Cerebrovascular Reactivity to Acetazolamide and Outcome in Patients With Symptomatic Internal Carotid or Middle Cerebral Artery Occlusion: A Xenon-133 Single-Photon Emission Computed Tomography Study

Background and Purpose— The present study prospectively evaluated relationships among baseline characteristics, cerebral hemodynamics, and outcome of patients with symptomatic major cerebral artery occlusion, by quantitative measurement of cerebral blood flow using xenon-133 (133Xe) inhalation and single-photon emission computed tomography (SPECT). Methods— Regional cerebrovascular reactivity (rCVR) to acetazolamide was calculated at entry to the study using 133Xe SPECT. Seventy consecutive patients aged less than 70 years with unilateral internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion were divided into 2 groups: normal or reduced rCVR, and prospectively followed up for a period of 24 months. Results— During the follow-up period, recurrent strokes occurred in 8 of the 23 patients with reduced rCVR at entry and in 3 of 47 patients with normal rCVR. Cumulative recurrence-free survival rates in all patients, and in each subgroup of patients with ICA or MCA occlusion and reduced rCVR on entry, were significantly lower than in those with normal rCVR (P =0.0030, P =0.0404, and P =0.0310, respectively; Kaplan-Meier analysis). Among the factors considered, only lower rCVR and resting regional cerebral blood flow values were significantly associated with the risk of stroke recurrence (P =0.0019 and P =0.0080, respectively; Cox regression multivariate analysis). Conclusions— The present study demonstrated that reduced rCVR to acetazolamide as determined by 133Xe SPECT is significantly associated with an increased risk of stroke recurrence in patients with symptomatic MCA or ICA occlusion.

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

[2]  C. Tulleken,et al.  Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors. , 1997, Stroke.

[3]  L. Cinotti,et al.  Amines for brain tomoscintigraphy. , 1987, Nuclear medicine communications.

[4]  H Abe,et al.  Acetazolamide test in detecting reduced cerebral perfusion reserve and predicting long-term prognosis in patients with internal carotid artery occlusion. , 1993, Neurosurgery.

[5]  A. Lachaux,et al.  Asymptomatic patients. , 1988, Hepatology.

[6]  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.

[7]  H Yonas,et al.  Qualitative versus quantitative assessment of cerebrovascular reserves. , 1998, Neurosurgery.

[8]  P M Rossini,et al.  Outcome of carotid artery occlusion is predicted by cerebrovascular reactivity. , 1999, Stroke.

[9]  I Kanno,et al.  Two Methods for Calculating Regional Cerebral Blood Flow from Emission Computed Tomography of Inert Gas Concentrations , 1979, Journal of computer assisted tomography.

[10]  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.

[11]  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.

[12]  N. Bornstein,et al.  Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients? , 1996, Stroke.

[13]  H Yonas,et al.  Compromised cerebral blood flow reactivity is a predictor of stroke in patients with symptomatic carotid artery occlusive disease. , 1995, Journal of vascular surgery.

[14]  M. Mato,et al.  Antiproliferative Effect and Cell Cycle Modulation by Melatonin on GH3 Cells , 2000, Hormone Research in Paediatrics.

[15]  G. Donnan,et al.  Transcranial Doppler detected cerebral microembolism following carotid endarterectomy. High microembolic signal loads predict postoperative cerebral ischaemia. , 1997, Brain : a journal of neurology.

[16]  B. Widder,et al.  Course of Cerebrovascular Reactivity in Patients With Carotid Artery Occlusions , 1994, Stroke.

[17]  T. Pilgram,et al.  Natural history of stenosis from intracranial atherosclerosis by serial angiography. , 1998, Stroke.

[18]  William J. Powers,et al.  Importance of Hemodynamic Factors in the Prognosis of Symptomatic Carotid Occlusion , 1998 .

[19]  H. Barnett Hemodynamic cerebral ischemia. An appeal for systematic data gathering prior to a new EC/IC trial. , 1997, Stroke.

[20]  H. Markus,et al.  Severely impaired cerebrovascular reactivity predicts stroke and TIA risk in patients with carotid artery stenosis and occlusion. , 2001, Brain : a journal of neurology.

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

[22]  M. Raichle,et al.  The effect of hemodynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation. , 1987, Annals of internal medicine.

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

[24]  M. Shichiri,et al.  Distribution of Atherosclerosis and Risk Factors in Atherothrombotic Occlusion , 1993, Stroke.

[25]  R. Haaxma Neuroanatomy and cranial computed tomography, Hans-Joachim Kretschmann, Wolfgang Weinrich. Georg Thieme Verlag, Stuttgart (1986), 168, figs and tables, DM 198.-., ISBN: 3 13 672601 4 , 1986 .

[26]  Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. , 1985, The New England journal of medicine.

[27]  C. Fitzek,et al.  Symmetrical infarction of the cervical spinal cord due to spontaneous bilateral vertebral artery dissection. , 1998, Stroke.

[28]  A. Baker,et al.  Cerebrovascular disease , 1959, Neurology.

[29]  Cardiogenic brain embolism. Cerebral Embolism Task Force. , 1986, Archives of neurology.

[30]  K. Minematsu,et al.  Sequential change of hemodynamic reserve in patients with major cerebral artery occlusion or severe stenosis , 2004, Neuroradiology.

[31]  B. Dobkin Recurrent ischemia in symptomatic carotid occlusion: Prognostic value of hemodynamic factors , 2001, Neurology.

[32]  P. Pasqualetti,et al.  Effect of Collateral Blood Flow and Cerebral Vasomotor Reactivity on the Outcome of Carotid Artery Occlusion , 2001, Stroke.

[33]  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.

[34]  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 .

[35]  K. Minematsu,et al.  Effect of Acetazolamide Reactivity and Long-term Outcome in Patients With Major Cerebral Artery Occlusive Diseases , 1998 .

[36]  United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: interim results , 1988, British medical journal.

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

[38]  W. Oldendorf,et al.  N-isopropyl-[123I] p-iodoamphetamine: single-pass brain uptake and washout; binding to brain synaptosomes; and localization in dog and monkey brain. , 1980, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

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

[40]  G. Leinsinger,et al.  Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in patients with ICA occlusion and hemodynamic cerebral ischemia. , 1994, Journal of neurosurgery.

[41]  W J Powers,et al.  Hemodynamic Effects of Middle Cerebral Artery Stenosis and Occlusion , 1998, AJNR. American journal of neuroradiology.

[42]  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.

[43]  Y Yonekura,et al.  Evidence of misery perfusion and risk for recurrent stroke in major cerebral arterial occlusive diseases from PET. , 1996, Journal of neurology, neurosurgery, and psychiatry.

[44]  W J Powers,et al.  Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. , 1999, JAMA.