Assessment of cerebral vasomotor reactivity by transcranial Doppler ultrasound and breath-holding. A comparison with acetazolamide as vasodilatory stimulus.

BACKGROUND AND PURPOSE Evaluating cerebrovascular vasomotor reactivity seems to be of prognostic relevance for patients with occlusive internal carotid artery disease. To evaluate its clinical usefulness, the recently introduced breath-holding maneuver as a carbon dioxide-dependent vasodilatory stimulus was compared with the acetazolamide challenge by means of transcranial Doppler ultrasound and stable xenon-enhanced computed tomography. METHODS In a total of 134 middle cerebral arteries of 74 patients (mean +/- SD age, 62 +/- 9 years) with unilateral or bilateral occlusive carotid artery disease, vasomotor reactivity was estimated by the increase of middle cerebral artery mean blood velocity by transcranial Doppler ultrasound, comparing the breath-holding maneuver and 1 g IV acetazolamide as vasodilatory stimuli. The carotid artery findings were classified as normal, stenosis of 50% to < 70%, 70% to < 90%, 90% to 99%, and occlusion. Eighteen of the 74 patients additionally underwent stable xenon-enhanced computed tomography to calculate the increase of mean cortical regional cerebral blood flow in the middle cerebral artery territory after acetazolamide stimulation. RESULTS The percentage of mean regional cerebral blood flow changes (n = 36 hemispheres) correlated best with the absolute mean blood velocity changes while breath-holding (P = .007, r = .4332). The absolute mean regional cerebral blood flow changes correlated best with the percentage of mean blood velocity changes after acetazolamide stimulation (P = .004, r = .4580). On all 134 middle cerebral arteries, both vasodilatory stimuli correlated highly significantly (P < .0001) when comparing increases in absolute (r = .5448) or relative (r = .3516) mean blood velocity. Both stimulation techniques similarly indicated significantly reduced vasomotor reactivity with increasing degree of internal carotid artery lesions (P < or = .01). However, the acetazolamide challenge differentiated more accurately between the various groups of internal carotid artery findings. CONCLUSIONS The assessment of vasomotor reactivity by transcranial Doppler ultrasound correlates with cerebral blood flow changes even when different vasodilatory stimuli are used. In cooperative patients the breath-holding maneuver as vasodilatory stimulus seems clinically useful for a first estimation of cerebral vasomotor reactivity.

[1]  W J Powers,et al.  Influence of cerebral hemodynamics on stroke risk: One‐year follow‐up of 30 medically treated patients , 1989, Annals of neurology.

[2]  M E Raichle,et al.  Positron emission tomography and its application to the study of cerebrovascular disease in man. , 1985, Stroke.

[3]  K Rootwelt,et al.  A Comparison of Transcranial Doppler and Cerebral Blood Flow Studies to Assess Cerebral Vasoreactivity , 1992, Stroke.

[4]  D Gur,et al.  Stable xenon CT cerebral blood flow imaging: rationale for and role in clinical decision making. , 1991, AJNR. American journal of neuroradiology.

[5]  B. Arnolds,et al.  Transcranial Doppler sonography. Examination technique and normal reference values. , 1986, Ultrasound in medicine & biology.

[6]  J. Wade,et al.  Reactivity of the cerebral circulation in patients with carotid occlusion. , 1986, Journal of neurology, neurosurgery, and psychiatry.

[7]  E. Højer‐Pedersen.  Effect of acetazolamide on cerebral blood flow in subacute and chronic cerebrovascular disease. , 1987, Stroke.

[8]  G. Leinsinger,et al.  A simple test to assess cerebrovascular reserve capacity using transcranial Doppler sonography and acetazolamide. , 1990, Stroke.

[9]  J. Patterson,et al.  Cerebral blood flow and CO2 responsiveness as an indicator of collateral reserve capacity in patients with carotid arterial disease , 1985, The British journal of surgery.

[10]  C. Giller,et al.  Effects of inhaled stable xenon on cerebral blood flow velocity. , 1990, AJNR. American journal of neuroradiology.

[11]  E B Ringelstein,et al.  Evaluation of Cerebral Vasomotor Reactivity by Various Vasodilating Stimuli: Comparison of CO2 to Acetazolamide , 1992, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[12]  G. Beck,et al.  Transcranial Doppler assessment of cerebral perfusion reserve in patients with carotid occlusive disease and no evidence of cerebral infarction , 1993, Neurology.

[13]  W. Sorteberg,et al.  Side‐to‐side differences and day‐to‐day variations of transcranial Doppler parameters in normal subjects. , 1990, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine.

