Impact Of Collateral Circulation Research Articles

Differences in stroke clinical presentation among sexes

IntroductionThere are sex-based differences in stroke epidemiology, treatment, and outcomes. In this manuscript, we discuss the differences that exist in the clinical presentation of acute stroke among sexes. DiscussionWe present the differences in stroke presentation among sexes including age at the time of presentation, severity of stroke on presentation, and stroke type and location. We discuss the atypical clinical presentations, explore the radiographic findings on presentation (including location, infarct core volume, the impact of collateral circulation, hematoma location in intracranial hemorrhage), and discuss differences in time elapsed between symptom onset and management amongst sexes. ConclusionDifferences exist in stroke clinical presentation amongst sexes. These disparities have public health implications, and as they become better understood, impact awareness campaigns in both the public and healthcare communities.

Role of collateral circulation in the recovery of left ventricular function after recanalization of chronic coronary total occlusion

Aim. To obtain extended data on the impact of collateral circulation on the recovery of left ventricular (LV) function after recanalization of chronic coronary total occlusion (CTO), especially in patients with reduced left ventricle ejection fraction (LVEF).Material and methods. This single-center, prospective, non-randomized study included 20 patients with single-vessel CTO with reduced LVEF (<50%), confirmed by magnetic resonance imaging (MRI), who underwent successful recanalization. All patients were divided into 2 groups depending on the severity of collateral circulation. After 1, 3 and 6 months, MRI was repeated to assess LV function recovery.Results. All patients had prior myocardial infarction, while in 70% of cases — in the area of the occluded artery. A previous attempt to recanalize CTO was noted in 30%. The mean baseline LVEF according to echocardiography was 38,80±6,72%. The most common target vessel was the right coronary artery (n=17, 85%), followed by the circumflex and anterior descending arteries — 1 (5%) and 2 (10%) patients, respectively. In the group with high collateral circulation, the initial LVEF according to MRI was higher compared to the group with mild collateral circulation (35,8±7,33% vs 30,7±8,82%, p=0,17). After 6 months, MRI showed significant changes in end-diastolic volume (from 226±71,1 ml to 203±55,2 ml) and LV endsystolic volume (from 153±72,8 ml to 118±57,6 ml), as well as mean increase in LVEF by 3,3%, 4,8% and 5,2% at 1, 3 and 6 months, respectively (p=0,01 compared with baseline). The predictors of LVEF recovery in multivariate regression analysis were the initial LVEF according to MRI, and the filling rate of distal CTO bed on coronary angiography (R2=0,63).Conclusion. Successful percutaneous coronary intervention with CTO improves LV function in patients with ischemic cardiomyopathy, regardless of the degree of collateral circulation. LV function recovery generally occurs within 3 months after revascularization.

Impact of Collateral Circulation on Futile Endovascular Thrombectomy in Acute Anterior Circulation Ischemic Stroke.

Collateral circulation is associated with the differential treatment effect of endovascular thrombectomy (EVT) in acute ischemic stroke. We aimed to verify the ability of the collateral map to predict futile EVT in patients with acute anterior circulation ischemic stroke. This secondary analysis of a prospective observational study included data from participants underwent EVT for acute ischemic stroke due to occlusion of the internal carotid artery and/or the middle cerebral artery within 8 hours of symptom onset. Multiple logistic regression analyses were conducted to identify independent predictors of futile recanalization (modified Rankin scale score at 90 days of 4-6 despite of successful reperfusion). In a total of 214 participants, older age (odds ratio [OR], 2.40; 95% confidence interval [CI], 1.56 to 3.67; p<0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR, 1.12; 95% CI, 1.04 to 1.21; p=0.004), very poor collateral perfusion grade (OR, 35.09; 95% CI, 3.50 to 351.33; p=0.002), longer door-to-puncture time (OR, 1.08; 95% CI, 1.02 to 1.14; p=0.009), and failed reperfusion (OR, 3.73; 95% CI, 1.30 to 10.76; p=0.015) were associated with unfavorable functional outcomes. In 184 participants who achieved successful reperfusion, older age (OR, 2.30; 95% CI, 1.44 to 3.67; p<0.001), higher baseline NIHSS scores (OR, 1.12; 95% CI, 1.03 to 1.22; p=0.006), very poor collateral perfusion grade (OR, 4.96; 95% CI, 1.42 to 17.37; p=0.012), and longer door-to-reperfusion time (OR, 1.09; 95% CI, 1.03 to 1.15; p=0.003) were associated with unfavorable functional outcomes. The assessment of collateral perfusion status using the collateral map can predict futile EVT, which may help select ineligible patients for EVT, thereby potentially reducing the rate of futile EVT.

