Collateral flow and ischemic brain lesions in patients with unilateral carotid artery occlusion

Introduction: Pencil Beam type presaturation (BeamSAT) pulse on a major cervical vessel enables selective suppression of blood flow signal of the applied vessel in MR angiography (MRA). By subtracting the BeamSAT pulse-added MRA of an internal carotid artery (ICA) from conventional MRA, only the contralateral ICA image (SubBeamSAT image) can be obtained (Figure A, B). In this way, an ICA-selective MRA with more physiologial flow pattern can be obtained, because it requires no powerful injection of contrast medium. Purpose: The aim of this study was to investigate whether preoperative assessment of the flow of Acom/A1 by SubBeamSAT image and posterior communicating artery (Pcom) by conventional MRA could identify patients at risk for intolerance to intraoperative temporary ICA occlusion. Method: 29 patients who underwent carotid endarterectomy (CEA) (n = 17) or carotid artery stenting (CAS) (n = 12) were enrolled in the current study. All patients underwent the SubBeamSAT images and conventional MRA pre- and post-operatively. Response to ICA temporally occlusion was recorded during the revascularization procedure. Results: Among twenty-nine patients, 4 patients who demonstrate neither the Acom/A1 flow on SubBeamSAT image (Figure. B) nor Pcom flow on MRA showed intolerance. In contrast, the remaining 25 patients who demonstrated Acom/A1 (Figure. A) and/or Pcom flow showed tolerance. Intolerance to ICA occlusion was excellently predicted by visualization of collateral flow via Acom and Pcom (specificity: 100%, sensitivity: 100%, p=0.00004). Conclusions: SubBeamSAT image is useful for evaluating the flow of Acom from A1 portion of the healthy side to A2 portion of the contralateral side, which is often difficult to evaluate with conventional MRA. With the SubBeamSAT image, it is feasible to evaluate the Acom/A1 flow accurately. In conclusion, SubBeamSAT image enables excellent prediction for the intolerance to temporary ICA occlusion.

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Anterior communicating artery collateral flow protection against ischemic change during carotid endarterectomy

Journal of Neurosurgery ◽

10.3171/jns.1993.79.3.0379 ◽

1993 ◽

Vol 79 (3) ◽

pp. 379-382 ◽

Cited By ~ 34

Author(s):

Maria V. Lopez-Bresnahan ◽

Lee A. Kearse ◽

Paulino Yanez ◽

Tina I. Young

Keyword(s):

Cerebral Ischemia ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Cerebral Arteries ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Anterior Communicating Artery ◽

Collateral Flow ◽

Content Type ◽

Carotid Circulation

✓ The purpose of this study was to determine whether preoperative angiographic patterns of collateral cerebral blood flow correlate with protection against intraoperative electroencephalographic (EEG) evidence of cerebral ischemia caused by carotid artery cross-clamping during carotid endarterectomy. Previous studies have shown that contralateral carotid artery occlusion and intracranial stenoses are associated with cerebral ischemia during carotid endarterectomy; however, the angiographic collateral flow patterns associated with cerebral ischemia have not been identified. This paper reports a retrospective study of 67 patients who underwent two- to four-vessel cerebral angiography followed by carotid endarterectomy with 16-channel EEG monitoring. The angiograms were reviewed for extracranial occlusive disease and collateral flow patterns, and the EEG recordings were analyzed for ischemic changes during carotid artery cross-clamping. Statistical analysis was by Fisher's exact test. Cross-filling of the anterior and middle cerebral arteries from the contralateral carotid artery through the anterior communicating artery correlated with a decreased incidence of EEG ischemic changes. Only 21% of patients with this collateral flow pattern showed ischemic changes compared to 50% of patients without this pattern (p < 0.03). Three angiographic findings occurring in combination on the side contralateral to surgery correlated with EEG ischemia: 1) occlusion of the contralateral internal carotid artery (five of seven or 71%, p < 0.03); 2) collateral flow from the external carotid circulation to the internal carotid circulation via the ophthalmic artery; and 3) collateral flow from the posterior circulation to the contralateral anterior circulation via the posterior communicating artery. The data presented here corroborate the correlation between contralateral carotid artery occlusion and cerebral ischemia during carotid endarterectomy. They also demonstrate that cross-filling of the anterior and middle cerebral arteries by the contralateral carotid artery protects against such ischemia. This collateral flow may serve as an indicator of tolerance to carotid artery cross-clamping.

