Collateral Assessment by CT Angiography as a Predictor of Outcome in Symptomatic Cervical Internal Carotid Artery Occlusion

Sundaram, Sandhya; Kannoth, Sudheeran; Thomas, Bright; Sarma, P. Sankara; Sylaja, PN

doi:10.3174/ajnr.a4957

Cited by 34 publications

(25 citation statements)

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“…In contrast, in Sundaram's study, among patients suffering intracranial carotid artery occlusion, the odds of a favorable outcome at 90 days after onset was higher in the group with ipsilateral ophthalmic artery or leptomeningeal collaterals than in those with a complete Willis' circle (Sundaram, Kannoth, Thomas, Sarma, & Sylaja, ). However, in their study, they included patients who were up to 3 weeks after onset, and their patients differed from candidates for EVMT.…”

Section: Discussionmentioning

confidence: 82%

“…Several methods, including CTA (Sundaram et al, ; Yeo et al, ) and MR (Alves et al, ), have been established to evaluate collateral status. Although CTA is highly accurate in the assessment of anatomical variations of Willis' circle, its sensitivity remains limited in its ability to reveal hypoplastic segments (Han et al, ), and time‐of‐flight (TOF) MRA has disadvantages in a setting involving slow flow at the site of occlusion, which often results in complete loss of the signal in arteries and the consequential underestimation of collateral status (Raymond & Schaefer, ).…”

Section: Discussionmentioning

confidence: 99%

“…A similar finding was presented in Silvestrini et al (2011), in which the preservation of at least two activated intracranial collateral vessels (the ophthalmic artery, AcoA or PcoA) produced a significant trend toward favorable outcomes in patients with internal carotid artery occlusion due to dissection. Several methods, including CTA (Sundaram et al, 2017;Yeo et al, 2015) and MR (Alves et al, 2018), have been established to evaluate collateral status. Although CTA is highly accurate in the assessment of anatomical variations of Willis' circle, its sensitivity remains limited in its ability to reveal hypoplastic segments (Han et al, 2011), and time-of-flight (TOF) MRA has disadvantages in a setting involving slow flow at the site of occlusion, which often results in complete loss of the signal in arteries and the consequential underestimation of collateral status (Raymond & Schaefer, 2017).…”

Section: Discussionmentioning

confidence: 99%

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Collateral grade of the Willis' circle predicts outcomes of acute intracranial internal carotid artery occlusion before thrombectomy

Zhao

Wang²,

et al. 2019

Brain and Behavior

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Background and PurposeEndovascular mechanical thrombectomy (EVMT) shows significant promise in improving acute ischemic stroke (AIS) with proximal artery occlusion, but outcomes have been variable. We explored the patients treated by thrombectomy to investigate the association between a favorable clinical outcome of EVMT in intracranial internal carotid artery occlusion (iICAO) and a set of predictors.MethodsA total of 38 iICAO patients treated by EVMTs were analyzed. Primary collateral grades (PCG) at baseline based on the integrity of Willis' circle were categorized into three degrees. The favorable outcomes, measured by modified Rankin scale (mRS), were defined as ≤2 at 90 days. The reperfusion was one of the most important confounders, defined as modified thrombolysis in cerebral infarction (mTICI) ≥ 2b. The other risk factors included demographic characteristics, vascular risk factors, stroke severity, procedural EVMT, and PCG at baseline was adjusted to reveal the association with favorable outcomes.ResultsOf 38 iICAO patients, 65.8% (25 in 38) achieved reperfusion. However, only 31.6% (12/38) achieved favorable outcomes at 90 days. With a PCG3, 61.5% of them achieved favorable outcomes, while only 37.5% of those with PCG2 and PCG1 achieved favorable outcomes (p = .003). In multivariable logistic regression, PCG was revealed as a predictor for favorable outcomes (OR 5.278, p = .019) after adjusting the reperfusion and other factors.ConclusionsThe PCG based on the integrity of Willis' circle might be an underlying predictor of the prognosis of AIS in patients with iICAO after EVMT. The function of intact anterior communicating artery (AcoA) and ipsilateral posterior communicating artery (PcoA) in favoring prognosis of the iICAO patients might need to be validation in future study.

