European Radiology

, Volume 29, Issue 5, pp 2651–2658 | Cite as

ASL perfusion features and type of circle of Willis as imaging markers for cerebral hyperperfusion after carotid revascularization: a preliminary study

  • Tianye Lin
  • Zhichao Lai
  • Zhentao Zuo
  • Yuelei Lyu
  • Feng FengEmail author
  • Hui You
  • Bo Hou
  • Jianxun Qu
  • Bing Wu
  • Changwei LiuEmail author



Cerebral hyperperfusion (CH) could be a disastrous outcome causing complication after carotid revascularization if not managed properly and timely. The aim of this study was to investigate the association between preoperative arterial spin labelling (ASL) perfusion features and circle of Willis (CoW) pattern with CH.


Forty-eight consecutive carotid stenosis patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were enrolled. All patients had single post-labelling delay (PLD) ASL, territory-ASL, and 3-dimensional time-of-flight MR angiography (3D TOF MRA) within 2 weeks before surgery and within 3 days after surgery. Spatial coefficient of variation (CoV) of cerebral blood flow (CBF), whole brain, and territory perfusion volume ratio were calculated from ASL and territory-ASL. Postoperative CoW was classified into two groups based on patency of the first segment of the anterior cerebral arteries (A1) and anterior communicating artery (AcomA). ASL perfusion features, type of CoW, and clinical characteristics were analyzed between CH group and non-CH group to identify CH risk factors.


Higher CoV (p = 0.005) of CBF, lower whole brain perfusion volume ratio (p = 0.012), missing any of A1 or AcomA in CoW (p = 0.002 for postoperative MRA and p = 0.004 for preoperative MRA), and large artery stroke history (p = 0.028) were significantly associated with higher risk of CH. Two cases with cerebral hyperperfusion syndrome (CHS) were also discussed, and their perfusion and angiographic features were shown.


Single-PLD ASL and MRA might be useful and non-invasive imaging tools to identify patients with higher risk of CH after carotid revascularization.

Key Points

• Cerebral hyperperfusion is a critical complication after carotid endarterectomy or carotid artery stenting.

• ASL and MRA can be used to identify patients at higher risk of cerebral hyperperfusion

• Pattern of circle of Willis, ASL perfusion features, and whole brain perfusion volume ratio are potential predicting markers for hyperperfusion after carotid revascularization.


Carotid stenosis Vascular surgical procedures Magnetic resonance imaging Spin labels Circle of Willis 



3-dimensional time-of-flight MR angiography


First segment of the anterior cerebral artery


Anterior communicating artery


Asymmetry index


Arterial transit time


Blood pressure


3-dimensional T1-weighted inversion-prepared fast spoiled gradient echo


Brain volume


Carotid artery stenting


Cerebral blood flow


Carotid endarterectomy


Cerebral hyperperfusion


Cerebral hyperperfusion syndrome


Spatial coefficient of variation


Circle of Willis


Cerebrovascular reserve


Dynamic susceptibility contrast


Fluid-attenuated inversion recovery


Internal carotid artery


Post-labelling delay


Perfusion volume



This work was supported in part by the Ministry of Science and Technology of China grant (2015CB351701) and the National Nature Science Foundation of China grant (31730039). This work also received funding from Peking Union Medical College.

Compliance with ethical standards


The scientific guarantor of this publication is Feng Feng.

Conflict of interest

The authors declare that they have no conflict of interest.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects or cohorts have been previously reported in “Effective collateral circulation may indicate improved perfusion territory restoration after carotid endarterectomy. 2018. Eur Radiol 28:727–735.”, and as a poster “Preoperative predictors of hyperperfusion after CEA: a study using vessel selective ASL” in ISMRM 2018.


• prospective

• observational

• performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Tianye Lin
    • 1
  • Zhichao Lai
    • 2
  • Zhentao Zuo
    • 3
  • Yuelei Lyu
    • 1
  • Feng Feng
    • 1
    Email author
  • Hui You
    • 1
  • Bo Hou
    • 1
  • Jianxun Qu
    • 4
  • Bing Wu
    • 4
  • Changwei Liu
    • 2
    Email author
  1. 1.Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
  2. 2.Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
  3. 3.Institute of BiophysicsChinese Academy of SciencesBeijingChina
  4. 4.GE HealthcareMR Research ChinaBeijingChina

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