Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study

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OBJECTIVE

Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.

METHODS

In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.

RESULTS

Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.

CONCLUSIONS

Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.

ABBREVIATIONS ASA = acetylsalicylic acid; AUC = area under the receiver operating characteristic curve; CBF = cerebral blood flow; CEA = carotid endarterectomy; CHS = cerebral hyperperfusion syndrome; ICA = internal carotid artery; MCA = middle cerebral artery; mRS = modified Rankin Scale; NOVA = noninvasive optimal vessel analysis; QMRA = quantitative phase-contrast MR angiography; TCD = transcranial Doppler.

Article Information

Correspondence Michael Reinert, Department of Neurosurgery, Neurocenter Luga-no, Lugano 6930, Switzerland. email: michael.reinert@eoc.ch.

INCLUDE WHEN CITING Published online April 14, 2017; DOI: 10.3171/2016.11.JNS161033.

Disclosures Dr. Amin-Hanjani receives non–study-related research support from VasSol, Inc. Dr. Arnold is a consultant for and receives non–study-related research support from Bayer Schering, BMS, Pfizer, Boehringer, and Covidien.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Blood flow values of the CEA patients as assessed by QMRA. Nonpatch CEA significantly increased blood flow in the operated ICA and ipsilateral MCA in all patients. A: A significant difference in blood flow was evident in the ipsilateral ICA in patients with or without CHS. Additionally, the postoperative flow values in the CHS patients were significantly higher than in non-CHS patients. B: MCA flow velocities were significantly higher in CHS patients than in non-CHS patients. C: Perioperative flow differences in CHS patients were significantly higher in both the ipsilateral ICA and MCA than in non-CHS patients. Data are given as the mean ± SEM. *p < 0.05, **p < 0.01, ***p < 0.001. ns = not significant; post = postoperative; pre = preoperative.

  • View in gallery

    Bland-Altman plots comparing sonography and QMRA. The narrower ± 1.96 (± SD) limits (dotted lines) indicate only moderate agreement for extracranial vessels (A and B) compared with intracranial vessels (C and D). There is a slight tendency toward better agreement between the 2 methods for smaller values. SD LOA = standard deviation with limits of agreement.

  • View in gallery

    Receiver operating characteristic curves for the discrimination of CHS and non-CHS patients assessed by QMRA. QMRA thresholds for discrimination between CHS and non-CHS patients were estimated to be approximately 3.49 for the mean flow value ratio in the ICA (AUC 0.8; sensitivity 75%; specificity 84%; likelihood ratio 4.75) (A) and 1.53 for the mean flow value ratio in the MCA (AUC 0.94; sensitivity 100%; specificity 90%; likelihood ratio 10) (B). The MCA ratio (p = 0.01) tended to be more efficient at predicting CHS than ICA ratio (p = 0.06). TCD thresholds for discrimination between CHS and non-CHS were estimated to be 0.26 for the mean flow value ratio in the ICA (AUC 0.89; sensitivity 100%; specificity 80%; likelihood ratio 5.0) (C) and 1.59 for the mean flow value ratio in the MCA (AUC 0.83; sensitivity 75%; specificity 80%; likelihood ratio 3.75) (D).

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