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Recurrent ischemia in symptomatic carotid occlusion

Prognostic value of hemodynamic factors

From the University Department of Neurology (Drs. Klijn, Kappelle, Algra, and van Gijn), Clinical Neurophysiology (Drs. van Huffelen and Visser), and Neurosurgery (Dr. Tulleken), and the Julius Center for Patient Oriented Research (Dr. Algra), University Medical Center Utrecht and the Rudolf Magnus Institute for Neurosciences, Utrecht, the Netherlands.

Address correspondence and reprint requests to Dr. C.J.M. Klijn, Department of Neurology, C03.236, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands; e-mail: c.j.m.klijn{at}neuro.azu.nl

OBJECTIVE: To identify hemodynamic factors that predict recurrence of ipsilateral cerebral ischemic events in patients with symptomatic carotid artery occlusion (CAO).

PATIENTS AND METHODS: The authors studied 117 consecutive patients with CAO and corresponding recent (6 months) ischemic symptoms of the brain or eye that were transient or at most mildly disabling. They determined, using Cox proportional hazards analysis, the prognostic value for recurrence of ipsilateral cerebral ischemic events of 1) clinical features believed to indicate hemodynamic compromise, 2) collateral blood flow pattern, and 3) transcranial Doppler CO₂-reactivity.

RESULTS: None of the 24 patients with symptoms of retinal ischemia alone had a recurrent cerebral ischemic event. In the 93 patients with cerebral ischemic symptoms on entry, recurrence of these symptoms was independently predicted by 1) the nature of the initial symptoms being of purported hemodynamic origin (limb-shaking, precipitation of symptoms by rising, exercise or low blood pressure, retinal claudication) (hazard ratio [HR] 3.8, 95% CI 1.5 to 9.5), 2) continuing symptoms after the CAO had been documented, but before inclusion in the study (HR 5.9, 95% CI 2.2 to 16.1), and 3) the presence of collateral blood flow via leptomeningeal vessels (HR 4.1, 95% CI 1.3 to 13.1). CO₂-reactivity did not predict recurrence of cerebral ischemic events.

CONCLUSIONS: Having cerebral in contrast to retinal ischemia, clinical features suggestive of hemodynamic compromise, continuing symptoms after demonstration of the CAO, and presence of leptomeningeal collaterals may help to identify patients with symptomatic CAO at high risk of future cerebral ischemia.

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