Effects of balloon angioplasty on perfusion- and diffusion-weighted magnetic resonance imaging results and outcome in patients with cerebral vasospasm

Object. The aim of this study was to analyze the effects and outcome of transluminal balloon angioplasty (TBA) on brain tissue perfusion by using combined perfusion- and diffusion-weighted (PW/DW) magnetic resonance (MR) imaging in patients with cerebral vasospasm after subarachnoid hemorrhage. Methods. Ten consecutive patients with cerebral vasospasm treated using TBA were included in this prospective study. Hemodynamically relevant vasospasm was diagnosed using a standardized PW/DW MR imaging protocol. Digital subtraction angiography was used to confirm vasospasm, and TBA was performed to dilate vasospastic arteries. The PW/DW imaging protocol was repeated after TBA. The evaluation of the passage of contrast medium after standardized application using the bolus tracking method allowed for the calculation of the time to peak (TTP) before and after TBA. Tissue at risk was defined based on perfusion delays in individual vessel territories compared with those in reference territories. In cases with proximal focal vasospasm, TBA could dilate spastic arteries. Follow-up PW/DW MR imaging showed the disappearance of, or a decrease in, the mismatch. A TBA-induced reduction in the perfusion delay of 6.2 +/- 1 seconds (mean +/- standard error of the mean) to 1.5 +/- 0.45 seconds resulted in the complete prevention of infarction; a reduction in the delay of 6.2 +/- 2.7 to 4.1 +/- 1.9 seconds resulted in the preservation of those brain tissue parts having only small infarcts in the vessel territories. Without TBA, however, the perfusion delay remained or even increased (11.1 +/- 3.7 seconds), and the complete infarction of a territory occurred. Conclusions. Angioplasty of vasospastic arteries leads to hemodynamic effects that can be quantified using PW/DW MR imaging. In cases of a severe PW/DW imaging mismatch successful TBA improved tissue perfusion and prevented cerebral infarction. The clinical significance of PW/DW MR imaging and the concept of tissue at risk is shown by cerebral infarction in vessels not accessible by TBA.