Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Early Restoration of Hypoperfusion Confirmed by Perfusion Magnetic Resonance Image after Emergency Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

  • Eun, Jin (Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Park, Ik Seong (Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea)
  • Received : 2022.05.04
  • Accepted : 2022.07.02
  • Published : 2022.11.01
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Emergency superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis in patients with large vessel occlusion who fails mechanical thrombectomy or does not become an indication due to over the time window can be done as an alternative for blood flow restoration. The authors planned this study to quantitatively measure the degree of improvement in cerebral perfusion flow using perfusion magnetic resonance imaging (MRI) after bypass surgery and to find out what factors are related to the outcome of the bypass surgery. Methods : For a total of 107 patients who underwent emergent STA-MCA bypass surgery with large vessel occlusion, the National Institute of Health stroke scale (NIHSS), modified Rankin score (mRS), infarction volume, and hypoperfusion area volume was calculated, the duration between symptom onset and reperfusion time, occlusion site and infarction type were analyzed. After emergency STA-MCA bypass, hypoperfusion area volume at post-operative 7 days was calculated and analyzed compared with pre-operative hypoperfusion area volume. The factors affecting the improvement of mRS were analyzed. The clinical status of patients who underwent emergency bypass was investigated by mRS and NIHSS before and after surgery, and changes in infarct volume, extent, degree of collateral circulation, and hypoperfusion area volume were measured using MRI and digital subtraction angiography (DSA). Results : The preoperative infarction volume was median 10 mL and the hypoperfusion area volume was median 101 mL. NIHSS was a median of 8 points, and the last normal to operation time was a median of 60.7 hours. STA patency was fair in 97.1% of patients at 6 months follow-up DSA and recanalization of the occluded vessel was confirmed at 26.5% of patients. Infarction volume significantly influenced the improvement of mRS (p=0.010) but preoperative hypoperfusion volume was not significantly influenced (p=0.192), and the infarction type showed marginal significance (p=0.0508). Preoperative NIHSS, initial mRS, occlusion vessel type, and last normal to operation time did not influence the improvement of mRS (p=0.272, 0.941, 0.354, and 0.391). Conclusion : In a patient who had an acute cerebral infarction due to large vessel occlusion with large ischemic penumbra but was unable to perform mechanical thrombectomy, STA-MCA bypass could be performed. By using time-to-peak images of perfusion MRI, it is possible to quickly and easily confirm that the brain tissue at risk is preserved and that the ischemic penumbra is recovered to a normal blood flow state.

Keywords

References

  1. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. : Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378 : 708-718, 2018 https://doi.org/10.1056/NEJMoa1713973
  2. Astrup J, Symon L, Branston NM, Lassen NA : Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 8 : 51-57, 1977 https://doi.org/10.1161/01.STR.8.1.51
  3. Back T : Pathophysiology of the ischemic penumbra--revision of a concept. Cell Mol Neurobiol 18 : 621-638, 1998
  4. Demeestere J, Wouters A, Christensen S, Lemmens R, Lansberg MG : Review of perfusion imaging in acute ischemic stroke: from time to tissue. Stroke 51 : 1017-1024, 2020 https://doi.org/10.1161/STROKEAHA.119.028337
  5. Desai SM, Haussen DC, Aghaebrahim A, Al-Bayati AR, Santos R, Nogueira RG, et al. : Thrombectomy 24 hours after stroke: beyond DAWN. J Neurointerv Surg 10 : 1039-1042, 2018 https://doi.org/10.1136/neurintsurg-2018-013923
  6. EC/IC Bypass Study Group : Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313 : 1191-1200, 1985 https://doi.org/10.1056/NEJM198511073131904
  7. Grubb RL Jr, Powers WJ, Clarke WR, Videen TO, Adams HP Jr, Derdeyn CP, et al. : Surgical results of the carotid occlusion surgery study. J Neurosurg 118 : 25-33, 2013 https://doi.org/10.3171/2012.9.JNS12551
  8. Jo H, Seo D, Kim YD, Ban SP, Kim T, Kwon OK, et al. : Quantitative radiological analysis and clinical outcomes of urgent EC-IC bypass for hemodynamic compromised patients with acute ischemic stroke. Sci Rep 12 : 8816, 2022 https://doi.org/10.1038/s41598-022-12728-x
  9. Kim H, Kim Y, Kim YW, Kim SR, Yang SH : Perfusion-weighted MRI parameters for prediction of early progressive infarction in middle cerebral artery occlusion. J Korean Neurosurg Soc 59 : 346-351, 2016 https://doi.org/10.3340/jkns.2016.59.4.346
  10. Kim JH, Yoon W, Kim CK, Roh H, Bae HJ, Kwon TH, et al. : Efficacy and safety of timely urgent superficial temporal artery-to-middle cerebral artery bypass surgery in patients with acute ischemic stroke: a singleinstitutional prospective study and a pooled analysis. Cerebrovasc Dis 50 : 34-45, 2021 https://doi.org/10.1159/000512106
  11. Lee SB, Huh PW, Kim DS, Yoo DS, Lee TG, Cho KS : Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke. Clin Neurol Neurosurg 115 : 1238-1244, 2013 https://doi.org/10.1016/j.clineuro.2012.11.022
  12. Leigh R, Knutsson L, Zhou J, van Zijl PC : Imaging the physiological evolution of the ischemic penumbra in acute ischemic stroke. J Cereb Blood Flow Metab 38 : 1500-1516, 2018 https://doi.org/10.1177/0271678X17700913
  13. McKetton L, Venkatraghavan L, Rosen C, Mandell DM, Sam K, Sobczyk O, et al. : Improved white matter cerebrovascular reactivity after revascularization in patients with steno-occlusive disease. AJNR Am J Neuroradiol 40 : 45-50, 2019 https://doi.org/10.3174/ajnr.A5912
  14. Moustafa RR, Baron JC : Pathophysiology of ischaemic stroke: insights from imaging, and implications for therapy and drug discovery. Br J Pharmacol 153 Suppl 1(Suppl 1) : S44-S54, 2008 https://doi.org/10.1038/sj.bjp.0707530
  15. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. : Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378 : 11-21, 2018 https://doi.org/10.1056/NEJMoa1706442
  16. Nussbaum ES, Janjua TM, Defillo A, Lowary JL, Nussbaum LA : Emergency extracranial-intracranial bypass surgery for acute ischemic stroke. J Neurosurg 112 : 666-673, 2010 https://doi.org/10.3171/2009.5.JNS081556
  17. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP : Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA 306 : 1983-1992, 2011 https://doi.org/10.1001/jama.2011.1610
  18. Schmiedek P, Olteanu-Nerbe V, Marguth F : Timing of extracranial-intracranial arterial bypass surgery with special reference to acute cerebral ischaemia. Neurosurg Rev 6 : 19-24, 1983 https://doi.org/10.1007/BF01742981
  19. Tsivgoulis G, Safouris A, Katsanos AH, Arthur AS, Alexandrov AV : Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials. Brain Behav 6 : e00418, 2016
  20. Vilela P, Rowley HA : Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 96 : 162-172, 2017 https://doi.org/10.1016/j.ejrad.2017.08.014