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Cezayirli PC, Türe H, Türe U. Microsurgical Treatment of Deep and Eloquent AVMs. Adv Tech Stand Neurosurg 2022; 44:17-53. [PMID: 35107672 DOI: 10.1007/978-3-030-87649-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Over the past 30 years, the treatment of deep and eloquent arteriovenous malformations (AVMs) has moved away from microneurosurgical resection and towards medical management and the so-called minimally invasive techniques, such as endovascular embolization and radiosurgery. The Spetzler-Martin grading system (and subsequent modifications) has done much to aid in risk stratification for surgical intervention; however, the system does not predict the risk of hemorrhage nor risk from other interventions. In more recent years, the ARUBA trial has suggested that unruptured AVMs should be medically managed. In our experience, although these eloquent regions of the brain should be discussed with patients in assessing the risks and benefits of intervention, we believe each AVM should be assessed based on the characteristics of the patient and the angio-architecture of the AVM, in particular venous hypertension, which may guide us to treat even high-grade AVMs when we believe we can (and need to) to benefit the patient. Advances in imaging and intraoperative adjuncts have helped us in decision making, preoperative planning, and ensuring good outcomes for our patients. Here, we present several cases to illustrate our primary points that treating low-grade AVMs can be more difficult than treating high-grade ones, mismanagement of deep and eloquent AVMs at the behest of dogma can harm patients, and the treatment of any AVM should be tailored to the individual patient and that patient's lesion.
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Affiliation(s)
- Phillip Cem Cezayirli
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Hatice Türe
- Department of Anesthesiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey.
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Rangel-Castilla L, Spetzler RF, Nakaji P. Normal perfusion pressure breakthrough theory: a reappraisal after 35 years. Neurosurg Rev 2014; 38:399-404; discussion 404-5. [PMID: 25483235 DOI: 10.1007/s10143-014-0600-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/03/2014] [Accepted: 09/28/2014] [Indexed: 11/26/2022]
Abstract
The intrinsic ability of the brain to maintain constant cerebral blood flow (CBF) is known as cerebral pressure autoregulation. This ability protects the brain against cerebral ischemia and hyperemia within a certain range of blood pressures. The normal perfusion pressure breakthrough (NPPB) theory described by Spetzler in 1978 was adopted to explain the edema and hemorrhage that sometimes occur after resection of brain arteriovenous malformations (AVMs). The underlying pathophysiology of edema and hemorrhage after AVM resection still remains controversial. Over the last three decades, advances in neuroimaging, CBF, and cerebral perfusion pressure (CPP) measurement have both favored and contradicted the NBBP theory. At the same time, other theories have been proposed, including the occlusive hyperemia theory. We believe that both theories are related and complementary and that they both explain changes in hemodynamics after AVM resection. The purpose of this work is to review the current status of the NBBP theory 35 years after its original description.
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Affiliation(s)
- Leonardo Rangel-Castilla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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3
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Meinel FG, Fischer J, Pomschar A, Wöhrle N, Koerte IK, Steffinger D, Laubender RP, Muacevic A, Reiser MF, Alperin N, Ertl-Wagner B. MRI evidence for preserved regulation of intracranial pressure in patients with cerebral arteriovenous malformations. Eur J Radiol 2014; 83:1442-7. [PMID: 24932847 DOI: 10.1016/j.ejrad.2014.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate intracranial pressure and associated hemo- and hydrodynamic parameters in patients with cerebral arteriovenous malformations AVMs. METHODS Thirty consecutive patients with arteriovenous malformations (median age 38.7 years, 27/30 previously treated with radiosurgery) and 30 age- and gender-matched healthy controls were investigated on a 3.0T MR scanner. Nidus volume was quantified on dynamic MR angiography. Total arterial cerebral blood flow (tCBF), venous outflow as well as aqueductal and craniospinal stroke volumes were obtained using velocity-encoded cine-phase contrast MRI. Intracranial volume change during the cardiac cycle was calculated and intracranial pressure (ICP) was derived from systolic intracranial volume change (ICVC) and pulse pressure gradient. RESULTS TCBF was significantly higher in AVM patients as compared to healthy controls (median 799 vs. 692 mL/min, p=0.007). There was a trend for venous flow to be increased in both the ipsilateral internal jugular vein (IJV, 282 vs. 225 mL/min, p=0.16), and in the contralateral IJV (322 vs. 285 mL/min, p=0.09), but not in secondary veins. There was no significant difference in median ICP between AVM patients and control subjects (6.9 vs. 8.6 mmHg, p=0.30) and ICP did not correlate with nidus volume in AVM patients (ρ=-0.06, p=0.74). There was a significant positive correlation between tCBF and craniospinal CSF stroke volume (ρ=0.69, p=0.02). CONCLUSIONS The elevated cerebral blood flow in patients with AVMs is drained through an increased flow in IJVs but not secondary veins. ICP is maintained within ranges of normal and does not correlate with nidus volume.
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Affiliation(s)
- Felix G Meinel
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Judith Fischer
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Andreas Pomschar
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Natalie Wöhrle
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Inga K Koerte
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Denise Steffinger
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Rüdiger P Laubender
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | | | - Maximilian F Reiser
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Noam Alperin
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Birgit Ertl-Wagner
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
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Gutiérrez-González R, Pérez-Zamarron A, Rodríguez-Boto G. Normal perfusion pressure breakthrough phenomenon: experimental models. Neurosurg Rev 2014; 37:559-67. [PMID: 24777643 DOI: 10.1007/s10143-014-0549-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 08/25/2013] [Accepted: 02/08/2014] [Indexed: 11/28/2022]
Abstract
One of the most life-threatening complications after the obliteration of intracranial arteriovenous malformations is the development of oedema and/or multifocal haemorrhage. Two main theories have been postulated so far in order to explain this situation. On one hand, "normal perfusion pressure breakthrough phenomenon" is based on the loss of cerebral vessel autoregulation due to the chronic vasodilation of perinidal microcirculation. On the other hand, the "occlusive hyperaemia" deals with thrombotic and venous obstruction phenomena that may also generate such manifestations. The aim of this study is to resume the main concepts of the "normal perfusion pressure breakthrough phenomenon" theory as well as the related animal models described up to date, their advantages and disadvantages, and the main conclusions obtained as a result of the experimental research.
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Affiliation(s)
- Raquel Gutiérrez-González
- Department of Neurosurgery, Fundación Jiménez Díaz (IIS-FJD), Avda Reyes Católicos 2, 28040, Madrid, Spain,
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Honarmand AR, Ansari SA, Alden TD, Soltanolkotabi M, Schoeneman SE, Hurley MC, Rahman O, Shaibani A. Endovascular management of pediatric high-flow vertebro-vertebral fistula with reversed basilar artery flow. A case report and review of the literature. Interv Neuroradiol 2013; 19:215-21. [PMID: 23693046 DOI: 10.1177/159101991301900211] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/17/2013] [Indexed: 11/17/2022] Open
Abstract
Vertebral artery arteriovenous fistula (VAVF) is mostly known as a post-traumatic and/or iatrogenic arteriovenous complication. However, spontaneous high-flow VAVF associated with flow reversal in the basilar artery has not been reported in children. We describe a unique asymptomatic presentation of a spontaneous high-flow VAVF associated with flow reversal in the basilar artery in a pediatric patient. The literature for classification, pathophysiology, treatment strategies, and post-procedural complications is also reviewed.
