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de Oca-Mora T, Castillo-Rangel C, Marín G, Zarate-Calderon C, Zúñiga-Cordova JS, Davila-Rodriguez DO, Ruvalcaba-Guerrero H, Forlizzi V, Baldoncini M. Advancing Neurosurgical Skills: A Comparative Study of Training Models for Intra-Extracranial Cerebral Bypass. World Neurosurg 2024:S1878-8750(24)01179-3. [PMID: 38986936 DOI: 10.1016/j.wneu.2024.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/04/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Training in anastomosis is fundamental in neurosurgery due to the precision and dexterity required. Biological models, although realistic, present limitations such as availability, ethical concerns, and the risk of biological contamination. Synthetic models, on the other hand, offer durability and standardized conditions, although they sometimes lack anatomical realism. This study aims to evaluate and compare the efficiency of anastomosis training models in the intra-extracranial cerebral bypass procedure, identifying those characteristics that enhance optimal microsurgical skill development and participant experience. METHODS A neurosurgery workshop was held from March 2024 to June 2024 with 5 vascular techniques and the participation of 22 surgeons. The models tested were the human placenta, the Wistar rat, the chicken wing artery, the nasogastric feeding tube, and the UpSurgeOn Mycro simulator. The scales used to measure these models were the Main Characteristics Score and the Evaluation Score. These scores allowed us to measure, qualitatively and quantitatively, durability, anatomical similarity, variety of simulation scenarios, risk of biological contamination, ethical considerations and disadvantages with specific infrastructure. RESULTS The human placenta model, Wistar rat model, and UpSurgeOn model were identified as the most effective for training. The human placenta and Wistar rat models were highly regarded for anatomical realism, while the UpSurgeOn model excelled in durability and advanced simulation scenarios. Ethical and cost implications were also considered. CONCLUSIONS The study identifies the human placenta and UpSurgeOn models as optimal for training in intra-extracranial bypass procedures, emphasizing the need for diverse and effective training models in neurosurgery.
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Affiliation(s)
- Thania de Oca-Mora
- Department of Neurosurgery, Hospital Regional "1° de Octubre", Institute of Social Security and Services for State Workers (ISSSTE), Mexico City, Mexico
| | - Carlos Castillo-Rangel
- Department of Neurosurgery, Hospital Regional "1° de Octubre", Institute of Social Security and Services for State Workers (ISSSTE), Mexico City, Mexico
| | - Gerardo Marín
- Neural Dynamics and Modulation Lab, Cleveland Clinic, Cleveland, Ohio USA.
| | - Cristofer Zarate-Calderon
- Department of Biophysics, Brain Research Institute, Universidad Veracruzana, Xalapa, Veracruz, Mexico
| | - Jonathan Samuel Zúñiga-Cordova
- Department of Vascular Neurosurgery, National Medical Center "20 de Noviembre", Institute of Social Security and Services for State Workers (ISSSTE), Mexico City, Mexico
| | - Daniel Oswaldo Davila-Rodriguez
- Department of Neurosurgery, Hospital Regional "1° de Octubre", Institute of Social Security and Services for State Workers (ISSSTE), Mexico City, Mexico
| | | | - Valeria Forlizzi
- Microsurgical Neuroanatomy Laboratory, Second Chair of Anatomy, University of Buenos Aires, Buenos Aires, Argentina
| | - Matias Baldoncini
- Neurosurgery. Petrona V. de Cordero Hospital, San Fernando, Buenos Aires, Argentina; Microsurgical Neuroanatomy Laboratory, Second Chair of Anatomy, University of Buenos Aires, Buenos Aires, Argentina
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Gomez-Vega JC, Ota N, Kusdiansah M, Noda K, Kamiyama H, Tanikawa R. A Practical Guide to Train the Side-to-side Anastomosis: Tips, Tricks and Technical Nuances. World Neurosurg 2024; 189:17-25. [PMID: 38750884 DOI: 10.1016/j.wneu.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Microanastomosis presents a challenge in neurosurgical procedures, requiring specialized skills. Regular practice outside the operating room is crucial. This study aims to provide a detailed description of the side-to-side anastomosis technique and analyze its advantages in preventing failures compared with other variations. METHODS We examined the technique, characteristics, and outcomes of side-to-side bypass procedures for complex aneurysms in the anterior cerebral artery territory at our institution over the past decade. We compared our technique with those described in the literature by other groups. RESULTS The Far East Neurosurgical Institute (FENI) technique was used in 15 patients, with 17 side-to-side anastomoses performed. The average anastomosis time was 27.5 minutes, with 100% patency in follow-up. Our technique demonstrated safety and effectiveness in treating intracranial aneurysms, yielding satisfactory short- and long-term functionality outcomes. We highlight the importance of maintaining a curvilinear arteriotomy shape, at least 3 times the diameter of the artery, and utilizing an interrupted suturing technique on the anterior wall. CONCLUSIONS This paper presents the first comprehensive description of the side-to-side anastomosis technique, supported with images and videos for training and replicability. Our technique enhances flow dynamics and reduces the risk of acute thrombus formation. Training in simulators and microsurgery practice centers outside the operating room is essential for acquiring and refining microsurgical skills.
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Affiliation(s)
- Juan Carlos Gomez-Vega
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan
| | - Muhammad Kusdiansah
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan; Department of Neurosurgery, National Brain Center Hospital Prof, Dr. Mahar Mardjono, Jakarta, Indonesia
| | - Kosumo Noda
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Stroke Center, Sapporo, Japan.
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Degollado-García J, Casas-Martínez MR, Mejia BRF, Balcázar-Padrón JC, Rodríguez-Rubio HA, Nathal E. Internal maxillary artery (IMax) - middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report. J Cerebrovasc Endovasc Neurosurg 2024; 26:51-57. [PMID: 37997040 PMCID: PMC10995475 DOI: 10.7461/jcen.2023.e2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 12/06/2023] Open
Abstract
Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.
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Affiliation(s)
- Javier Degollado-García
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Martin R. Casas-Martínez
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Bill Roy Ferrufino Mejia
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Juan C. Balcázar-Padrón
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Héctor A. Rodríguez-Rubio
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Edgar Nathal
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
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Yu LB, Shen M, Zhang Q, Zhang D. A Vessel Wall MRI Investigation in Patients With Moyamoya or Quasi-Moyamoya Disease: Diagnosis, Features, and Outcomes. J Craniofac Surg 2024; 35:e24-e28. [PMID: 37622552 DOI: 10.1097/scs.0000000000009681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/25/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND PURPOSE None of the previous studies have investigated the pathologic authenticity of affected arteries in moyamoya disease (MMD) and Quasi-MMD diagnosed by angiography. This study aimed to confirm the angiographic diagnosis of moyamoya as well as investigate the pathologic mechanisms in angiographically proven MMD and Quasi-MMD using high-resolution magnetic resonance imaging (MRI) in a large sample. METHODS We prospectively studied 116 patients who had angiographically proven MMD and Quasi-MMD. Each affected internal carotid artery, and middle cerebral artery was independently evaluated. In addition, clinical features and postoperative outcomes were compared between hemispheres with MMD and moyamoya syndrome (MMS). RESULTS Among 116 patients analyzed, 88 and 22 patients had angiographically proven MMD and Quasi-MMD, respectively. high-resolution magnetic resonance imaging confirmed bilateral MMD in 73 (83.0%) patients, 1 hemisphere with MMD and the other with intracranial atherosclerotic disease (ICAD) in 10 (11.4%) patients, and bilateral hemispheres with different vasculopathies in 5 (5.7%) patients. Detailed analysis of 204 affected hemispheres showed that several combinations of different vasculopathies were observed in the internal carotid artery and middle cerebral artery of the same hemisphere, such as ICAD-ICAD, ICAD-MMD, dissection-ICAD, and dissection-MMD. Hemispheres were assigned to MMD and MMS groups according to their vasculopathies. Transient ischemic attack occurred more frequently in hemispheres with MMD (48.1% versus 21.1%, P =0.024), whereas symptomatic ischemia was more common in hemispheres with MMS (57.9% versus 24.9%, P =0.002). However, postoperative cerebral infarction, symptom improvement and neo-formative collaterals showed no significant difference between hemispheres with MMD and MMS ( P >0.05). CONCLUSIONS Patients with angiographically proven MMD or Quasi-MMD needed more accurate evaluation combined with high-resolution magnetic resonance imaging. Highly selected patients with MMS might also obtain benefits from surgical revascularization.
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Affiliation(s)
- Le-Bao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Mi Shen
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
- Department of Neurosurgery, Beijing Hospital, Beijing, China
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Sebök M, van der Wouden F, Mader C, Pangalu A, Treyer V, Fisher JA, Mikulis DJ, Hüllner M, Regli L, Fierstra J, van Niftrik CHB. Hemodynamic Failure Staging With Blood Oxygenation Level-Dependent Cerebrovascular Reactivity and Acetazolamide-Challenged ( 15O-)H 2O-Positron Emission Tomography Across Individual Cerebrovascular Territories. J Am Heart Assoc 2023; 12:e029491. [PMID: 38084716 PMCID: PMC10863778 DOI: 10.1161/jaha.123.029491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Staging of hemodynamic failure (HF) in symptomatic patients with cerebrovascular steno-occlusive disease is required to assess the risk of ischemic stroke. Since the gold standard positron emission tomography-based perfusion reserve is unsuitable as a routine clinical imaging tool, blood oxygenation level-dependent cerebrovascular reactivity (BOLD-CVR) with CO2 is a promising surrogate imaging approach. We investigated the accuracy of standardized BOLD-CVR to classify the extent of HF. METHODS AND RESULTS Patients with symptomatic unilateral cerebrovascular steno-occlusive disease, who underwent both an acetazolamide challenge (15O-)H2O-positron emission tomography and BOLD-CVR examination, were included. HF staging of vascular territories was assessed using qualitative inspection of the positron emission tomography perfusion reserve images. The optimum BOLD-CVR cutoff points between HF stages 0-1-2 were determined by comparing the quantitative BOLD-CVR data to the qualitative (15O-)H2O-positron emission tomography classification using the 3-dimensional accuracy index to the randomly assigned training and test data sets with the following determination of a single cutoff for clinical application. In the 2-case scenario, classifying data points as HF 0 or 1-2 and HF 0-1 or 2, BOLD-CVR showed an accuracy of >0.7 for all vascular territories for HF 1 and HF 2 cutoff points. In particular, the middle cerebral artery territory had an accuracy of 0.79 for HF 1 and 0.83 for HF 2, whereas the anterior cerebral artery had an accuracy of 0.78 for HF 1 and 0.82 for HF 2. CONCLUSIONS Standardized and clinically accessible BOLD-CVR examinations harbor sufficient data to provide specific cerebrovascular reactivity cutoff points for HF staging across individual vascular territories in symptomatic patients with unilateral cerebrovascular steno-occlusive disease.
