Collateral Circulation in Ischemic Stroke: An Updated Review

Overview

Journal J Stroke

Date 2023 Mar 12

PMID 36907186

Authors

Gino Maguida

Ashfaq Shuaib

Affiliations

Soon will be listed here.

Abstract

The collateral circulation plays a crucial role in maintaining perfusion to brain tissue in ischemic stroke, which prolongs the time window for effective therapies to be provided and ultimately avoids irreversible damage that may lead to worse clinical outcomes. The understanding of this complex vascular bypass system has advanced greatly in the past few years, yet effective treatments for its potentiation as a therapeutic target remain a challenge. The assessment of the collateral circulation is now part of the routine neuroimaging protocols for acute ischemic stroke, which provides a more complete pathophysiological picture in each patient that allows for a better selection for acute reperfusion therapies and a more accurate prognostication of outcomes, among other potential uses. In this review, we aim to provide a structured and updated approach to the collateral circulation while highlighting ongoing research areas with promising future clinical applications.

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References

Bahr-Hosseini M, Saver J . Mechanisms of action of acute and subacute sphenopalatine ganglion stimulation for ischemic stroke. Int J Stroke. 2020; 15(8):839-848. DOI: 10.1177/1747493020920739. View

Feigin V, Brainin M, Norrving B, Martins S, Sacco R, Hacke W . World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke. 2022; 17(1):18-29. DOI: 10.1177/17474930211065917. View

Menon B, dEsterre C, Qazi E, Almekhlafi M, Hahn L, Demchuk A . Multiphase CT Angiography: A New Tool for the Imaging Triage of Patients with Acute Ischemic Stroke. Radiology. 2015; 275(2):510-20. DOI: 10.1148/radiol.15142256. View

Lin L, Yang J, Chen C, Tian H, Bivard A, Spratt N . Association of Collateral Status and Ischemic Core Growth in Patients With Acute Ischemic Stroke. Neurology. 2020; 96(2):e161-e170. DOI: 10.1212/WNL.0000000000011258. View

Ravindran A, Killingsworth M, Bhaskar S . Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy. Eur J Neurosci. 2020; 53(4):1238-1261. DOI: 10.1111/ejn.14955. View

Vagal A, Aviv R, Sucharew H, Reddy M, Hou Q, Michel P . Collateral Clock Is More Important Than Time Clock for Tissue Fate. Stroke. 2018; 49(9):2102-2107. PMC: 6206882. DOI: 10.1161/STROKEAHA.118.021484. View

Nishijima Y, Akamatsu Y, Yang S, Lee C, Baran U, Song S . Impaired Collateral Flow Compensation During Chronic Cerebral Hypoperfusion in the Type 2 Diabetic Mice. Stroke. 2016; 47(12):3014-3021. PMC: 5134912. DOI: 10.1161/STROKEAHA.116.014882. View

Marquez-Romero J, Huerta-Franco M, Vargas-Luna M, Madrigal-Gutierrez C, Esparza-Hernandez J, Velazquez-Barcena M . Dose Escalation and Safety of Capsaicin for Cerebral Perfusion Augmentation: A Pilot Study. Stroke. 2021; 52(7):2203-2209. DOI: 10.1161/STROKEAHA.120.032773. View

Pienimaki J, Sillanpaa N, Jolma P, Protto S . Carotid Artery Stenosis Is Associated with Better Intracranial Collateral Circulation in Stroke Patients. Cerebrovasc Dis. 2020; 49(2):200-205. DOI: 10.1159/000506826. View

10.

Lucitti J, Sealock R, Buckley B, Zhang H, Xiao L, Dudley A . Variants of Rab GTPase-Effector Binding Protein-2 Cause Variation in the Collateral Circulation and Severity of Stroke. Stroke. 2016; 47(12):3022-3031. PMC: 5134893. DOI: 10.1161/STROKEAHA.116.014160. View

11.

Abuduxukuer R, Guo Z, Zhang P, Qu Y, Yang Y . Safety and efficacy of remote ischemic conditioning combined with intravenous thrombolysis for acute ischemic stroke: A multicenter, randomized, parallel-controlled clinical trial (SERIC-IVT) Study design and protocol. Int J Stroke. 2022; 18(3):370-374. DOI: 10.1177/17474930221104991. View

12.

Kofler N, Corti F, Rivera-Molina F, Deng Y, Toomre D, Simons M . The Rab-effector protein RABEP2 regulates endosomal trafficking to mediate vascular endothelial growth factor receptor-2 (VEGFR2)-dependent signaling. J Biol Chem. 2018; 293(13):4805-4817. PMC: 5880142. DOI: 10.1074/jbc.M117.812172. View

13.

Khan A, De Boever P, Gerrits N, Akhtar N, Saqqur M, Ponirakis G . Retinal vessel multifractals predict pial collateral status in patients with acute ischemic stroke. PLoS One. 2022; 17(5):e0267837. PMC: 9070887. DOI: 10.1371/journal.pone.0267837. View

14.

Hung S, Kramer S, Werden E, Campbell B, Brodtmann A . Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship?. Front Neurol. 2022; 13:804187. PMC: 8886237. DOI: 10.3389/fneur.2022.804187. View

15.

Perovic T, Harms C, Gerhardt H . Formation and Maintenance of the Natural Bypass Vessels of the Brain. Front Cardiovasc Med. 2022; 9:778773. PMC: 8980479. DOI: 10.3389/fcvm.2022.778773. View

16.

Rudilosso S, Laredo C, Mancosu M, Moya-Planas N, Zhao Y, Chirife O . Cerebral perfusion and compensatory blood supply in patients with recent small subcortical infarcts. J Cereb Blood Flow Metab. 2018; 39(7):1326-1335. PMC: 6668517. DOI: 10.1177/0271678X18758548. View

17.

Sarraj A, Hassan A, Grotta J, Blackburn S, Day A, Abraham M . Early Infarct Growth Rate Correlation With Endovascular Thrombectomy Clinical Outcomes: Analysis From the SELECT Study. Stroke. 2020; 52(1):57-69. DOI: 10.1161/STROKEAHA.120.030912. View

18.

Menon B, Smith E, Coutts S, Welsh D, Faber J, Goyal M . Leptomeningeal collaterals are associated with modifiable metabolic risk factors. Ann Neurol. 2013; 74(2):241-8. PMC: 3836863. DOI: 10.1002/ana.23906. View

19.

Beard D, Li Z, Schneider A, Couch Y, Cipolla M, Buchan A . Rapamycin Induces an eNOS (Endothelial Nitric Oxide Synthase) Dependent Increase in Brain Collateral Perfusion in Wistar and Spontaneously Hypertensive Rats. Stroke. 2020; 51(9):2834-2843. PMC: 7484020. DOI: 10.1161/STROKEAHA.120.029781. View

20.

Morita Y, Fukuuchi Y, Koto A, Suzuki N, Isozumi K, Gotoh J . Rapid changes in pial arterial diameter and cerebral blood flow caused by ipsilateral carotid artery occlusion in rats. Keio J Med. 1997; 46(3):120-7. DOI: 10.2302/kjm.46.120. View