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Revaluation of collateral pathways as escape routes from hyperemia/hyperperfusion following surgical treatment for carotid stenosis

  • Clinical Article
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Abstract

Background

Although acetazolamide-challenged single-photon emission CT (SPECT) is recommended before carotid endarterectomy (CEA) and carotid artery stenting (CAS), given the relationship between preoperative decreased cerebrovascular reserve (CVR) and postoperative cerebral hyperperfusion syndrome (CHS), it is controversial whether all cases should be checked.

Methods

I-IMP-SPECT at rest was performed for 65 operative cases of carotid stenoses. At preoperative MR angiography we classified cases into two groups: G, featuring an anterior communicating artery with bilateral A1 with/without posterior communicating arteries; and P, a poor-escape-route group which did not match these criteria. Postoperative rCBF patterns were divided into two types: B, bilateral rCBF increase; and I, ipsilateral rCBF increase.

Results

Cases with high postoperative increase rate of rCBF were most frequently found in Group P and the Type I cases (p < 0.001). All four cases with hyperemia or hyperperfusion belonged to Group P. Only two out of 48 patients in Group G were Type I, both demonstrating a preoperative rCBF decrease rate more than 10 % as compared to the contralateral side.

Conclusions

From the present study, preliminary analysis of escape routes by preoperative MR angiography before surgical treatment of carotid stenosis is recommended and CVR investigation with acetazolamide-challenge SPECT should be considered for those relatively few cases with poor escape routes.

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Acknowledgments

We thank Norimasa Takayanagi, Daiichi Radioisotope Laboratory for his technical support regarding 3DSRT and FineSRT, and Naoko Abe, Kojiro Hirose and all other staff for their invaluable assistance with SPECT.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan

    Hiroyuki Katano, Mitsuhito Mase & Kazuo Yamada

  2. Department of Medical Informatics & Integrative Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan

    Hiroyuki Katano

  3. Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan

    Keita Sakurai & Shigenori Miyachi

Authors
  1. Hiroyuki Katano
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  2. Mitsuhito Mase
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  3. Keita Sakurai
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  4. Shigenori Miyachi
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  5. Kazuo Yamada
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Corresponding author

Correspondence to Hiroyuki Katano.

Additional information

Comment

Here is an excellent communication with a novel idea and hypothesis from an experienced carotid intervention group in Nagoya. The goal was to identify preoperatively anatomical arterial characteristics, specifically predictably poor runoff (the P group), that could predict potential postoperative hyperemia and hyperpefusion syndromes.

As a preamble, I should say that it has not been our policy to perform SPECT scans in the routine workup of carotid surgery patents. Our rate of postoperative intracerebral hemorrhage is vanishing small (almost zero) for unclear reasons, so we have not developed a practice strategy to predict at-risk patients. Katano and colleagues, however, with this sentinel work, have convinced me that a clearer understanding of the risks and a rational evaluation strategy are worthwhile.

To summarize succinctly, patients with a good escape route (G) based on collateral anatomy, had low risk of hyperperfusion clinically or by SPECT. Three quarters of their patients were G type patients. Only two of these developed ipsilateral hyperpefusion post-treatemnt (Group I). By contrast, poor-runoff patients (P) were at high risk to revert to the I group and to have clinical symptoms as well.

So I am convinced that these authors can predict in their practice which patients are at risk for hyperemia based on anatomy (P) and thus can narrow down the focus of SPECT studies based on preoperative MRA data. The question is, what should we do with the information? To me, patients needing CEA or CAS for established indications will receive treatment whether they are “P” patients or not. Perhaps I would be more aggressive about ICU care and strict blood pressure control postoperatively based on “P” status, or SPECT data, but strict BP control and ICU observation are already my practice standard. This may account for the fact that despite my imperfect knowledge of this pathophysiology, we essentially never seen postoperative hyperperfusion syndrome or intracerebral hemorrhage, even though we sometimes have patients anticoagulated postoperatively, for prosthetic heart valves or bilateral symptomatic carotid disease.

I have learned from the Nagoya team here, and I better understand the physiology of collateral circulation as a result, and this in itself is worthwhile to the readership.

Christopher Miranda Loftus

Philadelphia, USA

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Katano, H., Mase, M., Sakurai, K. et al. Revaluation of collateral pathways as escape routes from hyperemia/hyperperfusion following surgical treatment for carotid stenosis. Acta Neurochir 154, 2139–2149 (2012). https://doi.org/10.1007/s00701-012-1498-7

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  • DOI: https://doi.org/10.1007/s00701-012-1498-7

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