Impact of collateral circulation in a patient with chronic coronary occlusion

Impact of collateral circulation in a patient with chronic coronary occlusion

The importance of blood flow volume in the brain-supplying arteries for the clinical management - the impact of collateral circulation.

Aim: An assessment of increased compensatory blood flow in the brain-supplying arteries in patients with significant carotid artery stenosis. Materials and methods: Doppler ultrasound was performed in 218 patients over 60 years of age to evaluate both the degree of brain-supplying artery stenosis as well as the blood flow volume balance in all vessels supplying the brain: the internal carotid artery, the external carotid artery and the vertebral artery. The control group included 94 patients with no stenosis in the extracranial segments and no neurological manifestations, in whom blood flow values were calculated (the internal carotid artery – 290 mL/min, the external carotid artery – 125 mL/min, the vertebral artery – 80 mL/min); the total mean blood flow in the brain-supplying arteries was 985 mL/min. A 33% increase in blood flow was considered compensatory. In addition to the control group, 30 patients with asymptomatic stenosis of less than 50% and 12 patients after endarterectomy with mean blood flow of 920 mL/min and 960 mL/min, as well as two groups of particular interest to us, i.e. 38 patients with no compensatory blood flow increase despite significant stenosis (>50%) with mean blood flow of 844 mL/min and 44 patients with similar stenosis and with compensatory blood flow increase up to 1174 mL/min were included in the analysis. Results: Comparison of the two groups showed several significant differences: increased blood flow (118% vs. 86% of the norm) in patients with compensated stenosis, an increased number of asymptomatic patients (70% vs. 37%) and a threefold increase in the number of patients with occlusions (15 : 5) in the group of patients with increased blood supply to the brain. Conclusions: All potential blood-supplying vessels, including the external carotid artery, are involved in brain tissue perfusion in some of the patients with significant stenosis. Determining the degree of compensation may have an important impact on the indications for surgical treatment, which will make a valuable contribution to the current criteria (asymptomatic/symptomatic patients).

Abstract WP51: Currency of Collaterals: Validation and Clinical Utility of a Novel Imaging Paradigm for Triage to Endovascular Therapy

Background: The pivotal impact of collateral circulation on outcomes in endovascular therapy has fueled the development of numerous single and multiphase CTA collateral scales, yet synchronized validation with conventional angiography has never occurred. Multiphase flat detector CT angiography (mpFDCTA) enables direct patient transfer to the angiography suite and rapid collateral triage. We validated this novel collateral imaging paradigm and potential clinical utility for endovascular stroke treatment. Methods: Consecutive acute ischemic stroke patient data, including mpFDCTA followed within few minutes by digital subtraction angiography (DSA), in the setting of ICA or proximal MCA occlusions were analyzed. An independent core lab scored mpFDCTA with an established multiphase CTA collateral scale and separately graded ASITN collateral status on DSA, blind to all other data. Results: 24 consecutive cases (age 76.7 ± 7.3 years; 58.3% women; baseline NIHSS median 17 (4-23)) of acute stroke due to ICA or proximal MCA occlusion were analyzed with simultaneous mpFDCTA and DSA. Arterial occlusion sites included 18 M1 MCA, 5 ICA, 1 M2 MCA. ASPECTS was median 8 (4-10). Time from first noncontrast FDCT to intracranial DSA was 23.04 ± 7.6 minutes with mTICI ≥ 2b reperfusion in 91.7% of cases. mpFDCTA collateral score was median 3 (0-5) and DSA ASITN was median 2 (0-3), including the full range of potential collateral grades. mpFDCTA and ASITN were highly correlated (r=0.86, p&lt;0.001). mpFDCTA provided more complete collateral data compared to selective DSA injections in cases of ICAO. ROC analyses for prediction of clinical outcomes revealed an AUC of 0.76 for mpFDCTA collaterals and 0.70 for DSA ASITN collateral grades. Conclusions: Multiphase flat detector CT angiography (mpFDCTA) in the angiography suite provides a validated measure of collaterals, offering distinct advantages over conventional angiography. Direct patient transfer to the angiography suite and mpFDCTA collateral grading provides a novel and reliable triage paradigm for acute ischemic stroke.

