acute ischemic stroke patients. However, variations in vessel architecture between patients seemed to limit the capacity of CTP data to distinguish between vessel occlusion locations more accurately.
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Affiliation(s)
- Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
- *Correspondence: Daan Peerlings
| | | | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan W. Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Birgitta K. Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
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Chen KK, Lin CJ, Chu WF. Dispersion of Heterogeneous Medium in Pulsatile Blood Flow and Absolute Pulsatile Flow Velocity Quantification. IEEE TRANSACTIONS ON MEDICAL IMAGING 2023; 42:170-182. [PMID: 36094983 DOI: 10.1109/tmi.2022.3206241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Heterogeneous medium enhanced angiogr- ams are key diagnostic tools in clinical practice; the associated hemodynamic information is crucial for diagnosing cardiovascular diseases. However, the dynamics of such medium in physiological blood flow are poorly understood. Herein, we report a previously unnoticed dispersion pattern, which is a universal phenomenon, of a medium in pulsatile blood flow. We present a physical theory for studying the dispersion of a steadily injected heterogeneous medium into a thin tubular blood vessel in which the blood flow is pulsatile. In a thin tubular blood vessel, we demonstrate that variations of concentration associated with the heterogeneous medium obey a one-dimensional advection diffusion equation, and the diffusion has limited effect whenever a short vascular segment is considered. A distinct feature of the distribution of the medium in the axial distance-time plane is a "dilation-retraction" pattern. The time evolution signals at different axial positions exhibit distinct concentration waveforms. A numerical scheme is proposed for exploiting this information to estimate the pulsatile velocity. Artificial data are adopted to validate the scheme. Real X-ray angiography is also analyzed to support our theory and method. The theory is applicable whenever imaging protocols involve a heterogeneous medium in pulsatile flow.
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11
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
- Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Correspondence: Mohamad Abdalkader Department of Radiology, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA Tel: +1-617-614-4272 E-mail:
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Department of Neurology, Boston Medical Center, Boston, MA, USA
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12
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Wang Y, Wang J, Qiu J, Li W, Sun X, Zhao Y, Liu X, Zhao Z, Liu L, Nguyen TN, Chen H. Association between collaterals, cerebral circulation time and outcome after thrombectomy of stroke. Ann Clin Transl Neurol 2022; 10:266-275. [PMID: 36527245 PMCID: PMC9930428 DOI: 10.1002/acn3.51718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Cerebral circulation time (CCT) and collateral score (CS) are associated with functional outcomes in acute ischemic stroke (AIS) patients after endovascular treatment (EVT), and may be related to each other. We aim to determine the relationship between CS and CCT on functional outcomes. METHODS We retrospectively enrolled consecutive patients with anterior circulation large vessel occlusion (LVO) AIS who received EVT. CS and CCT were measured based on digital subtraction angiography (DSA). We defined CS 0-2 and 3-4 as poor and good collateral status, respectively, and used change of CCT (cCCT), which was defined as the change of stroke side CCT (sCCT) versus healthy side CCT (hCCT). Mediating analysis was used to evaluate the influence of cCCT on the association between CS and functional outcomes, and ROC curves were further used to explore the predictive ability of the interaction between cCCT and CS for functional outcomes. RESULTS A total of 100 patients were enrolled in the final analysis. A higher cCCT (r = -0.239; p = 0.017) was associated with lower CS, and cCCT mediated the association of CS with functional outcome. Logistic regression analysis found that CS, cCCT and cCCT-CS interactions were independently associated with functional outcome, and cCCT-CS interaction has better predictive performance, with a higher area under curve value than CS or cCCT alone (0.79 vs. 0.75 or 0.75). INTERPRETATION To our knowledge, this study provides the first report of the association of collateral status with cCCT, and their interaction effect on functional outcome in AIS-LVO patients receiving EVT.
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Affiliation(s)
- Ying‐Jia Wang
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Jia‐Qi Wang
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Jin Qiu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Wei Li
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xian‐Hui Sun
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Yong‐Gang Zhao
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xin Liu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Zi‐Ai Zhao
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Liang Liu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Thanh N. Nguyen
- Neurology, RadiologyBoston Medical CenterBostonMassachusettsUSA
| | - Hui‐Sheng Chen
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
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13
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Shrestha S, Bao H, Gu H, Gao C, Zeng Y, Xie K, Shi Y, Zhao L, He B, Zhao W, Tang Z, Li Z. Association of dissection features and primary collateral circulation with ischemic stroke in patients with spontaneous internal carotid artery dissection: evaluated using vessel wall-MRI and MRA. Br J Radiol 2022; 95:20210845. [PMID: 35816551 PMCID: PMC10996963 DOI: 10.1259/bjr.20210845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 05/15/2022] [Accepted: 07/01/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To study the ischemic stroke risk factors in spontaneous internal carotid artery dissection (ICAD) patients via analyzing the dissection features and primary collateral circulation using vessel wall-MRI and magnetic resonance angiography. METHODS ICAD patients who had undergone VW-MRI were included in this study. A total of 36 patients were included and divided into ICAD stroke (N = 23) and non-stroke (N = 13) group. Dissection imaging features [intramural hematoma (IMH), length of IMH, intimal flap, double lumen, intraluminal thrombus, degree of stenosis] and primary collateral status were analyzed. The primary collateral score (0-4) was evaluated based on presence of anterior communicating and ipsilateral anterior cerebral artery A1 segment (0-2) and ipsilateral posterior communicating artery (0-2). RESULTS There were no significant differences in dissection imaging features such as presence of double lumen, intimal flap, IMH, length of IMH and intraluminal thrombus between the two groups. Degree of stenosis and primary collateral score showed significant differences between the two groups. CONCLUSION Both the poor primary collateral circulation and severe stenosis may play an important role in occurrence of ischemic stroke for spontaneous ICAD patients and good primary collateral circulation can help to reduce the incidence of infarction. ADVANCES IN KNOWLEDGE ICAD is one of the major causes of ischemic stroke. Early evaluation of the status of the Circle of Willis in ICAD patients by MRI may help to make treatment strategies and improve clinical outcome.
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Affiliation(s)
- Srijana Shrestha
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Han Bao
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Heyi Gu
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Chao Gao
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Yizhen Zeng
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Kaipeng Xie
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Yixin Shi
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Lei Zhao
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Bo He
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Wei Zhao
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
| | - Zhiwei Tang
- Department of Neurosurgery, First Affiliated Hospital of
Kunming Medical University,
Kunming, China
| | - Zongfang Li
- Department of Radiology, First Affiliated Hospital of Kunming
Medical University, Kunming,
China
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Uniken Venema SM, Dankbaar JW, van der Lugt A, Dippel DWJ, van der Worp HB. Cerebral Collateral Circulation in the Era of Reperfusion Therapies for Acute Ischemic Stroke. Stroke 2022; 53:3222-3234. [PMID: 35938420 DOI: 10.1161/strokeaha.121.037869] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.
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Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
| | - Jan Willem Dankbaar
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, the Netherlands. (J.W.D.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center Rotterdam, the Netherlands. (A.v.d.L.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center Rotterdam, the Netherlands. (D.W.J.D.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
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Kaya K, Zavriyev AI, Orihuela-Espina F, Simon MV, LaMuraglia GM, Pierce ET, Franceschini MA, Sunwoo J. Intraoperative Cerebral Hemodynamic Monitoring during Carotid Endarterectomy via Diffuse Correlation Spectroscopy and Near-Infrared Spectroscopy. Brain Sci 2022; 12:brainsci12081025. [PMID: 36009088 PMCID: PMC9405597 DOI: 10.3390/brainsci12081025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 12/04/2022] Open
Abstract
Objective: This pilot study aims to show the feasibility of noninvasive and real-time cerebral hemodynamic monitoring during carotid endarterectomy (CEA) via diffuse correlation spectroscopy (DCS) and near-infrared spectroscopy (NIRS). Methods: Cerebral blood flow index (CBFi) was measured unilaterally in seven patients and bilaterally in seventeen patients via DCS. In fourteen patients, hemoglobin oxygenation changes were measured bilaterally and simultaneously via NIRS. Cerebral autoregulation (CAR) and cerebrovascular resistance (CVR) were estimated using CBFi and arterial blood pressure data. Further, compensatory responses to the ipsilateral hemisphere were investigated at different contralateral stenosis levels. Results: Clamping of carotid arteries caused a sharp increase of CVR (~70%) and a marked decrease of ipsilateral CBFi (57%). From the initial drop, we observed partial recovery in CBFi, an increase of blood volume, and a reduction in CVR in the ipsilateral hemisphere. There were no significant changes in compensatory responses between different contralateral stenosis levels as CAR was intact in both hemispheres throughout the CEA phase. A comparison between hemispheric CBFi showed lower ipsilateral levels during the CEA and post-CEA phases (p < 0.001, 0.03). Conclusion: DCS alone or combined with NIRS is a useful monitoring technique for real-time assessment of cerebral hemodynamic changes and allows individualized strategies to improve cerebral perfusion during CEA by identifying different hemodynamic metrics.
