Effect of stenting on cerebral CT perfusion in symptomatic and asymptomatic patients with carotid artery stenosis

Angiographic Pattern of M1 Stenosis Predicts Territorial Stroke in Patients Receiving Aggressive Medication without Stenting

OBJECTIVE

To evaluate the relationship between different angiographic patterns of middle cerebral artery M1 segment stenosis and related territorial stroke in patients receiving aggressive medical treatment without stenting.

METHODS

We retrospectively reviewed our patient registry database to identify ICAS patients diagnosed by digital subtraction angiography between January 2017 and December 2020 and identified 3 different angiographic patterns (normal, shift, and dilation) in 124 patients with M1 stenosis. The association between these patterns and recurrent ischemic stroke in the M1 territory was analyzed.

RESULTS

The rates of recurrent M1 territorial stroke and transient ischemic attack in the normal group, shift group, dilation group and shift-dilation group were 34.5%, 35.0%, 78.3%, and 44.4% respectively. In patients with the shift pattern, the rate of recurrent stroke is significantly higher at a deflection angle ≥9.32° than at a deflection angle <9.32°(P < 0.05). In patients with dilation pattern, the rate of recurrent stroke is significantly higher than patients with non-dilation pattern (72.3% vs. 36.8%, P < 0.05).

CONCLUSIONS

Angiographic patterns of M1 stenosis may predict recurrent territorial strokes, thus providing a surrogate marker to identify high-risk patients for potential endovascular treatment.

Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study

OBJECTIVE

Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients.

METHODS

The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined.

RESULTS

The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P = 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P = 0.48) were low and did not differ significantly between groups Y and E.

CONCLUSIONS

Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.

Comparative Study of Cerebral Perfusion in Different Types of Decompressive Surgery for Traumatic Brain Injury

Introduction Computed tomography perfusion (CTP) brain usefulness in the treatment of traumatic brain injury (TBI) is still being investigated. Comparative research of CTP in the various forms of decompressive surgery has not yet been reported to our knowledge. Patients with TBI who underwent decompressive surgery were studied using pre- and postoperative CTP. CTP findings were compared with patient's outcome.

Materials and Methods This was a single-center, prospective cohort study. A prospective analysis of patients who were investigated with CTP from admission between 2019 and 2021 was undertaken. The patients in whom decompressive surgery was required for TBI, were included in our study after applying inclusion and exclusion criteria. CTP imaging was performed preoperatively and 5 days after decompressive surgery to measure cerebral perfusion. Numbers of cases included in the study were 75. Statistical analysis was done.

Results In our study, cerebral perfusion were improved postoperatively in the all types of decompressive surgery (p-value < 0.05). But association between type of surgery with improvement in cerebral perfusion, Glasgow Coma Scale at discharge, and Glasgow Outcome Scale-extended at 3 months were found to be statistically insignificant (p-value > 0.05).

Conclusion CTP brain may play a role as a prognostic tool in TBI patients undergoing decompressive surgery.

A narrative review of the pathophysiology of ischemic stroke in carotid plaques: a distinction versus a compromise between hemodynamic and embolic mechanism

Atherosclerotic carotid artery stenosis causes about 10–20% of all ischemic strokes through two main mechanisms: hemodynamic impairment in case of significant stenosis and thromboembolism from an atherosclerotic plaque regardless of the degree of stenosis. The latter is the most frequent mechanism and appear to result from embolization from a vulnerable atherosclerotic plaque or acute occlusion of the carotid artery and propagation of thrombus distally. Downstream infarcts may occur in a territory of major cerebral artery or at the most distal areas between two territories of major cerebral arteries, the so-called watershed (WS), or border zone area. Although WS infarcts, especially deep WS infarct, were historically thought to be due to hemodynamic compromise, the role of microembolism has also been documented, both mechanisms may act synergistically to promote WS infarcts. Routine and more advanced imaging techniques may provide information on the underlying mechanism involved in ipsilateral ischemic stroke. A better understanding of ischemic stroke pathogenesis in carotid stenosis may limit the use of routine non-selective shunt, whose benefit-risk balance is debated, to patients with hemodynamic impairment.

