Increased stroke risk predicted by compromised cerebral blood flow reactivity

Howard Yonas M.D.1, Holly A. Smith B.S.1, Susan R. Durham B.S.1, Susan L. Pentheny R.N., P.A.-C.1, and David W. Johnson M.D.1
View More View Less
  • 1 Departments of Neurological Surgery and Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $45.00
USD  $515.00
USD  $612.00
Print or Print + Online Sign in

✓ The authors sought to determine risk for stroke in individuals with symptomatic carotid stenosis or occlusion based upon an assessment of cerebral blood flow (CBF) reserves. Vascular reserve was assessed by two consecutive xenon/computerized tomography (Xe/CT) CBF studies with intravenous acetazolamide introduced 20 minutes prior to the second study. Patients were assigned to one of two vasoreactivity groups. Group 2 included individuals who experienced a CBF reduction of more than 5% in at least one vascular territory and had a baseline flow of 45 cc/100 gm/min or less. Group 1 included all other individuals. Any territory with volume loss on CT of more than 50% was eliminated from analysis.

Sixty-eight individuals were followed at 6-month intervals for a mean of 24 months. In Group 1 two strokes were observed contralateral to the side with lowest reserve, for a stroke incidence of 4.4%; in Group 2 eight strokes were observed ipsilateral to the side with lowest reserve, for a stroke incidence of 36%. The latter group had a 12.6 times greater chance of stroke (p = 0.0007). History of stroke, history of transient ischemic attacks, baseline CBF, and degree of stenosis were not associated with an increased stroke rate. In this study, significantly compromised vascular reserves accompanied by relatively low initial flow identified individuals who subsequently demonstrated a significantly increased rate of ipsilateral stroke.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $515.00
USD  $612.00
  • 1.

    Baron JC, , Bousser MG, & Rey A, et al: Reversal of focal “misery-perfusion syndrome” by extra-intracranial arterial bypass in hemodynamic cerebral ischemia. A case study with 15O positron emission tomography. Stroke 12:454459, 1981 Baron JC, Bousser MG, Rey A, et al: Reversal of focal “misery-perfusion syndrome” by extra-intracranial arterial bypass in hemodynamic cerebral ischemia. A case study with 15O positron emission tomography. Stroke 12:454–459, 1981

    • Search Google Scholar
    • Export Citation
  • 2.

    Bullock R, , Mendelow AD, & Bone I, et al: Cerebral blood flow and CO2 responsiveness as an indicator of collateral reserve capacity in patients with carotid arterial disease. Br J Surg 72:348351, 1984 Bullock R, Mendelow AD, Bone I, et al: Cerebral blood flow and CO2 responsiveness as an indicator of collateral reserve capacity in patients with carotid arterial disease. Br J Surg 72:348–351, 1984

    • Search Google Scholar
    • Export Citation
  • 3.

    Carpenter DA, , Grubb RL Jr, & Powers WJ: Borderzone hemodynamics in cerebrovascular disease. Neurology 40:15871592, 1990 Carpenter DA, Grubb RL Jr, Powers WJ: Borderzone hemodynamics in cerebrovascular disease. Neurology 40:1587–1592, 1990

    • Search Google Scholar
    • Export Citation
  • 4.

    Chollet F, , Celsis P, & Clanet M, et al: SPECT study of cerebral blood flow reactivity after acetazolamide in patients with transient ischemic attacks. Stroke 20:458464, 1989 Chollet F, Celsis P, Clanet M, et al: SPECT study of cerebral blood flow reactivity after acetazolamide in patients with transient ischemic attacks. Stroke 20:458–464, 1989

    • Search Google Scholar
    • Export Citation
  • 5.

    EC/IC Bypass Study Group: Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313:11911200, 1985 EC/IC Bypass Study Group: Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313:1191–1200, 1985

    • Search Google Scholar
    • Export Citation
  • 6.

    Frackowiak RS, , Lenzi GL, & Jones T, et al: Quantitative measurement of regional cerebral blood flow and oxygen metabolism in man using 15O and positron emission tomography: theory, procedure, and normal values. J Comput Assist Tomogr 4:727736, 1980 Frackowiak RS, Lenzi GL, Jones T, et al: Quantitative measurement of regional cerebral blood flow and oxygen metabolism in man using 15O and positron emission tomography: theory, procedure, and normal values. J Comput Assist Tomogr 4:727–736, 1980

    • Search Google Scholar
    • Export Citation
  • 7.