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Affiliation(s)
- Martina Sebök
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | | | - Cäcilia Mader
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Athina Pangalu
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
- Department of NeuroradiologyUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Valerie Treyer
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Joseph Arnold Fisher
- Department of Anesthesia and Pain ManagementUniversity Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - David John Mikulis
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
- Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoOntarioCanada
| | - Martin Hüllner
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Luca Regli
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Jorn Fierstra
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
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Ma Y, Wang T, Wang H, Amin-Hanjani S, Tong X, Wang J, Tong Z, Kuai D, Cai Y, Ren J, Wang D, Duan L, Maimaitili A, Hang C, Yu J, Bai X, Powers WJ, Derdeyn CP, Wu Y, Ling F, Gu Y, Jiao L. Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial. JAMA 2023; 330:704-714. [PMID: 37606672 PMCID: PMC10445185 DOI: 10.1001/jama.2023.13390] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/29/2023] [Indexed: 08/23/2023]
Abstract
Importance Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. Objective To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. Design, Setting, and Participants This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). Interventions EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. Main Outcomes and Measures The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Results Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Conclusions and Relevance Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. Trial Registration ClinicalTrials.gov Identifier: NCT01758614.
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Affiliation(s)
- Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Sepideh Amin-Hanjani
- Cerebrovascular and Skull Base Surgery, Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Xiaoguang Tong
- Department of Neurosurgery, Huanhu Hospital, Tianjin, China
| | - Jiyue Wang
- Department of Neurosurgery, Liaocheng People’s Hospital, Shandong First Medical University and Shandong Academy of Medical Sciences, Liaocheng City, Shandong, China
| | - Zhiyong Tong
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Dong Kuai
- Department of Neurosurgery, The Affiliated Cardiovascular Hospital of Shanxi Medical University and Shanxi Cardiovascular Hospital (Institute), Taiyuan, Shanxi, China
| | - Yiling Cai
- Department of Neurology, Strategic Support Force Medical Center, Beijing, China
| | - Jun Ren
- Department of Neurosurgery, The Second Hospital of Lan Zhou University, Lan Zhou, China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
- Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Lian Duan
- Department of Neurosurgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, HaiDian District, Beijing, China
| | - Aisha Maimaitili
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Xinshi District, Urumqi, Xinjiang,China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Neurosurgical Institute of Nanjing University, Nanjing University Medical School, Nanjing, China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - William J. Powers
- Department of Neurology, Duke University School of Medicine, Duke South, Durham, North Carolina
| | - Colin P. Derdeyn
- Departments of Radiology and Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Feng Ling
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Liqun Jiao
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
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Abdelgadir J, Haskell-Mendoza AP, Magno AR, Suarez AD, Antwi P, Raghavan A, Nelson P, Yang LZ, Jung SH, Zomorodi AR. Revisiting flow augmentation bypass for cerebrovascular atherosclerotic vaso-occlusive disease: Single-surgeon series and review of the literature. PLoS One 2023; 18:e0285982. [PMID: 37205640 DOI: 10.1371/journal.pone.0285982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/07/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Despite advances in the nonsurgical management of cerebrovascular atherosclerotic steno-occlusive disease, approximately 15-20% of patients remain at high risk for recurrent ischemia. The benefit of revascularization with flow augmentation bypass has been demonstrated in studies of Moyamoya vasculopathy. Unfortunately, there are mixed results for the use of flow augmentation in atherosclerotic cerebrovascular disease. We conducted a study to examine the efficacy and long term outcomes of superficial temporal artery to middle cerebral artery (STA-MCA) bypass in patients with recurrent ischemia despite optimal medical management. METHODS A single-institution retrospective review of patients receiving flow augmentation bypass from 2013-2021 was conducted. Patients with non-Moyamoya vaso-occlusive disease (VOD) who had continued ischemic symptoms or strokes despite best medical management were included. The primary outcome was time to post-operative stroke. Time from cerebrovascular accident to surgery, complications, imaging results, and modified Rankin Scale (mRS) scores were aggregated. RESULTS Twenty patients met inclusion criteria. The median time from cerebrovascular accident to surgery was 87 (28-105.0) days. Only one patient (5%) had a stroke at 66 days post-op. One (5%) patient had a post-operative scalp infection, while 3 (15%) developed post-operative seizures. All 20 (100%) bypasses remained patent at follow-up. The median mRS score at follow up was significantly improved from presentation from 2.5 (1-3) to 1 (0-2), P = .013. CONCLUSIONS For patients with high-risk non-Moyamoya VOD who have failed optimal medical therapy, contemporary approaches to flow augmentation with STA-MCA bypass may prevent future ischemic events with a low complication rate.
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Affiliation(s)
- Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Aden P Haskell-Mendoza
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Amanda R Magno
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander D Suarez
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Prince Antwi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alankrita Raghavan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Patricia Nelson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Lexie Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
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8
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Cui B, Shan Y, Zhang T, Ma Y, Yang B, Yang H, Jiao L, Shan B, Lu J. Crossed cerebellar diaschisis-related supratentorial hemodynamic and metabolic status measured by PET/MR in assessing postoperative prognosis in chronic ischemic cerebrovascular disease patients with bypass surgery. Ann Nucl Med 2022; 36:812-822. [PMID: 35788959 PMCID: PMC9374607 DOI: 10.1007/s12149-022-01766-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Objective Cerebral ischemic status is an indicator of bypass surgery. Both hemodynamics and glucose metabolism are significant factors for evaluating cerebral ischemic status. The occurrence of crossed cerebellar diaschisis (CCD) is influenced by the degree of supra-tentorial perfusion and glucose metabolism reduction. This study aimed to investigate the relationship between the CCD-related supra-tentorial blood flow and metabolic status before bypass surgery in patients with chronic and symptomatic ischemic cerebrovascular disease and the prognosis of surgery. Methods Twenty-four participants with chronic ischemic cerebrovascular disease who underwent hybrid positron emission tomography (PET)/magnetic resonance (MR) before bypass surgery were included. Arterial spin labeling (ASL)-MR and FDG-PET were used to measure blood flow and metabolism, respectively. The PET images were able to distinguish CCD. The supratentorial asymmetry index (AI) and volume in the decreased blood flow region, decreased metabolism region and co-decreased region on the affected side, except for the infarct area, were respectively obtained before bypass surgery. The neurological status was determined using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores. Differences between CCD-positive (CCD +) and CCD-negative (CCD−) groups were investigated. Results Fourteen (58%) of the 24 patients were diagnosed as CCD +. Before surgery, the NIHSS and mRS scores of the CCD + were significantly higher than those of the CCD− (1.0(1.0) vs. 0.0(1.0), P = 0.013; 1.0(1.5) vs. 0.0(1.5), P = 0.048). After the surgery, the NIHSS and mRS scores of the CCD + showed a significant decrease (0.0(1.0) to 0.0(0.0), P = 0.011; 0.0(0.5) to 0.0(0.0), P = 0.008). Significant differences were observed in the supra-tentorial decreased metabolism region (all Ps ≤ 0.05) between the CCD + and CCD− groups, but no differences were observed in the preprocedural decreased supratentorial blood flow region (P > 0.05). The preprocedural NIHSS score was strongly correlated with the metabolism AI value in the decreased metabolism region (r = 0.621, P = 0.001) and the co-decreased region (r = 0.571, P = 0.004). Conclusions Supratentorial blood flow and metabolism are important indicators of CCD. This study showed that CCD + patients benefited more from bypass surgery than CCD− patients. Staging based on CCD-related supra-tentorial blood flow and metabolic status by hybrid PET/MR may help to personalize treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s12149-022-01766-0.
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Affiliation(s)
- Bixiao Cui
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yi Shan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Tianhao Zhang
- Institute of High Energy Physics, Beijing Engineering Research Center of Radiographic Techniques and Equipment, Chinese Academy of Sciences, Beijing, China.,School of Nuclear Science and Technology, University of Chinese Academy of Sciences, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Yang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Baoci Shan
- Institute of High Energy Physics, Beijing Engineering Research Center of Radiographic Techniques and Equipment, Chinese Academy of Sciences, Beijing, China.,School of Nuclear Science and Technology, University of Chinese Academy of Sciences, Beijing, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China. .,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China.
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9
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Murai Y, Sekine T, Ishisaka E, Tsukiyama A, Kubota A, Matano F, Ando T, Nakae R, Morita A. Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study. Neurosurgery 2022; 90:426-433. [PMID: 35064659 DOI: 10.1227/neu.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited. OBJECTIVE To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass. METHODS Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI. RESULTS The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA. CONCLUSION Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases.
