Vascular reserve in chronic cerebral ischemia measured by the acetazolamide challenge test: comparison with positron emission tomography.

PURPOSE To determine the value of the acetazolamide challenge test with stable xenon-enhanced CT (Xe CT) for making therapeutic decisions in patients with chronic cerebrovascular disease. METHODS We compared the Xe CT-measured acetazolamide response with various measures obtained by positron emission tomography. We performed both a positron emission tomographic scan and a Xe CT study in 11 patients with chronic cerebral ischemic diseases within a 1-week interval. An increase of cerebral blood flow after injection of acetazolamide was expressed as delta AT. Regional cerebral blood flow, cerebral oxygen metabolism, oxygen extraction fraction, and cerebral blood volume were measured with oxygen-15-labeled gases by positron emission tomography. RESULTS In low-cerebral blood flow regions, decreased delta AT was accompanied by a significant elevation of oxygen extraction fraction and cerebral blood volume, compared with oxygen extraction fraction and cerebral blood volume in regions of normal delta AT. Plotting of regional data indicated that delta was significantly dependent on oxygen extraction fraction and cerebral blood volume. The area of decreased vascular reserve determined by the Xe CT image corresponded to the area of "misery perfusion" determined by positron emission tomography. CONCLUSION The acetazolamide challenge test with Xe CT may offer an alternative to positron-emission tomography in detecting lesions with elevated oxygen extraction fraction and cerebral blood volume (misery perfusion) that result from chronic hemodynamic stress.

[1]  H. Kretschmann,et al.  Neuroanatomy and Cranial Computed Tomography , 1986 .

[2]  D. Sackett,et al.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. , 1991, The New England journal of medicine.

[3]  G. Sicard.  MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or mild (0–29%) carotid stenosis: European Carotid Surgery Trialist' Collaborative Group. Lancet 1991;337:1235-43 , 1992 .

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

[5]  H Yonas,et al.  CBF Measured by Xe-CT: Approach to Analysis and Normal Values , 1991, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[6]  Charles W. Dunnett,et al.  New tables for multiple comparisons with a control. , 1964 .

[7]  Marcus E. Raichle,et al.  Measurement of regional cerebral blood volume by emission tomography , 1978, Annals of neurology.

[8]  H. Barnett,et al.  Symptomatic carotid artery stenosis: a solvable problem. North American Symptomatic carotid Endarterectomy Trial. , 1992, Stroke.

[9]  O B Paulson,et al.  Effect of acetazolamide on cerebral blood flow and cerebral metabolic rate for oxygen. , 1984, The Journal of clinical investigation.

[10]  W. Baker,et al.  Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke: The EC/IC Bypass Study Group. N Engl J Med 1985;313:1191–1200 , 1986 .

[11]  D Comar,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 , 1981, Stroke.

[12]  T. Sundt.  Was the international randomized trial of extracranial-intracranial arterial bypass representative of the population at risk? , 1987, The New England journal of medicine.

[13]  N. Lassen,et al.  Evaluation of the cerebral vasodilatory capacity by the acetazolamide test before EC-IC bypass surgery in patients with occlusion of the internal carotid artery. , 1986, Stroke.

[14]  R B Buxton,et al.  The 15O Steady-State Method: Correction for Variation in Arterial Concentration , 1988, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[15]  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.

[16]  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.

[17]  S. Kety,et al.  THE DETERMINATION OF CEREBRAL BLOOD FLOW IN MAN BY THE USE OF NITROUS OXIDE IN LOW CONCENTRATIONS , 1945 .

[18]  R. Frackowiak,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 , 1980, Journal of computer assisted tomography.

[19]  K. B. Larson,et al.  In Vivo Determination of Cerebral Blood Volume with Radioactive Oxygen‐15 in the Monkey , 1975, Circulation research.

[20]  H. Fukuyama,et al.  Significance of Low Perfusion With Increased Oxygen Extraction Fraction in a Case of Internal Carotid Artery Stenosis , 1992, Stroke.

[21]  A A Lammertsma,et al.  Correction for the Presence of Intravascular Oxygen-15 in the Steady-State Technique for Measuring Regional Oxygen Extraction Ratio in the Brain: 1. Description of the Method , 1983, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[22]  M D Devous,et al.  The effect of acetazolamide on regional cerebral blood flow in normal human subjects as measured by single-photon emission computed tomography. , 1988, Investigative radiology.

[23]  M. Raichle,et al.  The effect of acetazolamide on cerebral blood flow and oxygen utilization in the rhesus monkey. , 1978, The Journal of clinical investigation.

[24]  W A Kalender,et al.  Brain perfusion studies by xenon-enhanced CT using washin/washout study protocols. , 1991, Journal of computer assisted tomography.

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

[26]  H. Yonas,et al.  Use of acetazolamide-challenge xenon CT in the assessment of cerebral blood flow dynamics in patients with arteriovenous malformations. , 1990, AJNR. American journal of neuroradiology.

[27]  M E Raichle,et al.  Extracranial‐intracranial bypass surgery , 1984, Neurology.

[28]  H. Barnett,et al.  "Stump" of Internal Carotid Artery - A Source for Further Cerebral Embolic Ischemia , 1978, Stroke.

[29]  Tadashi Nariai,et al.  Surgically Induced Angiogenesis to Compensate for Hemodynamic Cerebral Ischemia , 1994, Stroke.

[30]  H. Barnett.  Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. , 1978, Neurology.

[31]  Y Yonekura,et al.  PET and the autoradiographic method with continuous inhalation of oxygen-15-gas: theoretical analysis and comparison with conventional steady-state methods. , 1993, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[32]  D Comar,et al.  Noninvasive tomographic study of cerebral blood flow and oxygen metabolism in vivo. Potentials, limitations, and clinical applications in cerebral ischemic disorders. , 1981, European neurology.

[33]  M. Zilbovicius,et al.  Changes in regional cerebral blood flow during brain maturation in children and adolescents. , 1992, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[34]  N. Alpert,et al.  Positron imaging in ischemic stroke disease , 1984, Annals of neurology.

[35]  Peerless Sj.  Indications for the extracranial-intracranial arterial bypass in light of the EC-IC Bypass Study. , 1986 .

[36]  Y. Kuriyama,et al.  Mapping of local cerebral blood flow with stable xenon-enhanced CT and the curve-fitting method of analysis. , 1988, Radiology.

[37]  K Wienhard,et al.  Progressive Derangement of Periinfarct Viable Tissue in Ischemic Stroke , 1992, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[38]  S. Peerless.  Indications for the extracranial-intracranial arterial bypass in light of the EC-IC Bypass Study. , 1986, Clinical neurosurgery.

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

[40]  R. Wise,et al.  EVALUATION OF CEREBRAL PERFUSION RESERVE IN PATIENTS WITH CAROTID-ARTERY OCCLUSION , 1984, The Lancet.

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