Ophthalmic artery flow direction change predicts recurrence of ischemic stroke after carotid stenting: a longitudinal observational study

Abstract

Background and purpose The implantation of carotid artery stents prevents recurrent ischemic stroke in patients with carotid stenosis. This study aimed to investigate associations between change of ophthalmic artery flow (COAF) post carotid stenting and recurrent ischemic stroke, as well as the link toward the anterior and posterior circulations and patients’ prognosis after carotid stenting. Methods This retrospective, longitudinal cohort study recruited 87 left side carotid stenosed ischemic stroke patients undergoing left side carotid stenting between year of 2009 and 2013, and patients were followed up to 9 years after carotid procedures. Clinical data were derived from medical records. The primary outcome was stroke recurrence. Predictive factors were stenosis > 50% in one intracranial artery and ROAF. Kaplan–Meier and Cox regression analyses were used to identify risk factors associated with stroke recurrence. Results Among 87 included patients undergone left side carotid stent treatment, 44 had stroke recurrence within 3 years after carotid stenting. The recurrence group had significantly greater proportions of COAF after stenting (p = 0.001), and middle cerebral artery (MCA) and basilar artery or vertebral artery (BA/VA) stenosis > 50% (all p < 0.001) than the no-recurrence group. Survival was significantly shorter in patients with COAF than in those without (p < 0.01). Regression analysis showed that COAF was associated with stroke recurrence (HR: 3.638, 95% CI 1.54–8.62, p = 0.003). The recurrence rate was highest in patients with bilateral MCA stenosis > 50% (100%), followed by left MCA stenosis > 50% plus BA/VA stenosis > 50% (83.33%) or COAF (82.14%). Patients with bilateral MCA stenosis < 50% had no recurrence within 3-year follow-up. Conclusions Prognosis after carotid stenting is poorer for patients with MCA stenosis > 50%, BA/VA stenosis > 50% and/or COAF. Carotid duplex and magnetic resonance angiography provide definitive information for prognosis prediction.

Impact of cerebral collateral flow on stroke outcomes after carotid stenting

“…Reversal of ophthalmic artery/leptomeningeal anastomosis is associated with recurrent stroke only with the coexistence of primary collateral insufficiency, because both primary and secondary collaterals have been activated to support the hypoperfused cerebral hemisphere. 6 The disadvantages of transcranial color-coded duplex sonography (TCCS) include that it is operator-dependent, time-consuming, and requires advanced training in the medical institution to accurately perform the examination. However, TCCS allows noninvasive assessment of intracranial collaterals.…”

“…The present study showed that ipsilateral ROALA alone was not associated with recurrent stroke. Reversal of ophthalmic artery/leptomeningeal anastomosis is associated with recurrent stroke only with the coexistence of primary collateral insufficiency, because both primary and secondary collaterals have been activated to support the hypoperfused cerebral hemisphere 6 …”

“…stenting treatment based on results of the modified Rankin Scale (mRS) at three months after the treatment. [3][4][5] Another study also revealed the coexistence of intracranial large artery stenosis, specifically middle cerebral artery stenosis (>50% lumen reduction) identified using magnetic resonance imaging and arteriography (MRI/ MRA) with weak functional outcomes assessed by both Barthel Index and mRS. 6,7 Transcranial color-coded duplex (TCCD) is a noninvasive clinical neuroimaging modality with the advantages of mobility, repeatability, and noncontrast modality. Although its clinical use in combination with extracranial carotid duplex examination can thoroughly assess stroke patients' intracranial and extracranial basal artery vasculature conditions, it remains an underused and neglected tool.…”

“…Our previous studies reported that the detection of the reversal of the ophthalmic artery via extracranial carotid duplex examination predicted unfavorable outcomes after stenting treatment based on results of the modified Rankin Scale (mRS) at three months after the treatment 3–5 . Another study also revealed the coexistence of intracranial large artery stenosis, specifically middle cerebral artery stenosis (>50% lumen reduction) identified using magnetic resonance imaging and arteriography (MRI/ MRA) with weak functional outcomes assessed by both Barthel Index and mRS 6,7 . Transcranial color‐coded duplex (TCCD) is a noninvasive clinical neuroimaging modality with the advantages of mobility, repeatability, and noncontrast modality.…”