Impact of Collateral Circulation on Survival in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention With a Concomitant Chronic Total Occlusion

ObjectivesThis study sought to compare long-term clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients with a concomitant chronic total occlusion (CTO) with well-developed versus poorly developed collaterals toward the CTO. BackgroundIn STEMI patients, presence of a CTO is associated with increased morbidity and mortality. CTOs are often (partially) perfused by collateral vessels. Therefore, when the infarct-related artery (IRA) is the main donor vessel for the collateral blood supply of the CTO, infarct size may increase significantly. Well-developed collaterals to the infarct related vessel have been associated with improved clinical outcome after STEMI. However, the impact of well-developed collaterals toward a concomitant CTO in STEMI patients is unknown. MethodsConsecutive STEMI patients with a CTO in a non-IRA presenting for primary percutaneous coronary intervention (PCI) were divided according to the presence of angiographic, well-developed (grade 2 to 3) or poorly developed collaterals (grade 0 to 1). ResultsBetween 2000 and 2012 we included 413 STEMI patients with a single concomitant CTO. Well-developed collaterals to the CTO were present in 53%. Associated with poorly developed collaterals to the CTO were cardiogenic shock (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.11 to 3.07; p = 0.02), CTO located in the left circumflex artery (HR: 1.9; 95% CI: 1.00 to 3.43; p = 0.05), CTO diameter ≤2.5 mm (HR: 2.1; 95% CI: 1.07 to 4.12; p = 0.03), and CTO tapering (HR: 1.9; 95% CI: 1.21 to 2.85; p < 0.001). Patients with well-developed collaterals to the CTO had a better 5-year survival compared to those with poorly developed collaterals (74% vs. 63%; p = 0.01). The presence of well-developed collaterals to the CTO was independently associated with improved survival (HR: 1.5; 95% CI: 1.03 to 2.10; p = 0.04). ConclusionsIn STEMI patients with a CTO in a non-IRA, the presence of well-developed collaterals to the CTO is associated with improved survival.

Impact of Coronary Collaterals on Long-term Prognosis in Patients Treated With Primary Angioplasty

Introduction and objectivesThe beneficial effect of coronary collateral circulation (CC) in patients with ST-segment elevation myocardial infarction is controversial. The aim of this study was to evaluate the impact of CC before reperfusion with primary angioplasty (PA) on the long-term prognosis of these patients. MethodsRetrospective observational study of a cohort of 947 patients treated with PA and TIMI grade ≤ 1 flow in a single center from 2005 to 2013. Propensity score matching was used to create 2 groups of 175 patients each, matched by the degree of CC (Rentrop 0-1 vs Rentrop 2-3). In the matched cohort, we determined the impact of CC on total mortality, cardiovascular mortality, and a combined adverse cardiovascular event endpoint for a median follow-up of 864 (interquartile range, 396-1271) days. ResultsOf a total of 947 patients included, 735 (78%) had Rentrop 0 to 1 and 212 (22%) had Rentrop 2 to 3. During follow-up, 105 patients died, 71 from cardiovascular causes. In the matched cohort, the total mortality rate was similar between the 2 groups (Rentrop 0-1 [8.8%] vs Rentrop 2-3 [6.3%]; HR = 1.22; 95%CI, 0.50-2.94; P = .654). There were no differences in cardiovascular mortality (Rentrop 0-1 [4.6%] vs Rentrop 2-3 [2.3%]; sHR = 0.49; 95%CI, 0.14-1.62; P = .244) or the composite endpoint including cardiovascular death, reinfarction, target vessel revascularization, and coronary artery bypass surgery (Rentrop 0-1 [18.8%] vs Rentrop 2-3 [13.1%]; sHR = 0.68; 95%CI, 0.40-1.15; P = .157). ConclusionsIn this contemporary series, the presence of good CC before PA was not associated with better long-term clinical outcomes.

Impacto de la circulación colateral en el pronóstico a largo plazo de los pacientes tratados con angioplastia primaria

