J Korean Neurosurg Soc.  2013 Oct;54(4):280-288. 10.3340/jkns.2013.54.4.280.

Pre- and Post-Angioplasty Perfusion CT with Acetazolamide Challenge in Patients with Unilateral Cerebrovascular Stenotic Disease

• You SH
• Jo SM
• Kim YJ
• Lee JH
• Jo KD
• Park WS

• KMID: 1499332
• DOI: http://doi.org/10.3340/jkns.2013.54.4.280

Abstract

OBJECTIVE
Perfusion computed tomography (PCT) has the ability to measure quantitative value and produce maps of mean transit time (MTT), cerebral blood flow (CBF), and cerebral blood volume (CBV). We assessed cerebral hemodynamics by using these parameters and acetazolamide (ACZ) challenge for pre- and post-procedural evaluation in patients with unilateral cerebrovascular stenotic disease.
METHODS
Thirty patients underwent pre-procedural PCT with ACZ challenge, and 24 patients (80%) was conducted follow up PCT after angioplasty with same protocol. The mean MTT, CBF, and CBV were measured and compared in both middle cerebral arterial (MCA) territories before and after ACZ challenge. Hemispheric ratio and percent change after ACZ challenge were calculated before and after angioplasty.
RESULTS
The mean stenosis rate was 76.6%. Significant increases in MTT (32.6%, p=0.000) and significant decreases in CBF (-14.2%, p=0.000) were found in stenotic side MCA territories. After ACZ challenge, there were significant changes in MTT (37.4%, p=0.000), CBF (-13.1%, p=0.000), and CBV (-10.5%, p=0.001) in pre-procedural perfusion study. However, no significant increases were found in MTT, or decreases in CBF and CBV in post-procedural study. There were no significant changes after ACZ challenge also. In addition, the degrees of these changes (before and after ACZ challenge) were highly correlated with the stenotic degrees in pre-procedural perfusion study.
CONCLUSION
PCT with ACZ challenge appears to be a useful tool to assess the cerebral perfusion status especially in patients with unilateral symptomatic stenotic disease.

Keyword

Intracranial stenotic disease; Cerebrovascular reserve; Perfusion CT; Acetazolamide challenge

MeSH Terms

Acetazolamide*
Angioplasty
Blood
Blood Volume
Constriction, Pathologic
Follow-Up Studies
Hemodynamics
Humans
Perfusion*
Acetazolamide

Figure

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  Fig. 1 Diffusion magnetic resonance imaging (MRI) of a 64-year-old female at admission, showing typical borderzone infarction on the right hemisphere. Perfusion computed tomography (PCT) and internal cerebral artery (ICA) angiogram of this patient are shown on Fig. 2 and 3 respectively.

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  Fig. 2 Pre- and post-angioplasty mean transit time (MTT) maps before and after acetazolamide (ACZ) challenge. A : Pre-angioplasty MTT map before ACZ challenge. The hemispheric ratio of right middle cerebral artery (MCA) territory versus left MCA territory is 165.1%. B : Pre-angioplasty MTT map after ACZ challenge. The hemispheric ratio is 306.4%. C : Post-angioplasty MTT map before ACZ challenge. The hemispheric ratio of right MCA territory versus left MCA territory is 112.2%. D : Post-angioplasty MTT map after ACZ challenge. The hemispheric ratio is 117.3%.

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  Fig. 3 Right internal cerebral artery (ICA) angiograms before (A) and after (B) stent-angioplasty. A : Right ICA angiogram shows severe stenosis of middle cerebral artery (MCA) up to 84%. B : The stenotic lesion was fully recovered after stent-angioplasty.

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  Fig. 4 Linear regression plots of each parameter before angioplasty. A : Mean transit time (MTT) ratio shows positive linear relationship with the stenosis rate before acetazolamide (ACZ) challenge (Basal MTT), and the gradient is steeper after acetazolamide challenge (Diamox MTT). B : Cerebral blood flow (CBF) ratio before ACZ challenge (Basal CBF) shows negative linear relationship, and the gradient is steeper after ACZ challenge (Diamox CBF). C : Cerebral blood volume (CBV) ratio before ACZ challenge (Basal CBV) does not show significant linear relationship, however it shows significant negative relationship after ACZ challenge (Diamox CBV). Blue dot and line : values before ACZ challenge. Red dot and line: values after ACZ challenge.

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  Fig. 5 Linear regression plots of each parameter's hemispheric ratio change {absolute value of ratio difference=[hemispheric ratio after acetazolamide (ACZ) challenge-hemispheric ratio before ACZ challenge]} versus stenosis rate. The degrees of all the three parameters' ratio changes show positive linear relationships with the stenosis rate. The horizontal black dotted line indicates zero percent of hemispheric ratio change, and all the three lines cross with the horizontal black dotted line at near 60& of stenosis rate, and continue to rise. The gradient of mean transit time (MTT) is steeper than the others. Red dot and line : MTT. Green dot and line : cerebral blood flow (CBF). Blue dot and line: cerebral blood volume (CBV).

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