1Department of Anesthesiology and Critical Care Medicine, and 2Department of Neuropathology, Medical Research Institute, Tokyo Medical and Dental University, School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan*Corresponding author
Accepted for publication: March 26, 2001
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Abstract |
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Br J Anaesth 2001; 87: 46976
Keywords: complications, thromboembolism; rat; measurement techniques, magnetic resonance imaging; measurement techniques, diffusion-weighted imaging
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Introduction |
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Cerebral ischaemia induced by thromboembolism remains a crucial problem during the perioperative period. It may occur silently under general anaesthesia, and may cause prolonged unconsciousness, coma, or death as a result of neurological damage. One of the first steps in an attempt to prevent or attenuate this neurological damage in patients, especially those with risk factors for thromboembolism (i.e. a previous history of transient ischaemic attack, heart disease, peripheral vascular disease),6 is to evaluate the effects on thromboembolism of neuroprotective agents or anaesthetic agents that provide some neuroprotection. However, how thromboembolic stroke evolves in humans and animals is not fully understood.
Thromboembolic stroke in patients appears to evolve in a very complicated manner. One study of patients who had suffered an acute ischaemic stroke has shown that an increase in ischaemic lesion volume occurs during the first 53 h after the stroke.7 In 12 of these 28 patients, the initial lesion volume increased by 20% or more.7 On the other hand, arterial cerebral occlusion leading to acute ischaemic stroke may disappear as a natural process of thrombus disintegration and endogenous thrombolysis. Jorgensen and colleagues reported that the incidence of spontaneous reperfusion was 77% in patients with cortical infarcts.8 To determine the evolution of thromboembolic stroke, animal experiments involving sequential measurement of ischaemic lesion volume with relatively short intervals appear necessary. However, conventional structural imaging modalities (computed tomography, T1- or T2-weighted magnetic resonance imaging (MRI)) do not reliably depict evolving ischaemic lesions at the early stage of stroke.
Diffusion-weighted imaging (DWI) is a relatively new MRI technique that is sensitive to the microscopic motion of water molecules. The signal intensity in ischaemic brain regions on DWI appears high because the diffusion coefficient of water is reduced, presumably because of the formation of cytotoxic oedema.9 10 This phenomenon can be quantified by the calculation of apparent diffusion coefficient (ADC) images.11 12 The ADC may be calculated on a pixel-by-pixel basis from at least two DWIs with different diffusion weightings. This raises the possibility that the extent and spatial evolution of thromboembolic stroke can be evaluated using an ADC map.
The rat model of cerebral infarction was established by Kudo and colleagues.13 This animal model of thromboembolism creates cerebral infarction predominantly in the territory of the middle cerebral artery, with a low mortality rate and excellent reproducibility.13 To establish a remote-controlled rat thromboembolic stroke from outside the magnet, we have modified this model and observed sequential changes in the hemispheric ischaemic lesion area caused by thromboembolism.
The objective of the present study was to determine the evolution of thromboembolic stroke in rats under general anaesthesia using ADC maps. We focused on the effect of the change in lesion volume at the early stage of stroke on total evolution of thromboembolic stroke, because recent therapy in acute stroke is based on reperfusion of the ischaemic legion leading to salvage of the ischaemic penumbra, smaller infarct size, and improved outcome.14 15
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Methods |
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Clot formation
Nine adult male SpragueDawley rats weighing between 330 and 400 g were used. Anaesthesia was induced with 4% isoflurane in a Plexiglas chamber. The concentration of isoflurane was then reduced to 1.5%, 1% lidocaine was locally injected for analgesia, and 0.25 ml of blood drawn from a left femoral vein and stored at room temperature for 48 h for clot formation. The clot was fragmented by extruding it twice through a 27-gauge needle. The clot fragments were then diluted with saline solution to 0.3 ml and prepared for injection.
