The Cerebral Collateral Cascade

Faizy, Tobias D.; Mlynash, Michael; Kabiri, Reza; Christensen, Søren; Kuraitis, Gabriella; Mader, Marius Marc-Daniel; Flottmann, Fabian; Broocks, Gabriel; Lansberg, Maarten G.; Albers, Gregory W.; Marks, Michael P.; Fiehler, Jens; Wintermark, Max; Heit, Jeremy J

doi:10.1212/wnl.0000000000200340

Cited by 33 publications

(24 citation statements)

References 32 publications

(51 reference statements)

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“…We have recently described the CCC, which combines information about the quality of PAC bringing blood to ischemic brain, the robustness of TLC as the blood flows into capillaries, and how well VO occurs. 26 We will now discuss 3 critical stages of the CCC in more detail. These stages are PAC, TLC, and VO.…”

Section: Stroke Pathophysiology and The Comprehensive Collateral Cascadementioning

confidence: 99%

Rethinking the Collateral Vasculature Assessment in Acute Ischemic Stroke

Faizy

Heit

2021

Topics in Magnetic Resonance Imaging

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Occlusion of a cervical or cerebral artery results in disruption of blood flow to the brain and may result in irreversible infarction. Intracranial pial collaterals are a network of arteries that may preserve blood flow to otherwise critically hypoperfused brain areas until vessel recanalization is achieved. The robustness of these arterial collaterals is pivotal for the survivability of ischemic brain tissue and is associated with treatment success and long-term clinical outcome. More recently, the importance of venous outflow from ischemic brain tissue has been appreciated. Arterial collaterals and venous outflow are evaluated by neuroimaging parameters, and recent imaging advances have enabled a more comprehensive assessment of the entire collateral cascade in patients with acute ischemic stroke. Here we review novel imaging biomarkers for the assessment of arterial collaterals, tissue-level collateral blood flow, and venous outflow. We also summarize how a more comprehensive assessment of the cerebral blood flow leads to a better prediction of treatment efficacy and improved clinical outcomes.

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Section: Stroke Pathophysiology and The Comprehensive Collateral Cascadementioning

confidence: 99%

Rethinking the Collateral Vasculature Assessment in Acute Ischemic Stroke

Faizy

Heit

2021

Topics in Magnetic Resonance Imaging

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“…Combining the 3 may offer a better predictor of clinical and radiologic outcomes in patients undergoing thrombectomy. This intriguing hypothesis drives the recent article by Faizy et al 1 published in this issue of Neurology® , which builds on prior work by these authors.…”

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confidence: 55%

“…That is an exciting future, but in the meantime, we need a deeper understanding of the CCC and its implications. Studies like that of Faizy et al 1 help illuminate the path forward.…”

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confidence: 96%

Evaluating Collaterals in Stroke

Sharma

Leslie‐Mazwi

2022

Neurology

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The concept of the penumbra, brain tissue that is ischemic but not yet infarcted, has guided acute stroke care for >2 decades. Penumbral tissue usually remains functionally silent because cessation of neuronal transmission is a cellular adaptation to stress. The presenting clinical deficits in patients with stroke are thought to be caused by impairments in infarcted and penumbral tissue. In patients with large vessel occlusion (LVO) stroke, the volume of both the infarct and the penumbra factors into treatment decisions. Reperfusion therapy aims to save the penumbral tissue, allowing restoration of function and recovery. Given that the penumbra is sustained through collateral blood flow, inferring the presence of both infarct and penumbra through assessment of collaterals radiographically is conceptually appealing.

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“…While Tan score and HIR in adult patients has been strongly correlated, discrepancies have also been reported. Faizy et al 27 reported that patients with a mixed favorable/unfavorable "collateralome" appear to have worse radiographic and clinical outcomes than those with uniformly favorable collateral parameters.…”

Section: Discussionmentioning

confidence: 99%

Hyperacute Perfusion Imaging Before Pediatric Thrombectomy

et al. 2023

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Background:Perfusion imaging can identify adult patients with salvageable brain tissue who would benefit from thrombectomy in later time windows. The feasibility of obtaining hyperacute perfusion sequences in pediatric stroke is unknown. The aim of this study was to determine whether contrast perfusion imaging delayed time to treatment, and to assess perfusion profiles in children with large vessel occlusion stroke.Methods:The Save ChildS retrospective cohort study (January 2000–December 2018) enrolled children (1 month-18 years) with stroke who underwent thrombectomy from 27 European and United States stroke centers. This secondary analysis included patients with anterior circulation occlusion and available imaging for direct review by the neuroimaging core lab. Between-group comparisons were done using the Wilcoxon rank sum exact test for continuous variables or Fisher’s exact test for binary variables. Given the small number of patients, evaluation of perfusion imaging parameters was performed descriptively only.Results:Of 33 patients with available neuroimaging, 15 (45.4%) underwent perfusion (CT perfusion n=6; MR perfusion n=9); all were technically adequate. Median time from onset to recanalization did not differ between groups (4 hours [IQR 4-7.5] perfusion+; 3.4 hours [IQR 2.5-6.5] perfusion-, p=0.158). Target mismatch criteria was met by 10/15 patients (66.7%) and did not correlate with reperfusion status or functional outcome. Hypoperfusion intensity ratio was favorable in 11/15 patients, and correlated with older age but not NIHSS, time to recanalization, or stroke etiology. Favorable hypoperfusion intensity ratio was associated with better functional outcome at 6 months (Pediatric Stroke Outcome Measure 1.0 [IQR 0.5-2.0] versus 2.0 [1.5-3.0], p=0.026) and modified Rankin Scale 1.0 [0-1] versus 2.0 [1.5-3.5], p=0.048) in this small sample.Conclusions:Automated perfusion imaging is feasible to obtain acutely in children and does not delay time to recanalization. Larger prospective studies are needed to determine biomarkers of favorable outcome in pediatric ischemic stroke and to establish core and penumbral thresholds in children.

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The Cerebral Collateral Cascade

Cited by 33 publications

References 32 publications

Rethinking the Collateral Vasculature Assessment in Acute Ischemic Stroke

Rethinking the Collateral Vasculature Assessment in Acute Ischemic Stroke

Evaluating Collaterals in Stroke

Hyperacute Perfusion Imaging Before Pediatric Thrombectomy

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