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Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Tetsuro Sekine
- Department of Radiology, Musashi-Kosugi Hospital, Nippon Medical School, Kanagawa, Japan
| | - Eitaro Ishisaka
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Atsushi Tsukiyama
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Asami Kubota
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Takahiro Ando
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
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10
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Differences in Hemodynamic Alteration between Atherosclerotic Occlusive Lesions and Moyamoya Disease: A Quantitative 15O-PET Study. Diagnostics (Basel) 2021; 11:diagnostics11101820. [PMID: 34679518 PMCID: PMC8535090 DOI: 10.3390/diagnostics11101820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022] Open
Abstract
To clarify the differences in hemodynamic status between atherosclerotic steno-occlusive lesions (SOL) and moyamoaya disease (MMD), hemodynamic parameters were compared using 15O-PET. Twenty-four patients with unilateral SOL (67 ± 11 y) and eighteen with MMD (33 ± 16 y) were assigned to this study. MMD patients were divided into twelve unilateral and six bilateral lesions. All patients underwent 15O-PET to measure cerebral blood flow (CBF), blood volume (CBV), oxygen extraction fraction (OEF), and metabolic rate (CMRO2). Acetazolamide was administered after the baseline scan and the second 15O-water PET was performed to evaluate cerebrovascular reactivity (CVR). For the CBF calculation in 15O-water PET, the three-weighted integral method was applied based on a one-tissue compartment model with pixel-by-pixel delay correction to measure precise CBF and arterial-to-capillary blood volume (V0). Baseline hemodynamic parameters showed significantly lower CBF, V0, and CMRO2, but greater CBV, OEF, and delay (p < 0.01) in the affected hemispheres than in the unaffected hemispheres. After ACZ administration, both hemispheres showed a significant increase in CBF (p < 0.0001), but not in V0. CVR differed significantly between the hemispheres. The arterial perfusion pressure of the functioning arterial part tended to be reduced after acetazolamide administration in patients with past neurologic events caused by hemodynamic impairment. MMD patients showed greater inactive vascular and venous volumes compared with common atherosclerotic SOL patients. The hemodynamic status of cerebral circulation may vary according to the chronic process of steno-occlusive change and the development of collateral circulation. In order to evaluate physiologic differences between the two diseases, 15O-PET with an acetazolamide challenge test is useful.
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11
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Haynes J, Kronenburg A, Raz E, Rostanski S, Yaghi S, Ishida K, Shapiro M, Nelson PK, Tanweer O, Langer DJ, Riina HA, Eichel R, Nossek E. Superficial Temporal Artery to Middle Cerebral Artery Cranial Bypass for Nonmoyamoya Steno-Occlusive Disease in Patients Who Failed Optimal Medical Treatment: A Case Series. Oper Neurosurg (Hagerstown) 2021; 20:444-455. [PMID: 33475724 DOI: 10.1093/ons/opaa458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the post-Carotid Occlusion Surgery Study (COSS) era, multiple reviews suggested subset groups of patients as potential candidates for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. Among them are patients with recurrent strokes despite optimal medical therapy. There is a paucity of data on the outcome of bypass in these specific patients. OBJECTIVE To examine the safety and efficacy of direct STA-MCA bypass in patients with nonmoyamoya, symptomatic steno-occlusive disease with impaired distal perfusion, who failed optimal medical management or endovascular treatment. METHODS A retrospective review was performed to identify patients with cerebrovascular steno-occlusive disease who underwent bypass after symptomatic recurrent or rapidly progressive strokes, despite optimal conservative or endovascular treatment. RESULTS A total of 8 patients (mean age 60 ± 6 yr) underwent direct or combined direct/indirect STA-MCA bypass between 2016 and 2019. All anastomoses were patent. One bypass carried slow flow. There were no procedure-related permanent deficits. One patient developed seizures which were controlled by medications. A total of 7 out of 8 patients were stable or improved clinically at last follow-up (mean 27.3 ± 13.8 mo) without recurrent strokes. One patient did not recover from their presenting stroke, experienced severe bilateral strokes 4 mo postoperatively, and subsequently expired. Modified Rankin Scale (mRS) improved in 6 patients (75%), remained stable in 1 patient (12.5%), and deteriorated in 1 (12.5%). Good long-term functional outcome was achieved in 5 patients (63%, mRS ≤ 2). CONCLUSION Patients with symptomatic, hypoperfused steno-occlusive disease who fail optimal medical or endovascular treatment may benefit from cerebral revascularization. Direct or combined STA-MCA bypass was safe and provided favorable outcomes in this small series.
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Affiliation(s)
- Joseph Haynes
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Annick Kronenburg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eytan Raz
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Sara Rostanski
- Department of Neurology, NYU Langone Health, New York, New York
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, New York
| | - Koto Ishida
- Department of Neurology, NYU Langone Health, New York, New York
| | - Maksim Shapiro
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Peter Kim Nelson
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York
| | - Roni Eichel
- Department of Neurology, Shaare Zedek Medical Center, Affiliated Teaching Hospital of the Hebrew University Medical Faculty, Jerusalem, Israel
| | - Erez Nossek
- Department of Neurosurgery, NYU Langone Health, New York, New York
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12
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Spiessberger A, Strange F, Gruter BE, Wanderer S, Casoni D, Gruber P, Diepers M, Remonda L, Fandino J, Añon J, Marbacher S. An endovascular assisted, nonocclusive cerebral bypass: a technical feasibility study in a rabbit model. J Neurosurg 2021; 134:1846-1851. [PMID: 32502997 DOI: 10.3171/2020.3.jns20334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Temporary parent vessel occlusion performed to establish a high-flow interpositional bypass carries the risk of infarcts. The authors investigated the feasibility of a novel technique to establish a high-flow bypass without temporary parent vessel occlusion in order to lower the risk of ischemic complications. METHODS In 10 New Zealand white rabbits, a carotid artery side-to-end anastomosis was performed under parent artery patency with a novel endovascular balloon device. Intraoperative angiography, postoperative neurological assessments, and postoperative MRI/MRA were performed to evaluate the feasibility and safety of the novel technique. RESULTS A patent anastomosis was established in 10 of 10 animals; 3 procedure-related complications occurred. No postoperative focal neurological deficits were observed. The MRI/MRA findings include no infarcts and bypass patency in 50% of the animals. CONCLUSIONS The authors demonstrated the feasibility of an endovascular assisted, nonocclusive high-flow bypass. Future refinement of the device and technique in an animal model is necessary to lower the complication rate and increase patency rates.
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Affiliation(s)
- Alexander Spiessberger
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Fabio Strange
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Basil Erwin Gruter
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Stefan Wanderer
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Daniela Casoni
- 3Department of Biomedical Research, Faculty of Medicine, University of Bern; and
| | - Philipp Gruber
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Michael Diepers
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Luca Remonda
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Javier Fandino
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Javier Añon
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Serge Marbacher
- 1Department of Neurosurgery, Kantonsspital Aarau
- 2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
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13
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Li H, Chen C, Li Z, Ling C, Sun J, Wang H. Superficial Temporal Artery-Posterior Cerebral Artery Bypass for the Treatment of Chronic Basilar Artery Occlusion. World Neurosurg 2021; 150:e45-e51. [PMID: 33631388 DOI: 10.1016/j.wneu.2021.02.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the effect of superficial temporal artery-posterior cerebral artery (STA-PCA) bypass on chronic basilar artery occlusion (CBAO). METHODS A total of 4 patients who underwent STA-PCA bypass between January 2018 and October 2019 were enrolled in this study. Cerebral blood perfusion, ischemic events, STA diameter and blood flow changes, modified Rankin scale score (mRS), and National Institutes of Health Stroke Scale (NIHSS) score changes were recorded before and after bypass surgery. RESULTS The average time from basilar artery occlusion (confirmed by cerebral angiography or computed tomography angiography) to operation was 76 ± 38.89 days (range: 30-120 days). Average scores on the NIHSS were 6.8 ± 1.26 (5-8) and 5.2 ± 2.06 (3-7) before and after treatment, respectively. mRS scores averaged 1.8 ± 0.5 (1-2) and 1.5 ± 0.58 (1-2) points, respectively. There were no obvious complications or further stroke during the follow-up. The STA diameter and flow rate were significantly increased at 12 months after operation (P < 0.05). CONCLUSIONS STA-PCA bypass can improve cerebral blood flow perfusion in CBAO patients. The diameter and flow of the superficial temporal artery can be increased to meet the demand of blood supply.
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Affiliation(s)
- Hao Li
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chuan Chen
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhangyu Li
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Cong Ling
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jun Sun
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Wang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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14
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Yin L, Ouyang D, Lin L, Xin X, Ji Y. Salidroside regulates imbalance of Th17/Treg and promotes ischemic tolerance by targeting STAT-3 in cerebral ischemia-reperfusion injury. Arch Med Sci 2021; 17:523-534. [PMID: 33747287 PMCID: PMC7959015 DOI: 10.5114/aoms.2019.85349] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/05/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The balance between Th17 and Treg cells controls the immune response and is an important regulator of helper T cells acting on autoimmune diseases. Focal cerebral ischemia-reperfusion injury can induce imbalance of Th17/Treg cells in the brain and the peripheral immune system of rats. The aim of this study was to investigate the effect of salidroside (Sal) on the ratio of Th17 and Treg cells in an adult rat model of middle cerebral artery occlusion (MCAO). MATERIAL AND METHODS Forty rats were divided into 4 groups: normal group, sham group, surgery group, and Sal group. After treatment, the neurological deficits in rats were evaluated. Peripheral blood mononuclear cells were isolated and the count of Th17 and Treg cells was detected by flow cytometry. The infarct size and expression of RORγt and Foxp3 were detected in rat brain tissue. Rat spleen cells were isolated, CD4+ T cells were purified by immunomagnetic beads. Treg cells were induced by adding cytokine TGF-β. Th17 cells were induced by adding cytokine IL-6. The expression of STAT-3 was inhibited by SiRNA, and the effect of Sal on the differentiation of Th17/Treg cells was analyzed. The expression levels of IL-6, TNF-α, MCP-1, STAT-3 and NF-κ-B2 proteins were examined. RESULTS The results show that MCAO can induce an imbalance of Th17 and Treg cells in peripheral blood of rats. Sal treatment can significantly reduce the neurological deficit and infarct size of MCAO rats, reverse the oxidative stress of rat brain tissue, and inhibit the apoptosis of brain cells in MCAO rats. In the brain tissue of MCAO rats, Sal could significantly inhibit the expression of IL-6, TNF-α, MCP-1, STAT-3 and NF-κ-B2. Down-regulation of STAT-3 significantly reversed the therapeutic effects of Sal treatment. CONCLUSIONS Our results indicate that Sal can increase the tolerance of rat brain tissue to ischemia, inhibit cell apoptosis and reduce oxidative stress by targeting STAT-3.
