Pattern of Activated Pathways and Quality of Collateral Status in Patients with Symptomatic Internal Carotid Artery
Florian Connolly1, Jens E Röhl2, Javier Lopez-Prieto3
1Department of Neurology, University Hospital Charité, Berlin, Germany, florian.connolly@charite.de.
Insights
Internal carotid artery occlusion (ICAO) increases stroke risk. Transcranial color-coded sonography (TCCS) effectively assesses intracranial collaterals, with anterior communicating artery (ACoA) flow crucial for compensation.
Area of Science:
- Neurology
- Vascular Medicine
- Medical Imaging
Background:
- Internal carotid artery occlusion (ICAO) is a significant stroke risk factor.
- Cerebral hemodynamics in ICAO patients rely on collateral pathway activation.
- Assessing intracranial collaterals is vital for managing ICAO and stroke risk.
Purpose of the Study:
- To evaluate the hemodynamic capacity of intracranial collaterals in acute stroke patients with unilateral ICAO.
- To correlate transcranial color-coded sonography (TCCS) findings with stroke patterns.
- To determine the most effective collateral pathways for hemodynamic compensation in ICAO.
Main Methods:
- Prospective enrollment of acute stroke patients with unilateral ICAO.
- Assessment of anterior and posterior communicating arteries (ACoA, PCoA), ophthalmic artery (OA), and leptomeningeal collaterals (LMC) using TCCS.
- Categorization of middle cerebral artery (MCA) flow patterns (good, moderate, bad) and comparison with CT/MRI findings.
Main Results:
- 113 patients included; 52% had good collateral status.
- ACoA was most frequently activated (81%), followed by OA (63%) and PCoA (53%).
- Collateral quality, not number, determined status; ACoA and antegrade OA flow indicated good compensation.
Conclusions:
- TCCS effectively assesses intracranial collateral hemodynamic capacity in ICAO.
- Collateral sufficiency in ICAO may be more prevalent than previously thought.
- ACoA cross-flow and antegrade OA flow are key indicators of effective hemodynamic compensation.
Background:
Internal carotid artery occlusion (ICAO) is an important risk factor for stroke. Cerebral hemodynamics in patients with ICAO depends on the individual capacity to activate sufficient collateral pathways. Therefore, the assessment of intracranial collaterals is essential for the acute and long-term management of these patients and accurate estimation of further stroke risk.
Methods:
Acute stroke patients with unilateral ICAO were prospectively enrolled. We assessed the following collaterals by transcranial color-coded sonography (TCCS): the anterior and posterior communicating artery (ACoA, PCoA), the ophthalmic artery (OA), and leptomeningeal collaterals of the posterior cerebral artery (LMC). We subdivided the flow pattern of the Doppler spectrum in the middle cerebral artery (MCA) into 3 categories: (1) good, (2) moderate, and (3) bad according to the hemodynamic effects on the ipsilateral MCA flow. Finally, we compared the individual TCCS results with the stroke pattern detected on CT or MRI scan.
Results:
One hundred thirteen patients (age 66 ± 12 years; -female 24) were included. The collateral status was good, moderate, and bad in 59 (52%), 37 (33%), and 17 (15%) patients, respectively. The ACoA collateral was most frequently activated (81%), followed by the OA (63%), the PCoA (53%), and the LMC (22%). The quality of the collateral status was determined by the type (p = 0.0003) but not by the number (p = 0.19) of activated collateral pathways. Good collateral function was highly associated with primary collaterals (ACoA > PCoA). Best parameter for a good collateral status was an antegrade flow in the OA, indicating a high blood supply via the communicating arteries.
Conclusions:
TCCS allows the assessment of intracranial collaterals and their hemodynamic capacity. Prevalence of collateral sufficiency in ICAO seems to be higher than previously reported. ACoA cross flow is essential for the optimal hemodynamic compensation of ICAO. Antegrade OA flow indicates good collateral status.
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