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Circle of Willis Collateral During Temporary Internal Carotid Artery Occlusion I: Observations From Digital Subtraction Angiography

  • Stephen P. Lownie (a1), Ramiro Larrazabal (a2) and Maximilian K. Kole (a3)

Abstract

Introduction: Impaired collateral circulation can lead to stroke during carotid endarterectomy. Carotid stump pressure (CSP) is used as a surrogate measure of collateral flow. The objective was to determine whether anatomical features obtained from digital subtraction angiography correlate with CSP during temporary internal carotid artery occlusion. The second objective was to use these features in combination to predict CSP. Methods: Digital subtraction angiographies from 102 patients obtained before endarterectomy were reviewed for anatomical variables including: degree of ipsilateral and contralateral carotid artery stenosis; patency of the anterior communicating artery; presence of cross-flow into ipsilateral middle cerebral artery branches; and size (< or ≥1 mm calibre) of the ipsilateral proximal anterior cerebral (A1), the contralateral A1, and the ipsilateral posterior communicating arteries. At surgery, systemic mean arterial pressure (MAP) and CSP were recorded. Multiple regression analysis was used to assess for anatomical features significantly associated with CSP. A “predicted CSP” equation was applied to 54 subsequent patients and correlated with measured CSP. Results: Variables correlating with CSP included MAP (p=0.001); the presence of severe contralateral carotid stenosis (p=0.002); patency of the anterior communicating artery (p=0.013); and the size of the contralateral A1 segment (p=0.029). Angiographic cross-flow, ipsilateral A1 size, and ipsilateral posterior communicating artery size were not significant. Predicted CSP correlated significantly with measured CSP (p<0.0001; R 2=0.34). Conclusions: Anatomical features and systemic MAP are associated with carotid stump pressure during internal carotid artery occlusion and account for a significant amount of its variation.

Circulation collatérale dans le cercle artériel de Willis pendant une occlusion temporaire de la carotide interne. 1 : observations à l’angiographie numérique. Contexte: Pendant une endartérectomie carotidienne, une altération de la circulation collatérale peut donner lieu à un accident vasculaire cérébral. La pression dans le moignon carotidien (PMC) est utilisée comme mesure substitutive du flux collatéral. Le but de cette étude était de déterminer si les caractéristiques anatomiques obtenues à l’angiographie numérique correspondent à la PMC pendant une occlusion temporaire de la carotide interne. Le deuxième objectif était d’utiliser une combinaison de ces caractéristiques pour prédire la PMC. Méthodologie: Nous avons revu l’angiographie numérique obtenue chez 102 patients avant l’endartérectomie pour documenter les variables anatomiques dont le degré de sténose homolatéral et controlatéral de la carotide, la perméabilité de la communicante antérieure, la présence de flux transversal dans les branches de l’artère cérébrale moyenne homolatérale et la taille (calibre < ou ≥ 1mm) de l’artère cérébrale antérieure proximale homolatérale (A1), de l’A1 controlatérale et des artères communicantes postérieures homolatérales. Au moment de la chirurgie, la pression artérielle moyenne systémique (PAM) et la PMC ont été enregistrées. L’analyse de régression multiple a été utilisée pour identifier les caractéristiques anatomiques associées de façon significative à la PMC. La « PAM prédite » a été calculée prospectivement au moyen d’une équation chez 54 patients consécutifs et corrélée à la PMC mesurée. Résultats: Les variables corrélées à la PMC étaient les suivantes : la PAM (p=0,001) ; la présence d’une sténose carotidienne controlatérale sévère (p=0,002) ; la perméabilité de l’artère communicante antérieure (p=0,013) et la taille du segment A1 controlatéral (p=0,029). Le flux angiographique transversal, la taille de l’A1 homolatérale et la taille de l’artère communicante postérieure homolatérale n’étaient pas des variables significatives au point de vue statistique. La PMC prédite était corrélée de façon significative à la PMC mesurée (p<0,0001 ; R2=0,34). Conclusions: Les caractéristiques anatomiques et la PAM systémique sont associées à la pression dans le moignon carotidien pendant l’occlusion de la carotide interne et expliquent une grande partie de sa variation.

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Copyright

Corresponding author

Correspondence to: Stephen P. Lownie, Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5. Email: steve.lownie@lhsc.on.ca

References

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