After reviewing existing evidence underpinning the contribution of the two mechanisms in downstream ischemic stroke and the various imaging techniques available to investigate them, we will focus on the pathogenesis of WS infarcts that remains debated.

Brain imaging biomarkers of carotid artery disease

Extracranial carotid artery atherosclerotic disease is a major contributor to ischemic stroke. Carotid atherosclerotic disease can present with a spectrum of findings ranging from mild carotid intima-media thickness to high-risk vulnerable carotid plaque features and carotid stenosis. Before leading to clinically overt stroke or transient ischemic attack, there may be other markers of downstream ischemia secondary to carotid atherosclerotic disease. In this review article, we will review some of the imaging findings that may be seen downstream to carotid artery disease on various imaging modalities, including hemodynamic and perfusional abnormalities which may be seen on CT, MR, or using other advanced imaging techniques, white matter hyperintensities on brain imaging, silent or covert brain infarctions, cerebral microbleeds, and regional and generalized cerebral volume loss. Many of these imaging findings are seen routinely on brain magnetic resonance imaging in patients without overt clinical symptoms. Despite frequently being asymptomatic, many of these imaging findings are also strongly associated with increased risk of future stroke, cognitive impairment, and even mortality. We will review the existing evidence underpinning the associations between these frequently encountered imaging findings and carotid artery atherosclerotic disease. Future validation of these imaging findings could lead to them being powerful biomarkers of cerebrovascular health.

NSE, S100B and MMP9 Expression Following Reperfusion after Carotid Artery Stenting

Objective:

Previous studies have shown that the neuron-specific- enolase (NSE), S100B protein (S100B) and matrix metalloproteinase-9 (MMP9) are specific markers for studying cerebral injury. This study was aimed to demonstrate these biomarkers for their correlation with reperfusion after carotid artery stenting (CAS).

Methods:

In this study, a total of 44 patients who were diagnosed unilateral carotid artery stenosis by digital subtraction angiography (DSA) and underwent CAS, were selected as the operation groups. The patients' blood samples were collected at three different time points: T1, prior to operation; T2, next morning after operation (24 hours); T3, three days after operation (72 hours); All of the patients with the operation received computed tomography perfusion (CTP) at T1 and T3. The second group of 12 patients, who were excluded for carotid artery stenosis by DSA, were assigned to be the control group; Blood samples of these patients were collected at T1. The concentrations of NSE, S100B and MMP9 in serum from patients of both groups were detected by ELISA.

Results:

All of the operations were implanted in stents successfully without complications. (1) After CAS, rCBF increased while rMTT and rTTP decreased. (2) The concentrations of NSE, S100B and MMP9 in the serum decreased gradually (T1>T2>T3). There was no significant difference between the control group and the operation group at T1 (P>0.05) on their concentrations of NSE, S100B and MMP9 in the serum. When compared among the operation groups, the concentrations of NSE, S100B and MMP9 in the serum at T1 and T3 showed significant difference (P < 0.05). (3) Correlation analysis among the operation groups indicated that NSE, S100B, MMP9 and rCBF were positively correlated before operation (r = 0.69, 0.58 and 0.72, respectively, P < 0.05), as well as after operation (r = 0.75, 0.65 and 0.60, respectively, P < 0.05).

Conclusion:

We concluded that the concentrations of NSE, S100B and MMP9 in serum decreased with the improvement of cerebral reperfusion after CAS. NSE, S100B and MMP9 can be used as laboratory biochemical markers to evaluate the improvement of reperfusion after CAS. The results very well complement the imaging methods, such as CTP.

Relative Cerebral Blood Transit Time Decline and Neurological Improvement in Patients After Internal Carotid Artery Stenting

