Grubb R L, Derdeyn C P, Fritsch S M, Carpenter D A, Yundt K D, Videen T O, Spitznagel E L, Powers W J
Department of Neurology and Neurological Surgery, the Edward Mallinckrodt Institute of Radiology, Washington University, St Louis, MO, USA.
JAMA. 1998;280(12):1055-60. doi: 10.1001/jama.280.12.1055.
The relative importance of hemodynamic factors in the pathogenesis and treatment of stroke in patients with carotid artery occlusion remains controversial.
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.
Prospective, blinded, longitudinal cohort study of patients referred from a group of regional hospitals between 1992 and 1996.
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.
Telephone contact every 6 months recorded the subsequent occurrence of all stroke, ipsilateral ischemic stroke, and death.
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.
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.
血流动力学因素在颈动脉闭塞患者中风的发病机制和治疗中的相对重要性仍存在争议。
检验以下假设，即有症状颈动脉闭塞远端的II期脑血流动力学衰竭（通过正电子发射断层扫描[PET]测量的氧摄取增加）是接受药物治疗患者随后发生中风的独立危险因素。
1992年至1996年期间对一组地区医院转诊的患者进行前瞻性、盲法、纵向队列研究。
在转诊的419名受试者中，81名在闭塞颈动脉供血区域有过中风或短暂性脑缺血发作的患者被纳入研究。所有患者均随访至研究结束，平均随访时间为31.5个月。
每6个月进行电话联系，记录所有中风、同侧缺血性中风和死亡的后续发生情况。
39例II期血流动力学衰竭患者中有12例发生中风，42例无II期血流动力学衰竭患者中有3例发生中风（P = 0.005）；39例II期血流动力学衰竭患者中有11例中风为同侧，42例无II期血流动力学衰竭患者中有2例中风为同侧（P = 0.004）。两组各有6例死亡（P = 0.94）。II期血流动力学衰竭导致的年龄调整后相对风险，对于所有中风为6.0（95%置信区间[CI]，1.7 - 21.6），对于同侧中风为7.3（95%CI，1.6 - 33.4）。
II期血流动力学衰竭确定了一组有症状颈动脉闭塞患者的亚组，这些患者接受药物治疗时随后发生中风的风险较高。有必要对这个高危亚组进行评估手术血运重建的随机试验。
