Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion
1999
Context.—The relative importance of hemodynamic factors in the pathogenesis and
treatment of stroke in patients with carotid artery occlusion remains controversial.Objective.—To test the hypothesis that stage II cerebral hemodynamic failure (increased
oxygen extraction measured by positron emission tomography [PET]) distal to
symptomatic carotid artery occlusion is an independent risk factor for subsequent
stroke in medically treated patients.Design and Setting.—Prospective, blinded, longitudinal cohort study of patients referred
from a group of regional hospitals between 1992 and 1996.Patients.—From 419 subjects referred, 81 with previous stroke or transient ischemic
attack in the territory of an occluded carotid artery were enrolled. All were
followed up to completion of the study, with average follow-up of 31.5 months.Main Outcome Measures.—Telephone contact every 6 months recorded the subsequent occurrence
of all stroke, ipsilateral ischemic stroke, and death.Results.—Stroke occurred in 12 of 39 patients with stage II hemodynamic failure
and in 3 of 42 patients without (P=.005); stroke
was ipsilateral in 11 of 39 patients with stage II hemodynamic failure and
in 2 of 42 patients without (P=.004). Six deaths
occurred in each group (P=.94). The age-adjusted
relative risk conferred by stage II hemodynamic failure was 6.0 (95% confidence
interval [CI], 1.7-21.6) for all stroke and 7.3 (95% CI, 1.6-33.4) for ipsilateral
stroke.Conclusions.—Stage II hemodynamic failure defines a subgroup of patients with symptomatic
carotid occlusion who are at high risk for subsequent stroke when treated
medically. A randomized trial evaluating surgical revascularization in this
high-risk subgroup is warranted.
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