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Affiliation(s)
- Kutlu Kaya
- Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (A.I.Z.); (F.O.-E.); (M.A.F.)
- Department of Physiology, Faculty of Medicine, Hacettepe University, 06230 Ankara, Turkey
- Correspondence: (K.K.); (J.S.)
| | - Alexander I. Zavriyev
- Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (A.I.Z.); (F.O.-E.); (M.A.F.)
| | - Felipe Orihuela-Espina
- Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (A.I.Z.); (F.O.-E.); (M.A.F.)
- School of Computer Science, University of Birmingham, Birmingham B15 2TT, UK
| | - Mirela V. Simon
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Glenn M. LaMuraglia
- Division of Vascular and Endovascular Surgery in the General Surgical Services, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Eric T. Pierce
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Maria Angela Franceschini
- Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (A.I.Z.); (F.O.-E.); (M.A.F.)
| | - John Sunwoo
- Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (A.I.Z.); (F.O.-E.); (M.A.F.)
- Correspondence: (K.K.); (J.S.)
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16
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Kim M, Park SY, Lee SE, Lee JS, Hong JM, Lee SJ. Significance of Vertigo, Imbalance, and Other Minor Symptoms in Hyperacute Treatment of Posterior Circulation Stroke. Front Neurol 2022; 13:845707. [PMID: 35651338 PMCID: PMC9150563 DOI: 10.3389/fneur.2022.845707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background This study aimed to determine the clinical significance of acute vestibular syndrome (AVS)/acute imbalance syndrome (AIS) in posterior circulation stroke (PCS) and how it should be addressed in the thrombolysis code. Methods Our institution has recently changed its thrombolysis code from one that is generous to AVS/AIS to one that is exclusive. The subjects in this study were patients with PCS who presented before this transition (May 2016 to April 2018, period 1) and those who presented after (January 2019 to December 2020, period 2) with an onset-to-door time of 4.5 h. Hyperacute stroke treatment was compared between the two periods. The clinical significance of AVS/AIS was evaluated by dichotomizing the patients' clinical severity to minor or major deficits, then evaluating the significance of AVS/AIS in each group. Presenting symptoms of decreased mental alertness, hemiparesis, aphasia (anarthria), or hemianopsia were considered major PCS symptoms, and patients who did not present with these symptoms were considered minor PCS. Results In total, 114 patients presented in period 1 and 114 in period 2. Although the code activation rate was significantly lower in period 2 (72.8% vs. 59.7%), p = 0.04, there were no between-group differences in functional outcomes (mRS score at 3 months; 1 [0–3] vs. 0 [0–3], p = 0.18). In 77 patients with PCS and AVS/AIS, the difference in code activation rate was not significant according to changes in thrombolysis code. In minor PCS, AVS/AIS was associated with lower NIHSS scores, lower early neurological deterioration rates, and favorable outcomes. In major PCS, while AVS/AIS was not associated with outcomes, the majority of cases were prodromal AVS/AIS which simple vertigo and imbalance symptoms were followed by a major PCS symptom. Conclusions This study failed to show differences in outcome in patients with PCS according to how AVS/AIS is addressed in the stroke thrombolysis code. In patients with minor PCS, AVS/AIS was associated with a benign clinical course. Prompt identification of prodromal AVS/AIS is essential.
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Affiliation(s)
- Min Kim
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Eun Lee
- Department of Emergency Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
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Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy. J Stroke 2022; 24:207-223. [PMID: 35677976 PMCID: PMC9194547 DOI: 10.5853/jos.2022.00941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022] Open
Abstract
The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
- Correspondence: Jin Soo Lee Department of Neurology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5175 Fax: +82-31-219-5178 E-mail:
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Intracranial Flow Volume Estimation in Patients with Internal Carotid Artery Occlusion. Diagnostics (Basel) 2022; 12:diagnostics12030766. [PMID: 35328320 PMCID: PMC8947284 DOI: 10.3390/diagnostics12030766] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Carotid artery occlusion (CAO) in population studies has a reported prevalence of about 6 per 100,000 people; however, the data may be underestimated. CAO carries a significant risk of stroke. Up to 15% of large artery infractions may be secondary to the CAO, and in 27−38% of patients, ischaemic stroke is a first presentation of the disease. The presence of sufficient and well-developed collateral circulation has a protective influence, being a good prognostic factor in patients with carotid artery disease, both chronic and acute. Understanding the mechanisms and role of collateral circulation may be very important in the risk stratification of such patients. (2) Materials and Methods: This study included 46 patients (mean age: 70.5 ± 6 years old; 15 female, mean age 68.5 ± 3.8 years old and 31 male, mean age 71.5 ± 6.7 years old) with unilateral or bilateral ICA occlusion. In all patients, a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population >65 years old. (3) Results: In comparison with CBF values in the healthy population, three subgroups with CBF changes were identified among patients with ICA occlusion: patients with significant volumetric flow compensation (CBF higher than average + standard deviation for healthy population of the same age), patients with flow similar to the healthy population (average ± standard deviation), and patients without compensation (CBF lower than the average-standard deviation for healthy population). The percentage of patients with significant volumetric flow compensation tend to rise with increasing age, while a simultaneous decline was observed in the group without compensation. The percentage of patients with flow similar to the healthy population remained relatively unchanged. ICA played the most important role in volumetric flow compensation in patients with CAO; however, the relative increase in flow in the ICA was smaller than that in the ECA and VA. Compensatory increased flow was observed in about 50% of all patent extracranial arteries and was more frequently observed in ipsilateral vessels than in contralateral ones, in both the ECA and the VA. In patients with CAO, there was no decrease in CBF, ICA, ECA, and VA flow volume with increasing age. (4) Conclusions: Volumetric flow compensation may play an important predictive role in patients with CAO.
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Garg K, Chang H, Siracuse JJ, Jacobowitz GR, Torres J, Veith FJ, Patel VI, Maldonado TS, Sadek M, Cayne NS, Rockman CB. Severity of stenosis in symptomatic patients undergoing carotid interventions may influence perioperative neurologic events. J Vasc Surg 2022; 76:741-749.e1. [PMID: 35272001 DOI: 10.1016/j.jvs.2022.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/06/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies future embolic risk. In natural history studies, patients with moderate degrees of stenosis have a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced TIA or stroke are found to have both moderate and severe degrees of stenosis. We sought to examine the association carotid artery stenosis severity with outcomes in symptomatic patients undergoing carotid interventions including carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS) and transcervical carotid artery revascularization (TCAR). METHODS The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA and TCAR between 2003 and 2020. Patients were stratified into two groups based on the severity of stenosis - non-severe (0 - 69%) and severe (≥ 70%). Primary endpoints were periprocedural neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were periprocedural death, myocardial infarction (MI) and composite outcomes of stroke/death and stroke/death/MI per reporting standards for carotid interventions. RESULTS Of 29,614 symptomatic patients included in the analysis, 5,296 (17.9%) patients underwent TCAR, 7,844 (26.5%) underwent CAS, and 16,474 (55.6%) underwent CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was similarly significantly lower in patients with severe stenosis when compared to those with non-severe stenosis (2.6% vs. 3.2%, P=.024). In the TCAR cohort, the periprocedural neurologic even rate was lower in patients with severe stenosis when compared to those with non-severe stenosis (3% vs. 4.3%, P=.033). There was no similar difference noted in the CAS cohort, with periprocedural neurologic event rates of 3.8% in the severe group versus 3.5% in the non-severe group (P=.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of post procedural neurologic events in patients undergoing CEA (odds ratio [OR] 0.75, 95% confidence interval [CI], 0.6 - 0.92; P=.007) and TCAR (OR .83; CI, .69 - 0.99; P=.039), but not CAS. CONCLUSION Severe carotid stenosis as opposed to more moderate degrees of stenosis was associated with decreased rates of periprocedural stroke and TIAs in symptomatic patients undergoing TCAR and CEA, but not CAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology, and their inherent risks with carotid revascularization procedures.
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Affiliation(s)
- Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016.