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Affiliation(s)
- A R Honarmand
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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6
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Chyatte D. Normal pressure perfusion breakthrough after resection of arteriovenous malformation. J Stroke Cerebrovasc Dis 2012; 6:130-6. [PMID: 17894984 DOI: 10.1016/s1052-3057(97)80229-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/1996] [Accepted: 09/09/1996] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED Objectives. The syndrome of normal pressure perfusion breakthrough (NPPB) follows the surgical resection of a small fraction of cerebral arteriovenous malformations (AVM). Although intraoperative hyperemia occurs in NPPB, the relationship and temporal profile of vasomotor paralysis to NPPB are unknown. In the present study, serial transcranial Doppler (TCD) studies (static and stress) were correlated with clinic observations to determine the relationship and temporal profile of vasomotor paralysis to NPPB. Methods. Thirty-five patients underwent complete AVM removal with preservation of the normal arteries and veins. Serial TCD examinations were performed under static and stress conditions (CO(2), Diamox, or blood pressure challenge). Vasomotor paralysis was considered present when CO(2) or Diamox challenge produced less than a 10% change in flow velocity or when flow velocity changed with blood pressure over physiological ranges. Results. Two of 35 patients (6%) developed NPPB immediately after AVM resection. Results of TCD studies were consistent with vasomotor paralysis. NPPB and vasomotor paralysis abated together in both patients on postoperative day 3 to 4. In one patient, NPPB and vasomotor paralysis reoccurred on postoperative day 8 after liberalization of blood pressure control. CONCLUSIONS NPPB occurs in a small fraction of patients after AVM resection. The occurrence of NPPB correlates with vasomotor paralysis, and both are present immediately postoperatively and last several days. Improving vasomotor tone and clinical condition do not imply complete normalization of the cerebral circulation because NPPB and vasomotor paralysis can reoccur after liberalization of blood pressure control.
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Zacharia BE, Bruce S, Appelboom G, Connolly ES. Occlusive Hyperemia Versus Normal Perfusion Pressure Breakthrough after Treatment of Cranial Arteriovenous Malformations. Neurosurg Clin N Am 2012; 23:147-51. [DOI: 10.1016/j.nec.2011.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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8
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Postoperative intracranial haemorrhage: a review. Neurosurg Rev 2011; 34:393-407. [DOI: 10.1007/s10143-010-0304-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 09/27/2010] [Accepted: 11/10/2010] [Indexed: 01/31/2023]
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Starke RM, Komotar RJ, Connolly ES. Surgical Decision Making, Techniques, and Periprocedural Care of Cerebral Arteriovenous Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Alexander MD, Connolly ES, Meyers PM. Revisiting normal perfusion pressure breakthrough in light of hemorrhage-induced vasospasm. World J Radiol 2010; 2:230-2. [PMID: 21160635 PMCID: PMC2999324 DOI: 10.4329/wjr.v2.i6.230] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 06/02/2010] [Accepted: 06/28/2010] [Indexed: 02/06/2023] Open
Abstract
Cerebral arteriovenous malformations (AVMs) have abnormally enlarged arteries and veins prone to spontaneous hemorrhage. Immediately following surgical excision of a cerebral AVM, even normal brain tissue surrounding the lesion is subject to hemorrhage, a phenomenon termed normal perfusion pressure breakthrough (NPPB) syndrome. According to this theory, arteries supplying cerebral AVMs become dilated and lose their capacity to dilate or constrict to autoregulate pressure. Acutely after removal of a cerebral AVM, excessive blood pressure in these arterial feeders can cause normal brain tissue to bleed. However, this theory remains controversial. We present a patient with a cerebral AVM that demonstrated cerebrovascular reactivity and argues against an assumption underlying the theory of NPPB syndrome.
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Dynamic Autoregulation Testing Does Not Indicate Changes of Cerebral Blood Flow Before and After Resection of Small- and Medium-Sized Cerebral AVM. Transl Stroke Res 2010; 2:60-6. [DOI: 10.1007/s12975-010-0031-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Evidence for a predominant intrinsic sympathetic control of cerebral blood flow alterations in an animal model of cerebral arteriovenous malformation. Transl Stroke Res 2010; 1:210-9. [PMID: 24323523 DOI: 10.1007/s12975-010-0021-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 02/18/2010] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
Abstract
In terms of neurogenic cerebral blood flow (CBF) control, the activity of the sympathetic nervous system (SNS) has a regulating effect. The impact of a manipulation of both the peripheral (via the perivascular sympathetic net) and central components (via the intracortical noradrenergic terminals originating from the locus coeruleus) on CBF-and especially on hyperperfusion syndromes-is unclear. To test the specific patterns following such alterations, cortical oxygen saturation (rSO2), regional CBF (rCBF), and cortical interstitial norepinephrine (NE) concentrations were measured. Twelve weeks after either the creation of an extracranial AV fistula or sham operation, 80 male Sprague-Dawley rats underwent one of the following procedures: (1) no SNS manipulation, (2) peripheral SNS inhibition via bilateral sympathectomy, (3) central SNS inhibition via the neurotoxin DSP-4, or (4) complete SNS inhibition. Norepinephrine concentrations were lowest after complete inhibition (NE [nmol]: pre, 1.8 ± 1.2; post, 2.4 ± 1.8) and highest following peripheral inhibition (NE [nmol]: pre, 3.6 ± 1.9; post, 6.6 ± 4.4). Following fistula occlusion, rCBF (laser Doppler unit [LDU]) and rSO2 (%SO2) increases were highest after complete inhibition (pre: 204 ± 14 LDU, 34 ± 3%SO2; post: 228 ± 18 LDU, 39 ± 3%SO2) and lowest after peripheral inhibition (pre: 221 ± 18 LDU, 41 ± 2%SO2; post: 226 ± 14 LDU, 47 ± 2%SO2). Thus, a complete inhibition down-regulates SNS activity and provokes a cortical hyperperfusion condition. With this, the hitherto unknown predominant role of the intrinsic component could be demonstrated for the first time in vivo.