Introduction and objectivesThe beneficial effect of coronary collateral circulation (CC) in patients with ST-segment elevation myocardial infarction is controversial. The aim of this study was to evaluate the impact of CC before reperfusion with primary angioplasty (PA) on the long-term prognosis of these patients. MethodsRetrospective observational study of a cohort of 947 patients treated with PA and TIMI grade ≤ 1 flow in a single center from 2005 to 2013. Propensity score matching was used to create 2 groups of 175 patients each, matched by the degree of CC (Rentrop 0-1 vs Rentrop 2-3). In the matched cohort, we determined the impact of CC on total mortality, cardiovascular mortality, and a combined adverse cardiovascular event endpoint for a median follow-up of 864 (interquartile range, 396-1271) days. ResultsOf a total of 947 patients included, 735 (78%) had Rentrop 0 to 1 and 212 (22%) had Rentrop 2 to 3. During follow-up, 105 patients died, 71 from cardiovascular causes. In the matched cohort, the total mortality rate was similar between the 2 groups (Rentrop 0-1 [8.8%] vs Rentrop 2-3 [6.3%]; HR = 1.22; 95%CI, 0.50-2.94; P = .654). There were no differences in cardiovascular mortality (Rentrop 0-1 [4.6%] vs Rentrop 2-3 [2.3%]; sHR = 0.49; 95%CI, 0.14-1.62; P = .244) or the composite endpoint including cardiovascular death, reinfarction, target vessel revascularization, and coronary artery bypass surgery (Rentrop 0-1 [18.8%] vs Rentrop 2-3 [13.1%]; sHR = 0.68; 95%CI, 0.40-1.15; P = .157). ConclusionsIn this contemporary series, the presence of good CC before PA was not associated with better long-term clinical outcomes.Full English text available from: www.revespcardiol.org/en

Poor Collateral Circulation Assessed by Multiphase Computed Tomographic Angiography Predicts Malignant Middle Cerebral Artery Evolution After Reperfusion Therapies.

Collateral circulation (CC) has been associated with recanalization, infarct volume, and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant middle cerebral artery infarction (mMCAi) has not been evaluated. Our aim was to determine the impact of CC using multiphase computed tomographic angiography (during the acute stroke phase in the prediction of mMCAi. Patients with consecutive acute stroke with <4.5 hours who were evaluated for reperfusion therapies and presented with an M1-MCA or terminal internal carotid artery occlusion by CTA were included. CC was evaluated on 6 grades by multiphase CTA according to the University of Calgary CC Scale; CC status was defined as poor (grades, 0-3) or good (grades, 4-5). The mMCAi was defined according to clinical and radiological criteria. Recanalization was assessed with transcranial Doppler at 24 hours and final Thrombolysis in Brain Ischemia score≥2b in patients undergoing endovascular reperfusion treatment. Eighty-two patients were included. Mean age was 65.1±13.83 years, median baseline National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-20), and 67.9% M1 and 32.1% terminal internal carotid artery occlusions. Fifty-three patients received endovascular reperfusion treatment. Fifteen patients developed mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 versus 3.71; P=0.001). Endovascular reperfusion treatment was associated with lower rate of mMCAi development than only intravenous reperfusion treatment (9.4% versus 29.6%; P=0.028). Patients with poor CC had higher risk of developing mMCAi (13% versus 2%; P=0.001). On the multivariate analysis adjusted by age, vessel occlusion, baseline National Institutes of Health Stroke Scale, and recanalization, the presence of poor CC by multiphase CTA was the only independent predictor of mMCAi (P=0.048; odds ratio, 9.72; 95% confidence interval, 1.387-92.53). CC assessment by multiphase CTA independently predicts malignant MCA infarction progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may improve the early mMCAi detection and management.

Abstract T P34: Poor Collateral Circulation Assessed By Multiphase Cta Predicts Malignant Mca Evolution After Reperfusion Therapies

Background: Collateral circulation (CC) has been associated with recanalization, infarct volume, risk of haemorrhagic transformation and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant MCA infarction (mMCAi) has not been evaluated. Our aim was determine the impact of collateral circulation using multiphase CTA (mCTA) on acute phase in the prediction of mMCAi. Methods: Consecutive acute stroke &lt;4.5h patients that were evaluated for reperfusion therapies and with a M1-MCA or TICA occlusion by CTA were included. CC was evaluated on mCTA, CC evaluation was performed according to the University Calgary CC Scale; CC was also classified as poor (grades 0-3) or good (grades 4-5). The mMCAi was defined according to previously published clinical and radiological criteria. Recanalization was assessed with TCD at 24-hours and TICI score≥2a in endovascular treatment (ET) patients. Good outcome was defined as mRS 0-2 at 3months. Results: 82 patients were included. Mean age: 65.1 ±13.83 years, median baseline NIHSS 18(IQR 5.7), 67.9% M1 and 32.1% TICA occlusions, 53 patients received ET and 57 iv tPA, 15 patients develop a mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 Vs. 3.71 p=0.001), higher baseline NIHSS (19.86 Vs. 15.70 p=0.016), lower TIMI reperfusion scores (0 Vs. 2.79 p=00.5) and presence of TICA occlusion was more often compared with M1 occlusion (71% Vs. 11.9%, p=0.033) ET was associated with lower rate of mMCAi development as compared with only i.v. reperfusion treatment (9.4%Vs.29.6%, p=0.028). Furthermore, all patients with poor CC who did not recanalize developed mMCAi (6 Vs. 0, p=0.68) On the multivariate analysis adjusted to age, vessel occlusion, baseline NIHSS and recanalization, the presence of poor CC by mCTA was the only independent predictor of mMCAi (p=0.048 OR: 9.72, 95%IC: 1.387-92.53) Conclusion: CC assessment by mCTA independently predicts malignant MCA progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may help in the early malignant MCA detection and management.