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA 02210
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Jose Torres
- Department of Neurology, New York University Langone Medical Center, New York, NY, 10016
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian / Columbia University Irving Medical Center / Columbia University College of Physicians and Surgeons, New York, NY 10032
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
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Dmytriw AA, Bickford S, Pezeshkpour P, Ha W, Amirabadi A, Dibas M, Kitamura LA, Vidarsson L, Pulcine E, Muthusami P. Rotational Vertebrobasilar Insufficiency: Is There a Physiological Spectrum? Phase-Contrast Magnetic Resonance Imaging Quantification in Healthy Volunteers. Pediatr Neurol 2022; 128:58-64. [PMID: 35101804 DOI: 10.1016/j.pediatrneurol.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Some cases of cerebral ischemia have been attributed to dynamic flow limitation in neck vessels. It however remains unknown whether this represents the extreme end of a physiological response. METHODS Eighteen healthy volunteers were recruited to this prospective study. Cervical blood flow (ml/min/m2) was assessed using phase-contrast MRI, and cerebral perfusion ratios were assessed using arterial spin labeling perfusion at neutral position, predefined head rotations, as well as flexion and extension. Inter-reader agreements were assessed using intraclass correlation coefficient. RESULTS The mean age was 38.6 ± 10.8 (range = 22-56) years, for five male participants and 13 females. The means for height and weight were 168 cm and 73.2 kg, respectively. There were no significant differences in individual arterial blood flow with change in head position (P > 0.05). Similarly, the repeated-measures analysis of variance test demonstrated no significant difference in perfusion ratios in relation to head position movement (P > 0.05). Inter-reader agreement was excellent (intraclass correlation coefficient = 0.97). CONCLUSIONS There is neither significant change in either individual cervical arterial blood flow nor cerebral perfusion within the normal physiological/anatomical range of motion in healthy individuals. It is therefore reasonable to conclude that any such hemodynamic change identified in a patient with ischemic stroke be considered causative.
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Affiliation(s)
- Adam A Dmytriw
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada.
| | - Suzanne Bickford
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Parneyan Pezeshkpour
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Winston Ha
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Amirabadi
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Dibas
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Lee Ann Kitamura
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Logi Vidarsson
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Pulcine
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Prakash Muthusami
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
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Kaszczewski P, Elwertowski M, Leszczyński J, Ostrowski T, Gałązka Z. Volumetric Flow Assessment in Doppler Ultrasonography in Risk Stratification of Patients with Internal Carotid Stenosis and Occlusion. J Clin Med 2022; 11:jcm11030531. [PMID: 35159983 PMCID: PMC8836482 DOI: 10.3390/jcm11030531] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/27/2021] [Accepted: 01/17/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: Alterations of blood flow volume in extracranial arteries may be related to the risk of occurrence of neurological symptoms. The aim of this study was the estimation of cerebral blood flow (CBF) in Doppler ultrasonography, as well as comparison of the flow volume in asymptomatic patients over 65 years old with ≥50%, and symptomatic patients with ≥70% internal carotid artery (ICA) stenosis, in order to assess whether the changes in the CBF correlates with the presence of neurological symptoms. (2) Methods: 308 patients over 65 years old were included in the retrospective cohort observational study: 154 asymptomatic with ≥50% ICA stenosis, 123 healthy volunteers, and 31 symptomatic referred for surgical treatment. The study group was split according to ICA stenosis (50–69%, 70–99% and occlusion). In all patients an extensive Doppler ultrasound examination with measurements of flow volume in common, internal, external carotid (ECA) and vertebral arteries (VA) was performed. (3) Results: Among asymptomatic (A) and symptomatic (S) patients with carotid stenosis 3 subgroups were identified: 57/154—37% (A) and 8/31—25.5% (S)—with significantly increased flow volume (CBF higher than reference range: average CBF + std. dev in the group of healthy volunteers), 67/154—43.5% (A) and 12/31—39% (S)—with similar to reference group flow volume (CBF within range average ± std.dev), and 30/154—19.5% (A) and 11/31—35.5% (S)—with decreased flow volume in extracranial arteries (flow lower than average-std.dev. in healthy volunteers). In symptomatic patients the percentage of patients with significant compensatory increased flow tends to raise with the severity of the stenosis, while simultaneous decline of number of patients with mild compensation (unchanged total CBF) is observed. The percentage of patients without compensation remains unchanged. In the group referred for surgical treatment (symptomatic, ≥70% ICA stenosis) the percentage of patients with flow compensation is twice as low as in the asymptomatic ones with similar degree of the ICA stenosis (8/31—25.8% vs. 26/53—49%, p = 0.04). Compensatory elevated flow was observed most frequently in ECA. (4) Conclusions: The presence of significant volumetric flow compensation has protective influence on developing ischaemic symptoms, including TIA or stroke. The assessment of cerebral inflow in Doppler ultrasonography may provide novel and easily accessible tool of identifying patients prone to cerebral ischaemia. The multivessel character of compensation with enhanced role of ECA justifies the importance of including this artery in the estimation of CBF.
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Affiliation(s)
- Piotr Kaszczewski
- Correspondence: (P.K.); (J.L.); Tel.: +48-22-599-25-54 (P.K. & J.L.)
| | | | - Jerzy Leszczyński
- Correspondence: (P.K.); (J.L.); Tel.: +48-22-599-25-54 (P.K. & J.L.)
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22
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Independent role of circle of Willis for peri-procedural evaluation of carotid endarterectomy in patients with severe carotid stenosis. Clin Neurol Neurosurg 2021; 213:107102. [PMID: 34999387 DOI: 10.1016/j.clineuro.2021.107102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/21/2021] [Accepted: 12/15/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES In patients with severe carotid stenosis (CS), collateral circulation via circle of Willis (CoW) is considered a compensatory response to maintain blood flow. The aim of this study was to evaluate the impact of CoW in patients with severe CS throughout carotid endarterectomy (CEA). METHODS A database of patients (n = 124) undergoing CEA was sampled from 2013 to 2020. Severe CS was defined as 90-99% caliber stenosis and collateral circulation was identified by CoW opening. Baseline characteristics, Age-related white matter change (ARWMC) score, immediate neurologic events (INEs) and manifestations were recorded and compared. Correlation and regression analysis for CoW were further investigated. RESULTS All patients enrolled were divided into two groups regarding to the visualized CoW opening and complete CoW was noticed in 57 patients. The prevalence of complete CoW was higher among asymptomatic patients (n = 39, 68.4%), while higher percentage of TIA or previous stroke were noticed in incomplete CoW (n = 45, 67.2%). Patients with incomplete CoW had a significantly higher median ARWMC score and remarkable cerebral perfusion deficit (P < 0.05*). Totally, 4 INEs (6.0%) were noted in patients with incomplete CoW after CEA. Cerebral hyperperfusion syndrome (CHS) was noticed in 10 patients and early-phase of postoperative hypertension (EPOH) in 15 ones with incomplete CoW versus patients with complete CoW (14.9% and 22.4% vs 3.5% and 7.0%, P < 0.05). Correlation analysis showed strong relationship between CoW opening and peri-operative factors like pre-operative symptoms, ARWMC, CHS and EPOH (P < 0.05*). Overall, CoW opening was an independent predictor of both CHS and EPOH (95% CI, 0.021-0.715 and 0.060-0.949, P < 0.05*) with logistic regression. CONCLUSIONS Sufficient collateral circulation via CoW may promote ipsilateral cerebral perfusion and mitigate WMC in patients with severe CS. In addition, collaterals may improve the predictive power of the risk scale for post-procedural complications after CEA.
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23
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Franjić BD, Lovričević I, Brkić P, Dobrota D, Aždajić S, Hranjec J. Role of Doppler Ultrasound Analysis of Blood Flow Through the Ophthalmic and Intracranial Arteries in Predicting Neurologic Symptoms During Carotid Endarterectomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2141-2156. [PMID: 33368431 DOI: 10.1002/jum.15599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/11/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) is frequently performed under locoregional anesthesia. The intraoperative clamping of the internal carotid artery (ICA) leads to cerebral hypoperfusion, which may in some patients result in the development of neurologic symptoms (NS). The objective of our study was to investigate whether there is an association between the preoperative ultrasound (US) Doppler flow in the ophthalmic artery (OA) and intracranial artery and the occurrence of these intraoperative NS. METHODS We compared 50 patients with NS and 150 patients without NS during CEA. We analyzed their preoperative blood flow characteristics by Doppler US and their clinical and demographic characteristics. RESULTS The contralateral ICA occlusion increased the likelihood of intraoperative NS (odds ratio [OR], 8.4; P < .001). Abnormal contralateral OA flow also increased the likelihood of NS (OR, 1.84; P < .001), whereas ipsilateral abnormal OA flow reduced it (OR, 0.73; P = .06). Increased flow in the ipsilateral anterior cerebral artery (ACA) increased the likelihood of NS (OR, 3.3), whereas reversed flow decreased it (OR, 0.1; P = .03). Inverse flow in the contralateral ACA increased the risk (OR, 5.4), whereas increased flow reduced it (OR, 0.2; P = .02). Male patients had a higher risk of NS (P = .09) as well as older patients (P = .05). Eight percent of the patients with NS developed a transient ischemic attack or stroke. CONCLUSIONS Doppler US analysis of the OA and ACA in combination with analysis of ICA stenosis may be a promising predictor of NS during ICA clamping. This, in turn, may warn the patient and the surgeon of an increased risk during surgery.
