- Original research
- Open Access
Intervention versus standard medical treatment in patients with symptomatic occlusion of the internal carotid artery: a randomised oxygen-15 PET study
© Persoon et al.; licensee Springer. 2013
- Received: 22 September 2013
- Accepted: 25 November 2013
- Published: 5 December 2013
The aim of this randomised pilot study was to investigate the haemodynamic effects measured by oxygen-15 positron emission tomography (PET) of interventional treatment consisting of either endarterectomy or endovascular treatment of stenosed cerebropetal arteries, or tapering of antihypertensive medication in comparison with standard medical treatment alone in patients with symptomatic internal carotid artery (ICA) occlusion.
Twenty-three patients with symptomatic ICA occlusion underwent PET scanning at baseline and after 3 months. Twelve patients were randomised to intervention (either endarterectomy or endovascular treatment of stenosed cerebropetal arteries, or tapering of antihypertensive medication) and 11 to standard medical treatment alone. Primary outcome was a change in cerebral blood flow (CBF), cerebral blood volume (CBV) and/or oxygen extraction fraction (OEF) after 3 months measured by PET.
There were no differences in changes in CBF, CBV or OEF between the two groups. Only patients with compromised perfusion at presentation showed a borderline significant increase in CBF of 2.8 mL/min/100 mL (95% confidence interval 0.0 to 5.7) after intervention (n = 7).
This pilot study shows that in patients with symptomatic ICA occlusion, oxygen-15 PET did not detect differences in improvement of CBF, CBV or OEF between interventional and standard treatment.
- Carotid artery diseases
- Other cerebrovascular disease/stroke
In patients with transient ischaemic attack (TIA) or minor disabling ischaemic stroke associated with an occlusion of the internal carotid artery (ICA), the risk of recurrent stroke has been reported 5% to 6% per year . This risk may be as high as 12% per year in case of a demonstrated compromised flow to the brain [2–4]. In these ‘high-risk’ patients, revascularization surgery may be considered, but evidence that interventional treatment reduce the risk of stroke in comparison with the standard treatment consisting of antithrombotic medication and control of vascular risk factors is lacking.
A recent study has shown that increased oxygen extraction fraction (OEF) measured by positron emission tomography (PET) is still an independent predictor of subsequent stroke under current medical treatment . However, the Carotid Occlusion Surgery Study (COSS) included patients with symptomatic ICA occlusion and poor cerebral haemodynamics as demonstrated by increased OEF measured by PET and found no benefit of extracranial/intracranial (EC/IC) bypass surgery [4, 6]. This trial was stopped prematurely as the 2-year risk of ipsilateral stroke was between 20% and 25% in both surgical and non-surgical groups (p = .78). In this study, the proportion of patients who had a perioperative stroke (within 30 days after surgery) was 15% .
Other therapeutic strategies in patients with symptomatic ICA occlusion aiming to improve cerebral perfusion and reducing the risk of recurrent stroke are endarterectomy or endovascular treatment of a significant stenosis in one of the cerebropetal arteries that are part of collateral pathways [2, 7–10], or tapering of antihypertensive medication [11, 12].
These procedures have lower perioperative risks than an EC/IC bypass operation, but so far, their clinical effect has not been compared to standard treatment. Whether the application of these therapeutic strategies improves cerebral perfusion as compared with standard medical treatment is unclear.
The aim of this randomised pilot study was to investigate the haemodynamic effects as measured by oxygen-15 PET of endarterectomy or endovascular treatment of stenosed cerebropetal arteries, or tapering of antihypertensive medication in comparison with the standard medical treatment alone in patients with a symptomatic ICA occlusion.