Animal preparation
The animals were again anaesthetized with 1.5% isoflurane, and 1% lidocaine was locally administered. Under an operating microscope, the bifurcation of the right common carotid artery was exposed through a midline neck incision. The external carotid artery was ligated just above its origin. A polyethylene catheter (PE-50) was then introduced into the right common carotid artery and advanced into the internal carotid artery. Two PE-50 catheters were introduced into a right femoral vein and a right femoral artery for drug infusion, arterial pressure monitoring, and arterial blood sampling, respectively. Physiologic saline solution at 4 ml kg1 h1 was administered i.v. throughout the study. After a tracheostomy, each rat was ventilated with 40% oxygen and the respiratory rate controlled to maintain PaCO2 at approximately 40 mm Hg.
MRI
MRI was performed using a 4.7-T experimental imager/spectrometer system (Unity INOVA, Varian, Palo Alto, CA, USA) with a 330-mm horizontal bore magnet equipped with shielded gradients (maximal strength, 65 mT m1) and an 80-mm-ID quadrature detection coil. The slice plane was standardized by first obtaining preview spin-echo images. Spin-echo DWI (TR ms/TE ms=2000/64, 40-mm field of view, 128x128 matrix, 2-mm section thickness) consisted of nine coronal slices covering most of the rat brain. Diffusion weighting was applied along all three axes (b=0 and 1100 s mm2) and a single DWI required an acquisition time of approximately 18 min. DWI with a b value of 0 s mm2 corresponds to a T2-weighted image (T2WI).
Pairs of DWIs with two b values were used to generate maps of the ADC. ADC maps were calculated using the standard equation:16
ADC=ln(S0/S1)/(b1 b0)
where S0 and S1 are the signals of the two DWI scans and b0 and b1 are 0 and 1100 s mm2.
Experimental protocol
After placing the animals supine in the probe, anaesthesia was maintained with 1.5% isoflurane in 40% oxygen. The rats body temperature was monitored with a rectal probe, and maintained at 37.5±0.5°C using a water-circulating heating pad during the MRI study. After animal positioning and shimming, a set of baseline DWIs was acquired. Homologous blood clots were introduced into the right internal carotid artery via the catheter. Sets of DWIs were acquired at 60-min intervals for 300 min beginning 40 min after clot injection (T40, T100, T160, T220, T280, T340). Arterial blood samples were collected at baseline, and at T120 and T240, and analysed on a laboratory blood gas analyser (STAT profile 5TM gas analyzer, NOVA Biomedical, USA). If mean arterial pressure (MAP) was reduced to less than 80 mm Hg, dopamine was administered i.v. to maintain the MAP over 80 mm Hg.
Definition of lesion volume
The ischaemic lesion was defined arbitrarily as the pixels in which the ADC decreased to less than 70% of the mean ADC of the ipsilateral hemisphere at baseline. Lesion area on an ADC map was calculated by multiplying the number of these pixels by the area of one pixel (approximately 0.1 mm2). The lesion volume of ischaemic injury was determined by integration of the lesion areas for the nine slices. Two coronal slices which included the optic chiasm (slice A) and the area 4 mm caudal to it (slice B) were considered to represent the territory of the middle cerebral artery, and consequently the ischaemic lesion on slices A and B were divided by the hemispheric area to obtain the percentage lesion area, and results then compared with histopathology as described below. Sequential changes in the lesion volume on ADC maps were recorded.
Percentage change in the lesion volume (%LV) was defined as the percentage difference between the lesion volumes at Tt and Tt+60 (t=40, 100, 160, 220, 280) to calculate the percentage increase or decrease during each MRI acquisition interval. The absolute values of %
LV were compared at different times to evaluate when the lesion volume changed (increased or decreased) markedly. Total percentage change in lesion volume (total %
LV) was defined to calculate percentage increase or decrease in lesion volume during the whole MRI study after thromboembolism. %
LV and total %
LV were defined and calculated as follows.
1. As DWIs were acquired at 60-min intervals, the %LV between Tt and Tt+60 was defined as: %
LV (Tt t+60) (%) = [[lesion volume (Tt+60) lesion volume (Tt)]/lesion volume (Tt)]x100.
2. Total %LV was calculated as: Total %
LV (%) = [[lesion volume (T340) lesion volume (T40)]/lesion volume (T40)]x100.