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Affiliation(s)
- Björn Dario Franjić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivo Lovričević
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Petar Brkić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Duško Dobrota
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Stjepan Aždajić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Jasmina Hranjec
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
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Nagaishi M, Fujii Y, Sugiura Y, Suzuki K. Skull shape abnormalities in ischemic cerebrovascular and mental diseases in adults. Sci Rep 2021; 11:17616. [PMID: 34475458 PMCID: PMC8413272 DOI: 10.1038/s41598-021-97054-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/17/2021] [Indexed: 11/08/2022] Open
Abstract
Morphological changes in the child skull due to mechanical and metabolic stimulation and synostosis of the suture are well known. On the other hand, few studies have focused on clinical conditions relevant for adult skull deformity. We retrospectively reviewed computed tomography (CT) findings obtained from 365 cases that were treated for head injuries, moyamoya disease, cervical internal carotid artery stenosis, and mental diseases, and investigated the morphological changes in the skull associated with these diseases. The findings from head injuries were used not only for control subjects, but also for the analysis of generational changes in skull shape based on birth year. Head shape had a brachiocephalic tendency with occipital flattening in people born from the 1950s onwards. Cases of moyamoya disease, cervical internal carotid artery stenosis, and mental diseases showed significantly thicker frontal and occipital bone than those of control subjects. The skull thickening was especially noticeable in the frontal bone in moyamoya disease. Plagiocephaly was significantly frequent in moyamoya disease. These uncommon skull shapes are useful CT findings in screening subjects for early evidence of mental diseases and intracranial ischemic diseases with arterial stenosis.
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Affiliation(s)
- Masaya Nagaishi
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan.
| | - Yoshiko Fujii
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
| | - Yoshiki Sugiura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
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25
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Mechtouff L, Rascle L, Crespy V, Canet-Soulas E, Nighoghossian N, Millon A. A narrative review of the pathophysiology of ischemic stroke in carotid plaques: a distinction versus a compromise between hemodynamic and embolic mechanism. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1208. [PMID: 34430649 PMCID: PMC8350662 DOI: 10.21037/atm-20-7490] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/31/2021] [Indexed: 12/13/2022]
Abstract
Atherosclerotic carotid artery stenosis causes about 10–20% of all ischemic strokes through two main mechanisms: hemodynamic impairment in case of significant stenosis and thromboembolism from an atherosclerotic plaque regardless of the degree of stenosis. The latter is the most frequent mechanism and appear to result from embolization from a vulnerable atherosclerotic plaque or acute occlusion of the carotid artery and propagation of thrombus distally. Downstream infarcts may occur in a territory of major cerebral artery or at the most distal areas between two territories of major cerebral arteries, the so-called watershed (WS), or border zone area. Although WS infarcts, especially deep WS infarct, were historically thought to be due to hemodynamic compromise, the role of microembolism has also been documented, both mechanisms may act synergistically to promote WS infarcts. Routine and more advanced imaging techniques may provide information on the underlying mechanism involved in ipsilateral ischemic stroke. A better understanding of ischemic stroke pathogenesis in carotid stenosis may limit the use of routine non-selective shunt, whose benefit-risk balance is debated, to patients with hemodynamic impairment. After reviewing existing evidence underpinning the contribution of the two mechanisms in downstream ischemic stroke and the various imaging techniques available to investigate them, we will focus on the pathogenesis of WS infarcts that remains debated.
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Affiliation(s)
- Laura Mechtouff
- Stroke Center, Hospices Civils de Lyon, Lyon, France.,INSERM U1060, CarMeN Laboratory, University Claude Bernard Lyon 1, Lyon, France
| | - Lucie Rascle
- Stroke Center, Hospices Civils de Lyon, Lyon, France
| | - Valentin Crespy
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France
| | | | - Norbert Nighoghossian
- Stroke Center, Hospices Civils de Lyon, Lyon, France.,INSERM U1060, CarMeN Laboratory, University Claude Bernard Lyon 1, Lyon, France
| | - Antoine Millon
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France.,LIBM EA7424, Team Atherosclerosis, Thrombosis and Physical Activity, University Claude Bernard Lyon 1, Lyon, France
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26
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Friend AT, Rogan M, Rossetti GMK, Lawley JS, Mullins PG, Sandoo A, Macdonald JH, Oliver SJ. Bilateral regional extracranial blood flow regulation to hypoxia and unilateral duplex ultrasound measurement error. Exp Physiol 2021; 106:1535-1548. [PMID: 33866627 DOI: 10.1113/ep089196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/14/2021] [Indexed: 02/05/2023]
Abstract
NEW FINDINGS What is the central question of this study? Is blood flow regulation to hypoxia different between the internal carotid arteries (ICAs) and vertebral arteries (VAs), and what is the measurement error in unilateral extracranial artery assessments compared to bilateral? What is the main finding and its importance? ICA and VA blood flow regulation to hypoxia is comparable when factoring for vessel type and vessel side. Compared to bilateral assessment, vessels assessed unilaterally had individual measurement errors of up to 37%. Assessing the vessel with the larger resting blood flow, not the left or right vessel, reduces unilateral measurement error. ABSTRACT Whether blood flow regulation to hypoxia is similar between left and right internal carotid arteries (ICAs) and vertebral arteries (VAs) is unclear. Extracranial blood flow is regularly calculated by doubling a unilateral assessment; however, lateral artery differences may lead to measurement error. This study aimed to determine extracranial blood flow regulation to hypoxia when factoring for vessel type (ICAs or VAs) and vessel side (left or right) effects, and to investigate unilateral assessment measurement error compared to bilateral assessment. In a repeated-measures crossover design, extracranial arteries of 44 participants were assessed bilaterally by duplex ultrasound during 90 min of normoxic and poikilocapnic hypoxic (12.0% fraction of inspired oxygen) conditions. Linear mixed model analyses revealed no Condition × Vessel Type × Vessel Side interaction for blood flow, vessel diameter and flow velocity (all P > 0.05) indicating left and right ICA and VA blood flow regulation to hypoxia was similar. Bilateral hypoxic reactivity was comparable (ICAs, 1.4 (1.0) vs. VAs, 1.7 (1.1) Δ%·Δ S p O 2 -1 ; P = 0.12). Compared to bilateral assessment, unilateral mean measurement error of the relative blood flow response to hypoxia was up to 5%, but individual errors reached 37% and were greatest in ICAs and VAs with the smaller resting blood flow due to a ratio-scaling problem. In conclusion, left and right ICA and VA regulation to hypoxia is comparable when factoring for vessel type and vessel side. Assessing the ICA and VA vessels with the larger resting blood flow, not the left or right vessel, reduces unilateral measurement error.
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Affiliation(s)
- Alexander T Friend
- Extremes Research Group, School of Sport, Health and Exercise Sciences, College of Human Sciences, Bangor University, Bangor, UK
| | - Matthew Rogan
- Bangor Imaging Unit, School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | - Gabriella M K Rossetti
- Extremes Research Group, School of Sport, Health and Exercise Sciences, College of Human Sciences, Bangor University, Bangor, UK.,Centre for Integrative Neuroscience and Neurodynamics, School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Justin S Lawley
- Department of Sport Science, Division of Physiology, University of Innsbruck, Innsbruck, Austria
| | - Paul G Mullins
- Bangor Imaging Unit, School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | - Aamer Sandoo
- Extremes Research Group, School of Sport, Health and Exercise Sciences, College of Human Sciences, Bangor University, Bangor, UK
| | - Jamie H Macdonald
- Extremes Research Group, School of Sport, Health and Exercise Sciences, College of Human Sciences, Bangor University, Bangor, UK
| | - Samuel J Oliver
- Extremes Research Group, School of Sport, Health and Exercise Sciences, College of Human Sciences, Bangor University, Bangor, UK
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The slope of cerebral oxyhemoglobin oscillation is associated with vascular reserve capacity in large artery steno-occlusion. Sci Rep 2021; 11:8568. [PMID: 33883666 PMCID: PMC8060335 DOI: 10.1038/s41598-021-88198-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/05/2021] [Indexed: 11/08/2022] Open
Abstract
Inadequate cerebral perfusion is a risk factor for cerebral ischemia in patients with large artery steno-occlusion. We investigated whether prefrontal oxyhemoglobin oscillation (ΔHbO2, 0.6-2 Hz) was associated with decreased vascular reserve in patients with steno-occlusion in the large anterior circulation arteries. Thirty-six patients with steno-occlusion in the anterior circulation arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery) were included and compared to thirty-six control subjects. Patients were categorized into two groups (deteriorated vascular reserve vs. preserved vascular reserve) based on the results of Diamox single- photon emission computed tomography imaging. HbO2 data were collected using functional near-infrared spectroscopy. The slope of ΔHbO2 and the ipsilateral/contralateral slope ratio of ΔHbO2 were analyzed. Among the included patients (n = 36), 25 (69.4%) had deteriorated vascular reserve. Patients with deteriorated vascular reserve had a significantly higher average slope of ΔHbO2 on the ipsilateral side (5.01 ± 2.14) and a higher ipsilateral/contralateral ratio (1.44 ± 0.62) compared to those with preserved vascular reserve (3.17 ± 1.36, P = 0.014; 0.93 ± 0.33, P = 0.016, respectively) or the controls (3.82 ± 1.69, P = 0.019; 0.94 ± 0.29, P = 0.001). The ipsilateral/contralateral ΔHbO2 ratio could be used as a surrogate for vascular reserve in patients with severe steno-occlusion in the anterior circulation arteries.
