Anterior communicating artery collateral flow protection against ischemic change during carotid endarterectomy

1993 ◽  
Vol 79 (3) ◽  
pp. 379-382 ◽  
Author(s):  
Maria V. Lopez-Bresnahan ◽  
Lee A. Kearse ◽  
Paulino Yanez ◽  
Tina I. Young
Keyword(s):  
Cerebral Ischemia ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Cerebral Arteries ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Anterior Communicating Artery ◽  
Collateral Flow ◽  
Content Type ◽  
Carotid Circulation

✓ The purpose of this study was to determine whether preoperative angiographic patterns of collateral cerebral blood flow correlate with protection against intraoperative electroencephalographic (EEG) evidence of cerebral ischemia caused by carotid artery cross-clamping during carotid endarterectomy. Previous studies have shown that contralateral carotid artery occlusion and intracranial stenoses are associated with cerebral ischemia during carotid endarterectomy; however, the angiographic collateral flow patterns associated with cerebral ischemia have not been identified. This paper reports a retrospective study of 67 patients who underwent two- to four-vessel cerebral angiography followed by carotid endarterectomy with 16-channel EEG monitoring. The angiograms were reviewed for extracranial occlusive disease and collateral flow patterns, and the EEG recordings were analyzed for ischemic changes during carotid artery cross-clamping. Statistical analysis was by Fisher's exact test. Cross-filling of the anterior and middle cerebral arteries from the contralateral carotid artery through the anterior communicating artery correlated with a decreased incidence of EEG ischemic changes. Only 21% of patients with this collateral flow pattern showed ischemic changes compared to 50% of patients without this pattern (p < 0.03). Three angiographic findings occurring in combination on the side contralateral to surgery correlated with EEG ischemia: 1) occlusion of the contralateral internal carotid artery (five of seven or 71%, p < 0.03); 2) collateral flow from the external carotid circulation to the internal carotid circulation via the ophthalmic artery; and 3) collateral flow from the posterior circulation to the contralateral anterior circulation via the posterior communicating artery. The data presented here corroborate the correlation between contralateral carotid artery occlusion and cerebral ischemia during carotid endarterectomy. They also demonstrate that cross-filling of the anterior and middle cerebral arteries by the contralateral carotid artery protects against such ischemia. This collateral flow may serve as an indicator of tolerance to carotid artery cross-clamping.

Abstract T P100: Effect of Carotid Endarterectomy on Cerebral Hemodynamics Using Quantitative Magnetic Resonant Angiography

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Xinjian Du ◽  
Sepideh Amin-Hanjani ◽  
Fady Charbel
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Cerebral Artery ◽  
Flow Direction ◽  
Cerebral Arteries ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Cerebral Hemodynamics ◽  
Flow Measurements ◽  
Blood Flow Measurements

Objective: To examine the effect of carotid endarterectomy (CEA) on cerebral hemodynamics using quantitative magnetic resonance angiography (QMRA). Methods: A total of 42 patients with severe carotid artery stenosis were studied (6 patients had asymptomatic stenosis). 6 of 42 patients had contralateral carotid artery occlusion. Pre- and post-op blood flow measurements of major cerebral arteries were performed using QMRA (NOVA,Vasol, Inc.). Results: Patients ranged from 39 to 85 (mean 66) years old, 17 female. Ipsilateral carotid artery flow was significantly increased after CEA, 253 ± 110 ml/min compare to 159 ± 79 ml/min (p<0.001). Middle cerebral artery (MCA) flow was not significantly increased (p=0.11), 127 ± 39 ml/min versus pre-op 115 ± 33 ml/min after CEA. Ipsilateral anterior cerebral artery (ACA) flow direction of 6 patients changed to anterograde, 5 patients’ ipsilatral posterior communicating artery (PCOM) flow direction changed to posterior, 1 patient had both flow direction of Ipilateral ACA and PCOM changed after CEA. Post-op Ipsilateral hemisphere flow (IHF), defined as the sum of MCA, ACA2, and PCA flows, was increased (p=0.05) from 220 ± 45 ml/min to 251 ± 83 ml/min. Conclusions: Carotid stenosis can result in ICA flow compromise, and CEA can increase the flow rate of the ipsilateral carotid artery significantly. However, the collateral capacity of the circle of Willis appears to be the more important determinant of Intracranial ipsilateral MCA flow.