Clinical characteristics and angiographic findings of patients with symptomatic occlusion of the internal carotid artery ( n = 23)
Intervention n = 12
Standard n = 11
Age (years, mean ± SD)
68 ± 10
60 ± 12
Clinical features at presentation
Systolic blood pressure (mmHg, mean ± SD )
159 ± 25
167 ± 29
Diastolic blood pressure (mmHg, mean ± SD)
84 ± 15
91 ± 13
Vascular risk factors
Cigarette smoking (current or in last 5 years)
History of stroke >3 months ago
History of ischaemic heart disease
Contralateral ICA stenosis 50% to 69%
Stenosis 70% to 99%
Ipsilateral ECA stenosis ≥ 50%
Vertebral artery stenosis ≥ 50%
Collateral flow via anterior communicating artery
Collateral flow via ophthalmic artery
Collateral flow via posterior communicating artery
Patients were randomised between any intervention according to therapeutic strategy or standard medical treatment. In the intervention group, the therapeutic strategy consisted of, in order of preference, one of the following treatment options: (1) endarterectomy (CEA) of the contralateral ICA in case of a severe contralateral ICA stenosis in the presence of a functional anterior circle of Willis, (2) CEA of the external carotid artery (ECA) in case of a severe ipsilateral ECA stenosis in the presence of collateral blood supply via the ECA and ophthalmic artery, (3) endovascular treatment of the vertebral artery (VA) or subclavian artery in case of a severely stenosed VA or subclavian artery in the presence of collaterals via the vertebrobasilar system and (4) tapering of antihypertensive medication for 3 months. In addition to the intervention, patients received standard medical treatment consisting of antithrombotic medication (aspirin and dipyridamole), a statin, treatment of hypertension to a targeted blood pressure of 140/90 mmHg (except for those randomised to tapering of antihypertensive drugs) and control of other vascular risk factors such as smoking and obesity. To ensure equal distribution of patients with a low CBF in both groups , randomisation was carried out by minimisation for CBF in three categories (CBF ≤ 33 mL/100 g/min, CBF between 34 and 53 mL/100 g/min or CBF ≥ 54 mL/100 g/min), measured in the MCA territory of the symptomatic hemisphere by arterial spin labelling (ASL)-MRI . The ASL-MRI scan was made within 1 to 15 days of the baseline PET study, and included a three-dimensional (3D) T1 image for PET image analysis. Patients were examined by oxygen-15 PET at the time of inclusion and 3 months thereafter. Primary outcome was a change in CBF, CBV and/or OEF as measured by PET after 3 months. During those 3 months, we documented whether patients had recurrent TIA or stroke, defined as an acute onset of transient (<24 h) or permanent new focal neurological deficits of cerebral origin without haemorrhage on CT or MRI.
The institutional medical review board approved the study protocol, and all patients provided written informed consent.
PET data acquisition
Oxygen-15 PET scans were acquired using an ECAT EXACT HR + scanner (CTI/Siemens, Knoxville, TN, USA) . Each PET study consisted of three parts: (1) a dynamic emission scan (25 frames over 600 s) after intravenous administration of a bolus of 1,100 MBq [15O]H2O to measure CBF; (2) a dynamic emission scan (20 frames over 600 s) after a 30-s net inhalation of approximately 300 MBq [15O]O2 gas through a nasal cannula to derive oxygen consumption and calculate OEF; (3) an emission scan (3 frames over 360 s) following a net inhalation of approximately 200 MBq [15O]CO gas to measure CBV. Further details of the scanning procedure can be found elsewhere .
Individual anatomical 3D T1 MR images were co-registered with summed [15O]H2O images. A standard template of flow territories of middle cerebral artery (MCA), anterior cerebral artery (ACA) and posterior cerebral artery (PCA)  was warped onto the co-registered MR image using Automated Image Registration (AIR) software , applying non-rigid 12 parameter perspective warping. Statistical Parametric Mapping (SPM02, London, UK, application in Matlab 7.0.4; MathWorks, Inc., Natick, MD, USA) was used for segmentation of grey and white matter. Areas of infarction were excluded manually. Parametric CBF, CBV and OEF images were generated using in-house developed software (written in IDL, 6.2, ITT, Boulder CO, USA) .
Normal CBF, CBV and OEF values were derived from 14 scans in seven healthy subjects (mean age 66 ± 7 years; five men). They were all in a good physical and mental condition, which had been evaluated with medical history, a physical examination and screening laboratory tests. Subjects with a history of psychiatric or neurological illness, a Mini Mental State Examination score ≤ 27 or any significant abnormality of a laboratory test were excluded. They underwent a PET scan on two separate occasions with a median time interval of 7 days, as published previously . CBF, CBV and OEF values in patients were considered to be abnormal if they were beyond mean values of normal controls ±1.96 times the standard deviation (SD). Patients were divided into haemodynamic stages based on their values in grey matter of the affected MCA territory: patients with normal CBF (≥31.1 mL/min/100 mL), normal CBV (≤3.9 mL/100 mL) and normal OEF (≤55.7%) were classified in haemodynamic stage 0, patients with either decreased CBF (<31.1 mL/min/100 mL) or increased CBV (>3.9 mL/100 mL), but normal OEF in haemodynamic stage 1, and patients with increased OEF (>55.7%) in haemodynamic stage 2.
