Arterial Steal to the Penumbra Area in Patients with Acute MCA Occlusion: A Quantitative Angiographic Analysis

Purpose: In acute middle cerebral artery (MCA) occlusion, collateral vessels provide retrograde supply to the occluded territory. We hypothesized that such collateral flow reduces perfusion of the non-occluded donor region (steal effect).Materials and Methods: Patients with an MCA occlusion with opacification of both ipsi- and contralateral anterior cerebral arteries (ACA) on angiography prior to endovascular treatment were selected. Arteriovenous transit time (AVTT) for both ACA territories was compared for different grades of collateral supply to the MCA territory. In addition, the influence of diabetes and hypertension was analyzed. After successful revascularization, AVTT was re-assessed to determine reversibility.Results: Forty-one patients were analyzed. An AVTT of 8.6 seconds (standard deviation [SD] 2.4 seconds) was seen in the ACA territory of the affected hemisphere in comparison to 6.6 seconds (SD 2.1 seconds) for the contralateral side (P<0.001). A more prolonged (but not significant) AVTT was seen in cases with a higher collateral grade. No difference in AVTT was seen in patients with diabetes or hypertension. After successful MCA revascularization, AVTT delay was 7.4 seconds (SD 2.1 seconds).Conclusion: A cerebral steal effect occurs in patients with an acute MCA occlusion, probably related to augmented flow to the penumbra area.

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Abstract W P211: Investigating the Cause for “Collateral Failure” in Stroke-in-Progression: Intracranial Pressure Elevation Reduces Flow Through Collateral Vessels

Stroke ◽

10.1161/str.45.suppl_1.wp211 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Daniel Beard ◽

Damian McLeod ◽

Neil J Spratt

Keyword(s):

Intracranial Pressure ◽

Flow Velocity ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Minor Stroke ◽

Collateral Flow ◽

Mca Occlusion ◽

Intracranial Pressure Elevation ◽

Flow Through ◽

Collateral Vessels

Background: Adequacy of the collateral circulation is a major determinant of outcome in stroke patients. Recent human imaging data indicates that collateral failure, rather than reperfusion-reocclusion is the most common cause for early progression in minor stroke. Our previous experimental data shows that intracranial pressure (ICP) rises transiently 24 h after even minor stroke. Herein, we investigated the effect of ICP manipulation on blood flow through collateral vessels during MCA occlusion. Methods: We developed and validated a method to quantify flow velocity and vessel diameter of anterior-middle cerebral artery (ACA-MCA) leptomeningeal collaterals in rats during stroke, using fluorescent microspheres. BIood flow velocity and diameter was quantified in individual collateral vessels and used to calculate absolute flow during MCA occlusion and reperfusion (n = 6). In separate experiments, ICP was increased after MCA occlusion by fluid infusion into the lateral ventricles and effects on relative collateral flow were determined (n = 4). Results: In vitro validation indicated accurate flow quantification (R 2 = 0.99, P<0.0001). Collateral flow was seen to switch from bidirectional to unidirectional flow (toward occluded vessel) and increase by 595 ± 134 % within 10 min of vessel occlusion. Direction and flow changes were variable after MCA reperfusion, however there was a mean flow reduction of 52 ± 15 % by 5 mins. Artificially elevating ICP during MCA occlusion caused a reduction of cerebral perfusion pressure which was strongly correlated with collateral flow reduction (R 2 = 0.90, p<0.0001). Discussion: Our method permits real time quantification of flow through individual collateral vessels during stroke and reperfusion. Intracranial pressure elevation reduced collateral flow, proportional to its effect on cerebral perfusion pressure. Coupled with our previous data indicating significant ICP elevation after even minor stroke, this suggests that transient ICP elevation is the possible cause of the collateral failure recently described in patients with stroke-in-progression.

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A case of Young Stroke due to Moyamoya Disease

Journal of Armed Forces Medical College Bangladesh ◽

10.3329/jafmc.v15i1.48659 ◽

2020 ◽

Vol 15 (1) ◽

pp. 110-113

Author(s):

Md Abdur Razzak ◽

Ghulam Kawnayn ◽

Fateha Naznin ◽

Quazi Audry Arafat Rahman

Keyword(s):