    Frackowiak RSJ: Pathophysiology of human cerebral ischemia: studies with positron tomography and 15oxygen, in Sokoloff L (ed): Brain Imaging and Brain function. New York: Raven Press, 1985, pp 139161 Frackowiak RSJ: Pathophysiology of human cerebral ischemia: studies with positron tomography and 15oxygen, in Sokoloff L (ed): Brain Imaging and Brain Function. New York: Raven Press, 1985, pp 139–161

    • Search Google Scholar
    • Export Citation
  • 8.

    Gibbs JM, , Wise RJS, & Leenders KL, et al: Evaluation of cerebral perfusion reserve in patients with carotid-artery occlusion. Lancet 1:310314, 1984 Gibbs JM, Wise RJS, Leenders KL, et al: Evaluation of cerebral perfusion reserve in patients with carotid-artery occlusion. Lancet 1:310–314, 1984

    • Search Google Scholar
    • Export Citation
  • 9.

    Grubb RL Jr, , Raichle ME, & Eichling JO, et al: The effects of changes in PaCO2 on cerebral blood volume, blood flow, and vascular mean transit time. Stroke 5:630639, 1974 Grubb RL Jr, Raichle ME, Eichling JO, et al: The effects of changes in PaCO2 on cerebral blood volume, blood flow, and vascular mean transit time. Stroke 5:630–639, 1974

    • Search Google Scholar
    • Export Citation
  • 10.

    Gur D, , Good WF, & Wolfson SK Jr, et al: In vivo mapping of local cerebral blood flow by xenon-enhanced computed tomography. Science 215:12671268, 1982 Gur D, Good WF, Wolfson SK Jr, et al: In vivo mapping of local cerebral blood flow by xenon-enhanced computed tomography. Science 215:1267–1268, 1982

    • Search Google Scholar
    • Export Citation
  • 11.

    Herold S, , Brown MM, & Frackowiak RS, et al: Assessment of cerebral hemodynamic reserve: correlation between PET parameters and CO2 reactivity measured by intravenous 133xenon injection technique. J Neurol Neurosurg Psychiatry 51:10451050, 1988 Herold S, Brown MM, Frackowiak RS, et al: Assessment of cerebral hemodynamic reserve: correlation between PET parameters and CO2 reactivity measured by intravenous 133xenon injection technique. J Neurol Neurosurg Psychiatry 51:1045–1050, 1988

    • Search Google Scholar
    • Export Citation
  • 12.

    Johnson DW, , Stringer WA, & Marks MP, et al: Stable xenon CT cerebral blood flow imaging: rationale for and role in clinical decision making. AJNR 12:201213, 1991 Johnson DW, Stringer WA, Marks MP, et al: Stable xenon CT cerebral blood flow imaging: rationale for and role in clinical decision making. AJNR 12:201–213, 1991

    • Search Google Scholar
    • Export Citation
  • 13.

    Kanno I, , Uemera K, & Higano S, et al: Oxygen extraction fraction at maximally vasodilated tissue in the ischemic brain estimated from the regional CO2 responsiveness measured by positron emission tomography. J Cereb Blood Flow Metab 8:227235, 1988 Kanno I, Uemera K, Higano S, et al: Oxygen extraction fraction at maximally vasodilated tissue in the ischemic brain estimated from the regional CO2 responsiveness measured by positron emission tomography. J Cereb Blood Flow Metab 8:227–235, 1988

    • Search Google Scholar
    • Export Citation
  • 14.

    Kleiser B, & Widder B: Course of carotid artery occlusion with impaired cerebrovascular reactivity. Stroke 23:171174, 1992 Kleiser B, Widder B: Course of carotid artery occlusion with impaired cerebrovascular reactivity. Stroke 23:171–174, 1992

    • Search Google Scholar
    • Export Citation
  • 15.

    Lassen NA: Discussion, in Yonas H (ed): Cerebral Blood Flow Measurement with Stable Xenon-Enhanced Computed Tomography. New York: Raven Press, 1992, pp 238239 Lassen NA: Discussion, in Yonas H (ed): Cerebral Blood Flow Measurement with Stable Xenon-Enhanced Computed Tomography. New York: Raven Press, 1992, pp 238–239

    • Search Google Scholar
    • Export Citation
  • 16.

    Lassen NA, & Pälvölgyi R: Cerebral steal during hypercapnia and the inverse reaction during hypocapnia observed by the 133xenon technique in man. Scand J Clin Lab Invest 22 ( Suppl 102): 13D, 1968 Lassen NA, Pälvölgyi R: Cerebral steal during hypercapnia and the inverse reaction during hypocapnia observed by the 133xenon technique in man. Scand J Clin Lab Invest 22 (Suppl 102):13D, 1968

    • Search Google Scholar
    • Export Citation
  • 17.