We compared mean CBF in the MCA territory of patients with data in healthy subjects  and calculated a mean difference with 95% confidence interval (CI). In the patients, differences between mean baseline grey matter CBF, CBV and OEF values in ACA and MCA territories of patients at baseline and after 3 months were assessed by paired t tests with 95% confidence interval (CI). Mean absolute change, adjusted for age and sex, in CBF, CBV and OEF was compared between patients assigned to intervention and those who received standard treatment using linear regression analysis, and results were expressed as adjusted mean differences in change with 95% CI. Finally, pre-specified subgroup analyses were performed in patients with haemodynamic stage 1 or 2 at presentation and between patients who were randomised to treatment with surgery or stenting of a stenosis in a collateral artery (excluding those who had tapering of antihypertensive medication) and those who received standard medical treatment.
The mean time between PET scans at baseline and follow-up was 98 ± 10 (range 77 to 119) days. All patients were treated according to their randomisation. Randomisation occurred on average 5 ± 9 days after the baseline PET scan. Of the 12 patients assigned to intervention (Figure 1), eight patients underwent stenting or surgery after a mean time of 15 ± 10 (range 1 to 29) days following the baseline PET scan. In four patients, antihypertensive medication was tapered, which resulted in a mean increase in systolic blood pressure of 38 ± 9 mmHg. Intervention was complicated by a non-fatal myocardial infarction in one patient who underwent CEA of a contralateral ICA stenosis; none of the procedures were complicated by a stroke or hyperperfusion syndrome.
Comparison of haemodynamic state of the brain at baseline and after 3 months between patients assigned to intervention and those to standard treatment ( n = 23)
Intervention n = 12
Standard n = 11
Unadjusted difference in change (95% CI)
Adjusted difference in change *(95% CI)
Mean ± SD
Mean ± SD
CBF MCA (mL/min/100 mL)
31.3 ± 5.9
33.1 ± 5.4
31.6 ± 4.9
33.5 ± 4.7
0.34 ± 6.2
0.42 ± 4.1
−0.1 (−4.7 to 4.5)
−1.0 (−7.4 to 5.4)
CBF ACA (mL/min/100 mL)
32.6 ± 5.8
35.2 ± 5.5
32.0 ± 4.2
35.0 ± 5.7
−0.56 ± 6.2
−0.28 ± 4.9
−0.3 (−5.2 to 4.6)
−1.6 (−8.4 to 5.2)
CBV MCA (mL/100 mL)
3.0 ± 0.6
3.3 ± 0.9
3.5 ± 1.4
3.2 ± 0.6
0.60 ± 1.7
−0.09 ± 1.2
0.7 (−0.6 to 2.0)
0.09 (−1.7 to 1.9)
CBV ACA (mL/100 mL)
3.0 ± 0.6
3.4 ± 1.0
3.5 ± 1.3
3.1 ± 0.7
0.49 ± 1.6
−0.23 ± 1.3
0.7 (−0.6 to 2.0)
0.08 (−1.6 to 1.8)
OEF MCA (%)
46.4 ± 9.7
47.5 ± 5.5
46.3 ± 7.9
48.4 ± 5.8
−0.08 ± 6.1
0.85 ± 6.8
−0.9 (−6.5 to 4.7)
3.1 (−4.1 to 10.3)
OEF ACA (%)
44.4 ± 11.2
46.1 ± 6.2
44.2 ± 7.3
47.2 ± 5.2
−0.17 ± 7.4
1.1 ± 6.3
−1.3 (−7.3 to 4.7)
3.1 (−4.6 to 10.8)
Mean CBF and CBV for patients with symptomatic ICA occlusion, classified in haemodynamic stage 0 ( n = 10) and haemodynamic stage 1 or 2 ( n = 13)
Unadjusted difference in change (95% CI)
Adjusted difference in change *(95% CI)
Mean ± SD
Mean ± SD
Haemodynamic stage 0
N = 5
N = 5
CBF MCA (mL/min/100 mL)
37.0 ± 3.0
35.0 ± 5.6
33.9 ± 5.8
34.4 ± 5.2
−3.1 ± 8.1
−0.6 ± 5.3
−2.5 (−12.5 to 7.4)
−1.7 (−15.6 to 12.2)
CBV MCA (mL/100 mL)
3.1 ± 0.6
2.8 ± 0.7
3.0 ± 0.7
3.5 ± 0.4