Development of lesion area in specific regions
To analyse the development of an ischaemic lesion in some specific regions, cortex and caudate putamen on slice A and cortex and basal ganglia on slice B were selected. Then the lesion in these regions was subdivided into two parts according to their ADC values: severe lesion corresponds to ADC<400x106 mm2 s1 and moderate lesion corresponds to the ischaemic lesion whose ADC value is equal to or more than 400x106 mm2 s1 but less than 500x106 mm2 s1. Sequential changes in lesion area were recorded and analysed.
Histopathology
After MRI studies, the animals were killed with an overdose of i.v. pentobarbital, and the brain was removed and sectioned coronally at 2-mm intervals. The sections most closely corresponding to slices A and B were selected and stained with a 2% solution of triphenyltetrazolium chloride (TTC) to identify infarcted tissue, and then photographed. Using a computer imaging system, the infarcted areas were divided by the ipsilateral hemispheric area to obtain the percentage hemispheric infarcted area.
Data analysis
All data are expressed as mean (SD). MAP, arterial blood gas data, plasma glucose concentration, rectal temperature, lesion volume (area) on ADC maps, and the absolute value of %LV at different times were analysed using repeated measures analysis of variance followed by Tukeys multiple comparison test. The relationship between %
LV during each MRI acquisition interval and the total %
LV was analysed using linear fitting. The relationship between lesion volume on the ADC map and the time after clot injection was analysed for each rat using linear fitting. The percentage lesion area based on the ADC map at T340 was compared with the TTC stained percentage hemispheric infarcted area using correlation analysis for slices A and B. Statistical significance was set at the P<0.05 level.
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Results |
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Discussion |
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Diffusion-weighted MR imaging has been well established as a reliable non-invasive method for early detection of cerebral ischaemic stroke.17 18 The principle of diffusion measurement is that the spatial location of each water molecule is tagged such that any net movement of the water molecule over time results in a signal loss or darkening of the images. In the present study, this tagging was achieved by a pair of very strong pulsed magnetic field gradients (diffusion gradients) which were added to a spin-echo sequence. The first of these diffusion gradients causes the spinning protons to fall out of phase with one another, and the second gradient rephases the protons completely with one another only if there has been no movement of the water molecules between the application of the two diffusion gradients. When there is movement of water, the protons are not brought back completely into phase by the second diffusion gradient and the signal attenuation will occur on DWIs. DWI can detect abnormalities within min after the onset of ischaemia in animal models of stroke.1921 before lesions are apparent on conventional images. The high signal intensity on the DWIs after clot injection may be explained as an ischaemic change as a result of thromboembolism. The infarct lesions revealed by TTC staining may also suggest that the hyperintense areas on DWIs are ischaemic because of decreased blood flow, which is consistent with the histopathological findings of Kudo and colleagues.13
After injection of the clot, the ADC values were reduced in regions where the signal intensities were increased on the DWIs. Although the precise mechanism underlying the reduction in ADCs in ischaemic regions is unclear, this phenomenon is considered to represent the onset of intracellular water accumulation or cytotoxic oedema.10 22 23 Tissue adenosine triphosphate (ATP) reserves are depleted after the onset of ischaemia, and the subsequent failure of the Na+/K+-ATPase pump causes water protons and ions to migrate from the faster-diffusing, extracellular space into the slower-diffusing, more restricted intracellular compartment, resulting in an ADC decrease.
Thromboembolic stroke in patients evolves in a very complicated manner. For example, the ischaemic lesion may enlarge with time7 and result in large cerebral infarction. On the other hand, spontaneous reperfusion may occur8 and ischaemic penumbra may be salvaged. Many studies have shown a qualitative enlargement of thromboembolic stroke in rats but not quantitative changes in lesion volume in individual rats.2429 Thus, we designed the present study to examine how lesion volume after thromboembolism evolves quantitatively using ADC maps. Lesion volumes were measured sequentially at relatively short intervals (60 min). The precise mechanisms responsible for the change in lesion volume after thromboembolism are not fully understood. We assume many factors are involved, as described below.
