Preoperative single-slab 3D time-of-flight magnetic resonance angiography predicts development of new cerebral ischemic events after carotid endarterectomy

Clinical article

Restricted access

Object

Preoperative impairment of cerebral hemodynamics predicts the development of new cerebral ischemic events after carotid endarterectomy (CEA), including neurological deficits and cerebral ischemic lesions on diffusion weighted MR imaging. Furthermore, the signal intensity of the middle cerebral artery (MCA) on single-slab 3D time-of-flight MR angiography (MRA) can assess hemodynamic impairment in the cerebral hemisphere. The purpose of the present study was to determine whether, on preoperative MR angiography, the signal intensity of the MCA can be used to identify patients at risk for development of cerebral ischemic events after CEA.

Methods

The signal intensity of the MCA ipsilateral to CEA on preoperative MR angiography was graded according to the ability to visualize the MCA in 106 patients with unilateral internal carotid artery stenosis (≥ 70%). Diffusion weighted MR imaging was performed within 3 days of and 24 hours after surgery. The presence or absence of new postoperative neurological deficits was also evaluated.

Results

Cerebral ischemic events after CEA were observed in 16 patients. Reduced signal intensity of the MCA on preoperative MR angiography was the only significant independent predictor of postoperative cerebral ischemic events. When the reduced MCA signal intensity on preoperative MR angiography was defined as an impairment in cerebral hemodynamics, MR angiography grading resulted in an 88% sensitivity and 63% specificity, with a 30% positive- and a 97% negative-predictive value for the development of postoperative cerebral ischemic events.

Conclusions

Signal intensity of the MCA on preoperative single-slab 3D time-of-flight MR angiography is useful for identifying patients at risk for cerebral ischemic events after CEA.

Abbreviations used in this paper: CEA = carotid endarterectomy; ICA = internal carotid artery; MCA = middle cerebral artery; TOF = time-of-flight.

Article Information

Address correspondence to: Kuniaki Ogasawara, M.D., Department of Neurosurgery, Iwate Medical University, Uchimaru 19-1, Morioka 020-8505, Japan. email: kuogasa@iwate-med.ac.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    The degree of visualization of the ipsilateral MCA on MR angiograms was graded as follows: all M3 branches of the left MCA are visualized on the cortical surface (Grade A); one M3 branch is not on to the cortical surface (Grade B, arrow); one M2 branch is not visualized along its course (Grade C, arrow); and the M1 is not visualized along its course (Grade D, arrow).

  • View in gallery

    Graph demonstrating the number and incidence of new postoperative cerebral ischemic events among the 4 MR angiography (MRA) grades.

  • View in gallery

    Studies obtained in a 65-year-old man with symptomatic left ICA stenosis (95%) exhibiting right hemiparesis after recovering from general anesthesia after CEA. A diffusion weighted MR image obtained 6 hours after surgery (right) shows development of a new postoperative highly intense lesion in the left cerebral hemisphere compared with a preoperative image (left). The preoperative MR angiogram obtained in this patient is presented in Fig. 1C.

References

1

Arnold MSturzenegger MSchäffler LSeiler RW: Continuous intraoperative monitoring of middle cerebral artery blood flow velocities and electroencephalography during carotid endarterectomy: a comparison of the two methods to detect cerebral ischemia. Stroke 28:134513501997

2

Aso KOgasawara KSasaki MKobayashi MSuga YChida K: Preoperative acerebrovascular reactivity to acetazolamide measured by brain perfusion SPECT predicts development of cerebral ischemic lesions caused by microemboli during carotid endarterectomy. Eur J Nucl Med Mol Imaging 36:2943012009

3

Bernstein MAHuston J IIILin CGibbs GFFelmlee JP: High-resolution intracranial and cervical MRA at 3.0T: technical considerations and initial experience. Magn Reson Med 46:9559622001

4

Caplan LRHennerici M: Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 55:147514821998

5

Davis WLBlatter DDHarnsberger HRParker DL: Intracranial MR angiography: comparison of single-volume three-dimensional time-of-flight and multiple overlapping thin slab acquisition techniques. AJR Am J Roentgenol 163:9159201994

6

Derick RJGlaucoma therapy: carbonic anhydrase inhibitors. Mauger TFCraig EL: Hevener's Ocular Pharmacology ed 6St LouisCV Mosby Co1994. 4550

7

Endo HInoue TOgasawara KFukuda TKanbara YOgawa A: Quantitative assessment of cerebral hemodynamics using perfusion-weighted MRI in patients with major cerebral artery occlusive disease: comparison with positron emission tomography. Stroke 37:3883922006

8

Hirano TMinematsu KHasegawa YTanaka YHayashida KYamaguchi T: Acetazolamide reactivity on 123I-IMP single photon emission computed tomography in patients with major cerebral artery occlusive disease: correlation with positron emission tomography parameters. J Cereb Blood Flow Metab 14:7637701994