−0.2 ± 1.1
0.6 ± 1.0
−0.8 (−2.3 to 0.7)
−1.1 (−3.2 to 1.1)
Haemodynamic stage 1 or 2
N = 7
N = 6
CBF MCA (mL/min/100 mL)
27.2 ± 3.4
31.5 ± 5.2
30.0 ± 3.9
32.8 ± 4.6
2.8 ± 3.1
1.3 ± 3.2
1.6 (−2.2 to 5.4)
−1.1 (−7.8 to 5.7)
CBV MCA (mL/100 mL)
2.9 ± 0.6
3.7 ± 0.8
4.0 ± 1.7
3.0 ± 0.6
1.1 ± 1.9
−0.7 ± 1.1
1.8 (−0.2 to 3.8)
1.4 (−2.4 to 5.1)
The eight patients treated with surgery or stenting of a stenosis in a collateral artery had a mean CBF of 30.8 ± 5.4 mL/min/100 mL at baseline and 31.8 ± 5.2 mL/min/100 mL after 3 months (mean difference 0.97, 95% CI −4.6 to 6.6). In the 11 patients who received standard medical treatment alone, mean CBF was 33.1 ± 5.4 mL/min/100 mL at baseline and 33.5 ± 4.7 mL/min/100 mL after 3 months (mean difference 0.42, 95% CI −2.4 to 3.2). The change in CBF did not differ between these two groups of patients (adjusted mean difference of change −0.02 mL/min/100 mL, 95% CI −7.2 to 7.1).
During the period between PET scans at baseline and after 3 months, 10 (43%) of 23 patients had one or more recurrent TIAs and none had a stroke. At baseline, five of the ten patients were in haemodynamic stage 0, three in haemodynamic stage 1, and two in haemodynamic stage 2. Two of the eight patients (25%) who underwent CEA or stenting, three of the four (75%) who had tapering of antihypertensive medication and 5 of the 11 (45%) who received standard medical treatment had one or more recurrent TIAs during the 3 months follow-up period between PET scans at baseline and after 3 months. Clinical follow-up continued with an overall median duration of 2.9 (range 0.5 to 4.4) years. Three of the 23 patients (13%) had a recurrent ischaemic stroke during follow-up.
The first patient experienced multiple TIAs and a minor ischaemic stroke (modified Rankin scale 2) in the hemisphere ipsilateral to the ICA occlusion 47 days after CEA of the contralateral ICA. The second patient had been treated with CEA of the ipsilateral ECA. In this patient, CBF was 37.1 mL/min/100 mL at baseline, which deteriorated to 26.6 mL/min/100 mL after 3 months. Because of ongoing TIAs, he also underwent CEA of the contralateral ICA 5 months after the 3-month PET scan. Nine months later, he had a fatal ischaemic stroke in the hemisphere ipsilateral to the ICA occlusion. The third patient was randomised for standard treatment (not tapering antihypertensive medication). In this patient, CBF was 32.3 mL/min/100 mL at baseline, deteriorating to 28.5 mL/min/100 mL after 3 months. He continued to have TIAs during the period between the two PET scans and thereafter and underwent an uncomplicated EC/IC bypass operation 9 months after randomization. Three months thereafter, he had a fatal ischaemic stroke in the hemisphere contralateral to the ICA occlusion.
This study shows that patients with recent symptoms of cerebral ischaemia associated with occlusion of the ICA on average have a lower CBF in the hemisphere ipsilateral to the occlusion than healthy subjects. Oxygen-15 PET showed that interventions aimed at improving cerebral perfusion caused a borderline significant increase in CBF in patients who had an impaired haemodynamic state of the brain at presentation, but improvement in CBF was not different between interventional and standard treatment.