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Han M, Seo K, Choi J. Cervical Vascular Diseases Rarely Observed by Duplex Sonography: 3 Cases. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2021. [DOI: 10.15324/kjcls.2021.53.1.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Minho Han
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Kangsik Seo
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Junghye Choi
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
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29
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Zhuang C, Poublanc J, Mcketton L, Venkatraghavan L, Sobczyk O, Duffin J, Crawley AP, Fisher JA, Wu R, Mikulis DJ. The value of a shorter-delay arterial spin labeling protocol for detecting cerebrovascular impairment. Quant Imaging Med Surg 2021; 11:608-619. [PMID: 33532261 DOI: 10.21037/qims-20-148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background The aim of this study was to determine the relationship between blood oxygen level dependent (BOLD) cerebrovascular reactivity (CVR) and cerebral blood flow (CBF) obtained from arterial spin labeling (ASL) using different post labeling delays (PLD). Methods Forty-two patients with steno-occlusive diseases and impaired CVR were divided into two groups, one scanned with a 1.5-second (1.5-s) and the other with a 2.5-second (2.5-s) PLD ASL protocol. For all patients, a region of interest (ROI) was drawn around the CVR impairment. This affected ROI was then left-right flipped across the brain midline to obtain the control ROI. For both groups, the difference in grey matter CVR between affected and control ROI was first tested to confirm significance. The average grey matter CBF of affected and control ROIs were then compared. The same analysis method was used to compare affected and control hemispheres. Results In both groups of 1.5-s and 2.5-s PLD, CVR values in the affected ROI (-0.049±0.055 and -0.042±0.074%/mmHg, respectively) were significantly lower compared to that in the control ROI (0.152±0.054 and 0.152±0.053%/mmHg, respectively, P<0.0001). In the group with the 1.5-s PLD, CBF in the affected ROI (37.62±11.37 mL/100 g/min) was significantly lower compared to CBF in the control ROI (44.13±11.58 mL/100 g/min, P<0.05). However, in the group with the 2.5-s PLD, no significant differences could be seen between CBF in the affected ROI (40.50±14.82 mL/100 g/min) and CBF in the control ROI (39.68±12.49 mL/100 g/min, P=0.73). In the hemisphere-based analysis, CBF was significantly lower in the affected side than in the control side for the group with the 1.5-s PLD (P<0.05) when CVR was impaired (P<0.0001), but not for the group with the 2.5-s PLD (P=0.49). Conclusions In conclusion, our study reveals and highlights the value of a shorter-PLD ASL protocol, which is able to reflect CVR impairment. At the same time, we offer a better understanding of the relationship between BOLD CVR and CBF obtained from ASL.
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Affiliation(s)
- Caiyu Zhuang
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada.,Department of Medical Imaging, the First Affiliated Hospital, Medical College of Shantou University, Shantou, China
| | - Julien Poublanc
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Larissa Mcketton
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | | | - Olivia Sobczyk
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - James Duffin
- Department of Anaesthesia, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University Health Network, Toronto, Canada
| | - Adrian P Crawley
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Joseph A Fisher
- Department of Anaesthesia, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University Health Network, Toronto, Canada
| | - Renhua Wu
- Department of Medical Imaging, the Second Affiliated Hospital, Medical College of Shantou University, Shantou, China
| | - David J Mikulis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
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30
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Lukyanchikov VA, Orlov EA, Oganesyan MV, Gordeeva AA, Pavliv MP. [Anatomical bases of brain revascularization: choosing an extra-intracranial bypass option]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:120-126. [PMID: 34951769 DOI: 10.17116/neiro202185061120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Surgical brain revascularization is an important treatment for acute or chronic ischemia, intracranial aneurysms and skull base tumors. Individual anatomy of brain vessels should be clearly understood for this procedure. Variants of collateral cerebral blood flow in patients with cerebrovascular diseases depend on individual characteristics of circle of Willis and reserve mechanisms of collateral circulation. These anatomical variations require careful preoperative planning to choose the optimal revascularization option.
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Affiliation(s)
- V A Lukyanchikov
- University's Hospital of the Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
- Russian People's Friendship University, Moscow, Russia
| | - E A Orlov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M V Oganesyan
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Gordeeva
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M P Pavliv
- Sechenov First Moscow State Medical University, Moscow, Russia
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31
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Pathak R, Thakur S, Imade A, Sen L. Cerebral collateral circulation in acute stroke with occlusive internal carotid artery disease. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_15_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Emrecan B, Çekirdekoğlu K. Unilateral or bilateral cerebral perfusion in hemiarch replacement: A prospective randomized study. J Card Surg 2020; 36:680-686. [PMID: 33355947 DOI: 10.1111/jocs.15268] [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: 08/20/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. METHODS Forty-two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. RESULTS There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p = .170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p = .018) whereas cross-clamp time and cardiopulmonary bypass times were not (p = .693 and p = .584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p = .484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. CONCLUSION The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short.
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Affiliation(s)
- Bilgin Emrecan
- Department of Cardiac and Vascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Kadir Çekirdekoğlu
- Department of Cardiac and Vascular Surgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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Abstract
PURPOSE OF REVIEW This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. RECENT FINDINGS Six randomized controlled trials undoubtedly confirmed the benefits of using endovascular thrombectomy on the clinical outcome of patients with stroke with large vessel occlusion within 6 hours from symptom onset compared with those receiving only standard medical care. In a meta-analysis of individual patient data, the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale for one patient was 2.6. Recently, the concept of "tissue window" versus time window has proved useful for selecting patients for mechanical thrombectomy up to 24 hours from symptom onset. The DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention) trial included patients at a median of 12.5 hours from onset and showed the largest effect in functional outcome ever described in any acute stroke treatment trial (35.5% increase in functional independence). In DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 3), patients treated with mechanical thrombectomy at a median of 11 hours after onset had a 28% increase in functional independence and an additional 20% absolute reduction in death or severe disability. SUMMARY For patients with acute ischemic stroke and a large vessel occlusion in the proximal anterior circulation who can be treated within 6 hours of stroke symptom onset, mechanical thrombectomy with a second-generation stent retriever or a catheter aspiration device should be indicated regardless of whether the patient received treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.
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Zhan Y, Li MZ, Yang L, Feng XF, Lei JF, Zhang N, Zhao YY, Zhao H. The three-phase enriched environment paradigm promotes neurovascular restorative and prevents learning impairment after ischemic stroke in rats. Neurobiol Dis 2020; 146:105091. [DOI: 10.1016/j.nbd.2020.105091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/30/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023] Open
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Pirson FAV, Hinsenveld WH, Staals J, de Ridder IR, van Zwam WH, Schreuder THCML, Roos YBWEM, Majoie CBLM, van der Worp HB, Uyttenboogaart M, Lycklama À Nijeholt GJ, Schonewille WJ, van Oostenbrugge RJ. Peripheral Artery Disease in Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy; Results From the MR CLEAN Registry. Front Neurol 2020; 11:560300. [PMID: 33133007 PMCID: PMC7579421 DOI: 10.3389/fneur.2020.560300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023] Open
Abstract
Background and Purpose: Though peripheral artery disease (PAD) is a well-known risk factor for ischemic events, better outcomes have been described in acute ischemic stroke patients with co-existing PAD. This paradoxical association has been attributed to remote ischemic preconditioning (RIPC) and might be related to better collateral blood flow. The aim of this study is to compare outcomes after endovascular thrombectomy (EVT) in acute stroke patients with and without PAD and to assess the relation between PAD and collateral grades. Methods: We analyzed acute ischemic stroke patients treated with EVT for an anterior circulation large artery occlusion, included in the Dutch, prospective, multicenter MR CLEAN Registry between March 2014 and November 2017. Collaterals were scored on CT angiography, using a 4-point collateral score. We used logistic regression analysis to estimate the association of PAD with collateral grades and functional outcome, assessed with the modified Rankin Scale (mRS) at 90 days. Safety outcomes included mortality at 90 days, symptomatic intracranial hemorrhage, and stroke progression. Results: We included 2,765 patients for analysis, of whom 254 (9.2%) had PAD. After adjustment for potential confounders, multivariable regression analysis showed no association of PAD with functional outcome [mRS cOR 0.90 (95% CI, 0.7–1.2)], collateral grades (cOR 0.85, 95% CI 0.7–1.1), or safety outcomes. Conclusion: In the absence of an association between the presence of PAD and collateral scores or outcomes after EVT, it may be questioned whether PAD leads to RIPC in patients with acute ischemic stroke due to large vessel occlusion.
