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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References
Yasargil MG: Microsurgery Applied to Neurosurgery, Verag, Stutgart, 1969:95-119.
- Extracranial-intracranial bypass to reduce the risk of ischemic stroke.Health Technol Assess Rep. 1990; 6: 1-9
- Positional cerebral ischemia.J Neurol Neurosurg Psychiatry. 1976; 39: 385-391
- Orthostatic transient ischemic attacks: A symptom of large vessel occlusion.Stroke. 1984; 15: 1066-1067
- Orthostatic hypotension as a risk factor for symptomatic occlusive cerebrovascular disease.Neurology. 1989; 39: 30-34
- Concerning recurrent transient cerebral ischemic attacks.Can Med Assoc J. 1962; 86: 1091-1099
- Orthostatic limb shaking from carotid hypoperfusion.Neurology. 1999; 53: 650-651
- Repetitive involuntary movement associated with episodic cerebral ischemia.Ann Neurol. 1985; 18: 244-250
- Limb shaking–a carotid TIA.Stroke. 1985; 16: 444-448
- Rhythmic involuntary movement as a manifestation of transient ischemic attacks.Trans Am Neurol Assoc. 1981; 106: 46-48
- Recurrent ischemia in symptomatic carotid occlusion: Prognostic value of hemodynamic factors.Neurology. 2000; 55: 1806-1812
- Unilateral visual loss in bright light: An unusual symptom of carotid artery occlusive disease.Arch Neurol. 1979; 36: 675-676
- Critical perfusion of brain and retina.Brain. 1983; 106: 419-434
- Collateral circulation.Stroke. 2003; 34: 2279-2284
- Correlation of xenon-enhanced computed tomography-defined cerebral blood flow reactivity and collateral flow patterns.Stroke. 1994; 25: 1784-1787
- Rcbf in patients with carotid occlusion: Resting and hypercapnic flow related to collateral pattern.Stroke. 1982; 13: 155-162
- Collateral circulation via the ophthalmic artery or leptomeningeal vessels is associated with impaired cerebral vasoreactivity in patients with symptomatic carotid artery occlusion.Cerebrovasc Dis. 2002; 14: 22-26
- Pattern of collaterals, type of infarcts, and hemodynamic impairment in carotid artery occlusion.J Neurol Neurosurg Psychiatry. 2004; 75: 1697-1701
- Lack of correlation between pattern of collateralization and misery perfusion in patients with carotid occlusion.Stroke. 1999; 30: 1025-1032
- The pathophysiology of watershed infarction in internal carotid artery disease: Review of cerebral perfusion studies.Stroke. 2005; 36: 567-577
- Topographic distribution of misery perfusion in relation to internal and superficial border zones.AJNR Am J Neuroradiol. 2003; 24: 427-435
- Small rosarylike infarctions in the centrum ovale suggest hemodynamic failure.AJNR Am J Neuroradiol. 1998; 19: 1479-1484
- Acetazolamide reactivity on 123i-imp single photon emission computed tomography in patients with major cerebral artery occlusive disease: Correlation with positron emission tomography parameters.J Cereb Blood Flow Metab. 1994; 14: 763-770
- Vascular reserve in chronic cerebral ischemia measured by the acetazolamide challenge test: Comparison with positron emission tomography.AJNR Am J Neuroradiol. 1995; 16: 563-570
- Assessment of cerebral hemodynamic reserve: Correlation between PET parameters and CO2 reactivity measured by the intravenous 133 xenon injection technique.J Neurol Neurosurg Psychiatry. 1988; 51: 1045-1050
- Oxygen extraction fraction and cerebrovascular reactivity to Paco2 changes in ischemic brain measured by positron emission tomography [in Japanese].No To Shinkei. 1987; 39: 745-750
- Evaluation of cerebral perfusion reserve in patients with carotid-artery occlusion.Lancet. 1984; 1: 310-314
- Oxygen extraction fraction and acetazolamide reactivity in symptomatic carotid artery disease.J Neurol Neurosurg Psychiatry. 2004; 75: 33-37
- Can transcranial Doppler really detect reduced cerebral perfusion states?.Stroke. 1995; 26: 2053-2060
- Cerebral hemodynamic impairment: Methods of measurement and association with stroke risk.Neurology. 1999; 53: 251-259
- Sequential change of hemodynamic reserve in patients with major cerebral artery occlusion or severe stenosis.Neuroradiology. 1992; 34: 15-21
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.