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13
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Ng I, Tan WL, Ng PY, Lim J. Hypoxia inducible factor-1α and expression of vascular endothelial growth factor and its receptors in cerebral arteriovenous malformations. J Clin Neurosci 2005; 12:794-9. [PMID: 16165361 DOI: 10.1016/j.jocn.2005.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Revised: 02/28/2005] [Accepted: 02/28/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vascular endothelial growth factor (VEGF) and its tyrosine kinase family of receptors (VEGFR) (Flt-1, Flk-1, Flt-4) have been implicated in vascular angiogenesis and remodelling in cerebral arteriovenous malformations (CAVM). In this study, we investigate the role of hypoxia inducible factor-1 (HIF-1alpha) in CAVM and its relationship to VEGF and VEGFR. METHODS Surgical specimens from 26 patients undergoing CAVM resection were studied for HIF-1alpha , VEGF, Flt-1, Flk-1 and Flt-4. The mean age was 34.08 +/- 14.18 years. Twenty-one patients presented with intracerebral haemorrhage. RESULTS VEGF, Flt-1 and Flt-4 were expressed in all specimens. Flk-1 was expressed in 15 of 26 patients. HIF-1alpha was expressed in 15 of 26 patients. HIF-1alpha expression was significantly associated with VEGF, Flt-1 and Flk-1 expression (p < 0.05) CONCLUSIONS HIF-1alpha is expressed in human CAVM. The expression of HIF-1alpha is significantly related to VEGF and VEGFR expression, suggesting a possible role for its induction and role in maintaining angiogenesis and vascular remodelling.
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Affiliation(s)
- Ivan Ng
- Section of Cerebrovascular Surgery, Department of Neurosurgery, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore.
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14
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Zazulia AR, Markham J, Powers WJ. Cerebral Blood Flow and Metabolism in Human Cerebrovascular Disease. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50047-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schaller C, Schramm J, Haun D, Meyer B. Patterns of cortical oxygen saturation changes during CO2 reactivity testing in the vicinity of cerebral arteriovenous malformations. Stroke 2003; 34:938-44. [PMID: 12649527 DOI: 10.1161/01.str.0000060880.59712.14] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to test the hypothesis that patterns of cerebrovascular reactivity (CVR) in the vicinity of cerebral arteriovenous malformations (AVMs) before and after resection are not specific for this disease. METHODS With a microspectrophotometer, cortical oxygen saturation (So2) was measured under steady-state conditions (Paco2, 33 mm Hg) before and after removal of 22 AVMs and in 30 control subjects before and after transsylvian amygdalohippocampectomy. Intraoperative vasoreactivity tests were performed by induced changes of end-tidal CO2 (25, 45, and 25 mm Hg) with simultaneous recording of local So2 in all patients. CVR patterns were established by linear regression analysis (P<0.05) to define parallel (positive) versus inverse (negative) behavior, and reactivity indexes were calculated to define their degree. RESULTS Cortical oxygenation under steady-state conditions increased significantly (P<0.05) from preoperative to postoperative levels equally in both groups (preoperative AVM, 54.8+/-10.4%So2; postoperative AVM, 73.1+/-10.1%So2; preoperative control, 52.7+/-9.1%So2; postoperative control, 73.6+/-8.9%So2). The rate of inverse CVR patterns increased significantly (P<0.05) from before to after resection without showing statistically significant differences between groups. CONCLUSIONS Local CVR patterns on presumably normal human cortex of control subjects are heterogeneous, including inverse behavior, and are similar to those of AVM patients before surgery. After surgery, cortical hyperemia is present in both groups, and a significant increase in inverse reactivity patterns interpreted as microvascular steal is noted. An AVM-specific CVR pattern could not convincingly be proved.
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Schaller C, Urbach H, Schramm J, Meyer B. Role of Venous Drainage in Cerebral Arteriovenous Malformation Surgery, as Related to the Development of Postoperative Hyperperfusion Injury. Neurosurgery 2002. [DOI: 10.1227/00006123-200210000-00012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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17
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Meyer B, Stoffel M, Stuer C, Schaller C, Muhlbauer B, Schramm J. Norepinephrine in the Rat Cortex before and after Occlusion of Chronic Arteriovenous Fistulae: A Microdialysis Study in an Animal Model of Cerebral Arteriovenous Malformations. Neurosurgery 2002. [DOI: 10.1227/00006123-200209000-00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Norepinephrine in the Rat Cortex before and after Occlusion of Chronic Arteriovenous Fistulae: A Microdialysis Study in an Animal Model of Cerebral Arteriovenous Malformations. Neurosurgery 2002. [DOI: 10.1097/00006123-200209000-00028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hashimoto T, Young WL, Prohovnik I, Gupta DK, Ostapkovich ND, Ornstein E, Halim AX, Quick CM. Increased cerebral blood flow after brain arteriovenous malformation resection is substantially independent of changes in cardiac output. J Neurosurg Anesthesiol 2002; 14:204-8. [PMID: 12172292 DOI: 10.1097/00008506-200207000-00005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Brain arteriovenous malformation (BAVM) resection can result in an acute increase in cerebral blood flow (CBF) of unclear etiology. This observational study investigated the relationship between changes in CBF and cardiac output (CO) in patients undergoing microsurgical resection of BAVMs. In 20 patients undergoing a BAVM resection during an isoflurane-based anesthesia, we measured CBF and systemic cardiovascular parameters immediately before and after BAVM resection. CBF was measured on the hemisphere ipsilateral to the lesions and on the contralateral side, using intravenous cold 133Xe washout. Cardiac output was measured using thermodilution technique via a pulmonary artery catheter. There was an increase in global CBF after resection (25 +/- 8 versus 31 +/- 13 mL/100 g/min, preresection versus postresection, mean +/- SD, P =.002), ipsilateral CBF (25 +/- 8 versus 31 +/- 13 mL/100 g/min, P =.002), and contralateral CBF (24 +/- 7 versus 30 +/- 13 mL/100 g/min, P =.003). There was no change in CO, mean systemic arterial pressure, central venous pressure, or pulmonary artery diastolic pressure. The change in CBFGLOBAL was not correlated with changes in CO (r =.154, P =.517). BAVM resection resulted in global increases in CBF that was not substantially related to changes in CO or other systemic parameters.
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Affiliation(s)
- Tomoki Hashimoto
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California 94110, USA
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Abstract
The management of patients for intracranial vascular surgery is very challenging, requiring an aggressive multidisciplinary approach to provide care and improve outcome. This ensures early identification and treatment of the disease, resuscitation when indicated, and continuous and intensive perioperative monitoring to identify and treat potential complications. With advances in neuroimaging, interventional, and surgical techniques, we are increasingly involved in providing neuroanesthetic skills and insightful care to facilitate the successful management of these high-risk patients.
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Affiliation(s)
- Audrée A Bendo
- Department of Anesthesiology, SUNY/Downstate Medical Center, 450 Clarkson Avenue, Box 6, Brooklyn, NY 11203, USA.