Neurosurgical applications of ocular pneumoplethysmography

1981 ◽  
Vol 54 (5) ◽  
pp. 588-595 ◽  
Author(s):  
William F. Bingham
Keyword(s):  
Standard Deviation ◽  
Carotid Artery ◽  
Intracranial Aneurysm ◽  
Carotid Endarterectomy ◽  
Contralateral Side ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Content Type ◽  
Final Adjustment ◽  
Fine Print

✓ Ocular pneumoplethysmography (OPG), a semiautomated form of suction ophthalmodynamometry, was used to evaluate and follow 15 patients who underwent carotid endarterectomy and two patients in whom gradual carotid artery occlusion was performed for inoperable intracranial aneurysm. Postoperative corrected ophthalmic arterial pressures (COAP's) on the operated side in the carotid endarterectomy patients averaged 12.5 mm Hg higher than before surgery, the standard deviation being 4.9 mm Hg for clinically stable patients. There was no significant change in COAP on the contralateral side. Several problems were encountered in closing down carotid clamps, the most potentially serious being a precipitous fall in COAP with the final adjustment. The current uses of OPG and similar techniques are reviewed, and potential neurosurgical applications are discussed.

Cerebrovascular CO2 reactivity after carotid artery occlusion

1988 ◽  
Vol 69 (1) ◽  
pp. 24-28 ◽  
Author(s):  
Guy L. Clifton ◽  
Halcott T. Haden ◽  
John R. Taylor ◽  
Michael Sobel
Keyword(s):  
Carotid Artery ◽  
Bypass Surgery ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Collateral Flow ◽  
Physiological Basis ◽  
Content Type ◽  
Normal Individuals ◽  
Cerebrovascular Co2 Reactivity ◽  
Normal Men

✓ Cerebral blood flow (CBF) was measured in 39 men at normocapnia and after 5% CO2 inhalation using the xenon-133 technique. Twenty-three patients had unilateral carotid artery occlusion with no angiographic evidence of contralateral carotid artery stenosis or ophthalmic collateral flow. Eleven of these patients had undergone extracranial-intracranial (EC-IC) bypass surgery. Sixteen age-matched normal men underwent CBF measurements at normocapnia and hypercapnia to provide control data. Mean hemispheric CBF was not different between hemispheres ipsilateral and contralateral to the carotid artery occlusion either in the patients who had undergone bypass surgery or in those with carotid artery occlusion alone. Considering all patients with carotid artery occlusion, mean CO2 reactivity was decreased in the hemisphere ipsilateral to the occlusion as compared to the contralateral hemisphere in both groups. Based on data from normal individuals, a hemispheric difference in CO2 reactivity of more than 0.94%/mm Hg PaCO2 or a global CO2 reactivity of less than 0.66%/mm Hg PaCO2 was considered abnormal for an individual patient. Six of 23 patients with carotid artery occlusion (three with an EC-IC bypass) had global or hemispheric abnormalities in CO2 reactivity. Patients with impaired CO2 reactivity were not distinguishable from other patients by neurological examination, presence of transient ischemic attacks, or evidence of infarction on computerized tomography scanning. This test was safe and simple to perform and may be a useful means of detecting impaired cerebrovascular collateral reserve capacity. If impaired CO2 reactivity after carotid artery occlusion proves to be associated with a high risk of subsequent stroke, the test would provide a physiological basis for selecting a subgroup of patients who could be helped by cerebral revascularization.