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Affiliation(s)
- Lele Yin
- Department of Clinical laboratory, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Dongyun Ouyang
- Department of Immunobiology, College of Life Science and Technology, Jinan University, Guangzhou, China
| | - Lihong Lin
- Department of Clinical laboratory, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiufeng Xin
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yuhua Ji
- Department of Immunobiology, College of Life Science and Technology, Jinan University, Guangzhou, China
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15
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Joshi G, Yamada Y, Thavara BD, Tanaka R, Miyatini K, Nakao K, Kawase T, Takizava K, Kato Y. EC-IC Bypass; Our Experience of Cerebral Revascularization with Intraoperative Dual-Image Video Angiography (Diva). Asian J Neurosurg 2020; 15:499-506. [PMID: 33145198 PMCID: PMC7591183 DOI: 10.4103/ajns.ajns_84_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/07/2020] [Accepted: 06/04/2020] [Indexed: 11/04/2022] Open
Abstract
Background: Extracranial-intracranial (EC-IC) arterial bypass has been used in the treatment of various cerebrovascular ischemic disease due to atherosclerosis or Moyamoya disease, skull base tumors encasing large IC artery or complex IC aneurysms. Aim: The aim is to analyze surgical technique (EC-IC bypass) and its outcome with intraoperative use of dual image video angiography (DIVA) and Doppler ultrasound. Materials and Methods: We studied in this article a series of 23 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a superficial temporal artery-middle cerebral artery anastomosis was done for steno-occlusive disease, giant IC aneurysm or Moyamoya disease. The study was conducted between 2018 and 2020. We used dual-image video angiography (DIVA) and Doppler ultrasound to assess the luminal patency of anastomosis during the procedure. Results: In this study, three patients presented with Moyamoya disease, 4 had aneurysm, whereas 16 patients presented with the vascular steno-occlusive disease. The patients were divided into three categories (steno-occlusive disease, Moyamoya, and flow replacement for giant aneurysm). Dual image video angiography, along with intraoperative Doppler, helped us in the assessment of luminal patency of the anastomosis. Conclusion: Hemodynamic recovery after cerebrovascular bypass brings about a better outcome in ischemic stroke. The result of surgery improves with proper selection of patients with hemodynamic impairment (in Stage 2). With various modalities such as intraoperative Doppler, DIVA (Dual-image Video Angiography) and improved surgical techniques may aid in the reduction of complications and improve clinical outcome.
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Affiliation(s)
- Girish Joshi
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Apollo Specialty Hospital, Bengaluru, Karnataka, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Binoy Damodar Thavara
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| | - Riki Tanaka
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Kyosuke Miyatini
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Kazutaka Nakao
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Katsumi Takizava
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
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16
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Krylov VV, Luk'ianchikov VA, Polunina NA, Tokarev AS, Dalibaldian VA, Grigor'ev IV. [Surgical revascularization of the brain in patients with acute ischaemic stroke]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:124-132. [PMID: 32597893 DOI: 10.33529/angio2020207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM The study was aimed at developing a surgical policy for patients presenting with acute ischaemic stroke induced by lesions of the intra- and extracranial arteries. PATIENTS AND METHODS The patients were enrolled into the study resulting from the current practice of the Department of Emergency Neurosurgery of the Research Institute of Emergency Medicine named after N.V. Sklifosovsky. Sampling of patients was carried out from 1st January, 2014 to 10th October, 2017, eventually comprising all those (n=160) operated on for verified pathology of brachiocephalic arteries and acute impairment of cerebral circulation. RESULTS During the examination, 101 (63.1%) patients were found to have unilateral or bilateral stenosis of the internal carotid artery, 22 (10.7%) patients were diagnosed with occlusion of the internal carotid artery, and 36 (17.6%) had acute thrombosis of the internal carotid artery. All this was the cause of acute impairment of cerebral circulation. Also, 1 patient was found to have occlusion of the 1st segment of the vertebral artery. Depending on the type of the lesion to the internal carotid artery, the patients were subdivided into 3 groups: 1) patients with internal carotid artery stenosis who received carotid endarterectomy; 2) patients with occlusion of the internal carotid artery, subjected to creation of an extra-intracranial microanastomosis, and 3) those with thrombosis of the internal carotid artery, who depending on the degree of occlusion of the internal carotid artery and patency of the intracranial arteries underwent thrombintimectomy or an extra-intracranial microanastomosis. The indications for and contraindications to interventions were defined based on the existing symptomatic pathology of brachiocephalic arteries, the terms of acute impairment of cerebral circulation, perfusion of the brain, the risk for the development of malignant stroke and cerebral oedema, possible haemorrhagic transformation of the focus of ischaemia, the rehabilitational potential of the patient and the analysis of the current literature. The results of our work demonstrated that surgical treatment of patients in the cute period of ischaemic stroke makes it possible to improve the neurological outcomes in patients as compared with the preoperative status and is not accompanied by a high risk of surgical complications (with the haemorrhagic complication rate amounting to 0.6%). CONCLUSION Surgical revascularization of the brain in the acute period of ischaemic stroke is a safe and effective method of treatment in patients with different haemodynamically significant damage of brachiocephalic arteries, once the patients were correctly selected for the operation.
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Affiliation(s)
- V V Krylov
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov under the RF Ministry of Public Health, Moscow, Russia; Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
| | - V A Luk'ianchikov
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov under the RF Ministry of Public Health, Moscow, Russia; Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
| | - N A Polunina
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov under the RF Ministry of Public Health, Moscow, Russia; Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
| | - A S Tokarev
- Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
| | - V A Dalibaldian
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov under the RF Ministry of Public Health, Moscow, Russia; Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
| | - I V Grigor'ev
- Research Institute of Emergency Medicine named after N.V. Sklifosovsky under the Moscow Health Care Department, Moscow, Russia
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Moussouttas M, Rybinnik I. A critical appraisal of bypass surgery in moyamoya disease. Ther Adv Neurol Disord 2020; 13:1756286420921092. [PMID: 32547641 PMCID: PMC7273549 DOI: 10.1177/1756286420921092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/30/2020] [Indexed: 01/25/2023] Open
Abstract
Moyamoya disease (MMD) is a complex cerebrovascular disorder about which little
is known. Conventionally, revascularization surgery is recommended for patients,
despite an absence of conclusive data from adequate clinical trials.
Underscoring the uncertainty that exists in treating MMD patients, investigators
continue to present data comparing revascularization with conservative or
medical management, most of which originates from East Asia where MMD is most
prevalent. The purpose of this manuscript is to review contemporary large case
series, randomized trials, and recent meta-analyses that compare surgical and
medical treatments in adult patients with MMD, and to critically analyze the
modern literature in the context of current practice standards. Data from the
available literature is limited, but revascularization seems superior to
conservative therapy in adult patients presenting with hemorrhage, and in
preventing future hemorrhages. Conversely, evidence that surgery is superior to
medical therapy is not convincing in adult patients presenting with cerebral
ischemia, or for the prevention of future ischemic events. In contrast to East
Asian populations, MMD in Europe and in the Americas is predominantly an
ischemic disease that presents in adulthood. Adequate multinational trials are
warranted.
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Affiliation(s)
- Michael Moussouttas
- Department of Neurology, Cerebrovascular Division, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA
| | - Igor Rybinnik
- Department of Neurology, Cerebrovascular Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Rice CJ, Cho SM, Taqui A, Moore NZ, Witek AM, Bain MD, Uchino K. Early versus Delayed Extracranial-Intracranial Bypass Surgery in Symptomatic Atherosclerotic Occlusion. Neurosurgery 2020; 85:656-663. [PMID: 30239897 DOI: 10.1093/neuros/nyy411] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/02/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical trials of extracranial-intracranial (EC-IC) bypass surgery studied patients in subacute and chronic stage after ischemic event. OBJECTIVE To investigate the short-term outcomes of EC-IC bypass in progressive acute ischemic stroke or recent transient ischemic attacks. METHODS The study was a retrospective review at a single tertiary referral center from 2008 to 2015. Inclusion criteria consisted of EC-IC bypass within 1 yr of last ischemic symptoms ipsilateral to atherosclerotic occlusion of internal carotid or middle cerebral artery. Early bypass group who underwent surgery within 7 d of last ischemic symptoms were compared to late bypass group who underwent surgery >7 d from last ischemic symptom. The primary endpoint was perioperative ischemic or hemorrhagic stroke or intracranial hemorrhage within 7 d of surgery. RESULTS Of 126 patients who underwent EC-IC bypass during the period, 81 patients met inclusion criteria, 69 (85%) persons had carotid artery occlusion, 7 (9%) had proximal MCA occlusion, and 5 (6%) had both. Early surgery had a 31% (9/29) perioperative stroke rate compared to 11.5% (6/52) of patients undergoing late bypass (P = .04). Of patients with acute stroke within 7 d of surgery, 41% (7/17) had perioperative stroke within 7 d (P = .07). Six of nine patients (67%) with blood pressure dependent fluctuation of neurologic symptoms had perioperative stroke (P = .049). CONCLUSION EC-IC bypass in setting of acute symptomatic stroke within 1 wk may confer higher risk of perioperative stroke. Patients undergoing expedited or urgent bypass for unstable or fluctuating stroke symptoms might be at highest risk for perioperative stroke.