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Collateral grade of the Willis' circle predicts outcomes of acute intracranial internal carotid artery occlusion before thrombectomy

Zhao

Wang²,

et al. 2019

Brain and Behavior

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“…Following CTO of the ICA, perfusion pressure at the vascular occlusion is decreased ( 27 ). In response to the deficient blood supply from main arteries, the cerebral blood flow (CBF) immediately establishes collateral circulation; this involves immediate diversion of blood flow in the event of large-vessel occlusion, as well as chronic compensation by secondary collaterals such as the ipsilateral ophthalmic artery, ipsilateral posterior communicating artery, anterior communicating artery and pia mater collaterals ( 28 ). Effective leptomeningeal collateral circulation and the presence of more than 2 collaterals have been associated with good clinical condition without severe disability ( 28 ).…”

Section: Hemodynamicsmentioning

confidence: 99%

Current understanding of chronic total occlusion of the internal carotid artery (Review)

Guo

et al. 2017

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At present, there is limited understanding of chronic total occlusion (CTO) of the internal carotid artery (ICA). Therefore, the present report collected related cases from PubMed and reviewed the literature. Cerebral vessels may form collateral circulation immediately or gradually following CTO of the ICA. The natural history of CTO of the ICA includes a variety of outcomes, all of which are biased toward a non-benign progressive process and are characterized by insufficient cerebral perfusion, embolus detachment and cognitive dysfunction. The majority of cases of CTO of the ICA require treatment. In early studies, the results of external-ICA bypass were unsatisfactory, while recanalization is now considered the only viable option. The current treatment indications mainly depend on the degree of injury to the cerebrovascular reserve and the extent to which the oxygen extraction fraction is increased. The length, height and duration of ICA occlusion are also relevant, though more frequently, the condition depends on multiple factors. Endovascular interventional recanalization, carotid endarterectomy (CEA) and hybrid surgery may be conducted in a select group of patients. As novel materials are developed, the success rate of simple recanalization may gradually increase; however, hybrid surgery may be more representative of the current trend, as advanced CEA can remove carotid atherosclerosis plaques, thus reducing the technological demands of the subsequent interventional recanalization. There are many complications that may result from recanalization following CTO of the ICA, including hyperperfusion and technical errors; therefore, the operation must be conducted carefully. If the recanalization is successful, it typically results in a stable improvement of patient condition in the long term. However, despite these conclusions, more studies are required in the future to further improve current understanding of CTO of the ICA.

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“…Their results are consistent with our grading system. Sundaram et al (14) found that patients with 2 or more collaterals (ipsilateral OA, ipsilateral PCOM, ACOM, and Leptomeningeal collaterals) had excellent outcomes, indicating that as more collaterals were recruited, thus providing an effective compensatory mechanism. This finding is partially consistent with our grading system as more than 2 collaterals are important for maintaining adequate cerebral perfusion.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Intracranial Collateral Circulation Using Novel TCCS Grading System in Patients With Symptomatic Carotid Occlusion

et al. 2020

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Objectives: To establish a novel transcranial color-coded sonography (TCCS) grading system for collateral circulation in cases of symptomatic chronic total carotid occlusion (TCO), and to correlate this new grading system with cerebrovascular reserve capacity (CVR) measured by SPECT. Methods: Thirty-four patients with symptomatic chronic TCO recruited from the neurovascular ultrasound laboratory of the department of Neurology at Cairo University Hospital during 3 years' time period and diagnosed by color-coded duplex were subjected to: clinical assessment, grading of cerebral collaterals using a proposed TCCS criteria, Brain SPECT studies at rest and with dipyridamole stress. Results: The new grading system for cerebral collateral circulation showed a significant positive correlation with CVR (P < 0.001 and Spearman correlation coefficient 0.686). Conclusion: The current study showed that this new TCCS grading system for cerebral collaterals is a reliable indicator for cerebral perfusion and reserve capacity in cases of chronic symptomatic TCO.

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Collateral Assessment by CT Angiography as a Predictor of Outcome in Symptomatic Cervical Internal Carotid Artery Occlusion

Abstract: Assessment of collateral circulation with CTA can be a useful predictor of 3-month outcome in patients with symptomatic cervical ICA occlusion.

Cited by 34 publications

References 26 publications

Collateral grade of the Willis' circle predicts outcomes of acute intracranial internal carotid artery occlusion before thrombectomy

Collateral grade of the Willis' circle predicts outcomes of acute intracranial internal carotid artery occlusion before thrombectomy

Current understanding of chronic total occlusion of the internal carotid artery (Review)

Assessment of Intracranial Collateral Circulation Using Novel TCCS Grading System in Patients With Symptomatic Carotid Occlusion

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