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Affiliation(s)
- France A V Pirson
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter H Hinsenveld
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology and Radiology, University Medical Center Groningen, Groningen, Netherlands
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Ravindran AV, Killingsworth MC, Bhaskar S. Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy. Eur J Neurosci 2020; 53:1238-1261. [PMID: 32871623 DOI: 10.1111/ejn.14955] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/21/2022]
Abstract
The cerebral collaterals play an important role in penumbral tissue sustenance after an acute ischaemic stroke. Recent studies have demonstrated the potential role of collaterals in the selection of acute ischaemic stroke patients eligible for reperfusion therapy. However, the understanding of the significance and evidence around the role of collateral status in predicting outcomes in acute ischaemic stroke patients treated with reperfusion therapy is still unclear. Moreover, the use of pre-treatment collaterals in patient selection and prognosis is relatively underappreciated in clinical settings. A focused review of the literature was performed on the various methods of collateral evaluation and the role of collateral status in acute ischaemic stroke patients receiving reperfusion therapy. We discuss the methods of evaluating pre-treatment collaterals in clinical settings. The patient selection based on collateral status as well as the prognostic and therapeutic value of collaterals in acute ischaemic stroke, in settings of intravenous thrombolysis or endovascular therapy alone, and bridge therapy, are summarized. Recommendations for future research and possible pharmacological intervention strategies aimed at collateral enhancement are also discussed. Collaterals may play an important role in identifying acute ischaemic stroke patients who are likely to benefit from endovascular treatment in an extended time window. Future neuroscientific efforts to better improve our understanding of the role of collaterals in acute ischaemia as well as clinical studies to delineate its role in patient selection and acute stroke prognosis are warranted.
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Affiliation(s)
- Abina Vishni Ravindran
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
| | - Murray C Killingsworth
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia.,Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Department of Anatomical Pathology, NSW Health Pathology and Liverpool Hospital, Liverpool, NSW, Australia
| | - Sonu Bhaskar
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Sydney, NSW, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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Drozdowska BA, Elliott E, Taylor-Rowan M, Shaw RC, Cuthbertson G, Langhorne P, Quinn TJ. Cardiovascular risk factors indirectly affect acute post-stroke cognition through stroke severity and prior cognitive impairment: a moderated mediation analysis. ALZHEIMERS RESEARCH & THERAPY 2020; 12:85. [PMID: 32678028 PMCID: PMC7367370 DOI: 10.1186/s13195-020-00653-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cognitive impairment is an important consequence of stroke and transient ischaemic attack, but its determinants are not fully understood. Simple univariable or multivariable models have not shown clinical utility for predicting cognitive impairment. Cardiovascular risk factors may influence cognition through multiple, direct, and indirect pathways, including effects on prior cognition and stroke severity. Understanding these complex relationships may help clinical teams plan intervention and follow-up strategies. METHODS We analysed clinical and demographic data from consecutive patients admitted to an acute stroke ward. Cognitive assessment comprised Abbreviated Mental Test and mini-Montreal Cognitive Assessment. We constructed bias-corrected confidence intervals to test indirect effects of cardiovascular risk factors (hypertension, vascular disease, atrial fibrillation, diabetes mellitus, previous stroke) on cognitive function, mediated through stroke severity and history of dementia, and we assessed moderation effects due to comorbidity. RESULTS From 594 eligible patients, we included 587 in the final analysis (age range 26-100; 45% female). Our model explained R2 = 62.10% of variance in cognitive test scores. We found evidence for an indirect effect of previous stroke that was associated with increased risk of prevalent dementia and in turn predicted poorer cognitive score (estimate = - 0.39; 95% bias-corrected CI, - 0.75 to - 0.13; p = 0.02). Atrial fibrillation was associated with greater stroke severity and in turn with a poorer cognitive score (estimate = - 0.27; 95% bias-corrected CI, - 0.49 to - 0.05; p = 0.02). Conversely, previous TIA predicted decreased stroke severity and, through that, lesser cognitive impairment (estimate = 0.38; 95% bias-corrected CI, 0.08 to 0.75; p = 0.02). Through an association with reduced stroke severity, vascular disease was associated with lesser cognitive impairment, conditional on presence of hypertension and absence of diabetes mellitus (estimate = 0.36; 95% bias-corrected CI, 0.03 to 0.68; p = 0.02), although the modelled interaction effects did not reach statistical significance. CONCLUSIONS We have shown that relationships between cardiovascular risk factors and cognition are complex and simple multivariable models may be overly reductionist. Including direct and indirect effects of risk factors, we constructed a model that explained a substantial proportion of variation in cognitive test scores. Models that include multiple paths of influence and interactions could be used to create dementia prognostic tools for use in other healthcare settings.
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Affiliation(s)
- Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Emma Elliott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Robert C Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Rots ML, Fassaert LM, Kappelle LJ, de Groot MC, Haitjema S, Bonati LH, van Klei WA, de Borst GJ. Intra-Operative Hypotension is a Risk Factor for Post-operative Silent Brain Ischaemia in Patients With Pre-operative Hypertension Undergoing Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2020; 59:526-534. [DOI: 10.1016/j.ejvs.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/28/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
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Management of patients with isolated acute cervical carotid artery occlusion and normal neurological exam: Technical note and case series. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lee SJ, Hong JM, Choi JW, Park JH, Park B, Kang DH, Kim YW, Kim YS, Hong JH, Yoo J, Kim CH, Sohn SI, Hwang YH, Lee JS. Predicting Endovascular Treatment Outcomes in Acute Vertebrobasilar Artery Occlusion: A Model to Aid Patient Selection from the ASIAN KR Registry. Radiology 2020; 294:628-637. [PMID: 31990269 DOI: 10.1148/radiol.2020191227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The decision to perform endovascular treatment (EVT) for stroke related to vertebrobasilar occlusion (VBO) remains controversial. Purpose To identify preprocedural predictors of good outcomes and to develop a model to aid patient selection for VBO. Materials and Methods For this retrospective study using a Korean multicenter registry, a predictive model for good outcomes (modified Rankin scale score, 0-2) was generated based on a derivation sample of patients with VBO (January 2011-February 2016). Preprocedural parameters, including onset-to-puncture time, infarct volume, occlusion type as a surrogate marker of intracranial atherosclerotic stenosis-related occlusion or embolic occlusion (truncal-type occlusion vs branching site occlusion), and collateral status, were analyzed. Continuous variables were dichotomized based on receiver operating characteristic analysis. Multiple logistic regression analysis was performed to generate a predictive model. The model was internally validated with the bootstrap method and was externally validated with a single-center sample (April 2016-December 2018). Results A predictive model was generated from 71 patients (mean age, 67 years ± 11 [standard deviation]; 41 [58%] men) and was externally validated in 32 patients (mean age, 72 years ± 13; 19 [59%] men). The composite of initial DW imaging volume of less than 10 mL (odds ratio [OR], 19.3; 95% confidence interval [CI]: 3.0, 126.4; P = .002), onset-to-puncture time of less than 8 hours (OR, 8.7; 95% CI: 1.8, 42.0; P = .007), and branching-site occlusion (OR, 6.1; 95% CI: 1.5, 26.0; P = .01) could be used to predict good outcomes, with a median area under the receiver operating characteristic curve of 0.86 (interquartile range [IQR], 0.77-0.95; bootstrap optimism-corrected C statistic, 0.837) in the derivation sample and 0.78 (IQR, 0.62-0.95) in the validation sample. Results failed to show an association between collateral status and outcome (P = .67). Conclusion When selecting patients with vertebrobasilar occlusion for endovascular treatment, the combination of onset-to-puncture time of less than 8 hours, initial infarct volume of less than 10 mL, and presence of branching-site occlusions is indicative of a good outcome. © RSNA, 2020 Online supplemental material is available for this article.
