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(Stroke. 1995;26:1603-1606.)
© 1995 American Heart Association, Inc.
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From the Departments of Anesthesiology/Critical Care Medicine (W.A.K., R.P.) and Neurological Surgery (W.A.K.), University of Pittsburgh (Pa) School of Medicine (D.B.); Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany (P.B.); Department of Radiology, Division of Neuroradiology, University of Pittsburgh (Pa) Medical Center (S.P.); and Department of Radiology, Medical University of South Carolina, Charleston (J.H.).
| Abstract |
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Methods Thirty-one conscious patients underwent balloon test occlusion of the internal carotid artery and transcranial Doppler ultrasonography and xenon-enhanced CT assessment of blood flow velocity and CBF, respectively, of the middle cerebral artery and its distribution during balloon test occlusion.
Results A significant correlation was seen between the change in CBF and the change in blood flow velocity for both brain levels at which CBF was determined (P<.0001). The average change in blood flow velocity was -13.4%, and the change in CBF was -15.1% and -17.7% at the two anatomic levels examined.
Conclusions The data indicate that changes in blood flow velocity generally reflect changes in CBF throughout the middle cerebral artery vascular territory with abrupt occlusion of the internal carotid artery in unanesthetized humans.
Key Words: cerebral blood flow cerebral ischemia tomography, emission-computed ultrasonics
| Introduction |
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| Subjects and Methods |
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Balloon Test Occlusion Method
A complete balloon test occlusion examination was
performed as described previously.3 After baseline
neurological examination, a four-vessel angiogram was performed, and a
double lumen catheter was introduced (Swan-Ganz, Edward Laboratories)
into the femoral artery. The catheter was advanced within the ICA to
the level of the first or second cervical vertebral body. The patient
was given 5000 to 7000 U IV of heparin during the procedure. While
continuously measuring blood pressure through the angiographic catheter
in the distal ICA and intermittently measuring systemic blood pressure
using an automatic dynamometer (Critikon Dynamap), we inflated the
intra-arterial balloon with radiographic
contrast material until distal pressure fell and balloon deformation
consistent with the vessel was observed. Intracarotid occlusion
was further confirmed by injecting a small amount of
radiographic contrast material distal to the balloon and
observing a stagnant column of intracarotid radiopaque material. A
continuous neurological examination was performed for 5 minutes and
subsequently at 4- to 5-minute intervals. The balloon remained inflated
for a 15-minute period but was immediately deflated if the patient
showed any neurological alteration. If no neurological alteration was
seen, the patient was transferred to the CT suite with the balloon
deflated but still in place. After transfer to the CT suite, a lateral
scout image was acquired to verify that the balloon was at the same
location as it was in the fluoroscopy suite. We performed
xenon-enhanced CT CBF studies with the balloon deflated and during a
second 5-minute period of balloon reinflation using an identical
balloon inflation volume and being careful to minimize any movement of
the angiographic catheter. If there was any question about
maintenance of an occlusive position of the inflated balloon
while the patient was undergoing CT, a small amount of
radiographic contrast was injected to confirm the presence
of a stagnant column of intracarotid radiopaque material.
Xenon CT CBF Measurement
CBF studies were performed with the xenon CT CBF system,
including software and hardware adapted to our scanner (GE 9800,
General Electric Medical Systems). During the CBF studies, the patients
inhaled a gas mixture of 33% xenon/67% oxygen (Xe SCAN, Linde Medical
Gases). After two baseline scans per brain level, the xenon enhancement
was monitored with six scans per brain level during a 5-minute gas
inhalation period.5 The radiodensity enhancement of brain
tissue caused by the inhalation of stable xenon was used in a modified
Kety equation6 to calculate CBF.
For the first carotid occlusion, TCD monitoring was performed through the ipsilateral temporal window with isonation adjusted to the MCA. This artery was monitored continuously before, during, and after balloon occlusion. Subsequently, each patient underwent xenon CT CBF with the balloon deflated, followed by a repeat CBF study with the balloon inflated.
For each subject the MCA distribution on CT was manually determined post hoc, and the average CBF within this territory was calculated7 8 and correlated with MCA blood flow velocity.