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Asai JI, Hayashi T, Suzuki R, Fujimoto T, Nagashima G. Spontaneous resolution of an idiopathic cervical direct vertebral arteriovenous fistula after partial coil embolization in a patient presenting with myeloradiculopathy. Clin Neurol Neurosurg 2002; 104:146-51. [PMID: 11932046 DOI: 10.1016/s0303-8467(01)00194-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 53-year old female presented with paresis of the left upper extremity. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) disclosed a single high-flow vertebral arteriovenous fistula (AVF) with vertebral artery (VA) transection. The AVF was also fed by steal flow from the contralateral VA. The left posterior inferior cerebellar artery (PICA) branched just distal to the fistula. The fistula drained into the neighboring paravertebral veins and refluxed into the intradural venous systems. The dilated drainers compressed the spinal cord. Embolization was attempted at the drainer just behind the fistula orifice using platinum coils. The fistula was still fed slightly by right VA after the embolization, but spontaneous complete obliteration was achieved after one week. The clinical symptoms and signs disappeared. Although, detachable balloon embolization is the quickest and most effective procedure to obliterate a fistula, stepwise embolization using GDC can be considered, and may avoid the normal pressure perfusion break-through phenomenon. Spontaneous obliteration of the fistula after partial embolization in our case may result from intravenous embolization just behind the fistula orifice. It may therefore be a useful approach to the embolization of an AVF to begin the embolization at the venous side of the fistula.
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Affiliation(s)
- Jun-ichiro Asai
- Department of Neurosurgery, Fujigaoka Hospital, School of Medicine, Showa University, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan.
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Gupta DK, Young WL, Hashimoto T, Halim AX, Marshall RS, Lazar RM, Joshi S, Pile-Spellman J, Ostapkovich N. Characterization of the cerebral blood flow response to balloon deflation after temporary internal carotid artery test occlusion. J Neurosurg Anesthesiol 2002; 14:123-9. [PMID: 11907392 DOI: 10.1097/00008506-200204000-00006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors tested the hypothesis that cerebral blood flow (CBF) would increase after acute and relatively brief internal carotid artery (ICA) test occlusion, and examined the relationship of the postdeflation CBF to the development of neurologic symptoms. In 16 patients undergoing ICA test occlusion with deliberate hypotension, the authors measured intracarotid 133Xe CBF at baseline, occlusion, and deflation. Four patients developed neurologic symptoms during occlusion. As positive controls, 11 other patients received intracarotid verapamil or papaverine before deflation as part of another protocol. Balloon occlusion was 23.1 +/- 10.5 minutes (mean +/- standard deviation) in duration. At 1.3 +/- 1.6 minutes after balloon deflation, there was a trend (12 +/- 31%) for CBF to increase (48 +/- 9 mL/100 g/min versus 53 +/- 17 mL/100 g/min, P =.15), and a 16 +/- 27% decrease in cerebrovascular resistance (CVR; 2.1 +/- 0.6 mm Hg/100 g/min/mL versus 1.7 +/- 0.6 mm Hg/100 g/min/mL, P =.03) compared with baseline values. By comparison, patients who received a intracarotid dilator demonstrated a 53 +/- 55% increase in CBF (48 +/- 10 mL/100/min versus 70 +/- 23 mL/100 g/min, P = .007) and a 33 +/- 31% decrease in CVR (2.2 +/- 0.6 mm Hg/100 g/min/mL versus 1.4 +/- 0.6 mm Hg/100 g/min/mL, P = .0007) compared with baseline. Analysis of variance and regression analysis showed no other relationships between postocclusion CBF and balloon occlusion duration, distal internal carotid occlusion ("stump") pressure, or the development of neurologic symptoms. Acute, temporary interruption of ICA blood flow resulted in minimal postocclusive changes in cerebrovascular hemodynamics, even in those patients who developed neurologic symptoms during the period of test occlusion.
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Affiliation(s)
- Dhanesh K Gupta
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California 94110, USA
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Piepgras DG. Occlusive hyperemia. J Neurosurg 2001; 95:165-7. [PMID: 11453391 DOI: 10.3171/jns.2001.95.1.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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24
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Ogilvy CS, Stieg PE, Awad I, Brown RD, Kondziolka D, Rosenwasser R, Young WL, Hademenos G. AHA Scientific Statement: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 2001; 32:1458-71. [PMID: 11387517 DOI: 10.1161/01.str.32.6.1458] [Citation(s) in RCA: 283] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Ogilvy CS, Stieg PE, Awad I, Brown RD, Kondziolka D, Rosenwasser R, Young WL, Hademenos G. Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 2001; 103:2644-57. [PMID: 11382737 DOI: 10.1161/01.cir.103.21.2644] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Morgan M, Winder M. Haemodynamics of arteriovenous malformations of the brain and consequences of resection: a review. J Clin Neurosci 2001; 8:216-24. [PMID: 11386794 DOI: 10.1054/jocn.2000.0795] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The physiological manifestations of arteriovenous fistulae in humans have been studied since the 18th century. However, confusion regarding concepts of cerebral 'steal', 'normal perfusion breakthrough', and 'congestive hyperaemia' continue. Although the advent of more accurate monitoring of pressures and flows within the brain has provided useful information to help understand some of these proposed pathological hypotheses, disagreement still exists. The purpose of this review is to examine the current physiological data in attempt to explain the clinicopathological manifestations of arteriovenous malformations of the brain and the consequences of their removal.
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Affiliation(s)
- M Morgan
- North and West Cerebrovascular Unit, Department of Surgery, The University of Sydney, Australia
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27
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Van Roost D, Schramm J. What Factors Are Related to Impairment of Cerebrovascular Reserve before and after Arteriovenous Malformation Resection? A Cerebral Blood Flow Study Using Xenon-enhanced Computed Tomography. Neurosurgery 2001. [DOI: 10.1227/00006123-200104000-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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28
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Bulusu R, Manninen PH. Anesthesia for endovascular treatment of intracranial vascular lesions: Arteriovenous malformations, arteriovenous fistulae, aneurysms and tumors. ACTA ACUST UNITED AC 2000. [DOI: 10.1053/sa.2000.17789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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29
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Koller R. Anaesthetic management of patients undergoing surgery for cerebrovascular disease. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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30
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Meyer B, Schaller C, Frenkel C, Ebeling B, Schramm J. Distributions of local oxygen saturation and its response to changes of mean arterial blood pressure in the cerebral cortex adjacent to arteriovenous malformations. Stroke 1999; 30:2623-30. [PMID: 10582988 DOI: 10.1161/01.str.30.12.2623] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To test the hypothesis that neither "steal" as cortical ischemia caused by reduced perfusion pressure nor "breakthrough" on the grounds of loss of pressure autoregulation exist in brain tissue surrounding arteriovenous malformations (AVMs), we established patterns of cortical oxygen saturation (SO(2)) adjacent to AVMs and its behavior after alterations of mean arterial blood pressure. METHODS With a microspectrophotometer, SO(2) was scanned in the cortex around AVMs of 44 patients before and after resection and in that of a non-AVM group (n=42) before transsylvian dissection. Autoregulation was evaluated by linear regression analysis after elevation of mean arterial blood pressure (5 microg/min IV noradrenaline). SO(2) values were calculated as medians, percentage of critical values (<25% SO(2)), and coefficients of variance (approximate heterogeneity of SO(2) distributions). All values are given as mean+/-SD. RESULTS Forty patients with AVM had an uneventful postoperative course (group A). Four hyperemic complications ("breakthrough") occurred (group B). Autoregulation was tested intact in all groups at all times. Preoperative SO(2) distributions in groups A and C (non-AVMs) were identical. In group B, significantly (P<0.05) lower medians (group A, 52.9+/-16.3%; group B, 44.2+/-17.1%; group C, 51.9+/-11.5% SO(2)), more critical values (group A, 6.5+/-5.1%; group B, 14.7+/-11.1%; group C, 7.1+/-4.9%), and heterogeneous SO(2) distributions (group A, 20.2+/-12.7%; group B, 27.9+/-12.4%; group C, 26.8+/-10.9%) were seen. Increase of median values was significantly higher in group B (76.3+/-10.4% SO(2)) than in group A (65.9+/-13.4% SO(2)) after resection. CONCLUSIONS Severely hypoxic areas are uncommon in the cortex adjacent to AVMs and occur predominantly in patients prone to hyperemic complications. Reduced perfusion pressure is compensated in most cases, and moderate hyperemia prevails after excision. Reperfusion into unprotected capillaries of severely hypoxic cortical areas results in "breakthrough," for which vasoparalysis appears not to be the underlying mechanism.
