Evaluation of impaired dynamic cerebral autoregulation by the Mueller manoeuvre

Arterial blood pressure (ABP) shows polyphasic changes during the Mueller manoeuvre (voluntary negative intrathoracic pressure). The aim of the present study was to investigate (1) whether these changes could be applied to detect impaired dynamic cerebral autoregulation (dCA) in carotid stenosis and (2) whether the degree of indicated impairment correlates with transfer function phase as another current measure for dCA (deep breathing method) and CO₂‐reactivity. We examined 13 patients with severe unilateral carotid artery stenosis and 16 age‐matched controls during 15‐s Mueller manoeuvres (MM) at ?30 mmHg using bilateral transcranial Doppler sonography and non‐invasive ABP recordings (Finapres, 2300, Ohmeda, Englewood, CO, USA). After an initial biphasic oscillation, cerebral blood flow velocity (CBFV) and ABP decreased to below baseline. CBFV reincreased in controls and on contralateral sides in patients 6·0 s (3·8–9·5 s, median and range) after the onset of the decrease, despite a further fall in ABP. CBFV over the affected side revealed a significantly delayed reincrease (8·0 (5·6–10·3) s; P<0·01) combined with a relatively flat and inertial amplitude behaviour. An applied autoregulation index derived from the MM (mROR), phase shift and CO₂‐reactivity were severely reduced on the affected side in patients (P<0·01). Reduction of the mROR correlated significantly with reduction of phase shift (r=0·69; P=0·002) and CO₂‐reactivity (r=0·78; P=0·002). In conclusion, the different cerebral haemodynamic pattern during the MM in patients is likely to reflect impaired dCA. The degree of indicated impairment correlates with that of transfer function phase and CO₂‐reactivity. Therefore, the MM represents a convenient method for grading of compromised cerebral haemodynamics in patients with carotid artery stenosis.