Moyamoya Disease ◽

Past History ◽

Cerebral Arteries ◽

Armed Forces ◽

Cerebral Angiogram ◽

Medical College ◽

Middle Cerebral Arteries ◽

History Of ◽

Collateral Vessels ◽

The Right

Moyamoya disease is a disease in which certain arteries in the brain are constricted. Blood flow is blocked by the constriction, and also by blood clots (thrombosis). A collateral circulation develops around the blocked vessels to compensate for the blockage, but the collateral vessels are small, weak, and prone to bleeding, aneurysm and thrombosis which may result in TIA, recurrent ischemic or hemorrhagic stroke or seizure. The disease may manifest in pediatric age or young adults. In May 2019 we have diagnosed a young lady with Moyamoya disease who presented with right sided hemiplegia, motor aphasia and dysphagia. She was labeled as hypertensive 6 months prior to this event and used to take anti-hypertensive irregularly and gave past history of occasional headache. Her CT scan and MRI of brain revealed left sided ischemic infarct involving frontotemporoparietal region and cerebral angiogram revealed narrowing of left MCA and non-visualization of distal part. There is extensive fine collaterals (Moyamoya vessels) giving the appearance of puffed smoke. The right ACA and MCA were also narrowed with appearance of early collateral vessels. She was treated with aspirin, PPI, NG feeding, antihypertensive medication, physiotherapy, rehabilitation therapy and other supportive care. His condition gradually improved and discharged on 2.7.19. He was referred to Department of Neurosurgery for cerebral revascularization by STA-MCA (superficial temporal and middle cerebral arteries) bypass surgery after stabilization and MR perfusion study. Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 110-113

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Abstract TP146: Impaired Acute Collateral Flow Dynamics Experimental Stroke In Type 2 Diabetic Mice

Stroke ◽

10.1161/str.44.suppl_1.atp146 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Yosuke Akamatsu ◽

Chih C Lee ◽

Ruikang K Wang ◽

Jialing Liu

Keyword(s):

Blood Flow ◽

Neurologic Deficit ◽

Flow Dynamics ◽

Collateral Flow ◽

Doppler Flowmetry ◽

Collateral Arteries ◽

Significant Difference ◽

Blood Flow Dynamics ◽

Collateral Vessels

Introduction: Type 2 diabetes mellitus (T2DM) is a major risk factor for stroke, yet it is unclear whether T2DM associated-poor outcome after stroke is related to unfavorable cerebral blood flow dynamics. The current study aimed to investigate the effect of T2DM on acute blood flow dynamics and stroke outcome. Methood: Adult male db/db and db/+ mice (8-9 weeks of age) were subjected to permanent distal middle cerebral artery occlusion (pMCAo). Neurologic deficit was assessed with a 5-point scoring system (0 to 4) and infarction volume was determined at 48 hours after pMCAo by TTC staining. Hemodynamics was evaluated by laser doppler flowmetry. The number of connecting collateral vessels, functional microvascular network morphology, and vessel area density of the ischemic hemisphere were determined by DiI-labeling, and optical coherence tomography (OCT), respectively. Results: db/db mice had a higher baseline blood glucose level (341±39.7 vs. 172±26.5 mg/dl, p <0.01) and a larger infarct volume after pMCAO compared to db/+ mice (69.5±5.4 vs. 51.0±3.1 mm 3 , p <0.01). Neurologic deficit did not differ between groups at 2 hours after pMCAO, but was significantly worse in the db/db at 24 hours after pMCAo compared to db/+ mice (1.9±0.1 vs. 1.4±0.2, p <0.05), correlated with lower rCBF in the core of the MCA territory at 24 and 48 hours (10.9%±1.1 vs. 14.4%±0.8, p <0.05 and 9.5%±1.0 vs. 14.1%±1.2, p =0.01). Ipsilateral functional microvascular density as detected by OCT did not differ between groups at one hour after occlusion but was significantly lower in the db/db mice at 24 hr after pMCAo ( p <0.05). However, we did not observe a significant difference in the number of connecting collateral arteries between groups at 48 hours after pMCAo in this age group. Conclusion: Our results demonstrate that T2DM is associated with lower rCBF and lower density of functional blood vessels during the acute phase of pMCAo, which might in part, contribute to the observed worse outcome in the db/db mice. Ongoing experiments will investigate whether T2DM affects the flow dynamics in individual collateral following MCA occlusion and outward remodeling of the collateral vessels.

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Abstract WP46: Blood Pressure, Clinical Improvement And Recanalization Following Acute MCA Occlusion

Stroke ◽

10.1161/str.44.suppl_1.awp46 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Nandakumar Nagaraja ◽

Steven Warach ◽

Amie W Hsia ◽

Sungyoung Auh ◽

Lawrence L Latour ◽

...

