Neurointervention.  2020 Nov;15(3):126-132. 10.5469/neuroint.2020.00269.

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

• van den Berg R
• Wildeman JJ
• Berkhemer OA
• Immink RV
• Marquering HA
• Majoie CB
• Verbaan D
• van Bavel ET

• KMID: 2508064
• DOI: http://doi.org/10.5469/neuroint.2020.00269

Abstract

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.

Keyword

Acute stroke; Arterial occlusive diseases; Collateral circulation; Cerebrovascular circulation; Cerebral angiography

Figure

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  Fig. 1. Digital subtraction angiography in frontal projection (A–D) and lateral projection (E) after contrast injection in the left internal carotid artery showing the 4 seconds increase in arterio-venous transit time (AVTT) of the left anterior circulation compared to the right side. (A) The M1 segment of the middle cerebral artery (MCA) is occluded, both anterior cerebral arteries (ACA) are opacified at t=6 seconds. (B) The first cortical vein of the right ACA territory is visible at t=11 seconds (arrow), with early contrast in the superior sagittal sinus (arrowhead). (C) The first cortical vein of the left ACA territory (arrow) is visible at t=15 seconds. (D, E) At the late arterial phase (t=21 seconds), good collateral flow enables retrograde filling of the M4, M3 and M2 segments of the MCA.

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