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Antegrade Internal Carotid Artery Collateral Flow and Cerebral Blood Flow in Patients With Common Carotid Artery Occlusion

Journal of Ultrasound in Medicine ◽

10.7863/jum.2012.31.10.1561 ◽

2012 ◽

Vol 31 (10) ◽

pp. 1561-1566 ◽

Cited By ~ 2

Author(s):

Asako Nakamura ◽

Yoshiyuki Wakugawa ◽

Masahiro Yasaka ◽

Toshiyasu Ogata ◽

Kotaro Yasumori ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Common Carotid Artery ◽

Internal Carotid ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Collateral Flow ◽

Common Carotid Artery Occlusion

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Circle of Willis Collateral Flow in Carotid Artery Occlusion Is Depicted by 4D-CTA

World Neurosurgery ◽

10.1016/j.wneu.2018.02.189 ◽

2018 ◽

Vol 114 ◽

pp. 421-426.e1 ◽

Cited By ~ 2

Author(s):

Midas Meijs ◽

Frank-Erik de Leeuw ◽

Hieronymus D. Boogaarts ◽

Rashindra Manniesing ◽

Frederick Jan Anton Meijer

Keyword(s):

Carotid Artery ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Circle Of Willis ◽

Collateral Flow

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Abstract WP436: Reduced Blood Flow in the Pial Collaterals and Penetrating Arterioles During Chronic Hypoperfusion in Type 2 Diabetic Mice

Stroke ◽

10.1161/str.48.suppl_1.wp436 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Yasuo Nishijima ◽

Yosuke Akamatsu ◽

Atsushi Kanoke ◽

Shih Y Yang ◽

Teiji Tominaga ◽

...

Keyword(s):

Type 2 Diabetes ◽

Carotid Artery ◽

Carotid Artery Disease ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Circle Of Willis ◽

Cerebral Hypoperfusion ◽

Additional Risk Factor ◽

Collateral Flow

Introduction: The degree of cortical hypoperfusion following carotid steno-occlusion depends on the dynamic compensation from the collateral circulation. The presence of collaterals is associated with a reduced risk of stroke and transient ischemic attack (TIA) in patients with steno-occlusive carotid artery disease. Although metabolic syndrome negatively impacts collateral status among patients with ischemic stroke, it is unclear whether type 2 diabetes (T2DM) specifically affects leptomeningeal collateral flow regulation and the adaptation of collateral vessels at the circle of Willis during hypoperfusion. Methods: Spatial and temporal changes of the leptomeningeal collateral flow and the flow dynamics of the penetrating arterioles in the distal MCA and ACA branches over two weeks following unilateral common carotid artery occlusion (CCAO) were determined by optical coherent tomography in db/+ and db/db mice, a mouse model for obesity and type 2 diabetes. The temporal adaptation of the circle of Willis (CW) following CCAO was assessed by measuring CW vessel diameters. Results: Following unilateral CCAO, db/db mice exhibited diminished leptomeningeal collateral flow compensation compared to db /+ mice, which coincided with a reduced dilation of distal ACA branches, leading to reduced flow not only in pial vessels, but also in penetrating arterioles bordering the distal MCA and ACA. However, no apparent cell death was detected in either strain of mice during the first week after CCAO. db/db mice also experienced a more severe early reduction in the vessel diameters of several ipsilateral main feeding arteries in the CW, in addition to a delayed post-CCAO adaptive response by one to two weeks compared to db/+ mice. Conclusions: T2DM is an additional risk factor for hemodynamic compromise during cerebral hypoperfusion, which may increase the severity and the risk of stroke or TIA.