    Leinsinger G, , Fürst H, & Schmiedek P, et al: Cerebrovascular reserve capacity measured with 133-xenon dynamic SPECT before and after carotid endarterectomy, in Schmiedek K, , Einhaupt K, & Kirsch CM (eds): Stimulated Cerebral Blood Flow. Experimental Findings and Clinical Significance. Berlin: Springer-Verlag, 1992, pp 250256 Leinsinger G, Fürst H, Schmiedek P, et al: Cerebrovascular reserve capacity measured with 133-xenon dynamic SPECT before and after carotid endarterectomy, in Schmiedek K, Einhaupt K, Kirsch CM (eds): Stimulated Cerebral Blood Flow. Experimental Findings and Clinical Significance. Berlin: Springer-Verlag, 1992, pp 250–256

    • Search Google Scholar
    • Export Citation
  • 18.

    McCormick PW, , Tomecek FJ, & McKinney J, et al: Disabling cerebral transient ischemic attacks. J Neurosurg 75:891901, 1991 McCormick PW, Tomecek FJ, McKinney J, et al: Disabling cerebral transient ischemic attacks. J Neurosurg 75:891–901, 1991

    • Search Google Scholar
    • Export Citation
  • 19.

    Meyer JS, , Nakajima S, & Okabe T, et al: Redistribution of cerebral blood flow following STA-MCA by-pass in patients with hemispheric ischemia. Stroke 13:774784, 1982 Meyer JS, Nakajima S, Okabe T, et al: Redistribution of cerebral blood flow following STA-MCA by-pass in patients with hemispheric ischemia. Stroke 13:774–784, 1982

    • Search Google Scholar
    • Export Citation
  • 20.

    Norrving B, , Nilsson B, & Risberg J: rCBF in patients with carotid occlusion. Resting and hypercapnic flow related to collateral pattern. Stroke 13:155162, 1982 Norrving B, Nilsson B, Risberg J: rCBF in patients with carotid occlusion. Resting and hypercapnic flow related to collateral pattern. Stroke 13:155–162, 1982

    • Search Google Scholar
    • Export Citation
  • 21.

    Powers WJ: Cerebral hemodynamics in ischemic cerebrovascular disease. Ann Neurol 29:231240, 1991 Powers WJ: Cerebral hemodynamics in ischemic cerebrovascular disease. Ann Neurol 29:231–240, 1991

    • Search Google Scholar
    • Export Citation
  • 22.

    Powers WJ, , Martin WRW, & Herscovitch P, et al: Extracranial-intracranial bypass surgery: hemodynamic and metabolic results. Neurology 34:11681174, 1984 Powers WJ, Martin WRW, Herscovitch P, et al: Extracranial-intracranial bypass surgery: hemodynamic and metabolic results. Neurology 34:1168–1174, 1984

    • Search Google Scholar
    • Export Citation
  • 23.

    Powers WJ, , Press GA, & Grubb RL Jr, et al: The effect of hemodynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation. Ann Intern Med 106:2734, 1987 Powers WJ, Press GA, Grubb RL Jr, et al: The effect of hemodynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation. Ann Intern Med 106:27–34, 1987

    • Search Google Scholar
    • Export Citation
  • 24.

    Powers WJ, , Tempel LW, & Grubb RL Jr: Influence of cerebral hemodynamics on stroke risk: one-year follow-up of 30 medically treated patients. Ann Neurol 25:325330, 1989 Powers WJ, Tempel LW, Grubb RL Jr: Influence of cerebral hemodynamics on stroke risk: one-year follow-up of 30 medically treated patients. Ann Neurol 25:325–330, 1989

    • Search Google Scholar
    • Export Citation
  • 25.

    Ringelstein EB, , Sievers C, & Ecker S, et al: Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. Stroke 19:963969, 1988 Ringelstein EB, Sievers C, Ecker S, et al: Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. Stroke 19:963–969, 1988

    • Search Google Scholar
    • Export Citation
  • 26.

    Rogers RL, , Meyer JS, & Mortel KF: Additional predisposing risk factors for atherothrombotic cerebrovascular disease among treated hypertensive volunteers. Stroke 18:335341, 1987 Rogers RL, Meyer JS, Mortel KF: Additional predisposing risk factors for atherothrombotic cerebrovascular disease among treated hypertensive volunteers. Stroke 18:335–341, 1987

    • Search Google Scholar
    • Export Citation
  • 27.

