Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke

Zhe Zhang, Yuehua Pu, Donghua Mi, Liping Liu, Zhe Zhang, Yuehua Pu, Donghua Mi, Liping Liu

Abstract

Cerebral recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, improves the outcomes in patients with acute ischemic stroke (AIS) by restoring the cerebral perfusion of the ischemic penumbra. Cerebral hemodynamic evaluation after recanalization therapy, can help identify patients with high risks of reperfusion-associated complications. Among the various hemodynamic modalities, magnetic resonance imaging (MRI), computed tomography perfusion, and transcranial Doppler sonography (TCD) are the most commonly used. Poststroke hypoperfusion is associated with infarct expansion, while hyperperfusion, which once was considered the hallmark of successful recanalization, is associated with hemorrhagic transformation. Either the hypo- or the hyperperfusion may result in poor clinical outcomes. Individual blood pressure target based on cerebral hemodynamic evaluation was crucial to improve the prognosis. This review summarizes literature on cerebral hemodynamic evaluation and management after recanalization therapy to guide clinical decision making.

Keywords: hemodynamic evaluation; hemodynamics; hyperperfusion; ischemic stroke; mechanical thrombectomy; recanalization; thrombolysis.

Figures

Figure 1
Figure 1
A 75-year-old man who received a successful mechanical thrombectomy in the C1 segment of the left ICA 3 h 50min after the onset of AIS. The NIHSS score at baseline was 22. Twenty-four hours after the recanalization, the NIHSS score slightly decreased to 20, and a multimodal hemodynamic evaluation was performed. The non-contrast CT scan shows the hypointense infarct core in the left perforating MCA territory (A). The left ICA and MCA reappeared entirely on CTA, and the M1 segment of the left MCA showed no stenosis (B). The CTP series showed markedly increased CBF (C), mildly increased CBV (D), significantly decreased MTT (E), and higher TTP (F) in the left MCA territory compared to those in the infarct core. The mean flow velocity of the left MCA increased by 100% compared to that on the right side at the same depth (G, left MCA; H, right MCA). The patient was considered as having the hyperperfusion syndrome. The systolic blood pressure was controlled at <110 mmHg until the flow velocity of the left MCA was restored to the normal in 20 days (I). The patient had no hemorrhagic transformation or epileptic seizures but had an mRS score of 5 at 90 days, although the final infarct volume was only 12ml. Electroencephalographic monitoring was also performed (data not shown).

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