High-flow excimer laser-assisted extra-intracranial and intra-intracranial bypass

Schooneveld

et al. 2002

Background and Purpose-Chronic ocular ischemia is a rare form of ischemia of the eye in patients with carotid artery occlusion (CAO). The early and often asymptomatic stage of chronic ocular ischemia is referred to as venous stasis retinopathy (VSR). The aim of this study was to gain insight into the prevalence, cause, and outcome of VSR in patients with symptomatic CAO. Methods-In 110 patients with symptomatic CAO, we prospectively investigated the frequency of VSR, the association between the presence of VSR and impaired cerebral blood flow, and the proportion of patients who developed clinically manifest chronic ocular ischemia with ischemia of the anterior eye segment or blindness. Results-At study entry, VSR was found in 32 patients (29%; 95% CI, 21 to 38), particularly in those with symptoms classically associated with a hemodynamic cause, such as limb shaking (relative risk, 2.4; 95% CI, 1.0 to 5.9). Patients with VSR had lower pulsatility indexes in the ophthalmic artery in case of reversed flow, lower cerebral CO 2 reactivity, and lower cerebropetal blood flow than patients without VSR. On follow-up (mean, 29 months), clinically manifest chronic ocular ischemia developed in 4 patients (annual rate, 1.5%; 95% CI, 0.4 to 3.8); it tended to occur more often in patients in whom VSR was present at study entry (relative risk, 7.3; 95% CI, 0.8 to 68). Conclusions-One

Section: Patientsmentioning

confidence: 99%

Venous Stasis Retinopathy in Symptomatic Carotid Artery Occlusion

Schooneveld

et al. 2002

“…Patients with recurrent symptoms that were of presumed hemodynamic origin were offered high-flow EC/IC bypass surgery according to the method of Tulleken. 22,23 In all patients antithrombotic medication was prescribed (low-dose aspirin in the majority), and vascular risk factors were rigorously treated.…”

Section: Patientsmentioning

confidence: 99%

Magnetic Resonance Techniques for the Identification of Patients With Symptomatic Carotid Artery Occlusion at High Risk of Cerebral Ischemic Events

Algra

et al. 2000

Background and Purpose-We sought to assess whether MRI, MR angiography, or 1 H MR spectroscopy can be used to identify patients with symptomatic carotid artery occlusion (CAO) who are at high risk of recurrent ipsilateral cerebral ischemic events. Methods-In 115 consecutive patients with transient or moderately disabling symptoms of cerebral or retinal ischemia and ipsilateral CAO, we studied the prognostic value of (1) presence of a border-zone infarct; (2) quantitative flow in the middle cerebral artery (MCA) ipsilateral to the CAO; and (3) metabolic ratios in the centrum semiovale ipsilateral to the CAO. Results-Presence of a border-zone infarct and the rate of flow in the MCA did not have a significant relationship with recurrence of cerebral ischemic events. Patients with a low N-acetyl aspartate (NAA)/choline ratio had an annual risk of recurrent, ipsilateral, cerebral ischemic events of 16.0% (95% CI, 9.5 to 27.0), whereas this risk was 4.2% (95% CI, 2.2 to 8.0) in those with a normal NAA/choline ratio (hazard ratio, 0.43; 95% CI, 0.19 to 1.00). Patients who on entry had had only retinal symptoms had on average a higher NAA/choline ratio (mean difference, 0.25; 95% CI, 0.13 to 0.37) and a lower risk of recurrent cerebral ischemic events (odds ratio, 0.0; 95% CI, 0.0 to 0.6) than those with cerebral ischemic symptoms. Conclusions-NAA/choline

“…Furthermore, the excimer laser-assisted EC/IC bypass may be more efficient than the conventional STA-MCA bypass because it ensures high flow proximal in the vascular tree. 16,32 Many studies have reported improvement in cerebral hemodynamic measurements after a conventional STA-MCA bypass, 30,[33][34][35][36] but comparisons with similar patients who were not operated on are lacking. Others found that improvement in hemodynamic measures did not occur 37 or occurred in only some operated patients.…”

Section: Klijn Et Al High-flow Ec/ic Bypass In Symptomatic Carotid Ocmentioning

confidence: 99%

“…to develop a new EC/IC bypass technique. [13][14][15][16] For this bypass, the intracranial distal part of the internal carotid artery (ICA) or the proximal part of the MCA is used as the recipient artery. It is not necessary to temporarily clamp the recipient artery because the distal anastomosis is made with an excimer laser-assisted technique.…”

mentioning

confidence: 99%

Excimer Laser–Assisted High-Flow Extracranial/Intracranial Bypass in Patients With Symptomatic Carotid Artery Occlusion at High Risk of Recurrent Cerebral Ischemia

Zwan

et al. 2002

Background and Purpose-The goal of this study was to determine safety and long-term outcome of the excimer laser-assisted high-flow extracranial/intracranial (EC/IC) bypass in patients with symptomatic carotid artery occlusion (CAO) at high risk of recurrent stroke. Methods-In a prospectively collected cohort of 103 patients with symptomatic CAO, 15 patients were selected for excimer laser-assisted EC/IC bypass surgery on the basis of predefined selection criteria: (1) transient or moderately disabling symptoms of focal cerebral ischemia, not symptoms of the retina only; (2) continuing symptoms after documentation of the CAO; (3) evidence of a possible hemodynamic origin of symptoms; and (4) informed consent of the patient. Results-Eleven patients underwent the operation without complications One patient had a severely disabling stroke (Rankin grade 4) 11 days after the operation; the bypass was found occluded on reoperation. Two other patients had a moderately disabling stroke (Rankin grade 3) immediately after the operation. One patient died of myocardial infarction 1 day after surgery. Median follow-up time was 27 months. Of the 11 patients who underwent the operation without complications, 1 died 17 months after the operation of a brainstem stroke, and another patient had a new stroke ipsilateral to his CAO 10 months after the operation but without a change in Rankin grade. Conclusions-The excimer laser-assisted high-flow EC/IC bypass operation is a potentially promising procedure in patients with symptomatic CAO and a presumably high risk of recurrent stroke, but the procedure carries a definite risk. This risk is probably related not only to the procedure itself but also to the selection of patients.