Fractional Flow in Cerebrovascular Disorders
David S Liebeskind1, Edward Feldmann
1UCLA Stroke Center, Los Angeles, CA, USA.
Insights
Current stroke care focuses on outdated anatomical measures, leading to poor patient selection. Adopting hemodynamic parameters, like fractional flow, can improve the identification of critical lesions and guide advanced stroke treatments.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Medical Technology
Background:
- Traditional stroke care relies on anatomical stenosis measurements, which are insufficient for identifying high-risk lesions.
- Current acute ischemic stroke management, focused on time and complete revascularization, overlooks critical lesion characteristics and pathophysiology.
- This approach hinders understanding of ischemia, reperfusion, and related complications, impeding treatment advancements.
Purpose of the Study:
- To highlight the limitations of current stroke care paradigms.
- To advocate for a shift towards hemodynamic and pathophysiological assessments in cerebrovascular disease management.
- To introduce fractional flow as a key hemodynamic parameter for guiding stroke patient care.
Main Methods:
- Critique of traditional anatomical stenosis assessment in stroke.
- Comparison of current stroke care with advancements in cardiology.
- Introduction of hemodynamic principles, specifically fractional flow, for cerebrovascular evaluation.
Main Results:
- Anatomical stenosis measurements inadequately predict recurrent ischemia and lead to suboptimal patient selection.
- Current acute stroke protocols fail to account for lesion nature and degree, complicating understanding of reperfusion dynamics.
- Hemodynamic and pathophysiological approaches, analogous to cardiology, are proposed as superior guides for stroke care advancement.
Conclusions:
- A paradigm shift in stroke care is urgently needed, moving from anatomical to hemodynamic and pathophysiological assessments.
- Fractional flow is proposed as a critical hemodynamic parameter to guide the advancement of stroke patient care.
- Implementing these new approaches will enhance lesion identification, improve patient selection, and facilitate the development of more effective stroke treatments.
Abstract:
There is an urgent need for stroke experts to advance the care of their patients, yet current approaches are outmoded and have not been successful. The traditional emphasis on anatomical identification of disease, using percent luminal stenosis, results in suboptimal identification of lesions likely to produce recurrent ischemia and, consequently, results in poor patient selection and hampers the development of new aggressive treatments. The traditional emphasis on time since symptom onset and alleged need to achieve complete revascularization in patients with acute ischemic stroke ignores the very nature and degree of the underlying culprit lesion and hampers our understanding of the relationships between the patient's original ischemic state, revascularization, reperfusion, reperfusion injury and hemorrhagic transformation. The trajectory for the study and care of cerebrovascular patients needs to adapt, as it has in cardiology, employing hemodynamics and pathophysiology as the new guideposts for advancement. We introduce fractional flow as one hemodynamic parameter to be utilized to set a course on this new path for the care of stroke patients.
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