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Affiliation(s)
- Seong-Joon Lee
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Ji Man Hong
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jin Wook Choi
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Ji Hyun Park
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Bumhee Park
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Dong-Hun Kang
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Yong-Won Kim
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Yong-Sun Kim
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jeong-Ho Hong
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Joonsang Yoo
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Chang-Hyun Kim
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sung-Il Sohn
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Yang-Ha Hwang
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jin Soo Lee
- From the Departments of Neurology (S.J.L., J.M.H., J.S.L.), Radiology (J.W.C.), and Biomedical Informatics (B.P.), Ajou University School of Medicine, and Office of Biostatistics, Ajou Research Institute for Innovative Medicine (J.H.P., B.P.), Ajou University Medical Center, 164 World Cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do 16499, Republic of Korea; Departments of Neurosurgery (D.H.K.), Radiology (D.H.K., Y.W.K., Y.S.K.), and Neurology (Y.W.K., Y.H.H.), School of Medicine, Kyungpook National University, Daegu, Republic of Korea; and Departments of Neurology (J.H.H., J.Y., S.I.S.) and Neurosurgery (C.H.K.), Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
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Zanaty M, Roa JA, Jabbour PM, Samaniego EA, Hasan DM. Recanalization of the Chronically Occluded Internal Carotid Artery: Review of the Literature. World Neurosurg X 2019; 5:100067. [PMID: 31872191 PMCID: PMC6920090 DOI: 10.1016/j.wnsx.2019.100067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/13/2019] [Indexed: 12/01/2022] Open
Abstract
Introduction We reviewed the literature on interventions for patients with medically refractory chronically occluded internal carotid artery (COICA) to assess the risks and/or benefits after recanalization via an endovascular technique (ET) or hybrid surgery (HS, i.e., ET plus carotid endarterectomy). Methods A systematic search of the electronic databases was performed. Patients with COICA were classified into 4 different categories according to Hasan et al classification. Results Eighteen studies satisfied the inclusion criteria. Only 6 studies involved an HS procedure. We identified 389 patients with COICA who underwent ET or HS; 91% were males. The overall perioperative complication rate was 10.1% (95% confidence interval [CI]: 7.4%-13.1%). For types A and B, the successful recanalization rate was 95.4% (95% CI: 86.5%-100%), with a 13.7% (95% CI: 2.3%-27.4%) complication rate. For type C, the success rate for ET was 45.7% (95% CI: 17.8%-70.7%), with a complication rate of 46.0% (95% CI: 20.0%-71.4%) for ET and for the HS technique 87.6% (95% CI: 80.9%-94.4%), with a complication rate of 14.0% (95% CI: 7.0%-21.8%). For type D, the success rate of recanalization was 29.8% (95% CI: 7.8%-52.8%), with a 29.8% (95% CI: 6.1%-56.3%) complication rate. Successful recanalization resulted in a symmetrical perfusion between both cerebral hemispheres, resolution of penumbra, normalization of the mean transit time, and improvement in Montreal Cognitive Assessment (MoCA) score (ΔMoCA = 9.80 points; P = 0.004). Conclusions Type A and B occlusions benefit from ET, especially in the presence of a large penumbra. Type C occlusions can benefit from HS. Unfortunately, we did not identify an intervention to help patients with type D occlusions. A phase 2b randomized controlled trial is needed to confirm these findings.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jorge A Roa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Edgar A Samaniego
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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42
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Briyal S, Ranjan AK, Hornick MG, Puppala AK, Luu T, Gulati A. Anti-apoptotic activity of ET B receptor agonist, IRL-1620, protects neural cells in rats with cerebral ischemia. Sci Rep 2019; 9:10439. [PMID: 31320660 PMCID: PMC6639304 DOI: 10.1038/s41598-019-46203-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/04/2019] [Indexed: 02/08/2023] Open
Abstract
Endothelin-B receptor agonist, IRL-1620, provides significant neuroprotection following cerebral ischemia in rats. Whether this neuroprotection is due to inhibition of apoptosis is unknown. IRL-1620-treated rats following permanent middle cerebral artery occlusion (MCAO) showed significant improvement in neurological and motor functions along with a decrease in infarct volume at 24 h (-81.3%) and day 7 (-73.0%) compared to vehicle group. Cerebral blood flow (CBF) significantly improved in IRL-1620-treated animals compared to vehicle by day 7 post MCAO. IRL-1620-treated rats showed an increase in phospho-Akt and decrease in Bad level 7 h post-occlusion compared to vehicle, while Akt and Bad expression was similar in cerebral hemispheres at 24 h post-MCAO. The phospho-Bad level was lower in vehicle- but not in IRL-1620-treated rats at 24 h. Anti-apoptotic Bcl-2 expression decreased, while pro-apoptotic Bax expression increased in vehicle-treated MCAO rats, these changes were attenuated (P < 0.01) by IRL-1620. Mitochondrial membrane-bound Bax intensity significantly decreased in IRL-1620 compared to vehicle-treated MCAO rats. IRL-1620 treatment reduced (P < 0.001) the number of TUNEL-positive cells compared to vehicle at 24 h and day 7 post MCAO. The results demonstrate that IRL-1620 is neuroprotective and attenuates neural damage following cerebral ischemia in rats by increasing CBF and reducing apoptosis.
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Affiliation(s)
- Seema Briyal
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
| | - Amaresh K Ranjan
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
| | - Mary G Hornick
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
| | - Anupama K Puppala
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
| | - Thanh Luu
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, 60515, USA
| | - Anil Gulati
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA. .,Pharmazz, Inc., Research and Development, Willowbrook, IL, USA.
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43
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Lanza E, Gennaro N, Poretti D, Straffi L, Marcheselli S, Tramarin M, Pedicini V. Full recovery after non-target cerebral embolization of n-butyl-cyanoacrylate occurred during emergency treatment of a facial arteriovenous malformation. CVIR Endovasc 2019; 2:20. [PMID: 32026996 PMCID: PMC6966355 DOI: 10.1186/s42155-019-0063-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/12/2019] [Indexed: 01/15/2023] Open
Abstract
Background Non-target embolization is a well-known complication of endovascular procedures for arteriovenous malformation. However, few reports have described non target encephalic embolization, detailing its temporal evolution. Case presentation A 41-year-old man presented with a massive hemorrhage in the oral cavity due to an arteriovenous malformation involving the left hemiface and tongue. Under conscious sedation, selective angiography was followed by endovascular embolization with a mixture of n-butyl-cyanoacrylate-methacryloxy-sulfolane (NBCA-MS) with Lipiodol. The hemorrhage was successfully arrested, but the procedure was complicated with a reflux of embolic material from the right external carotid artery into the common carotid, caused by strong unexpected coughing. Non-target embolization was confirmed by emergency CT and subsequent MRI. After initial neurological impairment, the patient recovered fully and was discharged after one week. No sequelae were confirmed by 9-months follow-up with CT and MRI. We describe technical aspects, multimodality imaging, clinical presentation, and follow-up of this peculiar case. Conclusion Endovascular embolization of AVM fed by the external carotid is at risk for non-target brain embolization and general anesthesia should be considered to prevent inadvertent movements and master the delivery of the embolic agent A small amount of Lipiodol / NBCA-MS may be fully tolerated by the brain matter and partially reabsorbed without permanent deficit.
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Affiliation(s)
- Ezio Lanza
- Department of Radiology, Humanitas Research Hospital, Via R.L. Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Nicolò Gennaro
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy.
| | - Dario Poretti
- Department of Radiology, Humanitas Research Hospital, Via R.L. Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Laura Straffi
- Department of Neurology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, MI, Italy
| | - Simona Marcheselli
- Department of Neurology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, MI, Italy
| | - Marco Tramarin
- Department of Radiology, Humanitas Research Hospital, Via R.L. Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Vittorio Pedicini
- Department of Radiology, Humanitas Research Hospital, Via R.L. Montalcini 4, 20090, Pieve Emanuele, MI, Italy
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44
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Wallocha M, Chapot R, Nordmeyer H, Fiehler J, Weber R, Stracke CP. Treatment Methods and Early Neurologic Improvement After Endovascular Treatment of Tandem Occlusions in Acute Ischemic Stroke. Front Neurol 2019; 10:127. [PMID: 30873105 PMCID: PMC6400830 DOI: 10.3389/fneur.2019.00127] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/30/2019] [Indexed: 01/27/2023] Open
Abstract
Background and Purpose: A tandem occlusion of the intracranial circulation and the extracranial carotid artery (ICA) occurs in 10–20% of all strokes based on large vessel occlusion (LVO). The optimal treatment strategy for those patients is unknown. We report our management strategy and the outcome in these patients in a large single-center cohort. Materials and Methods: We retrospectively identified and analyzed all patients treated by Mechanical Thrombectomy (MT) for an intracranial LVO associated with an occlusion of the extracranial ICA between April 2009 and May 2016 (163/1,645, 9.9%). The following data was collected: Recanalization rate, occurrence of symptomatic intracranial hemorrhage (sICH), clinical result according to the early neurological improvement (ENI, NIHSS score improvement of ≥8 points after 24 h or NIHSS score of 0 or 1 after 3 days) and functional outcome and mortality during long term follow up. Secondary endpoints were the patency of the internal carotid artery at 24 h. Patient demographics and anti-aggregation regimen were recorded as co-variables. Results: 163/1,645 (9.9%) MT patients had a tandem occlusion. All thrombectomy procedures were performed with stent retrievers. PTA with or without additional placement of a stent was performed in 149 vs. 14 patients. The overall rate of TICI IIB/III recanalization was 91.4%. An early neurological improvement was found in 79 of 163 patients (48.4%), 51% (76/149) in the stent group and 21% (3/14) in the non stent group. 120/163 patients (73.6%) had a long term favorable outcome (mRS 0–2). The ICA re-occlusion rate at 24 h was 5.4% (8/149) in the stent group and 42% (6/14) in the non stent group. The rate of symptomatic hemorrhage was 4.9%. The regression analysis showed that only younger age (p = 0.002) and shorter recanalization times (p = 0.017) were associated with good outcome. Conclusion: Stent-PTA of the ICA in addition to MT with a stent retriever was safe and effective in tandem occlusion of the anterior brain circulation. PTA and MT without stenting in tandem lesions showed a higher early re-occlusion rate and lower rate of early neurological improvement. The technical approach should aim for the fastest possible recanalization of the intracranial vessels, either with stenting first or last.