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Affiliation(s)
- Cory J Rice
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sung-Min Cho
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ather Taqui
- Department of Vascular Neurology, Novant Health System, Charlotte, North Carolina
| | - Nina Z Moore
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alex M Witek
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mark D Bain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Wong TH, Shagera QA, Ryoo HG, Ha S, Lee DS. Basal and Acetazolamide Brain Perfusion SPECT in Internal Carotid Artery Stenosis. Nucl Med Mol Imaging 2020; 54:9-27. [PMID: 32206127 PMCID: PMC7062956 DOI: 10.1007/s13139-019-00633-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022] Open
Abstract
Internal carotid artery (ICA) stenosis including Moyamoya disease needs revascularization when hemodynamic insufficiency is validated. Vascular reserve impairment was the key to find the indication for endarterectomy/bypass surgery in the atherosclerotic ICA stenosis and to determine the indication, treatment effect, and prognosis in Moyamoya diseases. Vascular reserve was quantitatively assessed by 1-day split-dose I-123 IMP basal/acetazolamide SPECT in Japan or by Tc-99m HMPAO SPECT in other countries using qualitative or semi-quantitative method. We summarized the development of 1-day basal/ acetazolamide brain perfusion SPECT for ICA stenosis, both quantitative and qualitative methods, and their methodological issues regarding (1) acquisition protocol; (2) qualitative assessment, either visual or deep learning-based; (3) clinical use for atherosclerotic ICA steno-occlusive diseases and mostly Moyamoya diseases; and (4) their impact on the choice of treatment options. Trials to use CT perfusion or perfusion MRI using contrast materials or arterial spin labeling were briefly discussed in their endeavor to use basal studies alone to replace acetazolamide-challenge SPECT. Theoretical and practical issues imply that basal perfusion evaluation, no matter how much sophisticated, will not disclose vascular reserve. Acetazolamide rarely causes serious adverse reactions but included fatality, and now, we need to monitor patients closely in acetazolamide-challenge studies.
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Affiliation(s)
- Teck Huat Wong
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Qaid Ahmed Shagera
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Hyun Gee Ryoo
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Seunggyun Ha
- Division of Nuclear Medicine Department of Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dong Soo Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
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Gunawardena M, Rogers JM, Stoodley MA, Morgan MK. Revascularization surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion. J Neurosurg 2020; 132:415-420. [PMID: 30738386 DOI: 10.3171/2018.9.jns181075] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust. METHODS Consecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter. RESULTS From 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%-6.6%). CONCLUSIONS Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.
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Affiliation(s)
| | - Jeffrey M Rogers
- 2Department of Clinical Medicine, Macquarie University; and
- 3Faculty of Health Sciences, University of Sydney, New South Wales, Australia
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Van Der Veken J, Lo Presti A, Mulcahy MJ, Stoodley MA. When the fat hits the brain-salvage STA-MCA bypass for an intracranial ICA occlusion due to a fat embolus. BMJ Neurol Open 2020; 2:e000017. [PMID: 33681773 PMCID: PMC7871712 DOI: 10.1136/bmjno-2019-000017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Large fat embolus is a rare but potential reversible cause of ischaemic stroke. METHODS AND RESULTS We describe the neurosurgical management of a complete right internal carotid artery occlusion due to a large fat embolus, caused by a mitral valve replacement. CONCLUSION Knowledge of acute cerebral ischaemia due to large fat embolism and its hallmark 'hypodense artery' is mandatory. Extracranial to intracranial bypass is a feasible rescue treatment after failure of endovascular embolectomy.
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Affiliation(s)
- Jorn Van Der Veken
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Anna Lo Presti
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Michael J Mulcahy
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Marcus Andrew Stoodley
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
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Deep learning-based interpretation of basal/acetazolamide brain perfusion SPECT leveraging unstructured reading reports. Eur J Nucl Med Mol Imaging 2020; 47:2186-2196. [PMID: 31912255 DOI: 10.1007/s00259-019-04670-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/23/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Basal/acetazolamide brain perfusion single-photon emission computed tomography (SPECT) has been used to evaluate functional hemodynamics in patients with carotid artery stenosis. We aimed to develop a deep learning model as a support system for interpreting brain perfusion SPECT leveraging unstructured text reports. METHODS In total, 7345 basal/acetazolamide brain perfusion SPECT images and their text reports were retrospectively collected. A long short-term memory (LSTM) network was trained using 500 randomly selected text reports to predict manually labeled structured information, including abnormalities of basal perfusion and vascular reserve for each vascular territory. Using this trained LSTM model, we extracted structured information from the remaining 6845 text reports to develop a deep learning model for interpreting SPECT images. The model was based on a 3D convolutional neural network (CNN), and the performance was tested on the other 500 cases by measuring the area under the receiver-operating characteristic curve (AUC). We then applied the model to patients who underwent revascularization (n = 33) to compare the estimated output of the CNN model for pre- and post-revascularization SPECT and clinical outcomes. RESULTS The AUC of the LSTM model for extracting structured labels was 1.00 for basal perfusion and 0.99 for vascular reserve for all 9 brain regions. The AUC of the CNN model designed to identify abnormal perfusion was 0.83 for basal perfusion and 0.89 for vascular reserve. The output of the CNN model was significantly improved according to the revascularization in the target vascular territory, and its changes in brain territories were concordant with clinical outcomes. CONCLUSION We developed a deep learning model to support the interpretation of brain perfusion SPECT by converting unstructured text reports into structured labels. This model can be used as a support system not only to identify perfusion abnormalities but also to provide quantitative scores of abnormalities, particularly for patients who require revascularization.
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Superficial temporal artery to middle cerebral artery (STA-MCA) bypass via retrograde arterial anastomosis in a patient with common carotid artery occlusion: a case report. Acta Neurochir (Wien) 2020; 162:183-186. [PMID: 31748902 DOI: 10.1007/s00701-019-04145-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
Abstract
The standard superficial temporal artery to middle cerebral artery (STA-MCA) bypass depends on adequate antegrade flow in the STA. In the setting of occlusion of the common or external carotid arteries, revascularization requires modification of the standard bypass procedure. A patient with prior history of irradiation for head and neck carcinoma presented with an ischemic injury and fluctuating neurologic deficit not responsive to medical therapy. His left common carotid artery was occluded, but angiographic evaluation demonstrated retrograde filling of his left STA. Reverse STA-MCA bypass was performed, taking advantage of spontaneous collateralization which allowed for retrograde filling of the STA.
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Emergent Rescue Extracranial-Intracranial Bypass for Acute Carotid Stent Thrombosis Report. World Neurosurg 2019; 129:242-244. [PMID: 31207372 DOI: 10.1016/j.wneu.2019.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute stent thrombosis is a rare adverse event following endovascular treatment of carotid artery. Experience on the topic is scarce, making the therapeutic approach a clinical challenge. In cases of intraprocedural acute carotid stent thrombosis, thromboaspiration, thrombectomy, and thrombolysis have been used as successful modalities for achieving recanalization. CASE DESCRIPTION We describe a case of carotid artery dissection treated endovascularly and complicated by intraprocedural stent thrombosis, which was ultimately managed by emergent extracranial-intracranial bypass with radial artery graft connecting the external carotid artery to the ipsilateral middle cerebral artery. CONCLUSIONS Neurosurgical management may represent a rescue option for otherwise unmanageable acute carotid stent thrombosis.
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25
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Menon G, Menon S, Hegde A. Does Universal Bypass before Carotid Artery Occlusion Obviate the Need for Balloon Test Occlusion: Personal Experience with Extracranial-Intracranial Bypass in 23 Patients. J Neurosci Rural Pract 2019; 10:194-200. [PMID: 31001004 PMCID: PMC6454976 DOI: 10.4103/jnrp.jnrp_381_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim Carotid artery ligation carries a potential risk of ischemic complications even in patients with good collaterals and adequate cross-circulation. Preoperative assessment through balloon test occlusion (BTO) is technically challenging and not feasible in all patients. We analyze our experience with universal bypass without performing detailed cerebrovascular reserve (CVR) studies in 23 patients before carotid artery ligation. Patients and Methods This was a retrospective analysis of the case records of 23 patients who underwent cervical carotid artery ligation for various indications since January 2009. Results The study included 21 patients with cavernous carotid aneurysms, one patient with a large fusiform petrous carotid aneurysm, and one patient with recurrent glomus jugulare encasing the cervical internal carotid artery. The initial 12 patients underwent preoperative BTO with hypotensive challenge. All patients underwent a bypass procedure followed by carotid artery ligation irrespective of the BTO findings. Patients who successfully completed a BTO underwent a low-flow superficial temporal artery to middle cerebral artery bypass. A high-flow extracranial-intracranial bypass using a saphenous vein graft from external carotid artery to middle cerebral artery was done in all patients who either failed the BTO or did not undergo BTO. We had two operative mortalities and one poor outcome. All the other patients had a good recovery with a Glasgow outcome score of 5 at the last follow-up. Graft patency rates were 81.1% in both the low-flow and high-flow groups. Conclusion Universal high-flow bypass is safe, effective, and should be preferred in all patients before carotid artery ligation. It obviates the need for detailed CVR assessment, especially in centers with limited resources.
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Affiliation(s)
- Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal, Karnataka, India
| | - Sudha Menon
- Department of Ophthalmology, Kasturba Medical College, Manipal, Karnataka, India
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal, Karnataka, India
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Wangqin R, Krafft PR, Piper K, Kumar J, Xu K, Mokin M, Ren Z. Management of De Novo Carotid Stenosis and Postintervention Restenosis-Carotid Endarterectomy Versus Carotid Artery Stenting-a Review of Literature. Transl Stroke Res 2019; 10:460-474. [PMID: 30793257 DOI: 10.1007/s12975-019-00693-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 01/23/2023]
Abstract
The current literature indicates carotid endarterectomy (CEA) as the preferred treatment for symptomatic, moderate to severe carotid artery stenosis. However, recommendations for the management of acute tandem stenosis and complete occlusion, as well as postintervention restenosis of the carotid artery, remain controversial. Here, we review the literature evaluating these conditions and provide suggestions for clinical decision-making. Acute tandem stenosis or occlusion of the common and internal carotid arteries may be treated with angioplasty alone, reserving carotid artery stenting (CAS) or CEA for severe and complex cases. Patients who underwent CEA and developed ipsilateral restenosis may be subjected to angioplasty followed by CAS, which carries a lower risk of cranial nerve injury and subsequent restenosis of the artery. For post-CAS restenosis, current evidence recommends angioplasty and CAS for the management of moderate stenosis and CEA for severe stenosis of the carotid artery. Given the lack of level 1 evidence for the management of these conditions, the abovementioned recommendations may assist clinical decision-making; however, each case and its unique risks and benefits need to be assessed individually. Future studies evaluating and defining the risks and benefits of specific treatment strategies, such as CEA and CAS, in patients with acute tandem stenosis, occlusion, and postintervention restenosis of the carotid artery need to be conducted.