The hemodynamic effects of internal carotid artery stenosis and occlusion

1987 ◽  
Vol 66 (5) ◽  
pp. 755-763 ◽  
Author(s):  
A. David Mendelow ◽  
David I. Graham ◽  
Ursula I. Tuor ◽  
William Fitch
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Cerebral Arteries ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Internal Carotid Artery Stenosis ◽  
Artery Stenosis ◽  
Content Type ◽  
Anterior Section ◽  
Arterial Blood

✓ The purpose of this study was to determine in subhuman primates whether hemodynamic mechanisms (as compared with embolic mechanisms) contribute to cerebral ischemia following carotid artery occlusion or stenosis. Following carotid artery occlusion there was loss of cerebral autoregulation: cerebral blood flow (CBF) measured with the xenon-133 technique became passively dependent upon the mean arterial blood pressure (MABP) over an MABP range of 30 to 110 mm Hg. By contrast, autoregulation was preserved in normal animals and in animals with a 90% carotid artery stenosis. Regional CBF was measured with carbon-14-labeled iodoantipyrine autoradiography in normotensive baboons, in hypotensive animals, and in hypotensive animals with carotid artery occlusion or stenosis. With carotid artery occlusion and hypotension, reduced levels of local CBF were seen ipsilaterally in the boundary zones between the anterior and middle cerebral arteries with 35% of the area of an anterior section through the hemisphere displaying a CBF value of less than 20 ml/100 gm/min. Comparable values with hypotension were 21% with carotid artery stenosis, 20% with no proximal vascular lesion, and 1% in normotensive animals. These areas of reduced CBF corresponded with areas of boundary-zone ischemia seen with light microscopy. The study suggests that while hemodynamic ischemia develops with carotid artery occlusion, it does not occur with even a 90% carotid artery stenosis or in normal animals.

Emergency embolectomy for acute occlusion of the middle cerebral artery

1985 ◽  
Vol 62 (5) ◽  
pp. 639-647 ◽  
Author(s):  
Fredric B. Meyer ◽  
David G. Piepgras ◽  
Thoralf M. Sundt ◽  
Takehiko Yanagihara
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Excellent Result ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Left Middle Cerebral Artery ◽  
Collateral Flow ◽  
Content Type ◽  
Acute Occlusion

✓ Twenty cases treated with emergency embolectomy for acute occlusion of the middle cerebral artery were reviewed. There were 10 males and 10 females, with an average age of 55 years. The left middle cerebral artery was involved in 17 patients and the right in three. Flow was restored in 16 patients (75%). The embolus originated in the heart in seven, the carotid artery in seven, the aorta in three, an aneurysm in one, and an indeterminate source in two. It was technically most difficult to achieve patency with atheromatous emboli from the aorta. Two patients (10%) had an excellent result with no neurological deficit, five (25%) were left with a minimal deficit but were employable, seven (35%) had a fair result but were still independent and employable, four (20%) did poorly, and two (10%) died. Patients with an associated ipsilateral carotid artery occlusion did poorly. Collateral flow, as judged from preoperative angiograms, was the best predictor of outcome.

Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation

1994 ◽  
Vol 81 (5) ◽  
pp. 656-665 ◽  
Author(s):  
Charles G. Drake ◽  
Sydney J. Peerless ◽  
Gary G. Ferguson
Keyword(s):  
Internal Carotid ◽  
Cerebral Arteries ◽  
Cross Flow ◽  
Arterial Occlusion ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Collateral Flow ◽  
Anterior Circulation ◽  
Content Type ◽  
Giant Aneurysms

✓ Hunterian proximal artery occlusion was used in the treatment of 160 of 335 patients harboring giant aneurysms of the anterior circulation. One hundred and thirty-three of these aneurysms arose from the internal carotid arteries, 20 from the middle cerebral arteries, and seven from the anterior cerebral arteries. Ninety percent of the patients had satisfactory outcomes. The safety of internal carotid artery occlusion has been greatly enhanced by preoperative flow studies and by test occlusion with an intracarotid balloon to identify those patients who require preliminary extracranial-to-intracranial bypass, which was used in all of the middle cerebral occlusions. The anterior cerebral artery had magnificent leptomeningeal collateral flow that prevented infarction even without cross flow. Obliteration of the aneurysm by thrombosis was complete, or nearly so, in all but four patients whose treatment was completed. Analysis of poor outcome in 16 patients revealed that hemodynamic ischemic infarction was known to occur after only two of the carotid occlusions.

Contralateral Internal Carotid Artery Occlusion Impairs Early But Not 30-Day Stroke Rate Following Carotid Endarterectomy

Angiology ◽  
2010 ◽  
Vol 61 (7) ◽  
pp. 705-710 ◽  
Author(s):  
Erik Bagaev ◽  
A. Maximilian Pichlmaier ◽  
Theodosios Bisdas ◽  
Mathias H. Wilhelmi ◽  
Axel Haverich ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Carotid Endarterectomy ◽  
Internal Carotid ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Internal Carotid Artery Occlusion ◽  
Stroke Rate ◽  
Contralateral Internal Carotid Artery

The importance of internal carotid artery occlusion tolerance test in carotid endarterectomy under locoregional anesthesia

2016 ◽  
Vol 158 (6) ◽  
pp. 1077-1081
Author(s):  
Marcos Dellaretti ◽  
Laura T. de Vasconcelos ◽  
Jules Dourado ◽  
Renata F. de Souza ◽  
Renato R. Fontoura ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Carotid Endarterectomy ◽  
Internal Carotid ◽  
Tolerance Test ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Internal Carotid Artery Occlusion ◽  
Locoregional Anesthesia

Defining thresholds for critical ischemia by using near-infrared spectroscopy in the adult brain

1998 ◽  
Vol 89 (3) ◽  
pp. 389-394 ◽  
Author(s):  
Peter J. Kirkpatrick ◽  
Joseph Lam ◽  
Pippa Al-Rawi ◽  
Piotr Smielewski ◽  
Marek Czosnyka
Keyword(s):  
Infrared Spectroscopy ◽  
Cerebral Ischemia ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Near Infrared Spectroscopy ◽  
Near Infrared ◽  
Adult Brain ◽  
Content Type ◽  
Signal Changes ◽  
Fine Print

Object. Signal changes in adult extracranial tissues may have a profound effect on cerebral near-infrared spectroscopy (NIRS) measurements. During carotid surgery NIRS signals provide the opportunity to determine the relative contributions from the intra- and extracranial vascular territories, allowing for a more accurate quantification. In this study the authors applied multimodal monitoring methods to patients undergoing carotid endarterectomy and explored the hypothesis that NIRS can define thresholds for cerebral ischemia, provided extracranial NIRS signal changes are identified and removed. Relative criteria for intraoperative severe cerebral ischemia (SCI) were applied to 103 patients undergoing carotid endarterectomy. Methods. One hundred three patients underwent carotid endarterectomy. An intraoperative fall in transcranial Doppler—detected middle cerebral artery flow velocity (%ΔFV) of greater than 60% accompanied by a sustained fall in cortical electrical activity were adopted as criteria for SCI. Ipsilateral frontal NIRS recorded the total difference in concentrations of oxyhemoglobin and deoxyhemoglobin (Total ΔHbdiff). Interrupted time series analysis following clamping of the external carotid artery (ECA) and the internal carotid artery (ICA) allowed the different vascular components of Total ΔHbdiff (ECA ΔHbdiff and ICA ΔHbdiff) to be identified. Data obtained in 76 patients were deemed suitable. A good correlation between %ΔFV and ICA ΔHbdiff (r = 0.73, p < 0.0001) was evident. Sixteen patients (21%) fulfilled the criteria for SCI. All patients who demonstrated an ICA ΔHbdiff of greater than 6.8 µmol/L showed SCI, and in two patients within this group nondisabling watershed infarction developed, as seen on postoperative computerized tomography scans. No patient with an ICA ΔHbdiff less than 5 µmol/L exhibited SCI or suffered a stroke. Within the resolution of the criteria used an ICA ΔHbdiff threshold of 6.8 µmol/L provided 100% specificity for SCI, whereas an ICA ΔHbdiff less than 5 µmol/L was 100% sensitive for excluding SCI. When Total ΔHbdiff was used without removing the ECA component, no thresholds for SCI were apparent. Conclusions. Carotid endarterectomy provides a stable environment for exploring NIRS-quantified thresholds for SCI in the adult head.

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