Predictive value of angiographic testing for tolerance to therapeutic occlusion of the carotid artery.
OBJECTIVE
Controversy exists on how to assess a patient's tolerance before permanent carotid artery occlusion. We sought to determine the positive predictive value of synchronous opacification of hemispheric cortical veins at angiography of the contralateral carotid or vertebral artery as a predictor of tolerance to permanent carotid artery occlusion without development of ischemic injury.


METHODS
Seventy-six angiographic test occlusions were performed in 74 consecutive patients considered for therapeutic occlusion. Angiography of collateral cerebral vessels was performed during test occlusion. Synchronous filling (a < 0.5-second delay of opacification between the cortical veins of the occluded and collateral vascular territories) was considered a predictor for tolerance to permanent occlusion. To detect clinically silent ischemic defects, MR imaging was performed before and 6-12 weeks after permanent occlusion. Positive predictive value (95% confidence interval [CI]) of synchronous venous filling for absence of ischemic deficits after permanent occlusion was calculated.


RESULTS
No procedural complications of the test occlusion occurred. In 51 of 54 patients who passed the test, permanent occlusion was performed. Two patients, both in poor clinical condition after subarachnoid hemorrhage, died of diffuse vasospasm after permanent occlusion. Of the 49 surviving patients, one developed a transient discrete hemiparesis with small new hypoperfusion infarctions on MR images. All other patients remained neurologically unchanged with no new ischemic lesions on follow-up MR images. Positive predictive value of tolerance to carotid artery occlusion after passing the angiographic test was 98% (95% CI: 89-100%).


CONCLUSIONS
The angiographic test occlusion protocol reliably predicts tolerance to therapeutic carotid artery occlusion. It is safe and easy to perform.
van Rooij
Willem Jan
WJ
Department of Radiology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands.
Sluzewski
Menno
M
Slob
Marjan J
MJ
Rinkel
Gabriël J
GJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D021721:Balloon Occlusion; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000517:prevention & control; D002340:Carotid Artery Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging*; D002533:Cerebral Angiography; D002540:Cerebral Cortex / Q000098:blood supply*; D002544:Cerebral Infarction / Q000000981:diagnostic imaging / Q000517:prevention & control; D002550:Cerebral Veins / Q000000981:diagnostic imaging*; D003097:Collateral Circulation / Q000502:physiology; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000628:therapy*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D010865:Pilot Projects; D011237:Predictive Value of Tests; D011379:Prognosis; D014057:Tomography, X-Ray Computed