Introduction
Recent studies have shown that patients with increased oxygen extraction fraction
(OEF) as measured by positron emission tomography (PET) have a substantially increased
risk of stroke as a result of hemodynamic insufficiency. These patients appear to
be ideal candidates for extracranial (EC)-intracranial (IC) bypass. The feasibility
of this screening protocol, however, is controversial given PET's limited availability
and high expense. A better understanding of the clinical factors that identify patients
with potential hemodynamic insufficiency would streamline screening and improve cost-efficiency.
Methods
We performed a MEDLINE (1985-2007) database search for studies identifying clinical
and radiographic predictors of hemodynamic failure and increased OEF on PET. We used
the following key words, singly and in combination: “EC-IC bypass,” ”hemodynamic failure,”
and “misery perfusion.” Additional studies were identified manually by scrutinizing
references from manuscripts, major neurosurgical journals and texts, and personal
files. Each study was reviewed for methodology, clinical criteria, and correlation
with subsequent PET findings and stroke rates. A consensus was determined regarding
the predictive value of each marker.
Results
Our literature search revealed 5 clinical and radiographic markers that have been
used to identify patients with hemodynamic failure: orthostatic limb shaking, blurry
vision on exposure to heat, leptomeningeal and ophthalmic collateral circulation on
angiography, watershed infarction, and impaired vasodilatory response to acetazolamide.
Orthostatic limb shaking is a rare finding but is predictive of hemodynamic failure
and is associated with increased stroke risk. Blurry vision on exposure to heat is
not predictive of increased stroke risk. Leptomeningeal and ophthalmic collateral
circulation is a sensitive but not specific marker. Watershed infarction is highly
sensitive and impaired vasodilatory response to acetazolamide is associated with increased
OEF but may not be interchangeable.
Conclusions
Orthostatic limb shaking, watershed infarction, collateral circulation, and impaired
vasoreactivity to acetazolamide in patients with athero-occlusive disease may predict
hemodynamic failure, increased OEF on PET, and high stroke rates. Recognition of these
predictive markers may improve patient selection for surgical intervention, as such
individuals appear to benefit from EC-IC bypass.
Key Words
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Article Info
Publication History
Accepted:
April 21,
2008
Received in revised form:
March 4,
2008
Received:
December 21,
2007
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2008.04.005
Copyright
© 2008 National Stroke Association. Published by Elsevier Inc. All rights reserved.