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Validation of Ultrasound Parameters to Assess Collateral Flow via Ophthalmic Artery in Internal Carotid Artery Occlusion

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2013.10.012 ◽

2014 ◽

Vol 23 (5) ◽

pp. 1177-1182

Author(s):

Tomotaka Tanaka ◽

Ryosuke Doijiri ◽

Kozue Saito ◽

Katsufumi Kajimoto ◽

Masafumi Ihara ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Ophthalmic Artery ◽

Internal Carotid ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Internal Carotid Artery Occlusion ◽

Collateral Flow ◽

Ultrasound Parameters

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Transcranial Doppler Ultrasound as a Guide to Graded Therapeutic Occlusion of the Carotid Artery

Neurosurgery ◽

10.1227/00006123-199002000-00019 ◽

1990 ◽

Vol 26 (2) ◽

pp. 307-311 ◽

Cited By ~ 10

Author(s):

Cole A. Giller ◽

Phillip Steig ◽

Hunt H. Batjer ◽

Duke Samson ◽

Phillip Purdy

Keyword(s):

Carotid Artery ◽

Doppler Ultrasound ◽

Transcranial Doppler ◽

Giant Aneurysm ◽

Transcranial Doppler Ultrasound ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Carotid Occlusion ◽

Collateral Flow ◽

Therapeutic Occlusion

Abstract Although gradual carotid artery occlusion is an accepted and effective treatment for some surgically inaccessible intracranial aneurysms, there are no specific guidelines to determine the optimal amount of carotid artery narrowing at each adjustment. The technique of transcranial Doppler ultrasound, however, allows continuous measurement of blood velocity in the middle cerebral artery as the carotid artery is narrowed, so that hemodynamic effects and development of collateral flow can be immediately assessed at the bedside at each adjustment of the carotid artery diameter. This case report describes the use of transcranial Doppler to guide the rate of carotid occlusion in a patient with an unclippable giant aneurysm of the carotid artery. Sudden carotid occlusion and gradual occlusion at the usual rate were not tolerated by the patient. but repeatedly tightening the clamp until the first signs of attenuation of the Doppler signal allowed an expedient occlusion without complication. Transcranial Doppler ultrasound can provide a useful dynamic guide to gradual therapeutic carotid occlusion.

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Cerebrovascular CO2 reactivity after carotid artery occlusion

Journal of Neurosurgery ◽

10.3171/jns.1988.69.1.0024 ◽

1988 ◽

Vol 69 (1) ◽

pp. 24-28 ◽

Cited By ~ 21

Author(s):

Guy L. Clifton ◽

Halcott T. Haden ◽

John R. Taylor ◽

Michael Sobel

Keyword(s):

Carotid Artery ◽

Bypass Surgery ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Collateral Flow ◽

Physiological Basis ◽

Content Type ◽

Normal Individuals ◽

Cerebrovascular Co2 Reactivity ◽

Normal Men

✓ Cerebral blood flow (CBF) was measured in 39 men at normocapnia and after 5% CO2 inhalation using the xenon-133 technique. Twenty-three patients had unilateral carotid artery occlusion with no angiographic evidence of contralateral carotid artery stenosis or ophthalmic collateral flow. Eleven of these patients had undergone extracranial-intracranial (EC-IC) bypass surgery. Sixteen age-matched normal men underwent CBF measurements at normocapnia and hypercapnia to provide control data. Mean hemispheric CBF was not different between hemispheres ipsilateral and contralateral to the carotid artery occlusion either in the patients who had undergone bypass surgery or in those with carotid artery occlusion alone. Considering all patients with carotid artery occlusion, mean CO2 reactivity was decreased in the hemisphere ipsilateral to the occlusion as compared to the contralateral hemisphere in both groups. Based on data from normal individuals, a hemispheric difference in CO2 reactivity of more than 0.94%/mm Hg PaCO2 or a global CO2 reactivity of less than 0.66%/mm Hg PaCO2 was considered abnormal for an individual patient. Six of 23 patients with carotid artery occlusion (three with an EC-IC bypass) had global or hemispheric abnormalities in CO2 reactivity. Patients with impaired CO2 reactivity were not distinguishable from other patients by neurological examination, presence of transient ischemic attacks, or evidence of infarction on computerized tomography scanning. This test was safe and simple to perform and may be a useful means of detecting impaired cerebrovascular collateral reserve capacity. If impaired CO2 reactivity after carotid artery occlusion proves to be associated with a high risk of subsequent stroke, the test would provide a physiological basis for selecting a subgroup of patients who could be helped by cerebral revascularization.

