Relationship Between Collateral Circulation And Clinical Prognosis In Patients With Severe Internal Carotid Artery Stenosis Or Occlusion

Objective:In this study,digital subtraction angiography(DSA)was used to evaluate the relationship between collateral circulation and clinical prognosis in patients with severe internal carotid artery stenosis or occlusion.Meanwhile,the compensation effectiveness of collateral circulation for patients with severe internal carotid artery stenosis or occlusion was evaluated by DSA.It provides theoretical basis for the targeted therapy of collateral circulation and the judgment of clinical prognosis in these patients.Methods:This prospective study included 185 inpatients with severe internal carotid artery stenosis(≥70%)or occlusion diagnosed by DSA in the Department of Neurointerventional Surgery,Xianyang Hospital,Yan ’an University from January 2019 to April 2021.According to their clinical symptoms at admission,33 patients were asymptomatic,23 had transient ischemic attack(TIA),76 had mild neurological impairment,37 had moderate neurological impairment,and 16 had severe neurological impairment.The patients with mild,moderate and severe neurological impairment were all acute ischemic stroke patients within 48 hours of onset,and the national Insttitutes of Health Stroke Scale(NIHSS)score of the patients was recorded,which was based on grouping.General data of all patients were collected for statistical analysis,including age,sex,smoking history,hypertension,diabetes,coronary heart disease and hyperlipidemia.DSA examination results of all subjects were recorded,and then the clinical manifestations of each group at admission were compared:(1)Collateral circulation compensation,including:Anterior communicating artery(ACo A),posterior communicating artery(PCo A),ophthalmic artery,OA,leptomeningeal anastomoses(LMA),and neovascularization;(2)whether collateral circulation compensates;(3)the number of collateral compensations < 2 and the number of collateral compensations ≥2;(4)Whether there is a functional Willis circle compensation.In addition,all patients were followed up by telephone at 3 months and recorded modified Rankin score(m RS),among which 3 patients were lost to follow-up and 182 patients were left.According to m RS score,the patients were divided into two groups: 45 patients were grouped into m RS>2,and 137 patients were grouped into m RS≤2.Then the two groups were compared:with or without ocular artery compensation;Whether collateral circulation compensates;Collateral compensatory number < 2 and collateral compensatory number≥2;Whether the functional Willis ring compensates.These results were used to evaluate the effectiveness of ophthalmic arterial compensation and clinical prognosis.Finally,the collateral circulation was quantitatively evaluated by DSA.According to m RS score at 3-month follow-up,the patients were divided into m RS≥2 and m RS<2,and the critical score of good and bad collateral circulation was obtained by ROC curve analysis to evaluate the prognosis and functional outcome of the patients.Results:1.A total of 185 patients were included in this study,ranging in age from35 to 84 years old,with an average of(63.7±8.5)years old,including 141 males(76.2%).The general information of all patients included age,sex,smoking history and whether they had hypertension,diabetes,coronary heart disease and hyperlipidemia.There were no significant differences(P>0.05).2.Comparison among clinical manifestation groups at admission :(1)the compensation rate of ACo A was 60.0%(111/185),and there was no significant difference according to the compensation rate of ACo A among clinical manifestation groups at admission(P>0.05).(2)The PCo A compensation rate was 51.9%(96/185),and there was significant difference in the PCo A compensation rate among all clinical presentation groups at admission(P<0.05).Pair-based comparison between groups suggested that: The compensation rate of PCo A in asymptomatic group(54.5%,18/33),TIA group(56.5%,13/23),mild neurological deficit group(53.9%,41/76)and moderate neurological deficit group(59.5%,22/37)was higher than that in severe neurological deficit group(12.5%,2/16)(P<0.05).(3)The rate of OA compensation was 38.9%(72/185).There was no significant difference in the rate of OA compensation among the clinical presentation groups at admission(P>0.05).(4)The proportion of LMA compensation was 57.8%(107/185),and there was no significant difference in the rate of LMA compensation among the clinical presentation groups at admission(P>0.05).(5)The rate of patients with neovascularization was 8.6%(16/185),and there was significant difference in the rate of neovascularization among the clinical presentation groups at admission(P<0.001).Pair-based comparison between the groups suggested that: The compensation rate of neovascularization in asymptomatic group(6.1%,2/33),TIA group(8.7%,2/23),mild neurological deficit group(1.3%,1/76)and moderate neurological deficit group(8.1%,3/37)was lower than that in severe neurological deficit group(50.0%,8/16)(P<0.05).(6)There was no significant difference in the ratio of collateral compensation among all clinical presentation groups at admission(P>0.05);(7)When all patients were admitted to hospital,the ratio of side number ≥2 in each clinical presentation group was compared,and the results were statistically significant(P<0.05).Pairwise comparison between groups suggested: The ratio of side number ≥2 in asymptomatic group(75.8%,25/33),TIA group(87.0%,20/23),mild neurological deficit group(75.0%,57/76)and moderate neurological deficit group(70.3%,26/37)was higher than that in severe neurological deficit group(43.8%,20/23).7/16)(P<0.05);(8)The compensation ratio of all patients with functional complete circle of Willis in all clinical presentation groups at admission was compared,and the results were statistically significant(P<0.05).Pairwise comparison between groups suggested that: The compensation rate of functional circle of Willis in asymptomatic group(30.3%,10/33),TIA group(30.4%,7/23),mild neurological impairment group(21.1%,16/76)was higher than that in moderate neurological impairment group(8.1%,3/37)and severe neurological impairment group(0.0%,0/16)(P<0.05).3.Comparison between m RS>2 group and m RS≤2 group at 3 months follow-up :(1)the proportion of patients with ocular artery compensation in m RS≤2 group(86.1%,62/72)was significantly higher than that in m RS>2 group(13.9%,10/72),the difference was statistically significant(P<0.05);(2)There was no statistical significance in the compensation rate of collateral circulation between the two groups(P>0.05).(3)The proportion of patients with collateral circulation compensation ≥2 in m RS≤2 group(81.8%,108/132)was significantly higher than that in m RS>2 group(18.2%,24/132),and the difference was statistically significant(P<0.05).(4)The proportion of functional intact Willis circle in m RS≤2 group(91.7%,33/36)was significantly higher than that in m RS>2 group(8.3%,3/36),and the difference was statistically significant(P<0.05).4.Quantitative evaluation of collateral circulation by DSA,ROC curve analysis showed that the area under the curve was 0.887,the sensitivity was 85.1%,the specificity was 86.4%,and the maximum approximation index was 0.715.The effective critical value of good and bad collateral circulation was 3.5 points.Conclusions: 1.When patients with severe internal carotid artery stenosis or occlusion,patients with ocular artery compensation can present with asymptomatic TIA,or patients with acute ischemic stroke with mild symptoms within 48 hours of onset,and patients with ocular artery compensation have a good clinical prognosis in 3 months,which can be used as an effective collateral circulation.2.When patients with severe internal carotid artery stenosis or occlusion,asymptomatic patients,patients with TIA or acute ischemic stroke with mild symptoms within 48 hours of onset had richer collateral circulation compensation pathways and more complete circle of Willis,and the richer collateral circulation compensation pathways and more complete circle of Willis were associated with better clinical prognosis at 3 months.Tertiary collateral circulation,or neovascularization,suggests the possibility of severe cerebral infarction.3.When patients with severe internal carotid artery stenosis or occlusion,quantification of collateral circulation based on ROC curve can better predict the prognosis and functional outcome of patients with ischemic stroke.