    Rogg J, , Rutigliano M, & Yonas H, et al: The acetazolamide challenge: imaging techniques designed to evaluate cerebral blood flow reserve. AJR 153:605612, 1989 Rogg J, Rutigliano M, Yonas H, et al: The acetazolamide challenge: imaging techniques designed to evaluate cerebral blood flow reserve. AJR 153:605–612, 1989

    • Search Google Scholar
    • Export Citation
  • 28.

    Schmiedek P, , Gratzl O, & Spetzler R, et al: Selection of patients for extra-intracranial arterial bypass surgery based on rCBF measurements. J Neurosurg 44:303312, 1976 Schmiedek P, Gratzl O, Spetzler R, et al: Selection of patients for extra-intracranial arterial bypass surgery based on rCBF measurements. J Neurosurg 44:303–312, 1976

    • Search Google Scholar
    • Export Citation
  • 29.

    Sullivan HG, , Kingsbury TB IV, & Morgan ME, et al: The rCBF response to Diamox in normal subjects and cerebrovascular disease patients. J Neurosurg 67:525534, 1987 Sullivan HG, Kingsbury TB IV, Morgan ME, et al: The rCBF response to Diamox in normal subjects and cerebrovascular disease patients. J Neurosurg 67:525–534, 1987

    • Search Google Scholar
    • Export Citation
  • 30.

    Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders, 1987, pp 243260 Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders, 1987, pp 243–260

    • Search Google Scholar
    • Export Citation
  • 31.

    Vorstrup S: Tomographic cerebral blood flow measurements in patients with ischemic cerebrovascular disease and evaluation of the vasodilatory capacity by the acetazolamide test. Acta Neurol Scand Suppl 114:148, 1988 Vorstrup S: Tomographic cerebral blood flow measurements in patients with ischemic cerebrovascular disease and evaluation of the vasodilatory capacity by the acetazolamide test. Acta Neurol Scand Suppl 114:1–48, 1988

    • Search Google Scholar
    • Export Citation
  • 32.

    Vorstrup S, , Brun B, & Lassen NA: Evaluation of the cerebral vasodilatory capacity by the acetazolamide test before EC-IC bypass surgery in patients with occlusion of the internal carotid artery. Stroke 17:12911298, 1986 Vorstrup S, Brun B, Lassen NA: Evaluation of the cerebral vasodilatory capacity by the acetazolamide test before EC-IC bypass surgery in patients with occlusion of the internal carotid artery. Stroke 17:1291–1298, 1986

    • Search Google Scholar
    • Export Citation
  • 33.

    Yamashita T, , Kashiwagi S, & Nakano S, et al: Selecting patients for extracranial-intracranial bypass using Xe/CT blood flow studies and the Diamox test, in Yonas H (ed): Cerebral Blood Flow Measurement with Stable Xenon-Enhanced Computed Tomography. New York: Raven Press, 1992, pp 162169 Yamashita T, Kashiwagi S, Nakano S, et al: Selecting patients for extracranial-intracranial bypass using Xe/CT blood flow studies and the Diamox test, in Yonas H (ed): Cerebral Blood Flow Measurement with Stable Xenon-Enhanced Computed Tomography. New York: Raven Press, 1992, pp 162–169

    • Search Google Scholar
    • Export Citation
  • 34.

    Yasui N, , Suzuki A, & Sayama I, et al: Comparison of the clinical results of STA-MCA anastomosis and the medical treatment in the cerebral low perfusion patients with viable brain tissue. Neurol Res 13:8488, 1991 Yasui N, Suzuki A, Sayama I, et al: Comparison of the clinical results of STA-MCA anastomosis and the medical treatment in the cerebral low perfusion patients with viable brain tissue. Neurol Res 13:84–88, 1991

    • Search Google Scholar
    • Export Citation
  • 35.

    Yonas H, , Gur D, & Good BC, et al: Stable xenon CT blood flow mapping for evaluation of patients with extracranial-intracranial bypass surgery. J Neurosurg 62:324333, 1985 Yonas H, Gur D, Good BC, et al: Stable xenon CT blood flow mapping for evaluation of patients with extracranial-intracranial bypass surgery. J Neurosurg 62:324–333, 1985

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1300 304 10
Full Text Views 360 32 1
PDF Downloads 226 36 3
EPUB Downloads 0 0 0