Current knowledge of cerebral haemodynamic and metabolic changes over time in medically treated patients with an ICA occlusion is based on small patient series, and both improvement and deterioration over time have been described. In one study, ten medically treated patients with symptomatic ICA occlusion and increased OEF underwent a second PET scan after 12 to 59 months . Over time, patients showed on average an increase in CBF hemispheric (ipsilateral/contralateral) ratio and a decrease in OEF hemispheric ratio, but without changes in absolute values of CBF and OEF . Another study of seven patients with symptomatic ICA occlusion and normal CBF and OEF at baseline found a significant decrease in CBF and increase in OEF after 24 to 64 months, implicating haemodynamic deterioration over time . Other studies reported a bilateral increase in cerebrovascular reactivity measured by Transcranial Doppler (TCD) after CEA of a contralateral carotid stenosis in the presence of a symptomatic or asymptomatic ICA occlusion [9, 10, 24]. In contrast to these studies, we did not find a significant effect of treatment aimed at improving the flow state of the brain when compared to control patients in a randomised design. A possible explanation could be that the cerebral haemodynamic state also improved without intervention. Patients with haemodynamic compromise at baseline who received standard treatment showed a small non-significant increase in CBF. It has been shown before that patients with ICA occlusion and a compromised flow state of the brain may improve spontaneously over time . In addition, in patients with a normal haemodynamic state of the brain (stage 0) at baseline who underwent an intervention, particularly those treated by tapering of antihypertensive medication, a further increase in CBF may not be expected because of preserved cerebral autoregulation.
A limitation of our randomised pilot study is that we did not select patients on the basis of demonstrated cerebral haemodynamic compromise. The design of the study was aimed at including patients at high risk of recurrent stroke by selection on clinical criteria: ischaemic symptoms of the brain after documented occlusion, excluding patients with eye symptoms alone and those with symptoms only before the ICA occlusion were documented without ongoing symptoms thereafter . We had expected that these clinical criteria would have resulted in a much larger proportion of patients with haemodynamic stages 1 and 2. Because the average time between the last symptoms of patients and the baseline PET scan was 38 days, spontaneous improvement of a compromised flow state of the brain may have occurred before the PET scan took place. This may have contributed to the lack of a difference between the PET scan at baseline and after 3 months.
Another limitation might be heterogeneity in treating patients assigned to intervention. We have chosen for this randomization scheme rather than designing separate studies for each of the treatment options because all treatment options aim to improve cerebral perfusion. However, effects of tapering of antihypertensive medication on the haemodynamic state of the brain may well be different from those of surgery or stenting of stenosed arteries that may be important for collateral blood supply. Subgroup analysis of the present data comparing surgery or stenting of a stenosis in the contralateral ICA, ipsilateral ECA or VA with standard medical treatment alone did not show significant differences in CBF, but the number of patients in each group was small. Likewise, effects of surgery or stenting of the contralateral ICA on cerebral perfusion may be different than those of surgery or stenting of the ipsilateral ECA or VA. Furthermore, it has been described that both endarterectomy and stenting can be complicated by a hyperperfusion syndrome , but in none of the patients, this complication occurred.
The third limitation is that a relatively high number of patients had to be excluded because they did not have two successfully performed PET studies. Our failure rate was similar to the rate of 22% for quantitative studies in the St Louis Study [3, 6], and lower than in another PET study that reported a failure rate of 41% . Finally, the sample size in our study was probably too small to detect differences between the two treatment strategies except when they were large.
Although the results of this pilot study are not conclusive, some important lessons can be learned. Patients with TIA or ischaemic stroke in the hemisphere ipsilateral to the ICA occlusion are at risk of subsequent cerebral ischaemia. In these patients with symptomatic ICA occlusion, the clinical benefit of CEA or endovascular treatment of an additional stenosis in the cerebropetal arteries or tapering of antihypertensive medication has not been shown by a randomised trial. The recently published results of the Carotid Occlusion Surgery Study randomised trial  that showed no benefit of STA-MCA bypass surgery over medical treatment despite improvement of cerebral haemodynamics in the surgical group reinforce the need for other therapies to improve outcome in patients with ICA occlusion at high risk of recurrent stroke. Oxygen-15 PET is useful to identify a subgroup of patients with haemodynamic compromise, but we could not demonstrate that stenting or surgery of stenosed cerebropetal arteries or tapering of antihypertensive medication improved the haemodynamic state of the brain to a large extent in comparison with standard treatment. Whether revascularization of collaterals or tapering of antihypertensive medication can reduce the risk of recurrent stroke can only be determined in a large randomised trial of patients with a symptomatic ICA occlusion at high risk of stroke.