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Affiliation(s)
- Runqi Wangqin
- Department of Neurology, Duke University Medical Center, 2400 Pratt Street, Durham, NC, 27705, USA
| | - Paul R Krafft
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Keaton Piper
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Jay Kumar
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Kaya Xu
- Department of Neurosurgery, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou, China
| | - Maxim Mokin
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Zeguang Ren
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA.
- Center for Cerebrovascular Diseases, Shiyan Taihe Hospital, Shiyan, 442000, Hubei, China.
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White TG, Abou-Al-Shaar H, Park J, Katz J, Langer DJ, Dehdashti AR. Cerebral revascularization after the Carotid Occlusion Surgery Study: what candidates remain, and can we do better? Neurosurg Focus 2019; 46:E3. [DOI: 10.3171/2018.11.focus18536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVECerebral revascularization for carotid occlusion was previously a mainstay procedure for the cerebrovascular neurosurgeon. However, the 1985 extracranial-intracranial bypass trial and subsequently the Carotid Occlusion Surgery Study (COSS) provided level 1 evidence via randomized controlled trials against bypass for symptomatic atherosclerotic carotid occlusion disease. However, in a small number of patients optimal medical therapy fails, and some patients with flow-limiting stenosis develop a perfusion-dependent neurological examination. Therefore it is necessary to further stratify patients by risk to determine who may most benefit from this intervention as well as to determine perioperative morbidity in this high-risk patient population.METHODSA retrospective review was performed of all revascularization procedures done for symptomatic atherosclerotic cerebrovascular steno-occlusive disease. All patients undergoing revascularization after the publication of the COSS in 2011 were included. Perioperative morbidity and mortality were assessed as the primary outcome to determine safety of revascularization in this high-risk population. All patients had documented hypoperfusion on hemodynamic imaging.RESULTSAt total of 35 revascularization procedures were included in this review. The most common indication was for patients with recurrent strokes, who were receiving optimal medical therapy and who suffered from cerebrovascular steno-occlusion. At 30 days only 3 perioperative ischemic events were observed, 2 of which led to no long-term neurological deficit. Immediate graft patency was good, at 94%. Long term, no further strokes or ischemic events were observed, and graft patency remained high at 95%. There were no factors associated with perioperative ischemic events in the variables that were recorded.CONCLUSIONSCerebral revascularization may be done safely at high-volume cerebrovascular centers in high-risk patients in whom optimal medical therapy has failed. Further research must be done to develop an improved methodology of risk stratification for patients with symptomatic atherosclerotic cerebrovascular steno-occlusive disease to determine which patients may benefit from intervention. Given the high risk of recurrent stroke in certain patients, and the fact that patients fail medical therapy, surgical revascularization may provide the best method to ensure good long-term outcomes with manageable up-front risks.
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Affiliation(s)
| | | | | | - Jeffrey Katz
- 3Neurology, North Shore University Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell; and
| | - David J. Langer
- 2Department of Neurosurgery, Lenox Hill Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
| | - Amir R. Dehdashti
- Departments of 1Neurosurgery and
- 2Department of Neurosurgery, Lenox Hill Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
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Babić S, Tanasković S, Nešković M, Gajin P, Nenezić D, Stevanović P, Aleksić N, Ševković M, Ilijevski N, Matić P, Popov P, Vučurević G, Unić-Stojanović D, Radak D. Surgical Treatment of Proximal Segmental Occlusion of the Internal Carotid Artery. Surg Res Pract 2019; 2019:2976091. [PMID: 30719497 PMCID: PMC6334308 DOI: 10.1155/2019/2976091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/02/2018] [Accepted: 11/11/2018] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To present the feasibility, safety, and efficacy of carotid endarterectomy in patients with type II internal carotid artery occlusions, including the long-term outcomes. METHODS From March 2008 to August 2015, 74 consecutive patients (48 men with a mean age of 65.1 ± 8.06 years) underwent carotid endarterectomy because of internal carotid artery (ICA) segmental occlusions. These were verified with preoperative carotid duplex scans (CDS) and CT angiography (CTA). Also, brain CT scanning was performed in all these patients. The indication for treatment was made jointly by a vascular surgeon, neurologist, and an interventional radiologist in a multidisciplinary team (MDT) context. After successful treatment, all the patients were followed-up at 1, 3, 6, and 12 months, then every 6 months thereafter. RESULTS The most common symptom at presentation was transient ischaemic attack (TIA) in 49 patients (66.2%), followed by stroke in the past six months in the 17 remaining patients (23%). Revascularisation of the ICA with endarterectomy techniques was performed successfully in all the patients with an average clamp time of 11.9 min. All the procedures were performed under general anaesthesia in combination with a superficial cervical block. The early complication rate was 8.1% and included two cardiac events (2.7%) (one rhythm disorder and one acute coronary syndrome), three TIAs (4.1%), and one intracerebral hemorrhage (1.3%). Only one patient with the intracerebral hemorrhage died 5 days after surgery giving a postoperative mortality of 1.3% for this series. During the follow-up period (mean 50.4 ± 31.3 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 94.9%, 92.9%, and 82.9%, respectively. Likewise, the survival rates were 98.7%, 96.8%, 89%, and 77.6%, respectively. Ultrasound Doppler controls during follow-up detected 8 ICA restenoses; however, only 3 of these patients required further endovascular treatment. CONCLUSIONS Carotid endarterectomy of internal carotid artery (ICA) segmental occlusion is a safe and effective procedure associated with acceptable risk and good long-term results. Therefore, the current guidelines which do not recommend carotid endarterectomy in this patient group should be reassessed, with the requirement for ongoing large-scale randomized controlled trials to compare CEA with best medical therapy in this patient cohort.
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Affiliation(s)
- Srdjan Babić
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Tanasković
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Mihailo Nešković
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
| | - Predrag Gajin
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragoslav Nenezić
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Stevanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Surgery, Clinical Center Dr Dragisa Misovic, Belgrade, Serbia
| | - Nikola Aleksić
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
| | - Milorad Ševković
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
| | - Nenad Ilijevski
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Matić
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Petar Popov
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
| | - Goran Vučurević
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
| | - Dragana Unić-Stojanović
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Djordje Radak
- Department of Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Effect of Extra-intracranial Bypass on Cerebral Hemodynamics in Treatment of Occlusion-stenotic Disorder of Brahio-cephal Arteries: Applying of Perfusion Computed Tomography. Fam Med 2018. [DOI: 10.30841/2307-5112.4.2018.160823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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von Weitzel-Mudersbach P, Andersen G, Rosenbaum S. Low Morbidity after Extracranial-Intracranial Bypass Operation. The Danish Extracranial-Intracranial Bypass Study: A Nationwide Survey. Cerebrovasc Dis 2018; 45:252-257. [DOI: 10.1159/000489895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Patients with symptomatic atherosclerotic carotid artery occlusion (SACAO) have a high risk of a recurrent stroke. Extracranial-intracranial bypass (EC-IC bypass) has been shown not to improve outcome compared with medical treatment alone because long-term prevention of recurrent stroke in operated patients was offset by high perioperative stroke rates. We report our experience with EC-IC bypass operated at an experienced high-volume centre. Methods: We conducted a nationwide observational study of EC-IC bypass patients operated in the years 2007–2016 due to SACAO with ongoing clinical symptoms or progression on MRI and severe haemodynamic failure (SHF). Perioperative stroke and death within 30 days after the operation, ipsilateral stroke, bypass patency, transient ischaemic attack, and all-stroke events and deaths during long-term follow-up were registered prospectively. Results: EC-IC bypass was performed in 48 patients with SHF and SACAO. The mean age was 64 (45–83) years. The mean follow-up was 3.6 years. The stroke rate after 30 days was 4.2%. No further ipsilateral strokes occurred during follow-up. Clinical symptoms arrested in all patients. Bypass patency rate was 94%. Conclusions: The perioperative stroke rate in EC-IC bypass operation, performed at a highly experienced centre, was low. During long-term follow-up, no ipsilateral stroke occurred. Consequently, EC-IC-bypass should still be considered for selected patients with SACAO, if operation can be carried out in experienced centres with low perioperative morbidity.
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Cerebral Bypass Surgery: Level of Evidence and Grade of Recommendation. ACTA NEUROCHIRURGICA SUPPLEMENT 2018; 129:73-77. [DOI: 10.1007/978-3-319-73739-3_10] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Xu B, Li C, Guo Y, Xu K, Yang Y, Yu J. Current understanding of chronic total occlusion of the internal carotid artery. Biomed Rep 2017; 8:117-125. [PMID: 29435269 PMCID: PMC5776422 DOI: 10.3892/br.2017.1033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 01/08/2023] Open
Abstract
At present, there is limited understanding of chronic total occlusion (CTO) of the internal carotid artery (ICA). Therefore, the present report collected related cases from PubMed and reviewed the literature. Cerebral vessels may form collateral circulation immediately or gradually following CTO of the ICA. The natural history of CTO of the ICA includes a variety of outcomes, all of which are biased toward a non-benign progressive process and are characterized by insufficient cerebral perfusion, embolus detachment and cognitive dysfunction. The majority of cases of CTO of the ICA require treatment. In early studies, the results of external-ICA bypass were unsatisfactory, while recanalization is now considered the only viable option. The current treatment indications mainly depend on the degree of injury to the cerebrovascular reserve and the extent to which the oxygen extraction fraction is increased. The length, height and duration of ICA occlusion are also relevant, though more frequently, the condition depends on multiple factors. Endovascular interventional recanalization, carotid endarterectomy (CEA) and hybrid surgery may be conducted in a select group of patients. As novel materials are developed, the success rate of simple recanalization may gradually increase; however, hybrid surgery may be more representative of the current trend, as advanced CEA can remove carotid atherosclerosis plaques, thus reducing the technological demands of the subsequent interventional recanalization. There are many complications that may result from recanalization following CTO of the ICA, including hyperperfusion and technical errors; therefore, the operation must be conducted carefully. If the recanalization is successful, it typically results in a stable improvement of patient condition in the long term. However, despite these conclusions, more studies are required in the future to further improve current understanding of CTO of the ICA.