Impact of Collateral Circulation on Early Outcome and Risk of Hemorrhagic Complications after Systemic Thrombolysis

In stroke patients, collateral flow can rapidly be assessed on computed tomography angiography (CTA). In this study, the impact of baseline collaterals on early outcome and risk of symptomatic intracerebral hemorrhages after systemic thrombolysis in patients with proximal arterial occlusions within the anterior circulation were analyzed. Collateralization scores were determined on the CT angiography source images (0 = absent; 1 ≤ 50%, 2 > 50% but <100%, and 3 = 100% collateral filling) of patients with distal intracranial carotid artery and/or M1 segment occlusions treated from 2008 to December 2011. A collateral score of 0 to 1 was designated as poor and 2 to 3 as good collateral vessel status. Outcome variables included in hospital mortality, favorable outcome at discharge (modified Rankin score ≤ 2), and rates of symptomatic intracerebral hemorrhage based on the European-Australasian Acute Stroke Study II definition. Among 246 subjects (mean age of 74 years; median National Institutes of Health Stroke Scale N at admission 14), 205 patients (83%) had good collaterals, whereas 41 patients (17%) had poor collaterals, respectively. Patients with poor collaterals had significantly higher rates of in-hospital mortality (41% vs. 12%, P < 0·001), of symptomatic intracerebral hemorrhage (15% vs. 4·9%, P < 0·05) and had significantly lower rates of favorable early clinical outcome (0% vs. 28%, P < 0·001) compared with those with good collaterals. The grade of collateralization was independently associated with in-hospital mortality (P < 0·001), early clinical outcome (P < 0·01), and rates of symptomatic intracerebral hemorrhage (P < 0·01). Patients with proximal arterial occlusions within the anterior circulation and poor baseline collaterals have a poor early functional outcome and high rates of symptomatic intracerebral hemorrhage after systemic thrombolysis. Since similar findings have also been reported after endovascular therapy, strategies to improve collateral blood flow should be assessed in this patient population.

Impact of coronary artery collaterals on infarct size assessed by serial cardiac magnetic resonance imaging after primary percutaneous coronary intervention in patients with acute myocardial infarction

Coronary collaterals have been shown to protect ischemic myocardium from necrosis in patients with acute myocardial infarction (AMI). We sought to determine the impact of collateral circulation on infarct size in AMI using serial cardiac magnetic resonance (CMR). A total of 46 anterior AMI patients (age, 58.9+/-10.6 years; male 72.3%) undergoing primary percutaneous coronary intervention (PCI) were investigated. The infarct size was measured on serial CMR performed within 7 days after primary PCI (acute stage) and 3 months later (chronic stage). Thirty-four patients (73.9%) showed collateral flow before primary PCI. CMR taken at the acute stage showed no significant difference in infarct size between two groups. However, follow-up CMR revealed significantly smaller percentage of infarct thickness (51.8+/-14.0 vs. 62.5+/-11.7%, P = 0.035) and mass (22.3+/-9.9 vs. 30.9+/-11.6%, P = 0.042) in patients with collaterals. There were significant changes from the acute to chronic stage regarding left ventricular end-systolic (-18.2+/-10.0 vs. 0.8+/-2.5 ml, P = 0.022) and end-diastolic volume (-14.8+/-9.2 vs. 2.6+/-13.7 ml, P = 0.031), percentage of infarct mass (-6.1+/-2.8 vs. -0.8+/-1.1%, P = 0.034), and thickness (-8.9+/-3.3 vs. -3.1+/-2.8%, P = 0.029) in collateral group compared with noncollateral group on serial CMR. Serial CMR revealed the effect of collaterals in patients with AMI on reduction of infarct size and improvement of myocardial remodeling at the chronic stage.