S. Persoon was supported by a grant from the Netherlands Heart Foundation (grant number 2003B263) and the Foundation ‘De Drie Lichten’ (grant number 41/09). C.J.M. Klijn was supported by the Netherlands Organisation for Health Research and Development (grant number 907-00-103).
- Klijn CJ, Kappelle LJ, Algra A, van Gijn J: Outcome in patients with symptomatic occlusion of the internal carotid artery or intracranial arterial lesions: a meta-analysis of the role of baseline characteristics and type of antithrombotic treatment. Cerebrovasc Dis 2001, 12: 228–234. 10.1159/000047708View ArticleGoogle Scholar
- Klijn CJ, Kappelle LJ: Haemodynamic stroke: clinical features, prognosis, and management. Lancet Neurol 2010, 9: 1008–1017. 10.1016/S1474-4422(10)70185-XView ArticleGoogle Scholar
- Grubb RL Jr, Derdeyn CP, Fritsch SM, Carpenter DA, Yundt KD, Videen TO, Spitznagel EL, Powers WJ: Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 1998, 280: 1055–1060. 10.1001/jama.280.12.1055View ArticleGoogle Scholar
- Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP: Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the carotid occlusion surgery study randomized trial. JAMA 2011, 306: 1983–1992. 10.1001/jama.2011.1610PubMed CentralView ArticleGoogle Scholar
- Yamauchi H, Higashi T, Kagawa S, Nishii R, Kudo T, Sugimoto K, Okazawa H, Fukuyama H: Is misery perfusion still a predictor of stroke in symptomatic major cerebral artery disease? Brain 2012, 135: 2515–2526. 10.1093/brain/aws131View ArticleGoogle Scholar
- Derdeyn CP, Videen TO, Yundt KD, Fritsch SM, Carpenter DA, Grubb RL, Powers WJ: Variability of cerebral blood volume and oxygen extraction: stages of cerebral haemodynamic impairment revisited. Brain 2002, 125: 595–607. 10.1093/brain/awf047View ArticleGoogle Scholar
- Gertler JP, Cambria RP: The role of external carotid endarterectomy in the treatment of ipsilateral internal carotid occlusion: collective review. J Vasc Surg 1987, 6: 158–167. 10.1067/mva.1987.avs0060158View ArticleGoogle Scholar
- Countee RW, Vijayanathan T: External carotid artery in internal carotid artery occlusion. Angiographic, therapeutic, and prognostic considerations. Stroke 1979, 10: 450–460. 10.1161/01.STR.10.4.450View ArticleGoogle Scholar
- Rutgers DR, Klijn CJ, Kappelle LJ, Eikelboom BC, van Huffelen AC, van der Grond J: Sustained bilateral hemodynamic benefit of contralateral carotid endarterectomy in patients with symptomatic internal carotid artery occlusion. Stroke 2001, 32: 728–734. 10.1161/01.STR.32.3.728View ArticleGoogle Scholar
- Baracchini C, Meneghetti G, Manara R, Ermani M, Ballotta E: Cerebral hemodynamics after contralateral carotid endarterectomy in patients with symptomatic and asymptomatic carotid occlusion: a 10-year follow-up. J Cereb Blood Flow Metab 2006, 26: 899–905. 10.1038/sj.jcbfm.9600260View ArticleGoogle Scholar
- Leira EC, Ajax T, Adams HP Jr: Limb-shaking carotid transient ischemic attacks successfully treated with modification of the antihypertensive regimen. Arch Neurol 1997, 54: 904–905. 10.1001/archneur.1997.00550190090019View ArticleGoogle Scholar
- Rothwell PM, Howard SC, Spence JD: Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke 2003, 34: 2583–2590. 10.1161/01.STR.0000094424.38761.56View ArticleGoogle Scholar
- Banks JL, Marotta CA: Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007, 38: 1091–1096. 10.1161/01.STR.0000258355.23810.c6View ArticleGoogle Scholar
- Fox AJ: How to measure carotid stenosis. Radiology 1993, 186: 316–318.View ArticleGoogle Scholar