[14]  E. Ringelstein,et al.  The pathogenesis of strokes from internal carotid artery occlusion. Diagnostic and therapeutical implications. , 1983, Stroke.

[15]  J. Norris,et al.  Stroke risk and critical carotid stenosis. , 1990, Journal of neurology, neurosurgery, and psychiatry.

[16]  H Yonas,et al.  Increased stroke risk predicted by compromised cerebral blood flow reactivity. , 1993, Journal of neurosurgery.

[17]  N. Browse,et al.  EFFECT OF INTERNAL CAROTID ARTERY OCCLUSION ON MIDDLE CEREBRAL ARTERY BLOOD FLOW AT REST AND IN RESPONSE TO HYPERCAPNIA , 1986, The Lancet.

[18]  R. Aaslid,et al.  Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. , 1982, Journal of neurosurgery.

[19]  K. Zülch,et al.  The Cerebral Infarct: Pathology, Pathogenesis, and Computed Tomography , 1985 .

[20]  S. Vorstrup.  Tomographic cerebral blood flow measurements in patients with ischemic cerebrovascular disease and evaluation of the vasodilatory capacity by the acetazolamide test. , 1988, Acta neurologica Scandinavica. Supplementum.

[21]  B. Widder,et al.  Course of Carotid Artery Occlusions With Impaired Cerebrovascular Reactivity , 1992, Stroke.

[22]  J. Bogousslavsky,et al.  Borderzone infarctions distal to internal carotid artery occlussion: Prognostic implications , 1986, Annals of neurology.

[23]  K. Leenders,et al.  EVALUATION OF CEREBRAL PERFUSION RESERVE IN PATIENTS WITH CAROTID-ARTERY OCCLUSION , 1984, The Lancet.

[24]  H. Yonas,et al.  The acetazolamide challenge: imaging techniques designed to evaluate cerebral blood flow reserve. , 1989, AJR. American journal of roentgenology.

[25]  W. Stringer,et al.  Accuracy of xenon CT measurement of cerebral blood flow. , 1991, AJNR. American journal of neuroradiology.

[26]  K. Rootwelt,et al.  Cerebral Vasoreactivity in Unilateral Carotid Artery Disease: A Comparison of Blood Flow Velocity and Regional Cerebral Blood Flow Measurements , 1994, Stroke.

[27]  P. Adeleine,et al.  Cerebral Blood Flow Reserve Assessment in Symptomatic Versus Asymptomatic High‐Grade Internal Carotid Artery Stenosis , 1994, Stroke.

[28]  J. Allison,et al.  The rCBF response to Diamox in normal subjects and cerebrovascular disease patients. , 1987, Journal of neurosurgery.

[29]  H. Markus,et al.  Estimation of Cerebrovascular Reactivity Using Transcranial Doppler, Including the Use of Breath‐Holding as the Vasodilatory Stimulus , 1992, Stroke.

[30]  W. Powers.  Cerebral hemodynamics in ischemic cerebrovascular disease , 1991, Annals of neurology.

[31]  B. Norrving,et al.  rCBF in patients with carotid occlusion. Resting and hypercapnic flow related to collateral pattern. , 1982, Stroke.

[32]  E B Ringelstein,et al.  Clinical and hemodynamic aspects of low-flow infarcts. , 1991, Stroke.

[33]  R. Aaslid,et al.  Assessment of intracranial hemodynamics in carotid artery disease by transcranial Doppler ultrasound. , 1985, Journal of neurosurgery.

[34]  R S Frackowiak,et al.  Assessment of cerebral haemodynamic reserve: correlation between PET parameters and CO2 reactivity measured by the intravenous 133 xenon injection technique. , 1988, Journal of neurology, neurosurgery, and psychiatry.

[35]  A Hauge,et al.  Acute effects of acetazolamide on cerebral blood flow in man. , 1983, Acta physiologica Scandinavica.

[36]  N L Browse,et al.  Transcranial Doppler measurement of middle cerebral artery blood flow velocity: a validation study. , 1986, Stroke.

[37]  P A Schneider,et al.  Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. , 1988, Stroke.

[38]  A. Thie,et al.  99mTc‐HMPAO‐SPECT With Acetazolamide Challenge to Detect Hemodynamic Compromise in Occlusive Cerebrovascular Disease , 1992, Stroke.

[39]  M. Adiseshiah,et al.  Increase in middle cerebral artery velocity on breath holding: a simplified test of cerebral perfusion reserve. , 1990, European journal of vascular surgery.