Keyword(s):

Blood Pressure ◽

Clinical Improvement ◽

Clinical Information ◽

Collateral Flow ◽

Stroke Patients ◽

Mca Occlusion ◽

The Mean ◽

The Difference ◽

Pre Treatment ◽

B Test

Background: Blood pressure (BP) drop in the first 24 hours after stroke onset may occur in response to vessel recanalization. Clinical improvement could be due to recanalization or better collateral flow with persistent occlusion. We hypothesize that patients with combination of significant improvement on the NIHSS and a drop in BP at 24hr post tPA is associated with recanalization. Methods: We included intravenous t-PA patients from the Lesion Evolution of Stroke Ischemia On Neuroimaging (LESION) registry who had pre-treatment and 24 hour MRA scan, NIHSS scores at those times and an M1 MCA occlusion at baseline, but excluded those on pressors, pre tPA SBP<120 and tandem ICA occlusion. We classified recanalization status on the 24 hour MRA as none, partial or complete. We abstracted all BP measurements for the first 24 hours from the chart and calculated BP drop as the difference of the triage pre-tPA BP and the average of the last 3 hour readings preceding the 24 hour MRI. NIHSS improvement was defined as ≥4points improvement on NIHSS or NIHSS of 0 at 24hour. Patients with combination of drop in BP and NIHSS improvement were compared with others for recanalization status on 24hr MRA by Kendall Tau-b test. Results: Seventeen patients met the study criteria. There were 13 women, the mean age was 76 years and the median baseline NIHSS was 15. On the 24 hour MRA, 3, 8 and 6 patients had none, partial and complete recanalization, respectively. Patients with NIHSS improvement and a SBP drop ≥20 mmHg were more like to have recanalization at 24 hrs (57% Vs 0%, p=0.03). Similar patterns were seen for patients with NIHSS improvement and DBP drop ≥5mmHg (50% Vs 0%, p=0.04) or MAP drop ≥20mmHg (50% Vs 0%, p=0.04). Complete recanalization was only associated with the combination of NIHSS improvement with SBP drop ≥ 20mmHg (66% Vs 0%, p=0.04). A significant association was not found for recanalization with NIHSS improvement alone or drop in BP alone. Conclusion: There is an association of clinical improvement and BP drop in patients who recanalize. Bedside clinical information may be useful in the management of stroke patients.

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Abstract W P14: Endovascular Treatment for M2 Occlusions. A Descriptive Multicenter Experience on Behalf of the Catalan Stroke Code and Reperfusion Consortium (Cat-SCR).

Stroke ◽

10.1161/str.45.suppl_1.wp14 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Alan Flores ◽

Alejandro Tomasello ◽

Pere Cardona ◽

M Anges De Miquel ◽

Meritxell Gomis ◽

...

Keyword(s):

Endovascular Treatment ◽

Infarct Volume ◽

Hemorrhagic Transformation ◽

Favourable Outcome ◽

Routine Practice ◽

Dramatic Improvement ◽

Good Outcome ◽

Mca Occlusion ◽

Mean Time

Background: Patients with M2-MCA occlusion are not always considered for endovascular treatment. We aimed to study patients with an M2 occlusion treated with endovascular procedures. Methods: We studied patients prospectively included in the SONIIA register (January 2011-December 2012), a mandatory and externally audited register that monitors quality of reperfusion therapies in Catalonia under routine practice conditions. Baseline characteristics including NIHSS and occlusion location were collected. Complete recanalization was defined as a post-procedure TICI>2a, dramatic recovery: NIHSS drop>10 points or NIHSS<2 and good outcome as mRS<3 at 3 months. 24 hours CT scan determined the presence of hemorrhagic transformation (ECASS criteria) and infarct volume. Results: Of the 571 registered patients that received endovascular treatment, 65 (11.4%) presented an M2 occlusion on initial angiogram: mean age 66±15, female 47.7% median pre-procedure NIHSS 16(IQR:6). Mean time from symptom onset to groin puncture was 289±195 minutes, 35 patients (54%) received iv tPA before the procedure. Patients were treated with mechanic thrombectomy (n=49, 75.4%), ia tPA (n=3, 4.6%), both (n=7, 10.8%) or only diagnostic angiogram (n=6, 9.2%) according to interventionalist preferences. Patients who achieved complete recanalization (78.5%) had more often dramatic improvement (48% Vs 14.8%, p=0.023) smaller infarct volumes (8 vs. 82cc, p=0.013) and better outcome (66.3% Vs 30%; p=0.032) than those who did not recanalize. Rate of SICH was 9%. Independent predictors of dramatic improvement was complete recanalization (OR: 0,169 p=0.03 CI95%: 0.034-0.838) adjusted for age and baseline NIHSS Independent predictors of good outcome at 3 months were age (OR 1.067 p=0.033 CI95%: 1.005-1132) and baseline NIHSS (OR: 1.162 p=0.007 CI95%: 1.041-1.297) Conclusion: Endovascular treatment of M2 MCA occlusion seems safe. Induced recanalization may double the chances to achieve a favourable outcome

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Abstract WP150: BeamSAT MRI Help to Identify Patients at Risk for Intolerance to Temporary Internal Carotid Artery Occlusion During CEA and CAS

Stroke ◽

10.1161/str.48.suppl_1.wp150 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jun Tanaka ◽

Kohkichi Hosoda ◽

Yusuke Yamamoto ◽

Taichiro Imahori ◽

Atsushi Fujita ◽

...

