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

Affiliations
  • 1Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
  • 2Department of Biomedical Sciences, VU University Amsterdam, Amsterdam, The Netherlands
  • 3Department of Anesthesiology, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
  • 4Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
  • 5Department of Neurosurgery, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands

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

  • 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.


Reference

1. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, HERMES collaborators, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387:1723–1731.
Article
2. Liebeskind DS. Collateral circulation. Stroke. 2003; 34:2279–2284.
Article
3. Bang OY, Saver JL, Buck BH, Alger JR, Starkman S, Ovbiagele B, UCLA Collateral Investigators, et al. Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry. 2008; 79:625–629.
Article
4. Berkhemer OA, Jansen IG, Beumer D, Fransen PS, van den Berg LA, Yoo AJ, MR CLEAN Investigators, et al. Collateral status on baseline computed tomographic angiography and intra-arterial treatment effect in patients with proximal anterior circulation stroke. Stroke. 2016; 47:768–776.
5. Immink RV, van Montfrans GA, Stam J, Karemaker JM, Diamant M, van Lieshout JJ. Dynamic cerebral autoregulation in acute lacunar and middle cerebral artery territory ischemic stroke. Stroke. 2005; 36:2595–2600.
Article
6. Aries MJ, Elting JW, De Keyser J, Kremer BP, Vroomen PC. Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke. 2010; 41:2697–2704.
7. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, MR CLEAN Investigators, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372:11–20.
8. Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Cerebral Angiographic Revascularization Grading (CARG) Collaborators; STIR Revascularization working group; STIR Thrombolysis in Cerebral Infarction (TICI) Task Force, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013; 44:2650–2663.
9. Butcher KS, Parsons M, MacGregor L, Barber PA, Chalk J, Bladin C, EPITHET Investigators, et al. Refining the perfusion-diffusion mismatch hypothesis. Stroke. 2005; 36:1153–1159.
Article
10. Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J. MRI perfusion maps in acute stroke validated with 15O-water positron emission tomography. Stroke. 2010; 41:443–449.
Article
11. Dandona P, James IM, Woollard ML, Newbury P, Beckett AG. Instability of cerebral blood-flow in insulin-dependent diabetics. Lancet. 1979; 2:1203–1205.
Article
12. Shuaib A, Butcher K, Mohammad AA, Saqqur M, Liebeskind DS. Collateral blood vessels in acute ischaemic stroke: a potential therapeutic target. Lancet Neurol. 2011; 10:909–921.
Article
13. Omura-Matsuoka E, Yagita Y, Sasaki T, Terasaki Y, Oyama N, Sugiyama Y, et al. Hypertension impairs leptomeningeal collateral growth after common carotid artery occlusion: restoration by antihypertensive treatment. J Neurosci Res. 2011; 89:108–116.
Article
Full Text Links
  • NI
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr