Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery

Spetzler, Robert F.; Schuster, Herbert; Roski, Richard A.

doi:10.3171/jns.1980.53.1.0022

Cited by 208 publications

(38 citation statements)

References 15 publications

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“…4 The risk of stroke can virtually be eliminated by selection of patients whose cerebral blood flow falls less than 25% with carotid occlusion, 5 or by performing a EIAB and staged occlusion. 6 In our series of aneurysm patients the MCAP fell to an average ratio of 0.76 when the ICA was temporarily occluded. This is a considerably higher ratio than the 0.58 MCAP/MSBP ratio recorded from the unilateral ICA occlusion group secondary to cerebrovascular disease.…”

mentioning

confidence: 58%

Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease.

Spetzler¹,

Roski²,

Zabramski³

1983

Stroke

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SUMMARYWe measured the MCAP (middle cerebral artery pressure)/MSBP (mean systemic blood pressure) ratio in 76 patients who underwent an EIAB (extracranial-intracranial arterial bypass). Patients were divided into groups on the basis of angiographic findings. We found a definite correlation between increasing angiographic cerebral vascular occlusive disease and lower MCAP/MSBP ratios. Six of 32 patients with a preoperative neurologic deficit demonstrated mild but definite postoperative neurologic improvement. The mean MCAP/MSBP ratio in these six patients was significantly lower than that for the remainder of this group (p < .05). Finally, postoperative filling of the middle cerebral artery territory through the graft was found to correlate in an inverse linear relationship with MCAP/MSBP. Evidence is presented that hypoperfusion produced by occlusion of major cranial vessels plays an important role in temporary and permanent neurological deficits seen in patients with cerebrovascular disease.Stroke, Vol 14, No 4, 1983 THE PATHOPHYSIOLOGY OF TIA's (transient ischemic attacks) and strokes in patients with arteriographic evidence of occlusive cerebrovascular disease, is not fully understood. Embolic and cerebral hypoperfusion are considered to be the two major pathophysiologic mechanisms. To determine the presence of cerebral hypoperfusion in patients with cerebrovascular disease, we measured the middle cerebral artery pressure (MCAP) in 76 patients selected for cerebral revascularization. The mean systemic blood pressure (MSBP) was measured at the same time, and a MCAP/ MSBP ratio was analyzed and compared to the patient's preoperative angiographic findings, neurologic presentation, clinical outcome and post-operative caliber of the bypass. Clinical MaterialOur results are based on a series of 76 patients who underwent cerebral revascularization. The group is comprised of 31 female and 45 male patients, whose ages ranged from 21 to 74 years with a mean age of 54 years. Five patients underwent an EIAB (extracranialintracranial arterial bypass) and ligation of their ICA for the treatment of a giant internal carotid artery aneurysm. The remaining 71 patients were treated with a EIAB for symptomatic cerebrovascular occlusive disease. MethodsThe MCAP was measured by placing a thirty gauge needle, connected to a Bell and Howell transducer, into a cortical branch of the MCA (middle cerebral artery) at the point of intended anastomosis ( fig. 1). Although the small needle will blunt the systolic and diastolic spikes and waves it is perfectly accurate in

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confidence: 58%

Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease.

Spetzler¹,

Roski²,

Zabramski³

1983

Stroke

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“…To prevent late ischaemic complications [13,14], it may be safer to perform an external-internal carotid artery bypass operation before permanent occlusion of the ICA if the patient has a ratio of stump pressure to systemic pressure that is less than 60% with no marked decrease in CBF on 99 m Tc-HMPAO SPECT or in a xenon CT CBF study. Greater numbers of patients are required to confirm these results.…”

Section: Discussionmentioning

confidence: 99%

Stump pressure as a guide to the safety of permanent occlusion of the internal carotid artery

et al. 1996

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Does the absolute value of the stump pressure (post-occlusion back pressure) become a useful index of a good collateral circulation? The authors continuously monitored the mean arterial pressure before, during and after 20-minute balloon test occlusion in 24 patients. The stump pressure was then compared with the results of 99mTc-hexa-methyl propyleneamine (99mTc-HMPAO) single photon emission computed tomography (SPECT) performed after 20 minutes of test occlusion. Patients who failed to tolerate even brief periods of carotid occlusion and showed asymmetric decreases in cerebral blood flow (CBF) on SPECT were divided into high and moderate risk groups. Those with no significant change in CBF on the occluded side formed the minimum risk group. Mean stump pressure was over 50 mmHg in three of a total of 13 patients in the high and moderate risk groups, and below 50 mmHg in two of the 11 patients in the minimum risk group. The ratios of the initial mean stump pressure to the pre-occlusion mean arterial pressure (%) and of the final mean stump pressure at the end of occlusion to the post-opening mean arterial pressure (%) did not exceed 58% in any patient in the high and moderate risk groups, and were at least 60% in all patients of the minimum risk group. Maintenance of a mean stump pressure of 60% or more of the mean systemic pressure during test occlusion may be a more useful index of a good collateral circulation than the absolute value of mean stump pressure.

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“…Surgical exposure of a recently ruptured dissecting aneurysm carries the potential for severe and uncontrolled intraoperative rupture of a lesion that may not be readily amenable to simple clip reconstruction. In this setting, distal bypass combined with proximal or distal M1 occlusion may represent reasonable options to reverse or limit flow through the abnormal arterial segment [7,9,[16][17][18][19][20] In three of our cases, this paradigm only temporarily stabilized the situation, and further treatment was required to treat an enlarging aneurysm.…”

Section: Discussionmentioning

confidence: 99%

Treatment Strategies for Management of MCA-M1 Spontaneous Dissecting Aneurysms

Defillo¹

2014

JNSK

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Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery

Cited by 208 publications

References 15 publications

Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease.

Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease.

Stump pressure as a guide to the safety of permanent occlusion of the internal carotid artery

Treatment Strategies for Management of MCA-M1 Spontaneous Dissecting Aneurysms

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