Failure of cerebral hemodynamic selection in general or of specific positron emission tomography methodology?: Carotid Occlusion Surgery Study (COSS)

Abstract

Background and purpose: The Carotid Occlusion Surgery Study (COSS) was an improvement over the Extracranial-Intracranial Bypass Study, which did not utilize physiological selection. To assess possible reasons for early closure of the COSS trial, we reviewed COSS methods used to identify high-risk patients and compared results with separate quantitative data.

Methods: Increased oxygen extraction fraction (OEF) by positron emission tomography is a gold standard for ischemia, but the specific thresholds and equivalency of the semiquantitative OEF ratio utilized in COSS and quantitative OEF are at issue.

Results: The semiquantitative hemispheric OEF ratio used in COSS did not identify the same group of patients as did quantitative OEF using a threshold of 50%.

Conclusions: The failure of COSS is likely caused by a failure of the semiquantitative, hemispheric OEF ratio method rather than by the selection for bypass based on hemodynamic compromise.

Figures

Figure 1

(A) Regions of interest (ROI) volumes used in the Carotid Occlusion Surgery Study (COSS) to evaluate hemodynamic compromise. (B) Volumes of interest used to evaluate hemodynamic compromise in the Quantitative Occlusive Vascular Disease Study (QUOVADIS)

Figure 2

Correlation between COSS hemispheric OEF ratio (threshold- 1.12) versus quantitative OEF (threshold- 50%) in fourteen patients with unilateral carotid occlusion. The patients identified with hemodynamic compromise by the COSS OEF ratio were not the same patients identified by the quantitative OEF measured in QUOVADIS (unpublished).