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Cerebrovascular insufficiency as the criterion for revascularization procedures in selected patients: a correlation study of xenon contrast-enhanced CT and PWI

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Abstract

In order to identify patients who suffer from hemodynamic cerebral insufficiency and can benefit from cerebral revascularization procedures, xenon-CT scanning has been established to reliably measure the critical cerebrovascular reserve capacity. As a need for alternative quantification methods arises, this study aims to characterize the significance of both time-to-peak (TTP) and mean transit time (MTT) in perfusion-weighted imaging (PWI) in this particular subset of patients. Ten patients in routine preoperative work-up for cerebral revascularization were prospectively enrolled and underwent both XeCT scanning and PWI. Cerebrovascular reserve capacity (CVRC) was calculated for each region of interest (ROI, n = 504) after administration of a vasoactive stimulus. ROIs were anatomically matched with those of PWI after TTP and MTT were calculated. Highly significant negative correlation was found for TTP and CVRC for all ROIs (r = −0.3954, p < 0.0001; symptomatic ROIs: r = −0.4867, p < 0.0001). Correlation was weak for MTT and CVCR (r = −0.1287; p < 0.01). The optimum threshold for TTP to detect impaired cerebrovascular reactivity in our patient group was 4 s (specificity 90.8%, sensitivity 44.4%) for all ROIs (TTP > 4.4 s for symptomatic ROIs, specificity 88.4%, sensitivity 62.7%). An approximative equation to calculate the probability of pathological findings could be derived from the data. The positive predictive value (PPV) was 0.76 (symptomatic 0.78) with a negative predictive value (NPV) of 0.71 (symptomatic 0.78). While PWI currently is not able to replace XeCT in the direct quantification of CVRC, it may serve as a readily available follow-up tool. A TTP threshold of greater than 4 s allows to confirm a cerebrovascular compromise in a selected high-risk subgroup of patients.

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Acknowledgments

We would like to particularly thank the technicians of the Department of Neuroradiology for their support.

Disclosure

Preliminary results were presented at the “8th International Conference on Xenon CT and Related CBF Techniques” in Cambridge, UK in 2006 and the 58th meeting of the German Society of Neurosurgery, Leipzig, Germany in 2007.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Gerrit Alexander Schubert, Carolin Weinmann, Marcel Seiz & Claudius Thomé

  2. Department of Radiology, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Lars Gerigk

  3. Institute for Biomedical Statistics, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany

    Christel Weiss

  4. Department of Neurosurgery, Charite Universitätsmedizin Berlin, Berlin, Germany

    Peter Horn

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  1. Gerrit Alexander Schubert
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Correspondence to Gerrit Alexander Schubert.

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Comments

Maximilian Mehdorn, Kiel, Germany

Cerebral revascularization—both carotid endarterectomy (TEA) and extracranial–intracranial arterial anastomosis (ECIC)—has suffered major drawbacks since its initial highly popularized results. While TEA, due to the high incidence of arteriosclerotic stenoses in the extracranial circulation, has undergone a series of scientific trials demonstrating the benefit of surgery over medical treatment alone in well-defined patient population, the EC–IC Bypass Study published in 1985 was the only major study dealing in general with this microneurosurgical procedure and has shown that the algorithms of the late 1970s and the early 1980s in selecting candidates for this procedure were not sufficient to select patients at high risk of developing a hemodynamic stroke mainly due to carotid artery occlusion.

Many efforts have been directed to improve the criteria to select patients at risk from hemodynamic stroke, e.g. (1) the transcranial Doppler study of MCA blood flow velocity changes after exposure of the patient to diamox or CO2, (2) xenon perfusion studies or, more recently, the (3) cranial CT with perfusion studies. These studies should be repeatable because cerebrovascular insufficiency may change—often improve—over time, after a stroke, thus, making the decision for or against surgery even more difficult. While the first study is easily feasible and repeatable, it has certain problems, particularly, the need of a dedicated transcranial Doppler specialist in order to rule out inter-observer variability and the problem of acetacolamide in certain patients; xenon perfusion studies are considered the gold standard for many instances although the application to patients with cerebrovascular insufficiency may cause sedation effects. Cranial CT perfusion studies using contrast enhancing agents are not repeatable several times due to the radiation exposure and, depending on the machine used, they do not cover the major part of the brain volume.

Therefore, the study presented here by G. Schubert et al. from Mannheim aims to develop an alternative evaluation of cerebral perfusion and reserve capacity by means of MR imaging in the way of perfusion-weighted imaging (PWI), by comparing this new method to the gold standard of xenon CT. This method should be reliable, repeatable, objective, and easily applicable within the framework of modern neurosurgical workup of patients with cerebrovascular insufficiency. The authors suggest, by comparing both methods in a selected group of patients, that the application of PWI can equal the application of Xenon-CT. They are to be congratulated on their thoughtful evaluation of both methods. Understandably, the method will need to be tested in a multicenter setting in order to be validated for broad clinical use, and the reviewer is confident that they will be able to share their results on this subject in the near future, basing the indication for revascularization procedures again on objective findings. Obviously patients undergoing surgery on the basis of this method should be followed closely to prove this hypothesis.

Alexander Brawanski, Regensberg, Germany

In their paper, the authors evaluate an alternative method to test for CVRC. They used TTP and MTT and compared these in specific ROIs to the results of stable XeCT in ten patients with Moyamoya disease or unilateral or bilateral occlusive disease. The authors calculated the correlation and regression and used a ROC statistics for setting of an optimal threshold. They find a good correlation for TTP and CVRC and a worse one for MTT. Furthermore, the optimum threshold in the ROC was 4 s for the TTP parameter. The authors state, cautiously, that the TTP will not replace XeCT but could be useful as a follow up parameter. In principle, the idea of the paper is reasonable, namely to find a replacement for XeCT or other methods like HMPAO Spect with Diamox, that could be easily included in clinical routine studies. The major problem, however, is the fact, that the TTP and MTT are only indirectly related to CBF and its reactivity (N. Lassen, W. Perl, Tracer Kinetic Methods in medical Physiology, New York, 1979). Therefore, the results are not totally convincing. The idea, however, is reasonable and the look for alternatives should be pursued.

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Schubert, G.A., Weinmann, C., Seiz, M. et al. Cerebrovascular insufficiency as the criterion for revascularization procedures in selected patients: a correlation study of xenon contrast-enhanced CT and PWI. Neurosurg Rev 32, 29–36 (2009). https://doi.org/10.1007/s10143-008-0159-z

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