Crossed Cerebellar Diaschisis in Patients With Symptomatic Unilateral Anterior Circulation Stroke Is Associated With Hemodynamic Impairment in the IpsilateralMCATerritory

Abstract

Background In patients with steno‐occlusive disease, recent findings suggest that hemodynamic alterations may also be associated with crossed cerebellar diaschisis (CCD) rather than a functional disruption alone. Purpose To use a quantitative multiparametric hemodynamic MRI to gain a better understanding of hemodynamic changes related to CCD in patients with unilateral anterior circulation stroke. Study Type Prospective cohort study. Population Twenty‐four patients (25 datasets) with symptomatic unilateral anterior circulation stroke. Field Strength/Sequence 3T/two sequences: single‐shot (echo‐planar imaging) EPI sequence and T2* gradient echo perfusion‐weighted imaging study. Assessment The presence of CCD was inferred from the cerebellar asymmetry index (CAI) of the blood oxygenation‐level dependent cerebrovascular reactivity (BOLD‐CVR) exam, which was calculated from the mean BOLD‐CVR and standard deviation of the CAI of the healthy control group. For all perfusion‐weighted (PW)‐MRI parameters, the cerebellar and middle cerebral artery (MCA) territory asymmetry indices were calculated. Statistical Tests Independent Student's t‐test to compare the variables from the CCD positive(+) and CCD negative(–) groups and analysis of covariance (ANCOVA) to statistically control the effect of covariates (infarct volume and time since ischemia onset). Results CCD was present in 33% of patients. In the MCA territory of the affected hemisphere, BOLD‐CVR was significantly more impaired in the CCD(+) group as compared to the CCD(–) group (mean BOLD‐CVR ± SD [%BOLD signal/ΔmmHgCO2]: –0.03 ± 0.12 vs. 0.11 ± 0.13, P < 0.05). Moreover, the mean transit time (MTT) (asymmetry index (%) CCD(+) vs. CCD(–): 28 ± 23 vs. 4 ± 11, P < 0.05) and time to peak (TTP) (10 ± 10 vs. 2 ± 5, P < 0.05) in the MCA territory of the affected hemisphere were significantly prolonged, while cerebral blood volume was, on average, increased in the CCD(+) group (25 ± 15 vs. 4 ± 19, P < 0.05). Data Conclusion Our findings show that, in patients with symptomatic unilateral anterior circulation stroke, CCD is associated with hemodynamic impairment in the ipsilateral MCA territory, which further supports the concept of a vascular component of CCD. Level of Evidence 3 Technical Efficacy Stage 3

Investigating the Association of Wallerian Degeneration and Diaschisis After Ischemic Stroke With BOLD Cerebrovascular Reactivity

“…Both ipsilateral thalamic diaschisis as well as crossed cerebellar diaschisis could be well detected with novel blood oxygenation-level dependent cerebrovascular reactivity (BOLD-CVR) ( Sebök et al, 2018 ; van Niftrik et al, 2019 ). Ipsilateral thalamic diaschisis exhibited impaired BOLD-CVR in and thalamic atrophy whereas presence of crossed cerebellar diaschisis detected with BOLD-CVR showed an association with hemodynamic impairment, thereby further supporting the concept of a vascular component ( Sebök et al, 2021 ; van Niftrik et al, 2019 ; von Bieberstein et al, 2020 ).…”

“…Diaschisis is a process primarily showing remote neurophysiological changes after a supratentorial lesion ( Carrera and Tononi, 2014 ). Areas with diaschisis experience a decrease in cerebral blood flow, metabolism and BOLD-CVR and can be found directly after the stroke ( Baron et al, 1981 ; De Reuck et al, 1995 ; Kamouchi et al, 2004 ; Sebök et al, 2021 ). These classical hemodynamic features, normally found in diaschisis, were not found in the cerebral peduncle of subjects with Wallerian degeneration.…”

“…For the healthy cohort, a similar BOLD-CVR analysis was done. Average and standard deviations were calculated, of the cerebellar and thalamic asymmetry indices of the healthy control group ( Sebök et al, 2021 ). Diaschisis (i.e., crossed cerebellar diaschisis and ipsilateral thalamic diaschisis) was deemed present if the asymmetry index in BOLD-CVR was more than plus two standard deviations larger than that of the healthy cohort average ( Sebök et al, 2018 ; van Niftrik et al, 2019 ).…”

The Reproducibility of Cerebrovascular Reactivity Across MRI Scanners

“…Stimulus standardization requires precise, repeatable changes in PaCO 2 independent of subject, or patient, efforts. A standardized “brain stress test” would provide a uniform platform from which to assess and manage a wide variety of disorders affecting brain blood flow regulation, such as in steno-occlusive disease ( Brawley et al, 1967 ; Brawley, 1968 ; Symon, 1969 ; Kleiser and Widder, 1992 ; Yonas et al, 1993 ; Webster et al, 1995 ; Molina et al, 1999 ; Markus and Cullinane, 2001 ; Ogasawara et al, 2002 ; Sasoh et al, 2003 ; Mandell et al, 2008 , 2011 ; Fierstra et al, 2010 ; Silvestrini et al, 2011 ; Sobczyk et al, 2016 ), glioma ( Fierstra et al, 2018a ; Sebok et al, 2020 ), arteriovenous malformations ( Fierstra et al, 2011 ), traumatic brain injury ( Da Costa et al, 2016 ; Mutch et al, 2016 ) and remote stroke effects ( Sebok et al, 2018 ; Hendrik Bas van Niftrik et al, 2020 ; Sebok et al, 2021 ). The advancement of the clinical and research applications of CVR has required, first, the standardization of the method ( Sobczyk et al, 2014 ; Sobczyk et al, 2015 ), and second, the verification of the repeatability of the test ( Sobczyk et al, 2015 ; Sobczyk et al, 2016 ).…”

Editorial for “Crossed Cerebellar Diaschisis in Patients With Symptomatic Unilateral Anterior Circulation Stroke Is Associated With Hemodynamic Impairment in the Ipsilateral MCA Territory”

“…In a recent article published by Sebök et al in the current edition of JMRI, “Crossed cerebellar diaschisis in patients with symptomatic unilateral anterior circulation stroke is associated with hemodynamic impairment in the ipsilateral MCA territory,” 1 the authors employed the RespiRact to determine cerebrovascular reactivity (BOLD‐CVR). They detected cerebellar diaschisis in the setting of completed ischemic stroke and employed standard magnetic resonance imaging (MRI) techniques to measure perfusion‐weighted MR (PW‐MRI) parameters in the ischemic cortical vascular territory.…”