Radiographic and Clinical Predictors of Hemodynamic Insufficiency in Patients With Athero-Occlusive Disease

IntroductionRecent 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.MethodsWe 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.ResultsOur 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.ConclusionsOrthostatic 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.