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Affiliation(s)
- B Meyer
- Department of Neurosurgery, University of Bonn (Germany).
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31
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Panerai RB. Assessment of cerebral pressure autoregulation in humans--a review of measurement methods. Physiol Meas 1998; 19:305-38. [PMID: 9735883 DOI: 10.1088/0967-3334/19/3/001] [Citation(s) in RCA: 365] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Assessment of cerebral autoregulation is an important adjunct to measurement of cerebral blood flow for diagnosis, monitoring or prognosis of cerebrovascular disease. The most common approach tests the effects of changes in mean arterial blood pressure on cerebral blood flow, known as pressure autoregulation. A 'gold standard' for this purpose is not available and the literature shows considerable disparity of methods and criteria. This is understandable because cerebral autoregulation is more a concept rather than a physically measurable entity. Static methods utilize steady-state values to test for changes in cerebral blood flow (or velocity) when mean arterial pressure is changed significantly. This is usually achieved with the use of drugs, shifts in blood volume or by observing spontaneous changes. The long time interval between measurements is a particular concern in many of the studies reviewed. Parallel changes in other critical variables, such as pCO2, haematocrit, brain activation and sympathetic tone, are rarely controlled for. Proposed indices of static autoregulation are based on changes in cerebrovascular resistance, on parameters of the linear regression of flow/velocity versus pressure changes, or only on the absolute changes in flow. The limitations of studies which assess patient groups rather than individual cases are highlighted. Newer methods of dynamic assessment are based on transient changes in cerebral blood flow (or velocity) induced by the deflation of thigh cuffs, Valsalva manoeuvres, tilting and induced or spontaneous oscillations in mean arterial blood pressure. Dynamic testing overcomes several limitations of static methods but it is not clear whether the two approaches are interchangeable. Classification of autoregulation performance using dynamic methods has been based on mathematical modelling, coherent averaging, transfer function analysis, crosscorrelation function or impulse response analysis. More research on reproducibility and inter-method comparisons is urgently needed, particularly involving the assessment of pressure autoregulation in individuals rather than patient groups.
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Affiliation(s)
- R B Panerai
- Division of Medical Physics, Faculty of Medicine, University of Leicester, Leicester Royal Infirmary, UK
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32
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Joshi S, Young WL, Pile-Spellman J, Fogarty-Mack P, Sciacca RR, Hacein-Bey L, Duong H, Vulliemoz Y, Ostapkovich N, Jackson T. Intra-arterial nitrovasodilators do not increase cerebral blood flow in angiographically normal territories of arteriovenous malformation patients. Stroke 1997; 28:1115-22. [PMID: 9183335 DOI: 10.1161/01.str.28.6.1115] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The mechanism of adaptation to chronic cerebral hypotension in normal brain adjacent to cerebral arteriovenous malformations (AVMs) is unknown. To clarify these mechanisms, we performed cerebral blood flow (CBF) studies in structurally and functionally normal vascular territories during 53 distal cerebral angiographic procedures in 37 patients with AVMs. METHODS CBF was measured using the superselective intra-arterial 133Xe method before and after a 3-minute infusion of either verapamil (1 mg.min-1, n = 23), acetylcholine (1.33 micrograms.kg-1.min-1, n = 7), nitroprusside (0.5 microgram.kg-1.min-1, n = 16) or nitroglycerin (0.5 microgram.kg-1.min-1, n = 7). RESULTS Mean +/- SD systemic (76 +/- 13 mm Hg) and distal cerebral arterial (55 +/- 16 mm Hg; range, 20 to 97 mm Hg) pressures were not different among groups. Verapamil increased CBF (45 +/- 12 to 65 +/- 21 mL.100 g-1.min-1, P < .001). There was no effect of acetylcholine (no change [46 +/- 9 to 46 +/- 9 mL.100 g-1.min-1], NS) or nitroglycerin (36 +/- 14 to 36 +/- 13 mL.100 g-1.min-1, NS). Nitroprusside decreased CBF (40 +/- 12 to 31 +/- 11 mL.100 g-1.min-1, P < .001). The percent change in CBF after drug administration was proportional to cerebral arterial pressure for verapamil only (r = .57, P = .0051). CONCLUSIONS When infused intra-arterially in clinically relevant doses in both hypotensive and normotensive normal vascular territories remote from an AVM nidus, calcium channel blockade caused vasodilation, but there was an absence of response to nitric oxide-mediated vasodilators. These data suggest that (1) the nitric oxide pathway probably is not involved in the adaptation to chronic cerebral hypotension in AVM patients and (2) if our findings in vessels remote from or contralateral to the AVM are applicable to vessels of patients with other forms of cerebrovascular disease, clinically relevant doses of intra-arterial nitrovasodilators may not be useful in the manipulation of cerebrovascular resistance.
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Affiliation(s)
- S Joshi
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Abstract
Excision of human cerebral arteriovenous malformations (AVMs) can be complicated by postoperative edema and hemorrhage in adjacent brain tissue, despite the complete excision of the malformation. Various theories have purported to explain the hemodynamic basis for this predisposition, including disordered autoregulation causing "normal perfusion pressure breakthrough" and obstruction of venous drainage leading to "occlusive hyperemia." This study did not evaluate the arterial or venous circulations in this scenario, but rather examined the capillaries in adjacent brain parenchyma for any structural deficiencies that would predispose the brain to the postoperative formation of edema and hemorrhage. Arteriovenous fistulas (AVFs) were created surgically in the necks of 10 male Sprague-Dawley rats, which caused chronic cerebral hypoperfusion with a reduction in cerebral blood flow of between 25% and 50%. Ten age-matched animals were used as controls. Twenty-six weeks after AVF formation the animals were killed and perfusion fixed. Their brain tissue was prepared for light microscopic studies by staining for glial fibrillary acidic protein or for transmission electron microscopy. In the CA1 pyramidal cell region of the hippocampus, it was found that in the animals with AVFs there was increased capillary density and absent astrocytic foot processes in some of these vessels. It was concluded that these vessels had developed as a result of neovascularization in response to chronic cerebral ischemia and that their anatomical configuration made them prone to mechanical weakness and instability following the increase in perfusion pressure that occurs in adjacent brain parenchyma after AVM excision. The authors believe that this study pinpoints a structural accompaniment to the hemodynamic changes that occur in brain tissue in the vicinity of cerebral AVMs that predispose these areas to the formation of edema and hemorrhage after AVM excision.
