The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy.

Sundt, Thoralf M.

doi:10.1161/01.str.14.1.93

Cited by 134 publications

(30 citation statements)

References 69 publications

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“…7 It has not been possible to resolve this controversy because the complication rate of carotid endarterectomy is now so low that no surgical group can collect sufficient cases to demonstrate a conclusive advantage of any one policy. A critical factor confounding the debate has been the difficulty of measuring cerebral ischemia as the essential element upon which the assessment of shunting should be based.…”

mentioning

confidence: 99%

“…A critical factor confounding the debate has been the difficulty of measuring cerebral ischemia as the essential element upon which the assessment of shunting should be based. Sundt,7 who pioneered selective shunting based on regional cerebral blood flow (rCBF) and electroencephalographic (EEG) monitoring, achieved very low morbidity and mortality. He argued that failure to shunt in approximately 30% of cases would have been associated with a high probability of infarction.…”

mentioning

confidence: 99%

“…He argued that failure to shunt in approximately 30% of cases would have been associated with a high probability of infarction. 7 However, his large series contained few nonshunted severely ischemic cases and no shunted nonischemic cases.…”

mentioning

confidence: 99%

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Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators.

Halsey

1992

Stroke

192

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Background and Purpose: Controversy continues about the pathogenesis of perioperative stroke in carotid endarterectomy and the use of shunting. The purpose of this study was to determine, using transcranial Doppler ultrasonography, the severity of ischemia during clamping of the carotid artery as a basis for analysis of complications in patients operated on with and without shunting.Methods: In a retrospective study, 11 centers contributed 1,495 carotid endarterectomies monitored with transcranial Doppler. The cases were divided into groups with severe, mild, and no ischemia, and each group was subdivided according to shunt use. The perioperative rate of severe stroke attributable to intraoperative ischemia, in addition to total perioperative stroke, was determined for each subgroup.Results: Severe ischemia occurred in 7.2% of our cases but cleared spontaneously in about half of these. In those with persisting ischemia the rate of severe stroke was very high, while shunting protected against stroke in such cases. If ischemia did not occur, the stroke rate was higher with shunting, although not so high as in unshunted cases with severe ischemia. Slightly more than one third of the severe strokes were due to postoperative cerebral hemorrhage or carotid thrombosis, unrelated to clamp-induced ischemia or shunting.Conclusions: Carotid endarterectomy complications might be reduced by selectively shunting only for severe persisting ischemia. Monitoring of cerebral ischemia would be essential to selective shunting. (Stroke 1992;23:1583-1587 KEY WORDS • carotid endarterectomy • cerebral ischemia • ultrasonics

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confidence: 99%

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Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators.

Halsey

1992

Stroke

192

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“…Previous studies have revealed that preoperative persistent dilation of resistance vessels is the most likely cause of postoperative hyperperfusion after surgical revascularization such as CEA and STA-MCA anastomosis. 15,20,21,23,24,26) Hyperperfusion syndrome includes headache, seizure, focal neurological deficits, and intracerebral hemorrhage, and is sometimes lethal. 23) Nowadays, such vascular conditions can be identified as a decrease in cerebral perfusion reserve, using SPECT and PET, and may be a significant predictor for postoperative hyperperfusion.…”

Section: Discussionmentioning

confidence: 99%

“…12) Cerebral hyperperfusion is known to occur after revascularization surgery, including carotid endarterectomy (CEA) and superficial temporal artery to MCA (STA-MCA) anastomosis. 15,20,21,23,24,26) In particular, cerebral hyperperfusion syndrome occurs in about 30% of adult patients with moyamoya disease after STA-MCA anastomosis. 5) However, there are few reports of CCD due to cerebral hyperperfusion after bypass surgery.…”

Section: Introductionmentioning

confidence: 99%

Transient Crossed Cerebellar Diaschisis Due to Cerebral Hyperperfusion Following Surgical Revascularization for Moyamoya Disease

Hokari

Kuroda

Simoda

et al. 2012

Neurol. Med. Chir.(Tokyo)

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Crossed cerebellar diaschisis (CCD) often occurs after ischemic or hemorrhagic stroke that damages the cortico-ponto-cerebellar pathway. However, CCD due to cerebral hyperperfusion following cerebrovascular reconstruction is rare. A 61-year-old woman presented with transient CCD due to cerebral hyperperfusion following bypass surgery for adult moyamoya disease. She developed transient weakness of the right extremities and was diagnosed with moyamoya disease. First, she underwent superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis with indirect synangiosis on the left. Postoperative course was uneventful. Subsequently, she underwent STA-MCA anastomosis with indirect synangiosis on the right. She complained of mild headache on the right, and single photon emission computed tomography (SPECT) performed on the 7th postoperative day demonstrated hyperperfusion in the right frontal and temporal lobes associated with hypoperfusion in the left cerebellum. Magnetic resonance (MR) imaging demonstrated no new lesions and MR angiography showed patent STA-MCA bypass. Subsequent SPECT showed disappearance of both hyperperfusion and CCD. This case strongly suggests that cerebral hyperperfusion after bypass surgery for moyamoya disease may cause transient CCD. Although the clinical significance is still obscure, this phenomenon indicates the cortico-ponto-cerebellar pathway is interrupted due to hyperperfusion, suggesting the development of hyperperfusion syndrome. Careful observation of cerebral hemodynamics after bypass surgery is warranted to avoid hyperperfusion-related complications.

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Carotid Endarterectomy

Ferguson¹

1986

Arch Neurol

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The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy.

Cited by 134 publications

References 69 publications

Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators.

Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators.

Transient Crossed Cerebellar Diaschisis Due to Cerebral Hyperperfusion Following Surgical Revascularization for Moyamoya Disease

Carotid Endarterectomy

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