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Balloon Test Occlusion of Internal Carotid Artery in Recurrent Nasopharyngeal Carcinoma Before Endoscopic Nasopharyngectomy: A Single Center Experience

Frontiers in Oncology ◽

10.3389/fonc.2021.674889 ◽

2021 ◽

Vol 11 ◽

Author(s):

Renhao Yang ◽

Hui Wu ◽

Binghong Chen ◽

Wenhua Sun ◽

Xiang Hu ◽

...

Keyword(s):

Carotid Artery ◽

Collateral Circulation ◽

Delayed Cerebral Ischemia ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Collateral Flow ◽

Balloon Test Occlusion ◽

Recurrent Nasopharyngeal Carcinoma ◽

Collateral Pathways ◽

Cerebral Ischemic

ObjectivesEndoscopic nasopharyngectomy (ENPG) is a promising way in treating recurrent nasopharyngeal carcinoma (rNPC), but sometimes may require therapeutic internal carotid artery (ICA) occlusion beforehand. Balloon test occlusion (BTO) is performed to evaluate cerebral ischemic tolerance for ICA sacrifice. However, absence of neurological deficits during BTO does not preclude occur of delayed cerebral ischemia after permanent ICA occlusion. In this study, we evaluate the utility of near-infrared spectroscopy (NIRS) regional cerebral oxygen saturation (rSO2) monitoring during ICA BTO to quantify cerebral ischemic tolerance and to identify the valid cut-off values for safe carotid artery occlusion. This study also aims to find out angiographic findings of cerebral collateral circulation to predict ICA BTO results simultaneously.Material and Methods87 BTO of ICA were performed from November 2018 to November 2020 at authors’ institution. 79 angiographies of collateral flow were performed in time during BTO and classified into several Subgroups and Types according to their anatomic and collateral flow configurations. 62 of 87 cases accepted monitoring of cerebral rSO2. Categorical variables were compared by using Fisher exact tests and Mann–Whitney U tests. Receiver operating characteristic curve analysis was used to determine the most suitable cut-off value.ResultsThe most suitable cut-off △rSO2 value for detecting BTO-positive group obtained through ROC curve analysis was 5% (sensitivity: 100%, specificity: 86%). NIRS rSO2 monitoring wasn’t able to detect BTO false‐negative results (p = 0.310). The anterior Circle was functionally much more important than the posterior Circle among the primary collateral pathways. The presence of secondary collateral pathways was considered as a sign of deteriorated cerebral hemodynamic condition during ICA BTO. In Types 5 and 6, reverse blood flow to the ICA during BTO protected patients from delayed cerebral ischemia after therapeutic ICA occlusion (p = 0.0357). In Subgroup IV, absence of the posterior Circle was significantly associated with BTO-positive results (p = 0.0426).ConclusionAngiography of cerebral collateral circulation during ICA BTO is significantly correlated with ICA BTO results. Angiographic ICA BTO can be performed in conjunction with NIRS cerebral oximeter for its advantage of being noninvasive, real-time, cost-effective, simple for operation and most importantly for its correct prediction of most rSO2 outcomes of ICA sacrifice. However, in order to ensure a safe carotid artery occlusion, more quantitative adjunctive blood flow measurements are recommended when angiography of cerebral collateral circulation doesn’t fully support rSO2 outcome among clinically ICA BTO-negative cases.

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