In this study we hypothesized that the alleviation of neurological symptoms long after internal carotid artery (ICA) stenting may be related to sustained improvement of cerebral perfusion. Thirty-four subjects (F/M; 15/19) with >70% stenosis of a single internal carotid artery and neurological symptoms, who underwent a carotid artery stenting procedure, were studied. Brain computed tomography perfusion (CTP) imaging was performed before and 3 years after ICA stenting. The following relative variables were compared: cerebral blood flow (rCBF), cerebral blood volume (rCBV), mean transit time (rMTT), time to peak (rTTP), and permeability surface area product (rPS). A survey also was conducted to compare the patients' clinical symptoms. Overall, we found that a trend toward rMTT decline was the only persisting change after ICA stenting. We then stratified the patients into the subgroups of <2%, 2-5%, and > 5% rMTT decline and found that those with a rMTT decline >2% reported a prominent reduction in subjective clinical symptoms such as headache, dizziness, tinnitus, blurred vision, transient blindness, a sense of gravity of the head, and pain in the eyeballs. We conclude that a shortened mean rMTT, likely reflecting improved cerebral microcirculation, underlies the improvement of neurological symptoms in patients with ICA stenosis.

The Effect of Cerebrovascular Stenosis on -Peri-Hematoma Cerebral Perfusion and Clinical Outcomes in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage

Background

Many factors are associated with the cerebral hypoperfusion after spontaneous intracerebral hemorrhage (sICH), however, the effect of cerebrovascular stenosis on peri-hematoma cerebral blood flow (CBF) and 90-day poor outcomes in patients with spontaneous intracerebral hemorrhage is still unclear.

Material/Methods

From September 2016 to March 2017, we prospectively collected data on adults with supratentorial spontaneous intracerebral hemorrhages. Using the Propensity Score model, we compared the peri-hematoma CBF and 90-day poor outcomes (mRS ≥3) in the stenosis group and the control group.

Results

Before matching, a total of 116 patients were included in this study, 25 patients in the stenosis group and 91 patients in the control group. After matching, the patients in the stenosis group had a higher absolute decrease of CBF (p=0.003), higher relative decrease of CBF (p=0.016), and higher incidence of 90-day poor outcomes (p=0.041) than the control group. With subgroup analysis, the patients with Glasgow Coma Scale from 13 to 15 (p=0.035), hematoma in the cerebral lobe (p=0.003), mean arterial pressure lower than 120 mm Hg (p=0.003), absolute decrease of CBF higher than 15 mL/100 g per minute (p=0.007), and relative decrease of CBF higher than 30% (p=0.020) had poorer outcomes.

Conclusions

In our series, the stenosis of main cerebral vessels decreased the peri-hematoma CBF and increased the rate of 90-day poor outcomes. Despite higher Glasgow Coma Scale, the evaluation of cerebral perfusion in patients with sICH is needed, especially for the patients with hematoma in the cerebral lobe and lower mean arterial pressure; and treatments to keep adequate cerebral perfusion are needed.

Assessment of the Cerebral Hemodynamic Benefits of Carotid Artery Stenting for Patients with Preoperative Hemodynamic Impairment Using Cerebral Single Photon Emission Computed Tomography (SPECT) and Carbon Dioxide Inhalation

BACKGROUND The aim of this study was to evaluate the effects of carotid artery angioplasty and carotid artery stenting (CAS) on cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) in patients with preoperative cerebrovascular hemodynamic impairment. MATERIAL AND METHODS Seventeen patients with unilateral severe internal carotid artery (ICA) stenosis and ipsilateral CVR impairment underwent CAS. CBF and CVR were measured by single photon emission computed tomography (SPECT) with inhalation of carbon dioxide (CO2) one week before and three months after CAS. Sixty-eight ROIs in the middle cerebral artery (MCA) territory were analyzed in 17 patients. RESULTS Before CAS, CVR was impaired in all ROIs. CBF was impaired in 16 ROIs (23.5%). The percentage of ROIs with impaired CBF was significantly increased in patients with ≥90% carotid artery stenosis (p=0.047) without collateral flow through the circle of Willis (p=0.005). CAS significantly increased CVR in ROIs with a normal preoperative CBF and impaired CVR, indicating mild hemodynamic impairment (0.9±6.7% vs. 4.9±8.6%) (p=0.014). CAS significantly increased CBF in ROIs with preoperative impaired CBF and impaired CVR, indicating severe hemodynamic impairment (79.1±7.5% vs. 86.7±10.0%) (p<0.001). Following CAS, ROIs with normal CBF and impaired CVR had a significantly increased percentage of improved CVR (p=0.047); ROIs with impaired CBF and impaired CVR had a significantly increased percentage of improved CBF (p=0.027). CONCLUSIONS The severity of preoperative hemodynamic impairment, which is related to the degree of carotid artery stenosis and cerebral collateral flow, may influence hemodynamic benefits by CAS.