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Affiliation(s)
- Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Refractory Symptomatic Intracranial Atherosclerotic Stenosis. World Neurosurg 2017; 104:74-81. [PMID: 28434956 DOI: 10.1016/j.wneu.2017.04.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate blood flow changes after bypass surgery for refractory symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS We examined a cohort of consecutive patients with symptomatic ICAS. Superficial temporal artery-middle cerebral artery (MCA) bypass was performed in refractory patients with poor perfusion. Angiograms were graded systematically for antegrade, collateral, and bypass flow, and clinical variables were collected preoperatively, at 7 days postoperatively, and 3, 6, and 12 months postoperatively. RESULTS Among 185 consecutive cases with ICAS, 15 patients who were unsuitable for or did not respond to the best medical therapy or stenting underwent bypass surgery. No patients had new ischemic deficits within 7 days postoperatively. The mean follow-up period was 30.2 ± 12.3 months. Within this period, all anastomoses were patent by methods of ultrasound or computed tomography angiography. In 2 patients, stenotic lesions exhibited early postoperative occlusion conversion at 7 days on digital subtraction angiography. In 2 patients, stenotic lesions showed progression of occlusion at 6 and 8 months. The 2 lesions with early occlusion were both located in the MCA. The extent of retrograde blood flow via bypass anastomosis was correlated with early occlusion conversion. CONCLUSIONS For refractory ICAS in patients with compromised hemodynamics, direct bypass might induce early occlusion of a stenotic area. MCA lesions may have a greater tendency toward early occlusion conversion.
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Ma Y, Gu Y, Tong X, Wang J, Kuai D, Wang D, Ren J, Duan L, Maimaiti A, Cai Y, Huang Y, Wang X, Cao Y, You C, Yu J, Jiao L, Ling F. The Carotid and Middle cerebral artery Occlusion Surgery Study (CMOSS): a study protocol for a randomised controlled trial. Trials 2016; 17:544. [PMID: 27852286 PMCID: PMC5111211 DOI: 10.1186/s13063-016-1600-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/13/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion with haemodynamic insufficiency are at high risk for recurrent stroke when treated medically. METHODS The Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS) trial is an ongoing, government-funded, prospective, multicentre, randomised controlled trial. The CMOSS will recruit 330 patients with symptomatic ICA or MCA occlusion (parallel design, 1:1 allocation ratio) and haemodynamic insufficiency. Participants will be allocated to best medical treatment alone or best medicine plus extracranial-intracranial (EC-IC) bypass surgery. The primary outcome events are all strokes or deaths occurring between randomisation and 30 days post operation or post randomisation and ipsilateral ischaemic stroke within 2 years. Recruitment will be finished by December 2016. All the patients will be followed for at least 2 years. The trial is scheduled to complete in 2019. DISCUSSION The CMOSS will test the hypothesis that EC-IC bypass surgery plus best medical therapy reduces subsequent ipsilateral ischaemic stroke in patients with symptomatic ICA or MCA occlusion and haemodynamic cerebral ischaemia. This manuscript outlines the rationale and the design of the study. CMOSS will allow for more critical reappraisal of the EC-IC bypass for selected patients in China. TRIAL REGISTRATION NCT01758614 with ClinicalTrials.gov. Registered on 24 December 2012.
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Affiliation(s)
- Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fu Dan University, No. 12 Mid Wulumuqi Road, Shanghai, 200040, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Huanhu Hospital, No. 6 Jizhao Road, Tianjin, 300350, China
| | - Jiyue Wang
- Department of Neurosurgery, Brain Hospital, No. 45 Huashan Road, LiaoCheng, Shandong, 252000, China
| | - Dong Kuai
- Department of Neurosurgery, The 1st Affiliated Hospital of ShanXi Medical University, No. 85 South Jiefang Road, Taiyuan, Shanxi, 030001, China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Jun Ren
- Department of Neurosurgery, The 2nd Affiliated Hospital of LanZhou University, No. 80 Cuiyingmen Road, Lanzhou, Gansu, 730030, China
| | - Lian Duan
- Department of Neurosurgery, The 307 Hospital of PLA, No. 8 Dongda Street, Beijing, 100071, China
| | - Aili Maimaiti
- Department of Neurosurgery, The 1st Affiliated Hospital of XinJiang Medical University, No. 137 South Liyushan Road, Wulumuqi, Xinjiang Uyghur Autonomous Region, 830054, China
| | - Yiling Cai
- Department of Neurology, The 306 Hospital of PLA, No. 9 Anxiangbeili, Beijing, 100101, China
| | - Yujie Huang
- Department of Neurosurgery, Drum Tower Hospital, Medical School of Nanjing University, No. 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
| | - Xiaojian Wang
- Department of Neurosurgery, The 1st Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 650101, China
| | - Yi Cao
- Department of Neurosurgery, The 2nd Affiliated Hospital of Kunming Medical University, No. 324 Dianmian Road, Kunming, Yunnan, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37 Guoxue Street, Chengdu, Sichuan, 610041, China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, Hubei, 430030, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
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Yu Z, Shi X, Qian H, Liu F, Zhou Z, Sun Y, Yang Y. Internal maxillary artery to intracranial artery bypass: a case series of 31 patients with chronic internal carotid/middle cerebral arterial-sclerotic steno-occlusive disease. Neurol Res 2016; 38:420-8. [PMID: 27122096 DOI: 10.1080/01616412.2016.1177931] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of internal maxillary artery (IMA) - radial artery graft (RAG) - middle cerebral artery (MCA) bypass surgery for chronic arterial-sclerotic severe stenosis or occlusion of the internal carotid artery (ICA) or MCA. METHODS A retrospective study was conducted in 31 patients with ischemic cerebrovascular disease who underwent bypass surgery of the IMA with a RAG of the MCA. Twenty-seven patients had complete occlusion of the ICA or MCA, and four patients had severe stenosis of the M1 segment of the MCA. RESULTS Patent IMA-RAG-MCA in 30 (96.8%) patients was confirmed by angiography after surgery. One case developed a new motor aphasia due to unsuccessful bypass. Eleven transient ischemic attacks (TIA) and five ischemic strokes resolved following surgery. The other 14 cases showed some improvement without ischemic events at one month following surgery. Prior to surgery, mean ± SD National Institute of Health Stroke Scale (NIHSS) score was 5.4 ± 1.1 in the ischemic stroke group. In the first month post-procedure, the NIHSS score decreased significantly to 3.8 ± 1.2, (p < 0.01). Perfusion weighted imaging (PWI) or computed tomography perfusion (CTP) indicated improved hemodynamics in 30 patients. In addition, seven patients demonstrated improved glucose metabolism on 18-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET) postoperatively. No new neurological deficit occurred in the 30 patients during a 2.19 ± 1.59 years of follow-up. CONCLUSIONS By supplying an adequate flow to a larger flow territory of chronically stenotic/occlusive major cerebral arteries, IMA bypass surgery is efficient for restoring hemodynamics in selected patients and improving their neurological deficits.
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Affiliation(s)
- Zaitao Yu
- a Department of Neurosurgery , Fu Xing Hospital, Capital Medical University , Beijing , China
| | - Xiang'en Shi
- a Department of Neurosurgery , Fu Xing Hospital, Capital Medical University , Beijing , China.,b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
| | - Hai Qian
- b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
| | - Fangjun Liu
- b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
| | - Zhongqing Zhou
- b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
| | - Yuming Sun
- b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
| | - Yang Yang
- b Department of Neurosurgery , Sanbo Brain Hospital Capital Medical University , Beijing 100093 , China
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Hage ZA, Behbahani M, Amin-Hanjani S, Charbel FT. Carotid bypass for carotid occlusion. Curr Atheroscler Rep 2016; 17:36. [PMID: 25983136 DOI: 10.1007/s11883-015-0517-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 2-year risk of ipsilateral ischemic stroke following internal carotid artery occlusion (ICAO) in a patient undergoing maximal medical therapy is 5-8% per year. While medical therapy may reduce the risk of stroke, it does not completely eliminate it. Since the 1985 extracranial-intracranial (EC-IC) bypass study, additional trials have been conducted to further investigate the usefulness of EC-IC bypass surgery in more selected patients with cerebral ischemia and impaired hemodynamic reserve. These important studies will be briefly reviewed in this article, as well as a discussion regarding the utility of bypass surgery for ICAO in current clinical practice. In addition, a short discussion regarding the pathophysiology of carotid occlusion will be presented. We will also highlight our own institutional patient selection criteria based on the latest methods for hemodynamic assessment, as well as our intraoperative flow assisted surgical techniques (FAST), and post-operative patient follow-up.