Keyword(s):

At Risk ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Preoperative Assessment ◽

Contralateral Side ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Collateral Flow ◽

Patients At Risk

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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Moyamoya Disease

Pediatric Neurosurgery ◽

10.1093/med/9780190617073.003.0017 ◽

2019 ◽

pp. 149-156

Author(s):

Edward Smith

Keyword(s):

Moyamoya Disease ◽

Cerebral Arteries ◽

Pressure Control ◽

Vascular Supply ◽

External Carotid Artery ◽

External Carotid ◽

Middle Cerebral Arteries ◽

Detailed Assessment ◽

Collateral Vessels ◽

Carotid Circulation

Moyamoya disease is defined by stenosis of the distal intracranial internal carotid arteries up to and including the bifurcation, with segments of the proximal anterior and middle cerebral arteries, dilated basal collateral vessels, and bilateral findings. Detailed assessment with digital subtraction angiography will define the severity of disease (Suzuki stage) and presence of spontaneous transdural collateral vessels from external carotid artery branches. These collateral vessels must be protected during surgical intervention. The surgical goal is to establish a new vascular supply to the areas of the brain at risk for stroke, utilizing vessels from the external carotid circulation. Blood pressure control and avoidance of hyperventilation are key to minimize perioperative stroke risk. Preoperative hydration, ongoing use of aspirin, and good pain control will also minimize surgical complications.

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Postintravenous immunoglobulin stroke in a toddler with Down syndrome: a diagnostic challenge

BMJ Case Reports ◽

10.1136/bcr-2019-233149 ◽

2020 ◽

Vol 13 (5) ◽

pp. e233149 ◽

Cited By ~ 1

Author(s):

Teck-Hock Toh ◽

Everlyn Coxin Siew ◽

Chae-Hee Chieng ◽

Hussain Imam Mohd Ismail

Keyword(s):

Down Syndrome ◽

Cerebral Arteries ◽

Severe Pneumonia ◽

Cerebral Vessels ◽

Partial Recovery ◽

Diagnostic Challenge ◽

Middle Cerebral Arteries ◽

Collateral Vessels ◽

Carotid Doppler

Children with Down syndrome have a higher risk of stroke. Similarly, intravenous immunoglobulin (IV Ig) is also known to cause a stroke. We reported a 3-year-old boy with Down syndrome who presented with severe pneumonia and received IV Ig. He developed right hemiparesis 60 hours after the infusion. Blood investigations, echocardiography and carotid Doppler did not suggest vasculitis, thrombophilia or extracranial dissection. Brain computerised tomography (CT) showed acute left frontal and parietal infarcts. Initial magnetic resonance angiography (MRA) of cerebral vessels showed short segment attenuations of both proximal middle cerebral arteries and reduction in the calibre of bilateral supraclinoid internal carotid arteries. The boy was treated with enoxaparin and aspirin. He only had partial recovery of the hemiparesis on follow-up. A repeat MRA 13 months later showed parenchymal collateral vessels suggestive of moyamoya disease. We recommend imaging the cerebral vessels in children with a high risk of moyamoya before giving IV Ig.

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Functional anatomical site of intramural collaterals in dogs

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.1990.259.3.h706 ◽

1990 ◽

Vol 259 (3) ◽

pp. H706-H711 ◽

Cited By ~ 1

Author(s):

K. W. Scheel ◽

G. Daulat ◽

S. E. Williams

Keyword(s):

Coronary Artery ◽

Flow Measurement ◽

Isolated Heart ◽

Anatomical Site ◽

Collateral Flow ◽

Retrograde Flow ◽

Circumflex Coronary Artery ◽

Dog Heart ◽

Before And After ◽

Collateral Vessels

The objectives of the present study were to determine quantitatively whether the retrograde flow measurement reflects the total flow from collateral vessels or overestimates or underestimates collateral flow, and to determine the functional anatomical origin of intramural collaterals in the native dog heart. In an isolated heart preparation, three experimental procedures were used. 1) The left circumflex coronary artery was embolized with microspheres of different sizes; then retrograde flows and the peripheral coronary pressures were measured. 2) Epicardial collaterals were cauterized, and retrograde flows were measured before and after cautery. 3) Epicardial collaterals were cauterized followed by embolization of the circumflex coronary artery with different size spheres. We found that 1) the retrograde flow measurement underestimates the total collateral flow to the circumflex coronary artery by approximately 25%, 2) intramural collateral flow constitutes 58 +/- 3.5% of the retrograde flow measurement, 3) the antegrade component of blood flow that is not measured during a retrograde flow measurement is from the intramural collateral circulation, and 4) the functional site of origin of intramural collaterals is greater than 25 microns but less than 80 microns in diameter. We conclude that, in our preparation, retrograde flow underestimates total collateral flow, and that intramural collateral flow is a major component of retrograde flow in the native dog heart.

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