Multiple blood flow measurements before and after carotid artery stenting via phase-contrast magnetic resonance imaging: An observational study

After carotid artery stenting, the procurement of information about blood flow redistribution among brain-feeding arteries and its time trend is essential to understanding a patient’s physiological background and to determine their care regimen. Cerebral blood flow has been measured twice following carotid artery stenting in few previous studies, with some discrepancies in the results. The purpose of this study was to measure cerebral blood flow at multiple time points after carotid artery stenting, and to elucidate the time trend of cerebral blood flow and redistribution among arteries. Blood flow rates in 11 subjects were measured preoperatively, at one day, one week, and about three months, respectively after carotid artery stenting by using phase-contrast magnetic resonance imaging. The target vessels were the bilateral internal carotid arteries, the basilar artery, and the bilateral middle cerebral arteries. Lumen was semi-automatically defined using an algorithm utilizing pulsatility. The results showed that blood flow rates in the stented internal carotid artery and the ipsilateral middle cerebral artery increased following carotid artery stenting. Blood flow rates in the contralateral internal carotid artery and the basilar artery gradually declined, and they were lower than the preoperative values at three months after stenting. The sum of blood flow rates of the bilateral internal carotid arteries and the basilar artery increased after carotid artery stenting, and then decreased over the next three months. There was no significant change in the blood flow rate in the contralateral middle cerebral artery. From these results, it was concluded that redistribution among the bilateral internal carotid arteries and the basilar artery occurs after carotid artery stenting, and that it takes months thereafter to reach another equilibrium.

Carotid Artery Stenting and Blood-Brain Barrier Permeability in Subjects with Chronic Carotid Artery Stenosis

Failure of the blood-brain barrier (BBB) is a critical event in the development and progression of diseases such as acute ischemic stroke, chronic ischemia or small vessels disease that affect the central nervous system. It is not known whether BBB breakdown in subjects with chronic carotid artery stenosis can be restrained with postoperative recovery of cerebral perfusion. The aim of the study was to assess the short-term effect of internal carotid artery stenting on basic perfusion parameters and permeability surface area-product (PS) in such a population. Forty subjects (23 males) with stenosis of >70% within a single internal carotid artery and neurological symptoms who underwent a carotid artery stenting procedure were investigated. Differences in the following computed tomography perfusion (CTP) parameters were compared before and after surgery: global cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP) and PS. PS acquired by CTP is used to measure the permeability of the BBB to contrast material. In all baseline cases, the CBF and CBV values were low, while MTT and TTP were high on both the ipsi- and contralateral sides compared to reference values. PS was approximately twice the normal value. CBF was higher (+6.14%), while MTT was lower (−9.34%) on the contralateral than on the ipsilateral side. All perfusion parameters improved after stenting on both the ipsilateral (CBF +22.66%; CBV +18.98%; MTT −16.09%, TTP −7.62%) and contralateral (CBF +22.27%, CBV +19.72%, MTT −14.65%, TTP −7.46%) sides. PS decreased by almost half: ipsilateral −48.11%, contralateral −45.19%. The decline in BBB permeability was symmetrical on the ipsi- and contralateral sides to the stenosis. Augmented BBB permeability can be controlled by surgical intervention in humans.

Intracranial Blood Flow Changes in Patients with High-Grade Severe Carotid Artery Stenosis After Stenting

OBJECTIVE

We investigated whether the cerebral hemodynamic changes of pre- and poststenting in patients with severe carotid stenosis differ by stenosis grades.

METHODS

We prospectively recruited patients who underwent carotid artery stenting (CAS) after acute ischemic stroke from June 2014 to December 2015. We compared the mean relative cerebral blood flow (rCBF) changes (measured by whole-brain computed tomography perfusion) pre- and poststenting in patients with high-grade severe stenosis (HGSS) (90%-99%) versus patients with low-grade severe stenosis (LGSS) (70%-89%).

