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Hong, Lee, Seo, Je, Suh, Seol, Lee, Kim, and Yang: Correlation of Cerebrovascular Reserve as Measured by Acetazolamide-Challenged Perfusion CT with Collateral Circulation in Unilateral High Grade Carotid Stenosis
Neuroradiology

Journal of the Korean Society of Radiology 2014; 70(1): 1-12.

Published online: 14 January 2014

DOI: https://doi.org/10.3348/jksr.2014.70.1.1

Correlation of Cerebrovascular Reserve as Measured by Acetazolamide-Challenged Perfusion CT with Collateral Circulation in Unilateral High Grade Carotid Stenosis

Doran Hong, MD1, Young Hen Lee, MD1, Hyung Suk Seo, MD1, Bo-Kyung Je, MD1, Sang-il Suh, MD2, Hae Young Seol, MD2, Nam Joon Lee, MD3, Jung Hyuk Kim, MD3, Kyung-Sook Yang, MD4

1Department of Radiology, Ansan Hospital, Korea University College of Medicine, Ansan, Korea.

2Department of Radiology, Guro Hospital, Korea University College of Medicine, Seoul, Korea.

3Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea.

4Department of Biostatistics, Korea University College of Medicine, Seoul, Korea.

Corresponding author: Young Hen Lee, MD. Department of Radiology, Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, Korea. Tel. 82-31-412-5228, Fax. 82-31-412-5224, younghen@korea.ac.kr

Received 5 September 2013       Accepted 26 November 2013

Copyright © 2014 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

We correlated cerebrovascular reserve in unilateral high grade carotid artery stenosis or occlusion with a type of collateral circulation using acetazolamide-challenged perfusion CT (ACZ-PCT).

Materials and Methods

Among the patients who underwent ACZ-PCT in our institution, we retrospectively selected the patients with unilateral high grade internal carotid artery or middle cerebral artery stenosis (> 70%) or occlusion; we verified the types of their dominant collateral circulation by digital subtraction angiography or 3T MR-angiography; first, the primary collaterals flow through the circle of Willis; second, the secondary collaterals that flow through the opthalmic artery, the basal artery or other external carotid artery. Using ACZ-PCT, we measured the difference in percentage change of cerebral blood flow of the stenotic hemisphere against contralateral normal hemisphere and compared cerebrovascular reserves of lesional hemisphere, according to the type of collaterals.

Results

A total of 28 patients were included. The percentage changes of cerebral blood flow were significantly lower in the stenotic hemisphere than the contralateral hemisphere (14.34 ± 36.43% and 34.53 ± 47.82%, p < 0.001), and in the hemisphere predominantly supplied by secondary collaterals than primary (7.03 ± 32.71% and 24.37 ± 42.03%, p < 0.05), respectively.

Conclusion

Cerebrovascular reserves in the ipsilateral hemisphere predominantly supplied by secondary collaterals were more impaired than primary collaterals in patients with unilateral high grade carotid stenosis or occlusion.

Keywords: Carotid Stenosis, Cerebrovascular Insufficiency, Collateral Circulations, Perfusion Imaging

Figures and Tables

Fig. 1
Locations of regions of interest (ROI) in cerebral perfusion CT.
A, B. Diffusion weighted image (A) and apparent diffusion coefficient map (B) show acute infarction at left basal ganglia in a 50-year male patient.
C. Four ROIs in both middle cerebral artery (MCA) territories of perfusion CT before and after acetazolamide infusion are demonstrated at the level of basal ganglia.
D. This is a representative arterial input and venous outflow time-attenuation curves at left MCA cortical flow territory. This time-attenuation curve is then used to calculate the perfusion CT parameters.
E-H. Examples of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time to peak enhancement (TTP) on perfusion CT before acetazolamide infusion at the level of basal ganglia (right to left).
jksr-70-1-g001
Fig. 2
Percentage change of cerebral blood flow (CBF) in patient with left proximal middle cerebral artery occlusion with secondary collaterals. A 55-year-old woman without evidence of ischemic symptom.
A. There is no definable abnormal sign on the initial brain MRI T2 weighted image.
B, C. Left middle cerebral artery is occluded just distal to distal internal cerebral artery bifurcation on time of flight MR angiography (B) and digital subtraction angiography (DSA) (C).
D. Secondary collaterals from ipsilateral anterior cerebral artery and external carotid artery are noted on DSA.
E. Relative preservation of CBF is shown in left frontotemporal cortex on baseline perfusion study, the value are 52.48 mL/100 g/min and 50.92 mL/100 g/min in occlusive and mirrored hemisphere, respectively.
F. But there is paradoxical response in stenotic area on post-acetazolamide study. Percentage change of CBF is -8.44%, suggesting significant decreased cerebrovascular reserve as compared with 21.70% in contralateral cortex.
jksr-70-1-g002
Fig. 3
Percentage change of cerebral blood flow (CBF) in patient with left proximal internal cerebral artery (ICA) occlusion with primary collaterals. A 71-year-old woman without ischemic symptom.
A. There is no demonstrable abnormal finding on the initial brain MRI T2 weighted image.
B, C. Total occlusion of left proximal ICA is demonstrated on contrast-enhanced MR angiography (MRA) (B). However, left middle cerebral artery (MCA) is visualized on her time of flight MRA through anterior communicating artery (C).
D. Ipsilateral anterior cerebral artery, MCA and their cortical branches distal to occluded left ICA are visualized on digital subtraction angiography, suggesting primary collaterals.
E, F. Cerebral blood flow maps of baseline (E) and post-acetazolamide (F) cerebral perfusion study show relative preserved cerebrovascular reserve in left frontotemporal cortex. The percentage change of CBF is 32.88% and 35.87% is measured in mirrored hemisphere.
jksr-70-1-g003
Table 1
Demographics and Risk Factors of Patients
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Table 2
Patient Characteristic in Primary and Secondary Collateral Circulation
jksr-70-1-i002

Note.-p value < 0.05 is statistically significant.

*Student t-test.

†Fisher's exact test.

DSA = digital subraction angiography, ICA = internal cerebral artery, MCA = middle cerebral artery, MRA = MR angiography

Table 3
Comparison of Quantitatively Measured Cerebrovascular Reserve Using Acetazolamide Perfusion CT: Percentage Change of Cerebral Blood Flow
jksr-70-1-i003

Note.-Data are mean ± standard deviation.

*Wilcoxon-signed rank test.

†Mann-Whitney test

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