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Affiliation(s)
- Marta Wallocha
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Essen, Germany.,Department for Neuroradiological Diagnosis and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - René Chapot
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Hannes Nordmeyer
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Jens Fiehler
- Department for Neuroradiological Diagnosis and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph Weber
- Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Christian Paul Stracke
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus Essen, Essen, Germany.,Department for Neuroradiological Diagnosis and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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45
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Intensive blood pressure control may not be safe in subacute ischemic stroke by intracranial atherosclerosis. J Hypertens 2018; 36:1936-1941. [DOI: 10.1097/hjh.0000000000001784] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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46
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Li MZ, Zhang Y, Zou HY, Wang YL, Cheng BCY, Wang L, Zhang QX, Lei JF, Zhao H. Xiaoshuan enteric-coated capsule alleviates cognitive impairment by enhancing hippocampal glucose metabolism, hemodynamics and neuroplasticity of rat with chronic cerebral hypoperfusion. Sci Rep 2018; 8:7449. [PMID: 29748641 PMCID: PMC5945608 DOI: 10.1038/s41598-018-25929-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 05/01/2018] [Indexed: 11/29/2022] Open
Abstract
Chronic cerebral hypoperfusion (CCH) is identified as a critical risk factor of dementia in patients with cerebrovascular disease. Xiaoshuan enteric-coated capsule (XSECC) is a compound Chinese medicine approved by Chinese State Food and Drug Administration for promoting brain remodeling and plasticity after stroke. The present study aimed to explore the potential of XSECC to improve cognitive function after CCH and further investigate the underlying mechanisms. CCH was induced by bilateral common carotid artery occlusion (BCCAO) in rats. XSECC (420 or 140 mg/kg) treatment remarkably reversed BCCAO-induced cognitive deficits. Notably, after XSECC treatment, magnetic resonance angiography combined with arterial spin labeling noninvasively demonstrated significantly improved hippocampal hemodynamics, and 18F-FDG PET/CT showed enhanced hippocampal glucose metabolism. In addition, XSECC treatment markedly alleviated neuropathologies and improved neuroplasticity in the hippocampus. More importantly, XSECC treatment facilitated axonal remodeling by regulating the phosphorylation of axonal growth related proteins including protein kinase B (AKT), glycogen synthase kinase-3β (GSK-3β) and collapsin response mediator protein-2 (CRMP2) in the hippocampus. Taken together, the present study demonstrated the beneficial role of XSECC in alleviating BCCAO-induced cognitive deficits by enhancing hippocampal glucose metabolism, hemodynamics and neuroplasticity, suggesting that XSECC could be a useful strategy in cerebral hypoperfusion state and dementia.
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Affiliation(s)
- Man-Zhong Li
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China.,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China
| | - Yi Zhang
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China
| | - Hai-Yan Zou
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China.,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China
| | - Ya-Li Wang
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China.,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China
| | - Brian-Chi Yan Cheng
- College of Professional and Continuing Education, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China
| | - Lei Wang
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China.,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China
| | - Qiu-Xia Zhang
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China.,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China
| | - Jian-Feng Lei
- Medical Imaging laboratory of Core Facility Center, Capital Medical University, Beijing, 100069, China
| | - Hui Zhao
- School of Traditional Chinese Medicine, Capital Medical University, Beijing, 100069, China. .,Beijing Key Lab of TCM Collateral Disease Theory Research, Beijing, 100069, China.
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47
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Kennedy McConnell FA, Payne SJ. Autoregulating Cerebral Tissue Selfishly Exploits Collateral Flow Routes Through the Circle of Willis. ACTA NEUROCHIRURGICA. SUPPLEMENT 2018; 126:275-279. [PMID: 29492574 DOI: 10.1007/978-3-319-65798-1_54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Ischemic stroke is a leading cause of death and disability. Autoregulation and collateral blood flow through the circle of Willis both play a role in preventing tissue infarction. A steady-state model of the cerebral arterial network was used to investigate the interaction of these mechanisms when autoregulation is impaired ipsilateral to an occluded artery. MATERIALS AND METHODS Twelve structural variants of the circle of Willis were modelled with left internal carotid artery occlusion and coupled with (1) a passive model of the cerebral vascular bed, (2) a steady-state model of an autoregulating cerebral vascular bed, and (3) a model in which the contralateral hemisphere autoregulates and the ipsilateral hemisphere does not. RESULTS Results showed that if the autoregulatory response is impaired ipsilaterally, then, in the autoregulating hemisphere, cerebral flows are preserved at the expense of those on the ipsilateral side. CONCLUSIONS Thus, although autoregulation is an essential facilitator of collateral flow through the circle of Willis, contralateral autoregulation can exacerbate flow reductions if not balanced by the same response in the vascular beds on the ipsilateral side. The status of the autoregulatory response in both hemispheres can strongly influence cerebral blood flows and tissue survival and should, therefore, be monitored in stroke.
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Affiliation(s)
- Flora A Kennedy McConnell
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, OX1 3PJ, UK.
| | - Stephen J Payne
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, OX1 3PJ, UK
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48
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Zhang H, Fujiwara N, Kobayashi M, Yamada S, Liang F, Takagi S, Oshima M. Development of patient-specific 1D-0D simulation based on MRI and SPECT data. ACTA ACUST UNITED AC 2018. [DOI: 10.17106/jbr.32.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Hao Zhang
- Department of Mechanical Engineering, The University of Tokyo
| | - Naoya Fujiwara
- Center for Spatial Information Science, The University of Tokyo
| | | | - Shigeki Yamada
- Department of Neurosurgery, Stroke Center, Rakuwakai Otowa Hospital
| | - Fuyou Liang
- Department of Naval Architecture and Ocean Engineering, Shanghai Jiao Tong University
| | - Shu Takagi
- Department of Mechanical Engineering, The University of Tokyo
| | - Marie Oshima
- Interfaculty Initiative in Information Studies, The University of Tokyo
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49
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Zhao M, Zhang D, Wang S, Zhang Y, Deng X, Zhao J. The Collateral Circulation in Moyamoya Disease: A Single-Center Experience in 140 Pediatric Patients. Pediatr Neurol 2017; 77:78-83. [PMID: 29107436 DOI: 10.1016/j.pediatrneurol.2017.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/17/2017] [Accepted: 08/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The patterns and clinical significance of the presence of collaterals in moyamoya disease has not been elucidated thoroughly. We aimed to summarize the clinical features of collaterals in pediatric moyamoya disease. BASIC PROCEDURES We reviewed consecutive pediatric patients with moyamoya vasculopathy who were admitted to our hospital from 2009 to 2015. Only pediatric moyamoya patients with digital subtraction angiography examinations were included in this study. We classified spontaneous collaterals into two groups by their origins, the internal carotid artery and vertebral artery (ICA-VA)-originated collaterals and the external carotid artery (ECA)-originated collaterals. MAIN FINDINGS A total of 140 pediatric patients with moyamoya disease (mean age, 10.1 ± 3.7 years) were included in this study. We identified collaterals originated from ICA-VA in 122 (87.1%) pediatric patients (222 hemispheres). Patients in the ICA-VA collaterals group had similar Suzuki stages with patients without collaterals originated from ICA-VA (mean, 3.86 vs 3.50; P = 0.157). We identified collaterals originated from ECAs in 70 (50.0%) pediatric patients (106 hemispheres) with moyamoya disease. The infarctions were more common in patients with ECA-originated collaterals than in patients without ECA-originated collaterals (25 versus 12; P = 0.021). PRINCIPAL CONCLUSIONS Our results demonstrate that collaterals originating from ECAs are associated with advanced Suzuki stages and infarction presentations in children with moyamoya disease.
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Affiliation(s)
- Meng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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50
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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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