RESULTS

Among 24 patients included in the study (mean age, 66.2 ± 7.2 years; 91.7% men), 62.5% (15/24) were in the HGSS group and 37.5% (9/24) were in the LGSS group. In the HGSS group, rCBF increased in territories of the anterior cerebral artery (P = 0.021), middle cerebral artery (P < 0.001), posterior cerebral artery (P = 0.001), and basil ganglia (P = 0.003) after stenting. Of the patients with HGSS, 53.3% (8/15) had collateral flow through anterior communicating artery (AcomA) prestenting. After stenting, all the AcomA collaterals in HGSS reverted to normal (P = 0.002).

CONCLUSIONS

The improvement of brain perfusion combined with the normalization of collateral flow through the circle of Willis after CAS was observed only in patients with HGSS.

Evaluation of Cerebral Hyperperfusion After Carotid Artery Stenting Using C‑Arm CT Measurements of Cerebral Blood Volume

PURPOSE

Hyperperfusion syndrome (HPS) after carotid artery stenting (CAS) causes serious symptoms; therefore, early evaluation after CAS is considered to be important. Measurement of cerebral blood volume using C‑arm computed tomography (C-arm CBV) has recently become possible. Here, the usefulness of C‑arm CBV for the evaluation of hyperperfusion was investigated.

METHODS

C-arm CBV was measured before and immediately after CAS in 30 patients. The regions of interest (ROI) were set in the bilateral middle cerebral artery perfused regions, and the affected/healthy side ratio of measured C‑arm CBV (CBV ratios) was determined to evaluate cerebral perfusion. For comparing values before and after CAS, the CBV ratio increase rate (postoperative CBV ratios/preoperative CBV ratios) was also determined.

RESULTS

C-arm CBV was successfully measured in 30 patients. Intracerebral hemorrhage (ICH) was detected in 3 patients, and no other patient had hyperperfusion syndrome. In the patients who developed ICH, postoperative C‑arm CBV on the affected side was high, and a marked increase was confirmed in the postoperative CBV ratios. Postoperative CBV ratios were 1.03 ± 0.40 and 1.45 ± 0.68 in the non-ICH and ICH groups, and CBV ratio increase rates were 2.7 ± 24.0% and 28.5 ± 26.7% in the non-ICH and ICH groups, respectively; these differences were statistically significant (P < 0.01).

CONCLUSION

C-arm CT allows CBV measurements immediately after CAS without requiring transport of the patient out of the angiography room, and it may enable the evaluation of hyperperfusion before and after CAS.

First-ever ischemic stroke in elderly patients: predictors of functional outcome following carotid artery stenting

Age is an important risk factor for stroke, and carotid artery stenosis is the primary cause of first-ever ischemic stroke. Timely intervention with stenting procedures can effectively prevent secondary stroke; however, the impact of stenting on various periprocedural physical functionalities has never been thoroughly investigated. The primary aim of this study was to investigate whether prestenting characteristics were associated with long-term functional outcomes in patients presenting with first-ever ischemic stroke. The secondary aim was to investigate whether patient age was an important factor in outcomes following stenting, measured by the modified Rankin scale (mRS). In total, 144 consecutive patients with first-ever ischemic stroke who underwent carotid artery stenting from January 2010 to November 2014 were included. Clinical data were obtained by review of medical records. The Barthel index (BI) and mRS were used to assess disability before stenting and at 12-month follow-up. In total, 72/144 patients showed improvement (mRS[+]), 71 showed stationary and one showed deterioration in condition (mRS[-]). The prestenting parameters, ratio of cerebral blood volume (1.41 vs 1.2 for mRS[-] vs mRS[+]), BI (75 vs 85), and high-sensitivity C-reactive protein (hsCRP 5.0 vs 3.99), differed significantly between the two outcome groups (P<0.05). The internal carotid artery/common carotid artery ratio (P=0.011), BI (P=0.019), ipsilateral internal carotid artery resistance index (P=0.003), and HbA1c (P=0.039) were all factors significantly associated with patient age group. There was no significant association between age and poststenting outcome measured by mRS with 57% of patients in the ≥75 years age group showing mRS(-) and 43% showing mRS(+) (P=0.371). Our findings indicate that in our elderly patient series, carotid artery stenting may benefit a significant proportion of carotid stenotic patients regardless of age. Ratio of cerebral blood volume, BI, and admission hsCRP could serve as important predictors of mRS improvement and may facilitate differentiation of patients at baseline.