Statistical Analysis
Repeated mean blood flow velocity and
physiological data were analyzed by ANOVA
and protected t tests. CBF data underwent paired
t tests, and correlations were determined with Pearson's
correlation coefficient. SPSS software was used for
statistical procedures (SPSS, Inc).
| Results |
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| Discussion |
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TCD does not measure CBF but rather blood flow velocity. This velocity is affected by a number of variables including CBF, vascular caliber, hematocrit, viscosity, and insonation depth and angle.10 Sorteberg et al11 examined the relationship between absolute rCBF and blood flow velocity in 17 normal subjects, observing a statistically significant correlation. However, there was wide scatter along the regression line, making blood flow velocity unsuitable to predict rCBF in a given patient. Moreover, others have reported a poor correlation between blood flow velocity and rCBF.12 13 These observations indicate that a one-time measurement of blood flow velocity cannot be used reliably to estimate CBF in a given subject.
Several investigations have examined the relationship between changes in rCBF and changes in blood flow velocity. Several methods have been used to induce changes in these measurements. These generally include alterations in brain tissue PCO2 or changes in intracranial arterial pressure. Techniques of altering tissue PCO2 include altering ventilation or inspired CO214 or administering acetazolamide.15 16 Methods of altering intracranial arterial pressure include changing blood pressure by administration of vasoactive drugs14 17 18 or decreasing cardiac preload14 18 19 20 21 or inflow interruption by occlusion of the carotid artery.1 2 In addition, assessment of the relationship of rCBF to blood flow velocity during exercise has also been reported.22 23 In all of these studies and others, conditions were further varied with respect to the presence or absence of cerebrovascular disease, use of anesthesia, and method of determining rCBF. Accordingly, the results are somewhat variable, most likely due to the disparate conditions.
There have been several case reports on the effects of carotid occlusion on blood flow velocity without rCBF assessment in unanesthetized subjects.24 25 In these cases a decrement in blood flow velocity resulted from carotid occlusion with a decrease in pulsatility index. Correlation of carotid occlusioninduced decrements in blood flow velocity with CBF was performed in anesthetized patients with cerebrovascular disease with the use of 133Xe rCBF technology.1 2 Such data obtained during carotid endarterectomy suggest that blood flow velocity changes can estimate cortical CBF decreases as measured by gamma counter detection of radioactive xenon entering the brain. The correlation in that situation is strong at lower CBF. However, this technique does not assess deeper structures in the brain and can be misleading if cortical flow is low with persistent perfusion in deeper structures.26 Moreover, the lack of correlation at higher rCBF may have been related to the fact that TCD measures blood flow velocity in some MCA territories not measured by 133Xe rCBF. Our data provide additional information regarding the relationship between rCBF and MCA blood flow velocity in awake subjects without known arteriosclerotic disease undergoing abrupt carotid occlusion. Importantly, we provide evidence of a positive correlation between rCBF and blood flow velocity in this situation, assessing the entire MCA territory with stable xenon CT CBF.
An additional factor in evaluating data involving decrements in intracranial arterial pressure is whether the arterial pressure is below the autoregulatory threshold, since this may involve alterations in vascular caliber.27 Data from studies assessing and/or correlating rCBF and blood flow velocity within the autoregulatory range indicate that CBF changes briefly until autoregulatory adjustments occur, after which it returns to its prior level. Blood flow velocity varies with changes in CBF.18 21 Our data and observations of Halsey et al1 2 and Larsen et al18 also indicate that rCBF and blood flow velocity vary proportionately when intracranial arterial pressure decreases below the lower limit of CBF autoregulation.
We observed two instances of rather poor correlation (ie, a 5% velocity increase with a 34% CBF decrease and a 25% velocity increase with a 6% CBF increase), which suggests that TCD readings may occasionally misrepresent CBF. Because we were unable to measure TCD and CBF simultaneously, it is also possible that the variability was due to the measurements being made during different balloon inflations. Nonetheless, overall the data support the theory that TCD generally reflects MCA territory CBF in situations of abrupt carotid occlusion.
| Selected Abbreviations and Acronyms |
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| Acknowledgments |
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| Footnotes |
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Received March 21, 1995; revision received June 9, 1995; accepted June 16, 1995.
| References |
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