- Hofmeijer J, Anema PC, van den Tweel I: New algorithm for treatment allocation reduced selection bias and loss of power in small trials. J Clin Epidemiol 2008, 61: 119–124. 10.1016/j.jclinepi.2007.04.002View ArticleGoogle Scholar
- Bokkers RP, Bremmer JP, van Berckel BN, Lammertsma AA, Hendrikse J, Pluim JP, Kappelle LJ, Boellaard R, Klijn CJ: Arterial spin labeling perfusion MRI at multiple delay times: a correlative study with H(2)(15)O positron emission tomography in patients with symptomatic carotid artery occlusion. J Cereb Blood Flow Metab 2010, 30: 222–229. 10.1038/jcbfm.2009.204PubMed CentralView ArticleGoogle Scholar
- Brix G, Zaers J, Adam LE, Bellemann ME, Ostertag H, Trojan H, Haberkorn U, Doll J, Oberdorfer F, Lorenz WJ: Performance evaluation of a whole-body PET scanner using the NEMA protocol. J Nucl Med 1997, 38: 1614–1623.Google Scholar
- Bremmer JP, van Berckel BN, Persoon S, Kappelle LJ, Lammertsma AA, Kloet R, Luurtsema G, Rijbroek A, Klijn CJ, Boellaard R: Day-to-day test-retest variability of CBF, CMRO(2), and OEF measurements using dynamic (15)O PET Studies. Mol Imaging Biol 2011, 13: 759–768. 10.1007/s11307-010-0382-1PubMed CentralView ArticleGoogle Scholar
- Tatu L, Moulin T, Bogousslavsky J, Duvernoy H: Arterial territories of the human brain: cerebral hemispheres. Neurology 1998, 50: 1699–1708. 10.1212/WNL.50.6.1699View ArticleGoogle Scholar
- Woods RP, Grafton ST, Holmes CJ, Cherry SR, Mazziotta JC: Automated image registration: I. General methods and intrasubject, intramodality validation. J Comput Assist Tomogr 1998, 22: 139–152. 10.1097/00004728-199801000-00027View ArticleGoogle Scholar
- Boellaard R, Knaapen P, Rijbroek A, Luurtsema GJ, Lammertsma AA: Evaluation of basis function and linear least squares methods for generating parametric blood flow images using 15O-water and positron emission tomography. Mol Imaging Biol 2005, 7: 273–285. 10.1007/s11307-005-0007-2View ArticleGoogle Scholar
- Derdeyn CP, Videen TO, Fritsch SM, Carpenter DA, Grubb RL Jr, Powers WJ: Compensatory mechanisms for chronic cerebral hypoperfusion in patients with carotid occlusion. Stroke 1999, 30: 1019–1024. 10.1161/01.STR.30.5.1019View ArticleGoogle Scholar
- Yamauchi H, Fukuyama H, Nagahama Y, Oyanagi C, Okazawa H, Ueno M, Konishi J, Shio H: Long-term changes of hemodynamics and metabolism after carotid artery occlusion. Neurology 2000, 54: 2095–2102. 10.1212/WNL.54.11.2095View ArticleGoogle Scholar
- Markus HS, Harrison MJ, Adiseshiah M: Carotid endarterectomy improves haemodynamics on the contralateral side: implications for operating contralateral to an occluded carotid artery. Br J Surg 1993, 80: 170–172. 10.1002/bjs.1800800212View ArticleGoogle Scholar
- Widder B, Kleiser B, Krapf H: Course of cerebrovascular reactivity in patients with carotid artery occlusions. Stroke 1994, 25: 1963–1967. 10.1161/01.STR.25.10.1963View ArticleGoogle Scholar
- Persoon S, Luitse MJ, de Borst GJ, van der Zwan A, Algra A, Kappelle LJ, Klijn CJ: Symptomatic internal carotid artery occlusion: a long-term follow-up study. J Neurol Neurosurg Psychiatry 2011, 82: 521–526. 10.1136/jnnp.2010.208330View ArticleGoogle Scholar
- Buczek J, Karlinski M, Kobayashi A, Bialek P, Czlonkowska A: Hyperperfusion syndrome after carotid endarterectomy and carotid stenting. Cerebrovasc Dis 2013, 35: 531–537. 10.1159/000350736View ArticleGoogle Scholar
- Hattori N, Bergsneider M, Wu HM, Glenn TC, Vespa PM, Hovda DA, Phelps ME, Huang SC: Accuracy of a method using short inhalation of (15)O-O(2) for measuring cerebral oxygen extraction fraction with PET in healthy humans. J Nucl Med 2004, 45: 765–770.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.