9

Hirooka ROgasawara KInoue TFujiwara SSasaki MChida K: Simple assessment of cerebral hemodynamics using single-slab three-dimensional time-of-flight magnetic resonance angiography in patients with cervical internal carotid artery steno-occlusive diseases: comparison with quantitative perfusion single-photon emission computed tomography. AJNR Am J Neuroradiol [epub ahead of print]2008

10

Kikuchi KMurase KMiki HYasuhara YSugawara YMochizuki T: Quantitative evaluation of mean transit times obtained with dynamic susceptibility contrast-enhanced MR imaging and with (133)Xe SPECT in occlusive cerebrovascular disease. AJR Am J Roentgenol 179:2292352002

11

Kim JHLee SJShin TKang KHChoi PYKim JH: Correlative assessment of hemodynamic parameters obtained with T2*-weighted perfusion MR imaging and SPECT in symptomatic carotid artery occlusion. AJNR Am J Neuroradiol 21:145014562000

12

Kim JSMoon DHKim GECho YPKim JSRyu JS: Acetazolamide stress brain-perfusion SPECT predicts the need for carotid shunting during carotid endarterectomy. J Nucl Med 41:183618412000

13

Kodama TWatanabe K: Influence of imaging parameters, flow velocity, and pulsatile flow on three-dimensional time-of-flight MR angiography: experimental studies. Eur J Radiol 26:83911997

14

Marchal GBosmans HVan Fraeyenhoven LWilms GVan Hecke PPlets C: Intracranial vascular lesions: optimization and clinical evaluation of three-dimensional time-of flight MR angiography. Radiology 175:4434481990

15

Mille TTachimiri MEKlersy CTicozzelli GBellinzona GBlangetti I: Near infrared spectroscopy monitoring during carotid endarterectomy: which threshold value is critical?. Eur J Vasc Endovasc Surg 27:6466502004

16

Naylor ARMerrick MVSlattery JMNotghi AFerrington CMMiller JD: Parametric imaging of cerebral vascular reserve: 2. Reproducibility, response to CO2 and correlation with middle cerebral artery velocities. Eur J Nucl Med 18:2592641991

17

North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:4454531991

18

Ogasawara KIto HSasoh MOkuguchi Kobayashi MYukawa H: Quantitative measurement of regional cerebrovascular reactivity to acetazolamide using [123I]iodoamphetamine autoradiographic method with single photon emission computed tomography: validation study using [15O] H2O positron emission tomography. J Nucl Med 44:5205252003

19

Ogasawara KOgawa AYoshimoto T: Cerebrovascular reactivity to acetazolamide and outcome in patients with symptomatic internal carotid or middle cerebral artery occlusion: a xenon-133 single-photon emission computed tomography study. Stroke 33:185718622002

20

Ogasawara KTomitsuka NKobayashi MKomoribayashi NFukuda TSaitoh H: Stevens-Johnson syndrome associated with intravenous acetazolamide administration for evaluation of cerebrovascular reactivity: case report. Neurol Med Chir (Tokyo) 46:1611632006

21

Schnaudigel SGröschel KPilgram SMKastrup A: New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke 39:191119192008

22

Schneider JRDroste JSSchindler NGolan JFBernstein LPRosenberg RS: Carotid endarterectomy with routine electroencephalography and selective shunting: influence of contralateral internal carotid artery occlusion and utility in prevention of perioperative strokes. J Vasc Surg 35:111411212002

23

Thomas SDAl-Kwifi OEmery DJWilman AH: Application of magnetization transfer at 3.0 T in three-dimensional time-of-flight magnetic resonance angiography of the intracranial arteries. J Magn Reson Imaging 15:4794832002

24

van der Schaaf ICHorn JMoll FLAckerstaff RG: Transcranial Doppler monitoring after carotid endarterectomy. Ann Vasc Surg 19:19242005

25

Verhoeven BAde Vries JPPasterkamp GAckerstaff RGSchoneveld AHVelema E: Carotid atherosclerotic plaque characteristics are associated with microembolization during carotid endarterectomy and procedural outcome. Stroke 36:173517402005

26

Wardlaw JMDennis MSMerrick MVWarlow CP: Relationship between absolute mean cerebral transit time and absolute mean flow velocity on transcranial Doppler ultrasound after ischemic stroke. J Neuroimaging 12:1041112002

27

Wiginton CDKelly BOto AJesse MAristimuno PErnst R: Gadolinium-based contrast exposure, nephrogenic systemic fibrosis, and gadolinium detection in tissue. AJR Am J Roentgenol 190:106010682008

28

Wolf OHeider PHeinz MPoppert HSander DGreil O: Microembolic signals detected by transcranial Doppler sonography during carotid endarterectomy and correlation with serial diffusion-weighted imaging. Stroke 35:e373e3752004

29

Yong SWBang OYLee PHLi WY: Internal and cortical border-zone infarction: clinical and diffusion-weighted imaging features. Stroke 37:8418462006

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 53 53 13
Full Text Views 54 54 9
PDF Downloads 51 51 3
EPUB Downloads 0 0 0

PubMed

Google Scholar