First, mean percentage lesion volume tended to increase with time after thromboembolism in the present study; however, the increase was not statistically significant. This enlargement of lesion volume may be most likely explained by an ischaemic penumbra. The lesion observed on the first ADC map after the thromboembolic stroke may be regarded as the central most severely ischaemic region (core30). The lesion area that was not visible on the ADC map on the early stage of the thromboembolism but was detected later during the MRI study may represent penumbra.30 31 Although cerebral perfusion was not evaluated in the present study, the most likely scenario is that cerebral blood flow in the penumbra reduced slightly and the ADC decreased little or did not change32 on the first ADC map after thromboembolism. This hypoperfused tissue may be above the threshold for infarction, at least initially;33 however, it may be irreversibly injured on the time course of the MRI study.
Development of severe ischaemic lesions in the cortex on slices A and B may support our assumption that the enlargement of lesion volume may be most likely explained by an ischaemic penumbra. The increase in severe ischaemic lesion area may be explained that the regions with higher ADC value (400x106 mm2 s1) became injured during the time course of the experiment. The area of moderate lesion was unchanged because the higher ADC regions (
500x106 mm2 s1) may have been injured and showed a decrease in their ADC value to 400500x106 mm2 s1.
Second, as shown in Figure 3, the lesion volume in individual rats showed some fluctuation during the MRI study. Transient reduction in lesion volume (transient recoveries of ADCs) in such animals may be, in part, explained by recanalization and subsequent reperfusion (spontaneous reperfusion8 34), a passage of emboli or a development of adequate collateral circulation. Disappearance of arterial cerebral occlusion is often seen clinically as a natural process of thrombus disintegration and endogenous thrombolysis. Although it is impossible to prove in the present study without measurement of cerebral perfusion, the proportional relationship between ADC and cerebral perfusion32 may indirectly support our assumption.
Third, pseudonormalization of the ADC may be another factor that affected the time course of lesion volume. In rodent stroke models, ADC begins to normalize at 2448 h. This normalization does not imply tissue recovery but the beginning of tissue necrosis (pseudonormalization).35 36 As ADC is increased by vasogenic oedema,22 pseudonormalization is considered to be attributed to a balance of cytotoxic and vasogenic oedema. Lesion area was evident on T2WI at T220 in the present study, suggesting that vasogenic oedema occurred at that time. Lesion volume based on ADC maps may have been affected by pseudonormalization of ADC during the latter half of the time course of the MRI study; however, we assume the extent of underestimation of lesion volume because of pseudonormalization, if it occurred, may be small as the TTC stained infarcted area correlated well with lesion volume on the final ADC map.
The fact that the absolute value of %LV was largest at T40100 may imply that lesion volume markedly increases or decreases at the early stage of thromboembolism. Irrespective of the mechanisms responsible for the sequential change observed in lesion volume, our data demonstrate that total %
LV shows significant correlation to %
LV at this period (T40100) but not thereafter. This suggests that enlargement or diminution of lesion volume during this period plays an important role in the total evolution of thromboembolic stroke in this model. Our results also suggest that only a small increase or even a decrease in lesion volume may be detected throughout the whole period of thromboembolism in rats in which the ischaemic lesion is partly salvaged at the early stage of thromboembolic stroke.
There is no absolute threshold of ADC decrease that predicts if a lesion is irreversible; maximal decreases in the ADC area are even reversible for short periods.37 This is why the threshold ADC values should be set arbitrarily. The mean (SD) ADC value on slices A and B at baseline were 718 (40)x106 and 703 (44)x106 mm2 s1, respectively. We have set the threshold at 70% of the baseline, which corresponded to approximately 500x106 mm2 s1, by modifying the study by Busch and colleagues.38 Morikawa and colleagues reported on the adverse effect of hyperglycaemia on transient focal brain ischaemia using the threshold ADC value of 500x106 mm2 s1.39 One may expect that 2 SD from the mean ADC at baseline would be better as the threshold ADC. The mean 2 SD ADC on slices A and B correspond to 583x106 and 539x106 mm2 s1, respectively in the present study, which would have estimated the lesion volume (area) a little larger than our analysis.
In conclusion, the largest percentage change in lesion volume was found at the early stage of thromboembolism, and showed significant correlation with the total percentage change in lesion volume. Marked enlargement or diminution of the lesion volume may be observed at the early stage of thromboembolism. Thromboembolic stroke, which is partly salvaged at the early stage, may likely evolve to a lesser extent thereafter.
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Acknowledgements |
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References |
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