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Affiliation(s)
- L H Sekhon
- Department of Surgery, University of Sydney, New South Wales, Australia
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Hoffman WE, Charbel FT, Edelman G, Abood C. Brain tissue response to CO2 in patients with arteriovenous malformation. J Cereb Blood Flow Metab 1996; 16:1383-6. [PMID: 8898716 DOI: 10.1097/00004647-199611000-00038] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We tested whether cerebral arteriovenous malformations (AVM) alter brain tissue oxygen pressure, PO2, carbon dioxide pressure PCO2, and pH before, during, and after hypercapnia. A craniotomy was performed and a sensor inserted into normal brain tissue (control) (n = 7) or into tissue adjacent to an AVM (n = 9). Under baseline conditions, tissue PO2 was 80% lower in AVM compared to control patients, but PCO2 and pH were normal. During a 10 mm Hg increase in PaCO2, tissue PO2 increased only in AVM patients, PCO2 increased in both groups, and pH decreased only in controls. When hypercapnia was reversed, tissue PCO2 decreased below baseline and pH increased in AVM patients. Results suggest that tissue CO2 washout and elevated pH result from increases in blood flow during hypercapnia. This response may be related to symptoms of hyperperfusion during AVM resection.
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Affiliation(s)
- W E Hoffman
- Department of Anesthesiology, University of Illinois at Chicago, USA
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35
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Irikura K, Morii S, Miyasaka Y, Yamada M, Tokiwa K, Yada K. Impaired autoregulation in an experimental model of chronic cerebral hypoperfusion in rats. Stroke 1996; 27:1399-404. [PMID: 8711809 DOI: 10.1161/01.str.27.8.1399] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE To verify the hypothesis that impaired autoregulation may contribute to cerebral swelling or hemorrhage after a sudden recovery of perfusion pressure, we studied the chronic effects of cerebral hypoperfusion on the autoregulatory responses of the pial arterioles in situ. METHODS Eight to 12 weeks after a carotid-jugular fistula was created in rats, experiments were performed under alpha-chloralose and urethane anesthesia. Regional cerebral blood flow (rCBF) was determined by the hydrogen clearance method, and carotid pressure was measured. Using a closed cranial window, we determined the autoregulatory responses of the arterioles (30 to 50 microns) to both hypertension induced by norepinephrine and sudden fistula closure at various mean arterial pressures (MAPs). RESULTS rCBF on the fistula side was reduced by 27%. Carotid pressure was significantly lower than normal but was immediately increased by fistula closure. The pial arterioles showed marked elongation and enlargement. During induced hypertension, the arterioles in the fistula group started to dilate at an MAP lower than that of the control group (130 versus 180 mm Hg, respectively). The arterioles constricted when the fistula was occluded at normal MAP. However, when the fistula was occluded at an MAP higher than 130 mm Hg, the vessels dilated. CONCLUSIONS It was demonstrated that (1) chronic hypoperfusion induced impairment of the upper limit of autoregulation and (2) sudden fistula closure under hypertensive conditions caused vasodilation of the arterioles. These findings suggest that rapid restoration of perfusion pressure is possibly followed by a pressure breakthrough phenomenon in a chronically hypoperfused cerebrovasculature.
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Affiliation(s)
- K Irikura
- Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa, Japan
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Spiekermann BF, Stone DJ, Bogdonoff DL, Yemen TA. Airway management in neuroanaesthesia. Can J Anaesth 1996; 43:820-34. [PMID: 8840062 DOI: 10.1007/bf03013035] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Airway management in neurosurgical patients presents unique challenges to the anaesthetist. This review will consider specific approaches to numerous problems in airway management related to logistical, physiological and anatomical concerns. The goal is to provide a clinically oriented and practical discussion regarding issues of airway management in neurosurgical patients. SOURCE The recent literature has been reviewed regarding airway management options and related perioperative complications in the neurosurgical population. This is interlaced with approaches to many of the problems and their solutions based on experience gained in a very busy university neurosurgical practice over the past decade. PRINCIPAL FINDINGS Specific pathophysiological alterations in the neurosurgical patient influence the technique chosen for securing an airway. These relate to the presence of increased intracranial pressure, intracranial aneurysms or arteriovenous malformations. Other important disorders influencing airway management include severe coronary artery disease, acromegaly and congenital airway difficulties. Stereotactic neurosurgery and conscious sedation for various neurosurgical procedures also provide unique challenges. There are other considerations unique to the neurosurgical patient such as intra-and postoperative airway obstruction and the timing of postoperative extubation. CONCLUSION The demands for airway management in neuroanaesthesia require expertise in the various modes of securing the airway while considering the patient's physiological requirements as well as the unique surgical demands.
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Affiliation(s)
- B F Spiekermann
- Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
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37
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Multimodal therapy of cerebral arteriovenous malformations. J Clin Neurosci 1996; 3:207-15. [DOI: 10.1016/s0967-5868(96)90052-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/1995] [Accepted: 08/11/1995] [Indexed: 11/18/2022]
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Young WL, Kader A, Ornstein E, Baker KZ, Ostapkovich N, Pile-Spellman J, Fogarty-Mack P, Stein BM. Cerebral hyperemia after arteriovenous malformation resection is related to "breakthrough" complications but not to feeding artery pressure. The Columbia University Arteriovenous Malformation Study Project. Neurosurgery 1996; 38:1085-93; discussion 1093-5. [PMID: 8727137 DOI: 10.1097/00006123-199606000-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
To study the pathophysiology of idiopathic postoperative brain swelling or hemorrhage after arteriovenous malformation resection, termed normal perfusion pressure breakthrough (NPPB), we performed cerebral blood flow (CBF) studies during 152 operations in 143 patients, using the xenon-133 intravenous injection method. In the first part of the study, CBF was intraoperatively measured (isoflurane/N2O anesthesia) during relative hypocapnia in 95 patients before and after resection. The NPPB group had a greater increase (P < 0.0001) in mean +/- standard deviation global CBF (28 +/- 6 to 47 +/- 16 ml/100 g/min, n = 5) than did the non-NPPB group (25 +/- 7 to 29 +/- 10 ml/100 g/min, n = 90); both arteriovenous malformation groups showed greater increase (P < 0.05) than did controls undergoing craniotomy for tumor (23 +/- 6 to 23 +/- 6 ml/100 g/min, n = 22). Ipsilateral and contralateral CBF changes were similar. In a second cohort of patients with arteriovenous malformations, CBF was measured at relative normocapnia and it increased (P < 0.002) from pre- to postresection (40 +/- 13 to 49 +/- 15 ml/100 g/min, n = 57). There were no NPPB patients in this latter cohort. The feeding mean arterial pressure was measured intraoperatively before resection or at the last embolization before surgery (n = 64). The feeding mean arterial pressure (44 +/- 16 mm Hg) was 56% of the systemic arterial pressure (78 +/- 12 mm Hg, P < 0.0001) and was not related to changes in CBF from pre- to postresection. There was an association between increases in global CBF from pre- to postresection and NPPB-type complications, but there was no relationship of these CBF changes to preoperative regional arterial hypotension. These data do not support a uniquely hemodynamic mechanism that explains cerebral hyperemia as a consequence of repressurization in hypotensive vascular beds.
