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Ischemic stroke
Original research
Post-reperfusion hyperperfusion after endovascular stroke treatment: a prospective comparative study of TCD versus MRI
  1. Markus Kneihsl1,2,
  2. Nicole Hinteregger2,
  3. Oliver Nistl2,
  4. Hannes Deutschmann2,
  5. Susanna Horner1,
  6. Birgit Poltrum1,
  7. Simon Fandler-Höfler1,
  8. Isra Hatab1,
  9. Melanie Haidegger1,
  10. Daniela Pinter1,
  11. Alexander Pichler1,
  12. Karin Willeit3,
  13. Micheal Knoflach3,
  14. Christian Enzinger1,2,
  15. Thomas Gattringer1,2
  1. 1 Department of Neurology, Medical University of Graz, Graz, Austria
  2. 2 Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
  3. 3 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
  1. Correspondence to Professor Thomas Gattringer, Department of Neurology, Medical University of Graz, Graz, Steiermark, Austria; thomas.gattringer{at}medunigraz.at

Abstract

Background Increased middle cerebral artery (MCA) blood flow velocities on transcranial duplex sonography (TCD) were recently reported in individual patients after successful mechanical thrombectomy (MT) and were related to intracranial hemorrhage and poor outcome. However, the retrospective study design of prior studies precluded elucidation of the underlying pathomechanisms, and the relationship between TCD and brain parenchymal perfusion still remains to be determined.

Methods We prospectively investigated consecutive patients with stroke successfully recanalized by MT with TCD and MRI including contrast-enhanced perfusion sequences within 48 hours post-intervention. Increased MCA flow on TCD was defined as >30% mean blood flow velocity in the treated MCA compared with the contralateral MCA. MRI blood flow maps served to assess hyperperfusion rated by neuroradiologists blinded to TCD.

Results A total of 226 patients recanalized by MT underwent post-interventional TCD and 92 patients additionally had perfusion MRI. 85 patients (38%) had increased post-interventional MCA flow on TCD. Of these, 10 patients (12%) had an underlying focal stenosis. Increased TCD blood flow in the recanalized MCA was associated with larger infarct size, vasogenic edema, intracranial hemorrhage and poor 90-day outcome (all p≤0.005). In the subgroup for which both TCD and perfusion MRI were available, 29 patients (31%) had increased ipsilateral MCA flow velocities on TCD. Of these, 25 patients also showed parenchymal hyperperfusion on MRI (sensitivity 85%; specificity 62%). Hyperperfusion severity on MRI correlated with MCA flow velocities on TCD (rs=0.379, p<0.001).

Conclusions TCD is a reliable bedside tool to identify post-reperfusion hyperperfusion, correlates well with perfusion MRI, and indicates risk of reperfusion injury after MT.

  • MRI
  • Stroke
  • Ultrasound
  • Thrombectomy
  • Blood Flow

Data availability statement

Data are available upon reasonable request. Study data are available from the corresponding author on reasonable request.

https://doi.org/10.1136/jnis-2022-019213

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    Data availability statement

    Data are available upon reasonable request. Study data are available from the corresponding author on reasonable request.

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    Footnotes

    • Contributors MK: study design, acquisition and interpretation of data, manuscript preparation. NH: acquisition of data. OL: acquisition of data. HD: acquisition of data, critical revision of the manuscript content. SH: critical revision of the manuscript content. BP: acquisition of data. SF-H: acquisition of data, critical revision of the manuscript content. IH: acquisition of data. MH: acquisition of data. DP: acquisition of data. AP: acquisition of data. CE: study design, critical revision of the manuscript content. KW: critical revision of the manuscript content. MiK: critical revision of the manuscript content. TG: study design, acquisition and interpretation of data, manuscript preparation, critical revision of the manuscript. All authors have read and approved the final manuscript and agreed to be accountable for all aspects of the work. MK is responsible for the overall content as guarantor.

    • Funding This study was funded by Austrian Science Fund (FWF).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.