Brain perfusion evaluated by perfusion-weighted magnetic resonance imaging before and after stenting internal carotid artery stenosis in asymptomatic and symptomatic patients

PURPOSE

To evaluate the brain perfusion with MRI perfusion weighted imaging (PWI) before and after ICA stenting in asymptomatic and symptomatic patients.

MATERIALS AND METHODS

PWI was performed 3-21 days before and 3 days after ICA stenting in 31 asymptomatic patients with ICA >70% stenosis - Group I, and in 14 symptomatic patients with ICA >50% stenosis - Group II. PWI was evaluated qualitatively and quantitatively in 5 cerebral territories with: mean transit time (MTT), cerebral blood volume (CBV) and cerebral blood flow (CBF). Mean values of perfusion parameters were measured before and after stenting ΔMTT, ΔCBV, ΔCBF were calculated as subtraction of after-treatment values from those before treatment.

RESULTS

In qualitative evaluation after ICA stenting perfusion was normalized in 21 patients (80.8%) in Group I and in 8 patients (80%) in Group II. In quantitative estimation MTT decreased significantly after CAS on stented side vs. non-stented side in all examined patients regardless of the group, p<0.05. MTT decreased more in Group II than in Group I in all territories (p<0.05) with the exception of temporal lobe. CBV and CBF have shown insignificant differences.

Changes in computed tomography perfusion parameters after superficial temporal artery to middle cerebral artery bypass: an analysis of 29 cases

Introduction Analysis of computed tomography perfusion (CTP) studies before and after superficial temporal artery to middle cerebral artery (STA-MCA) bypass is warranted to better understand cerebral steno-occlusive pathology. Methods Retrospective review was performed of STA-MCA bypass patients with steno-occlusive disease with CTP before and after surgery. CTP parameters were evaluated for change after STA-MCA bypass. Results A total of 29 hemispheres were bypassed in 23 patients. After STA-MCA bypass, mean transit time (MTT) and time to peak (TTP) improved. When analyzed as a ratio to the contralateral hemisphere, MTT, TTP, and cerebral blood flow (CBF) improved. There was no effect of gender, double vessel versus single vessel bypass, or time until postoperative CTP study to changes in CTP parameters after bypass. Conclusions Blood flow augmentation after STA-MCA bypass may best be assessed by CTP using baseline MTT or TTP and ratios of MTT, TTP, or CBF to the contralateral hemisphere. The failure of cerebrovascular reserve to improve after cerebral bypass may indicate irreversible loss of autoregulation with chronic cerebral vasodilation or the inability of CTP to detect these improvements.

Improved Hemodynamic Parameters in Middle Cerebral Artery Infarction After Decompressive Craniectomy

Background and Purpose—

Decompressive craniectomy (DC) reduces mortality and improves functional outcome in patients with malignant middle cerebral artery infarction. However, little is known regarding the impact of DC on cerebral hemodynamics. Therefore, our goal was to study the hemodynamic changes that may occur in patients with malignant middle cerebral artery infarction after DC and to assess their relationship with outcomes.

Methods—

Twenty-seven patients with malignant middle cerebral artery infarction who were treated with DC were studied. The perfusion CT hemodynamic parameters, mean transit time, cerebral blood flow, and cerebral blood volume were evaluated preoperatively and within the first 24 hours after DC.

Results—

There was a global trend toward improved cerebral hemodynamics after DC. Preoperative and postoperative absolute mean transit times were associated with mortality at 6 months, and the ratio of post- and preoperative cerebral blood flow was significantly higher in patients with favorable outcomes than those with unfavorable outcomes. Patients who underwent surgery 48 hours after stroke, those with midline brain shift >10 mm, and those who were >55 years showed no significant improvement in any perfusion CT parameters.

Conclusions—

DC improves cerebral hemodynamics in patients with malignant middle cerebral artery infarction, and the level of improvement is related to outcome. However, some patients did not seem to experience any additional hemodynamic benefit, suggesting that perfusion CT may play a role as a prognostic tool in patients undergoing DC after ischemic stroke.