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Affiliation(s)
- W L Young
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, USA
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39
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Young WL, Kader A, Ornstein E, Baker KZ, Ostapkovich N, Pile-Spellman J, Fogarty-Mack P, Stein BM. Cerebral Hyperemia after Arteriovenous Malformation Resection Is Related to“Breakthrough” Complications but Not to Feeding Artery Pressure. Neurosurgery 1996. [DOI: 10.1227/00006123-199606000-00005] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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40
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Sorimachi T, Takeuchi S, Koike T, Minakawa T, Abe H, Tanaka R. Blood pressure monitoring in feeding arteries of cerebral arteriovenous malformations during embolization: a preventive role in hemodynamic complications. Neurosurgery 1995; 37:1041-7; discussion 1047-8. [PMID: 8584143 DOI: 10.1227/00006123-199512000-00002] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
To study the hemodynamics of arteriovenous malformations and to avoid hemodynamic complications during and after artificial embolization, we measured arterial blood pressures in 21 feeders in 14 patients through a microcatheter system. Before embolization, the pressures were significantly low in feeders with branches terminating in the malformation (terminal divided branches) and comparatively low in arteriovenous malformations with rapid blood flow through the malformation. The pressures in feeders with brain-nutrifying branches distal to the nidus (transient branches) were significantly high. Therefore, transient branches might be distinguishable from terminal divided branches with the use of feeder pressure monitoring. A hemorrhagic complication occurred in one patient. The feeder pressure in this patient was low before embolization and showed the maximum change among the patients after embolization. It seems that the lower the feeder pressure, the more likely complications are to occur, owing to remarkable hemodynamic alterations. Feeder pressure monitoring may be useful for preventing hemodynamic complications, especially when angiographic findings show feeding arteries giving off terminal divided or transient branches or rapid blood flow through the malformation.
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Affiliation(s)
- T Sorimachi
- Department of Neurosurgery, Niigata University, Japan
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41
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Klötzch C, Henkes H, Nahser HC, Kühne D, Berlit P. Transcranial color-coded duplex sonography in cerebral arteriovenous malformations. Stroke 1995; 26:2298-301. [PMID: 7491654 DOI: 10.1161/01.str.26.12.2298] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE It is well known that significant changes in cerebral hemodynamics may occur during the treatment of cerebral arteriovenous malformations with the complication of intracerebral hemorrhage and parenchymal edema. We used transcranial color-coded duplex sonography to study alterations in blood flow velocities during staged embolization. METHODS Forty-one patients aged 40 +/- 13 years (mean +/- SD) with angiographically proven cerebral arteriovenous malformations were studied. The blood flow velocities of the anterior, middle, and posterior cerebral arteries were measured in 16 patients with supratentorial arteriovenous malformations, both before the first and then after each successive embolization (three to seven treatments). RESULTS In 29 of 41 patients (71%), transcranial color-coded duplex sonography satisfactorily revealed the malformations and their main feeders. After the final embolization, we found a reduction in the peak flow velocity in treated feeders of 23 +/- 28% compared with the values before the first embolization. The untreated feeders showed an increase in peak flow velocities of 12 +/- 23% as an expression of increased collateral flow. After the treatment of the supplying feeders, we observed a reduction in flow velocity of 25 +/- 13% in seven patients, with cross-filling of the arteriovenous malformation through the contralateral anterior cerebral artery and the anterior communicating artery. CONCLUSIONS The technical advantage of transcranial color-coded duplex sonography compared with transcranial Doppler sonography is that it allows the exact identification of different feeding arteries in arteriovenous malformations. Repeated measurements during stepwise embolization with corrected insonation angle are easily achieved, and noninvasive quantification of hemodynamic changes is possible. The method may be helpful in the planning of the different steps of embolization.
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Affiliation(s)
- C Klötzch
- Department of Neurology, Alfreid-Krupp-Hospital, Essen, Germany
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42
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Diehl RR, Linden D, Lücke D, Berlit P. Phase relationship between cerebral blood flow velocity and blood pressure. A clinical test of autoregulation. Stroke 1995; 26:1801-4. [PMID: 7570728 DOI: 10.1161/01.str.26.10.1801] [Citation(s) in RCA: 302] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE This study investigates the usefulness, as a test of dynamic autoregulation, of phase shift angle analysis between oscillations in cerebral blood flow velocity (CBFV) and in arterial blood pressure (ABP) during deep breathing. METHODS Fifty healthy volunteers, 20 patients with occlusive cerebrovascular diseases (OCD), and 10 patients with arteriovenous malformations (AVM) took part in the study. All subjects received transcranial Doppler monitoring of both middle cerebral arteries (MCAs). In addition, continuous blood pressure monitoring was performed with the use of noninvasive servo-controlled infrared finger plethysmography during deep breathing at a rate of 6/min. With the use of a high-pass filter model of autoregulation, autoregulation was quantified as phase shift angle between oscillations in CBFV and ABP at a frequency of 6/min. A phase shift angle of 0 degrees indicates total absence of autoregulation, while 90 degrees can be gauged as optimal autoregulation. In addition, vasomotor reactivity of both MCAs to CO2 stimulation was assessed among patients and calculated as percent increase in CBFV per millimeter of mercury of increase in CO2. RESULTS All normal subjects showed positive phase shift angles between CBFV and ABP (mean +/- SD, 70.5 +/- 29.8 degrees). OCD patients presented with significantly decreased phase shift angles for the MCA only on the pathological side (51.7 +/- 35.1 degrees; P < .05). Patients with AVM showed significantly reduced phase shift angles on both the affected side (26.8 +/- 13.5 degrees; P < .001) and the unaffected side (40.6 +/- 26.6 degrees; P < .01). In patients' groups, phase shift angle and vasomotor reactivity correlated significantly (r = .66; P < .001) after results from all MCAs were pooled. CONCLUSIONS Results confirm the high-pass filter model of cerebral autoregulation: Normal subjects showed predicted positive phase shift angles between CBFV and ABP oscillations. Patients with expected autoregulatory disturbances showed significant decreases in phase shift angles. Close correlations existed between autoregulation and CO2-induced vasomotor reactivity.
