Hemodynamic cerebral ischemia during carotid endarterectomy evaluated by intraoperative monitoring and post-operative diffusion-weighted imaging

Abstract BACKGROUND The potential morbidity of cerebral ischemia after carotid endarterectomy (CEA) has been recognized, but its reported incidence varies widely. OBJECTIVE To prospectively evaluate the development of cerebral ischemic complications in patients treated by CEA at a high-volume cerebrovascular center. METHODS Fifty patients with moderate or severe carotid stenosis awaiting CEA were studied with perioperative diffusion-weighted imaging of the brain and standardized neurological evaluations. Microsurgical CEA was performed by 1 of 2 vascular neurosurgeons. Radiological studies were evaluated by faculty neuroradiologists who were blinded to the details of the clinical situation. RESULTS Preoperative diffusion-weighted imaging studies were performed within 24 hours of surgery. A second study was obtained within 24 (92% of patients), 48 (4% of patients), or 72 (4% of patients) hours after surgery. Intraluminal shunting was used in 1 patient (2%), and patch angioplasty was used in 2 patients (4%). No patient had diffusion-weighted imaging evidence of procedure-related cerebral ischemia. Nonischemic complications consisted of postoperative confusion in an 87-year-old man with a urinary tract infection and a marginal mandibular nerve paresis in another patient. Radiological studies were normal in both patients. CONCLUSION CEA is a relatively safe procedure that may be performed with an acceptable risk of cerebral ischemia in select patients. The low rate of ischemic complications associated with CEA sets a standard to which other carotid revascularization techniques should be held. The current results are presented with a discussion of the senior author's preferred surgical technique and a brief review of the literature.

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Perioperative Cerebral Ischemic Complications after Carotid Endarterectomy Without Shunting: A Series of 400 Consecutive CEA Evaluated by Intraoperative Monitoring and Post-operative Diffusion-weighted Imaging

Surgery for Cerebral Stroke ◽

10.2335/scs.40.94 ◽

2012 ◽

Vol 40 (2) ◽

pp. 94-99 ◽

Cited By ~ 2

Author(s):

Kazuya NAKASHIMA ◽

Hideyuki OHNISHI ◽

Yoshihiro KUGA ◽

Yuuji KODAMA ◽

Takashi TOMINAGA ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Intraoperative Monitoring ◽

Diffusion Weighted Imaging ◽

Diffusion Weighted ◽

Ischemic Complications ◽

Cerebral Ischemic

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Diffusion-weighted MR imaging of acute cerebral ischemia

Acta Radiologica ◽

10.1080/02841859809172209 ◽

1998 ◽

Vol 39 (5) ◽

pp. 460-473 ◽

Cited By ~ 20

Author(s):

T. Q. Li ◽

Z. G. Chen ◽

T. Hindmarsh

Keyword(s):

Cerebral Ischemia ◽

Mr Imaging ◽

Diffusion Weighted Imaging ◽

Tissue Injury ◽

Therapeutic Effects ◽

Tissue Water ◽

Ischemic Lesion ◽

Diffusion Weighted Images ◽

Diffusion Weighted ◽

Acute Cerebral Ischemia

Diffusion-weighted MR imaging has been used in studies on experimental animal models and on patients with acute cerebral ischemia. Compared with CT and conventional MR techniques, diffusion-weighted imaging can provide earlier and more precise detection of the location and the extent of an ischemic lesion during the critical first few hours after the onset of stroke Quantitative apparent diffusion coefficient (ADC) mapping of the brain water can also be carried out by recording a series of diffusion-weighted images with different amplitudes of the displacement encoding gradients. ADC maps can provide important information about the extra- and intracellular water homeostasis. ADC reduction of the tissue water is one of the early signals of the pathophysiological cascade resulting from ischemic tissue injury. Diffusion MR imaging has become a valuable tool in stroke research. It may also prove a valuable tool in monitoring the efficiency of therapeutic effects in stroke patients It is our intention to provide an overview of the recent development in this area with emphasis on the diffusion-weighted MR techniques, and to discuss the possible underlying biophysical mechanisms responsible for the contrast of diffusion-weighted imaging

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Physiological and Metabolic Interpretation of Diffusion-Weighted Imaging Changes During Cerebral Ischemia

Israel Journal of Chemistry ◽

10.1560/0bcg-d9vn-kgm9-hkfc ◽

2003 ◽

Vol 43 (1-2) ◽

pp. 115-127 ◽

Cited By ~ 1

Author(s):

Thomas Hilger ◽

Mathias Hoehn

Keyword(s):

Cerebral Ischemia ◽

Diffusion Weighted Imaging ◽

Diffusion Weighted

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Polynitroxyl Albumin Reduces Infarct Size in Transient Focal Cerebral Ischemia in the Rat: Potential Mechanisms Studied by Magnetic Resonance Imaging

Journal of Cerebral Blood Flow & Metabolism ◽

10.1097/00004647-199809000-00012 ◽

1998 ◽

Vol 18 (9) ◽

pp. 1022-1031 ◽

Cited By ~ 35

Author(s):

Christian Beaulieu ◽

Elmar Busch ◽

Joachim Röther ◽

Alexander de Crespigny ◽

Carleton J. C. Hsia ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Cerebral Ischemia ◽

Magnetic Resonance ◽

Middle Cerebral Artery ◽

Diffusion Weighted Imaging ◽

Focal Cerebral Ischemia ◽

Treated Group ◽

Resonance Imaging ◽

Diffusion Weighted ◽

Transient Focal Cerebral Ischemia

Nitroxide free radicals are known to protect cells from oxidative damage. Diffusion-weighted and perfusion-weighted magnetic resonance imaging was used to evaluate the effects of polynitroxyl albumin(PNA) in a middle cerebral artery intraluminal suture model of transient focal cerebral ischemia in the rat. Three groups of Sprague-Dawley rats were investigated: (1) PNA(N = 6), (2) human serum albumin (N = 6), and (3) saline (N = 7). The middle cerebral artery was occluded for 2 hours. Treatment was started 30 minutes after induction of ischemia. A total dose of 1% body weight (volume/weight) of PNA (23.5 mg/dL protein and 110 mmol/L nitroxide), albumin (23.5 mg/dL), or saline was injected intravenously at three time points: 0.5% at 0.5 hours, 0.25% at 2 hours (i.e., just before reperfusion), and 0.25% at 4 hours after occlusion. Six sets of diffusion- and perfusion-weighted magnetic resonance images were acquired throughout the 2 hours of ischemia and the 2 hours of reperfusion. The rats were killed at 24 hours, and the brains were stained with 2,3,5-triphenyltetrazolium chloride (TTC). Diffusion-weighted imaging showed that the growth of the ischemic lesion was suppressed in the PNA-treated group. The 4 hours diffusion-weighted imaging-derived hemispheric lesion volume in the PNA-treated group (25% ± 9%) was significantly smaller than that in the saline-treated(43% ± 13%; P = 0.016) or albumintreated groups (38% ± 6%; P = 0.017). A larger difference was observed for the 24-hour TTC-derived lesion volumes in the PNA (8% ± 7%), saline (35% ± 8%; P< 0.001), and albumin (31% ± 6%; P < 0.001) groups. Perfusion-weighted imaging demonstrated a marked improvement in cerebral perfusion in the PNA-treated group during ischemia and reperfusion. In conclusion, treatment with PNA results in an improvement in perfusion and a reduction of infarct volume in a model of transient focal cerebral ischemia in the rat.

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