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Affiliation(s)
- Ziad A Hage
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Lukshin VA, Usachev DY, Pronin IN, Shmigel'skiy AV, Akhmedov AD, Shevchenko EV. Criteria of the efficacy of surgical brain revascularization in patients with chronic cerebral ischemia. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2016; 80:53-62. [PMID: 27070258 DOI: 10.17116/neiro201680253-62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE The article analyzes results of surgical revascularization in patients with symptoms of chronic cerebral ischemia caused by occlusion of the carotid arteries. MATERIAL AND METHODS We analyzed 404 surgeries for placement of extra-intracranial microvascular anastomoses (EICMAs) performed in 376 patients between 2000 and 2015. All patients underwent detailed neurological and neuropsychological examinations before surgery and throughout the follow-up period using the neurological deficit scale (NIHSS). Additionally, the medical history data, technical features of surgery, and results of instrumental tests were recorded. For a more detailed study of the cerebral circulation, a SCT perfusion examination was conducted in 58 patients before and after placement of EICMA. RESULTS All patients were divided into 3 groups, depending on the surgical treatment outcomes: improvement (53%), without significant changes (43%), and worsening of clinical symptoms (4%). A statistical analysis revealed that the efficacy of EICMA surgery ranged from 22 to 79% and was reliably confirmed by hemodynamic and anamnestic factors as well as by technical details of surgery. CONCLUSION When determining the indications for surgical revascularization in patients with ischemic stroke consequences, the patient's age, occlusion duration, location and size of ischemic lesions should be considered. Also, the choice of the acceptor artery and blood flow through the created anastomosis are of great importance.
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Affiliation(s)
- V A Lukshin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D Yu Usachev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A D Akhmedov
- Burdenko Neurosurgical Institute, Moscow, Russia
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Esposito G, Amin-Hanjani S, Regli L. Role of and Indications for Bypass Surgery After Carotid Occlusion Surgery Study (COSS)? Stroke 2016; 47:282-90. [DOI: 10.1161/strokeaha.115.008220] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/20/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Giuseppe Esposito
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
| | - Sepideh Amin-Hanjani
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
| | - Luca Regli
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
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Kim T, Oh CW, Kwon OK, Hwang G, Kim JE, Kang HS, Cho WS, Bang JS. Stroke prevention by direct revascularization for patients with adult-onset moyamoya disease presenting with ischemia. J Neurosurg 2015; 124:1788-93. [PMID: 26636391 DOI: 10.3171/2015.6.jns151105] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Moyamoya disease (MMD) is a progressive disease that can cause recurrent stroke. The authors undertook this retrospective case-control study with a large sample size in an attempt to assess the efficacy of direct or combined revascularization surgery for ischemia in adults with MMD. METHODS The authors investigated cases involving patients with moyamoya disease presenting with ischemia who visited Seoul National University Bundang Hospital and Seoul National University Hospital between 2000 and 2014. Among 441 eligible patients, 301 underwent revascularization surgery and 140 were treated conservatively. Variables evaluated included age at diagnosis, sex, surgical record, Suzuki stage, and occurrence of stroke. Patients were stratified into 2 groups based on whether or not they had undergone revascularization surgery. Actuarial 1-, 5-, and 10-year stroke rates were calculated using the life table method. Risk factor analysis for 5-year stroke occurrence was conducted with multivariate regression. RESULTS Of the 441 patients, 301 had been surgically treated (revascularization group) and 140 had not (control group). The mean follow-up durations were 45 and 77 months, respectively. The actuarial 10-year cumulative incidence rate for any kind of stroke was significantly lower in the revascularization group (9.4%) than in the control group (19.6%) (p = 0.041); the relative risk reduction (RRR) was also superior (52.0%) in the revascularization group, and the number needed to treat was 10. The 10-year rate of ischemic stroke was greater (13.3%) in the control group than in the revascularization group (3.9%) (p = 0.019). The RRR for ischemic stroke in the revascularization group was 70.7%, and the number needed to treat was 11. However, the actuarial 1- and 5-year rates of ischemic stroke did not significantly differently between the groups. Overall, revascularization surgery was shown to be an independent protective factor, as revealed by multivariate analysis. CONCLUSIONS Direct or combined revascularization for patients with adult-onset moyamoya disease presenting with ischemia can prevent further stroke.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi; and
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi; and
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi; and
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi; and
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi; and
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Abstract
Carotid occlusion is a disease that presents a difficult decision for the treating provider. Traditionally, many providers would opt for expectant management with risk factor reduction and supportive therapy. There is a growing body of literature however pointing to possible improved outcomes of more aggressive treatments, including reopening of the occluded carotid. In this review, we discuss the difficulties involved in diagnosing a patient presenting with symptomatic carotid occlusion, the natural history of the disease, and the emerging treatment options and paradigms of different institutions based on recent literature.
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Andereggen L, Andres RH, Arnold M, Raabe A, Schmidli J, Reinert M. Two-stage carotid saphenous vein interposition graft and superficial temporal artery bypass for acute carotid occlusion. J Vasc Surg Cases 2015; 1:161-164. [PMID: 31724617 PMCID: PMC6849918 DOI: 10.1016/j.jvsc.2015.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/17/2015] [Indexed: 11/28/2022] Open
Abstract
The safety and efficacy of bypass surgery to achieve cerebral revascularization for cerebral hypoperfusion are controversial. However, bypass surgery still plays an important role for a select group of patients. The indication to perform a high-flow or low-flow bypass in cases of acute symptomatic artery occlusion is not defined. Neurologic symptoms in acute symptomatic occlusion are usually blood pressure dependent, and acute blood flow restoration may be considered. This report reviews the case of a patient with an acute carotid occlusion in which a two-stage bypass technique was used to achieve revascularization and discusses the issues influencing the decision-making.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, University Hospital Bern, Neurocenter, Inselspital, Bern, Switzerland.,Department of Neurosurgery and F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Robert H Andres
- Department of Neurosurgery, University Hospital Bern, Neurocenter, Inselspital, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Neurocenter, Inselspital, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, University Hospital Bern, Neurocenter, Inselspital, Bern, Switzerland
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, Inselspital, Bern, Switzerland
| | - Michael Reinert
- Department of Neurosurgery, University Hospital Bern, Neurocenter, Inselspital, Bern, Switzerland.,Department of Neurosurgery, Neurocentro Lugano, Lugano, Switzerland
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Pancucci G, Potts MB, Rodríguez-Hernández A, Andrade H, Guo L, Lawton MT. Rescue Bypass for Revascularization After Ischemic Complications in the Treatment of Giant or Complex Intracranial Aneurysms. World Neurosurg 2015; 83:912-20. [PMID: 25700972 DOI: 10.1016/j.wneu.2015.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/29/2015] [Accepted: 02/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical trapping or endovascular deconstruction commonly is used for the treatment of giant or complex intracranial aneurysms. Preoperative balloon test occlusion and cerebral blood flow studies and intraoperative neurophysiologic monitoring can indicate whether sufficient collateralization exists or whether revascularization is needed. Hemodynamic insufficiency can occur, however, despite passing these tests, necessitating posttreatment revascularization. METHODS We conducted a retrospective review of patients who underwent surgical or endovascular parent vessel occlusion for the management of giant or complex intracranial aneurysms and subsequently required rescue bypass for symptoms of hemodynamic insufficiency. Pre- and postrevascularization functional status was measured with the modified Rankin Scale. RESULTS During a 15-year period from 1997 to 2012, a rescue bypass was performed in 5 patients each harboring a giant or complex intracranial internal carotid artery (ICA) aneurysm that was treated with surgical trapping or endovascular deconstruction in a previous procedure. All bypasses were extracranial-to-intracranial and included cervical ICA to middle cerebral artery, subclavian to middle cerebral artery, and cervical ICA to supraclinoid ICA anastomoses via either a saphenous vein or radial artery graft. Functional outcome at time of last follow-up was improved in each patient (improvement in modified Rankin Scale of 1-3 points). CONCLUSIONS Ischemic complications must always be anticipated in the treatment of giant or complex intracranial aneurysms, even if pre- and intraoperative blood flow studies indicate sufficient collateralization. Here we show that extracranial-to-intracranial bypass is an effective option to rescue unanticipated hemodynamic insufficiency after parent vessel occlusion. This study emphasizes the need for cerebrovascular surgeons to maintain proficiency in complex bypass techniques.
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Affiliation(s)
- Giovanni Pancucci
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hugo Andrade
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - LanJun Guo
- Neurophysiological Monitoring Service, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Kiyofuji S, Inoue T, Hasegawa H, Tamura A, Saito I. A3-A3 anastomosis and superficial temporal artery-radial artery graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia with cognitive and executive dysfunction: a technical note. Acta Neurochir (Wien) 2014; 156:2085-93; discussion 2093. [PMID: 25248326 DOI: 10.1007/s00701-014-2228-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Executive functions are complex cognitive control functions that include cognitive flexibility, inhibition (self-control, self-regulation), and working memory. Bilateral frontal lobe ischemia is associated with cognitive impairment, especially in the context of dysexecutive syndrome. This report describes two patients who underwent bilateral anterior cerebral artery (ACA) reconstruction by A3-A3 anastomosis in conjunction with superficial temporal artery (STA)-radial artery (RA) graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia accompanying cognitive and executive dysfunction. METHOD A 74-year-old woman and a 73-year-old woman were admitted to our hospital for unilateral cerebral infarction in the frontal lobe. Magnetic resonance angiogram (MRA) demonstrated severe bilateral ACA steno-occlusive pathology in both patients. Considering the presence of impaired cognitive function with dysexecutive syndrome as well as hemodynamic compromise shown by single photon emission computed tomography (SPECT), we proceeded with A3-A3 anastomosis in conjunction with STA-RA-A3 bypass. Various neuropsychiatric tests were performed before and after the surgery. RESULTS We confirmed good bypass patency without periprocedural complications. One patient recovered from apallic and bedridden status and regained ambulatory condition and ability to take in an oral diet. Another patient demonstrated improved scores in several cognitive tests with some persistent executive dysfunction. CONCLUSIONS Bilateral ACA revascularization was technically feasible in two patients. This bypass surgery could have some positive effects in some basic cognitive function, such as memory, attention, and concentration by bilateral ACA hemodynamic improvement, although executive function, which is specific to prefrontal function, might not be reversible.
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