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Affiliation(s)
- R R Diehl
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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Young WL, Kader A, Pile-Spellman J, Ornstein E, Stein BM. Arteriovenous malformation draining vein physiology and determinants of transnidal pressure gradients. The Columbia University AVM Study Project. Neurosurgery 1994; 35:389-95; discussion 395-6. [PMID: 7800130 DOI: 10.1227/00006123-199409000-00005] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Arteriovenous malformation (AVM) draining vein pressure (DVP) may have an influence on both the natural history of the disease and treatment outcome. The purposes of this study were to assess the relationship between DVP and other clinical and physiological variables and to characterize the transmission of arterial pressure across the AVM nidus. DVP measurements were carried out during elective AVM resection with isoflurane/nitrous oxide anesthesia with arterial carbon dioxide pressure of approximately 30 mm Hg. The gradient between the right atrium and operative measurement site was noted. Pre-excision feeding mean arterial pressure and DVP were measured with a 26-gauge needle simultaneously with systemic mean arterial pressure and central venous pressure (CVP). DVP was tested with systemic mean arterial pressure increased to approximately 20 mm Hg with phenylephrine or CVP increased with a Valsalva maneuver. Finally, preresection and postresection DVP values were compared. Relative to the site of measurement, DVP was 7 +/- 5 mm Hg at a CVP of -4 +/- 5 mm Hg (n = 45). There was no influence of presentation, presence of deep venous drainage, size, location, or prior embolization on DVP. In 19 patients, DVP decreased (8 +/- 4 to 5 +/- 3; P < 0.05) whereas CVP increased from pre- to postresection (-4 +/- 5 to -2 +/- 5; P < 0.05). For the phenylephrine challenge (n = 11), there was no difference (P = 0.84) between the delta DVP (2 +/- 1 mm Hg) and the delta CVP (2 +/- 3 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W L Young
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York
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Diehl RR, Henkes H, Nahser HC, Kühne D, Berlit P. Blood flow velocity and vasomotor reactivity in patients with arteriovenous malformations. A transcranial Doppler study. Stroke 1994; 25:1574-80. [PMID: 7913776 DOI: 10.1161/01.str.25.8.1574] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE A large percentage of patients with a cerebral arteriovenous malformation (AVM) show focal neurological signs or have a history of intracranial hemorrhage. The present study used transcranial Doppler sonography to assess the clinical significance of hemodynamic disturbances in the intracranial arteries of patients with an AVM. METHODS Eighteen patients with untreated AVMs were examined clinically, angiographically, and with transcranial Doppler sonography (blood flow velocity measurement and vasomotor reactivity in all main intracranial arteries). RESULTS A pathological increase in blood flow velocity (57.6%) and a decrease in vasomotor reactivity (72.7%) were frequently found in AVM feeding arteries. Vasomotor reactivity was also reduced in several nonfeeding arteries both ipsilateral (53.3%) and contralateral (30.8%) to the AVM. AVM size was a poor predictor of pathological transcranial Doppler results. Vasomotor reactivity of arteries ipsilateral to an AVM in patients with a history of hemorrhage was significantly higher (2.10 +/- 1.66% per mm Hg; mean +/- SD) than in patients with no history of bleeding (1.12 +/- 1.48% per mm Hg; P < .05). In patients with focal neurological signs but no history of hemorrhage, the percentage of arteries ipsilateral (100%) and contralateral (63.6%) to an AVM showing a pathological vasomotor reactivity was significantly larger than in nonhemorrhagic patients without focal signs (66.7% and 22.2%, respectively; both P < .05). CONCLUSIONS Our results suggest two distinct relations between transcranial Doppler results and clinical findings: (1) Relatively normal vasomotor reactivity values in arteries ipsilateral to an AVM indicate a high-pressure AVM with an increased risk of hemorrhage. (2) A strongly pathological vasomotor reactivity in arteries ipsilateral and contralateral to an AVM indicates a low-pressure AVM with a higher prevalence of hemodynamically induced neurological signs.
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Affiliation(s)
- R R Diehl
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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Fleischer LH, Young WL, Pile-Spellman J, terPenning B, Kader A, Stein BM, Mohr JP. Relationship of transcranial Doppler flow velocities and arteriovenous malformation feeding artery pressures. Stroke 1993; 24:1897-902. [PMID: 8248974 DOI: 10.1161/01.str.24.12.1897] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Feeding mean arterial pressure immediately proximal to the nidus of arteriovenous malformations may influence the frequency of spontaneous intracerebral hemorrhage. This study assessed the usefulness of transcranial Doppler ultrasound velocities as a noninvasive estimate of feeding mean arterial pressure. METHODS We studied 41 patients undergoing 73 staged treatments of arteriovenous malformations with endovascular embolization, surgery, or both. Before treatment during the awake state, transcranial Doppler mean and peak velocities were recorded in proximal Willisian vessels. During superselective angiography with the patient under conscious sedation or during surgery with the patient under general anesthesia, feeding mean arterial pressure was measured through a 1.5F transfemoral intracranial microcatheter or a 26-g needle by direct puncture. Measurement of insonated artery diameter was possible in 41 embolizations, and a flow velocity index (mL/min) and Reynolds' number were estimated. RESULTS Mean +/- SEM feeding mean arterial pressure was 38 +/- 2 mm Hg at a systemic mean arterial pressure of 77 +/- 2 mm Hg; mean velocity was 102 +/- 4 cm/s. There was an inverse correlation between feeding mean arterial pressure and parent artery mean velocity (y = -0.74x + 130, r = .35, P = .0025). The best correlation was for the first treatment in each patient (n = 27) using the highest peak velocity obtainable in a Willisian vessel ipsilateral to the arteriovenous malformation (y = -1.61x + 221, r = .62, P = .0005). Flow velocity index (775 +/- 106 mL/min) did not correlate with feeding mean arterial pressure, but there was a weak correlation with Reynolds' number (y = -12x + 1616, r = .27, P = .1283). Mean Reynolds' number was 1257 +/- 119. CONCLUSIONS Transcranial Doppler mean velocity is correlated with feeding mean arterial pressure but only weakly predictive. Considerations influencing the relation of distal feeding mean arterial pressure to proximal mean velocity might include the influence of other fistulae in the circuit between major inflow and outflow channels as well as turbulent flow at vascular branch points between point of insonation and the nidus, as suggested by Reynolds' number values of more than 400.
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Affiliation(s)
- L H Fleischer
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032
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Pressure Autoregulation Is Intact after Arteriovenous Malformation Resection. Neurosurgery 1993. [DOI: 10.1097/00006123-199310000-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Pressure Autoregulation Is Intact after Arteriovenous Malformation Resection. Neurosurgery 1993. [DOI: 10.1097/00006123-199310000-00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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