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Crassard I, Berthet K, Lavallée P, Houot M, Payen D, Baron JC, Amarenco P, Lukaszewicz AC. Temporary application of lower body positive pressure improves intracranial velocities in symptomatic acute carotid occlusion or tight stenosis: A pilot study. Int J Stroke 2021; 17:308-314. [PMID: 33759644 DOI: 10.1177/17474930211008003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with isolated cervical carotid artery occlusion not eligible to recanalization therapies but with compromised intracranial hemodynamics may be at risk of further clinical events. Apart from lying flat until spontaneous recanalization or adjustment of the collateral circulation hopefully occurs, no specific treatment is currently implemented. Improving collateral flow is an attractive option in this setting. Lower body positive pressure (LBPP) is known to result in rapid venous blood shift from the lower to the upper body part, in turn improving cardiac preload and output, and is routinely used in acute hemorrhagic shock. We report here cerebral blood flow velocities measured during LBPP in this patient population. METHODS This is a retrospective analysis of the clinical, physiological, and transcranial Doppler monitoring data collected during and 15 min after LBPP in 21 consecutive patients (10 females, median age: 54 years) with recently symptomatic isolated carotid occlusion/tight stenosis (unilateral in 18) mostly due to atherosclerosis or dissection. LBPP was applied for 90 min at a median 5 days after symptom onset. RESULTS At baseline, middle-cerebral artery velocities were markedly lower on the symptomatic, as compared to asymptomatic, side. LBPP significantly improved blood flow velocities in both the symptomatic and asymptomatic middle-cerebral artery as well as the basilar artery, which persisted 15 min after discontinuing the procedure. LBPP also resulted in mild but significant increases in mean arterial blood pressure. CONCLUSIONS LBPP improved intracranial hemodynamics downstream recently symptomatic carotid occlusion/tight stenosis as well as in the contralateral and posterior circulations, which persisted after LBPP deflation. Randomized trials should determine if this easy-to-use, noninvasive, nonpharmacologic approach has long-lasting benefits on the intracranial circulation and improves functional outcome.
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Affiliation(s)
| | - Karine Berthet
- Neurology Department, Hôpital Lariboisière, Paris, France.,Neuraltide, iPEPS, Brain and Spine Institute, Paris, France
| | - Philippa Lavallée
- Department of Neurology and Stroke Center, Hôpital Bichat, Paris, France
| | - Marion Houot
- Centre of Excellence for Neurodegenerative Disease (CoEN), Hôpital Salpêtrière, Paris, France.,Institute of Memory and Alzheimer's disease (IM2A), Department of Neurology, Hôpital Salpêtrière, AP-HP, Paris, France.,Clinical Investigation Centre, Institut du Cerveau et de la Moelle épinière (ICM), Hôpital Salpêtrière, Paris, France
| | - Didier Payen
- Université de Paris, UFR de Médecine Sorbonne, Paris, France
| | - Jean-Claude Baron
- Université de Paris, Institute of Psychiatry and Neuroscience of Paris (IPNP), 27102INSERM U1266, Paris, France.,Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, Hôpital Bichat, Paris, France
| | - Anne-Claire Lukaszewicz
- Department of Anesthesiology and Intensive Care, Hôpital Edouard Herriot, Hospices Civils de Lyon, France.,EA 7426 PI3, Université de Lyon-BioMerieux, Lyon, France
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Pranevicius O, Pranevicius M, Liebeskind DS. Partial aortic occlusion and cerebral venous steal: venous effects of arterial manipulation in acute stroke. Stroke 2011; 42:1478-81. [PMID: 21441149 DOI: 10.1161/strokeaha.110.603852] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute ischemic stroke therapy emphasizes early arterial clot lysis or removal. Partial aortic occlusion has recently emerged as an alternative hemodynamic approach to augment cerebral perfusion in acute ischemic stroke. The exact mechanism of cerebral flow augmentation with partial aortic occlusion remains unclear and may involve more than simple diversion of arterial blood flow from the lower body to cerebral collateral circulation. The cerebral venous steal hypothesis suggests that even a small increase in tissue pressure in the ischemic area will divert blood flow to surrounding regions with lesser tissue pressures. This may cause no-reflow (absence of flow after restoration of arterial patency) in the ischemic core and "luxury perfusion" in the surrounding regions. Such maldistribution may be reversed with increased venous pressure titrated to avoid changes in intracranial pressure. We propose that partial aortic occlusion enhances perfusion in the brain by offsetting cerebral venous steal. Partial aortic occlusion redistributes blood volume into the upper part of the body, manifested by an increase in central venous pressure. Increased venous pressure recruits the collapsed vascular network and, by eliminating cerebral venous steal, corrects perifocal perfusion maldistribution analogous to positive end-expiratory pressure recruitment of collapsed airways to decrease ventilation/perfusion mismatch in the lungs.
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