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

Klijn, Catharina J.M.; Kappelle, L. Jaap; Zwan, Albert van der; Gijn, J. van; Tulleken, Cornelis A.F.

doi:10.1161/01.str.0000030319.78212.51

Cited by 63 publications

(28 citation statements)

References 53 publications

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“…12,17,29 Although the EC-IC bypass trials were conducted for patients with symptomatic ICA stenoocclusive disease, they failed to show the benefit of surgery over the "best medical therapy." 24,35 Similar failures were noted in a recent clinical trial of intracranial stent placement for patients with severe (70%-99%) intracranial stenosis.…”

Section: Discussionmentioning

confidence: 99%

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries

Low¹,

Teo²,

Lwin³

et al. 2015

JNS

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Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. results A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). 99mTc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamidechallenge 99m Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). coNclusioNs STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.http://thejns.org/doi/abs/10.3171/2014.11.JNS141553KeY words acute ischemic stroke; intracranial atherosclerosis; cerebral vasodilatory reserve; SPECT; external carotid-internal carotid bypass; superficial temporal artery; middle cerebral artery; bypass; vascular disorders 662©AANS, 2015 ec-ic bypass for intracranial stenosis

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Section: Discussionmentioning

confidence: 99%

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries

Low¹,

Teo²,

Lwin³

et al. 2015

JNS

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“…[95][96][97] Several case series have demonstrated benefit from ECIC bypass if the patient population is carefully defined. In a study by Mendelowitsch et al, 98 85% of the patients had no further cerebrovascular events after surgery in the average follow-up period of 44 months, and only 11% experienced another cerebrovascular event.…”

Section: Pre-and Postoperative Evaluation Of Extracranialintracranialmentioning

confidence: 99%

The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia

Vagal¹,

Leach²,

Fernández-Ulloa³

et al. 2009

AJNR Am J Neuroradiol

162

116

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SUMMARY:The acetazolamide (ACZ) challenge test is a useful clinical tool and a reliable predictor of critically reduced perfusion. In patients with chronic steno-occlusive disease, the ability to maintain normal cerebral blood flow by reducing vascular resistance secondary to autoregulatory vasodilation is compromised. Identification of the presence and degree of autoregulatory vasodilation (reflecting the cerebrovascular reserve) is a significant prognostic factor in patients with chronic cerebrovascular disease. The pharmacologic challenge of a vasodilatory stimulus such as ACZ can also be used to optimize the treatment strategies for these patients. The pathophysiology, methods, and clinical applications of the ACZ challenge test are discussed in this article. Viability of the cerebral parenchyma is dependent on the ability of the brain vasculature to provide adequate levels of cerebral blood flow (CBF). In patients with chronic stenoocclusive disease, the ability to maintain normal CBF by reducing vascular resistance is compromised. Identification of the degree of autoregulatory vasodilation reflects cerebrovascular reserve (CVR), which is a significant prognostic factor in chronic cerebrovascular disease.1-5 Flow reserve can be assessed with the use of paired blood flow measurements, with the initial measurement obtained at baseline and the second, after a vasodilatory stimulus, such as acetazolamide (ACZ). 6 Pathophysiology of Chronic Cerebrovascular DiseaseChronic cerebral hypoperfusion is usually the result of occlusion or stenosis of large arteries in the neck or the circle of Willis. Clinical symptoms and manifestations of brain ischemia in patients with chronic cerebrovascular disease (CVD) develop as a consequence of 2 main mechanisms: embolic events from atherosclerotic plaques resulting in local compromise of blood flow and systemic hemodynamic alterations that further reduce an already compromised cerebral perfusion state. 7The hemodynamic changes due to a decline in cerebral perfusion pressure have been studied by many investigators. 6,[8][9][10][11] Chronic CBF restriction causes a progressive decrease in cerebral perfusion pressure (CPP). Initially, decreases of CPP cause varying degrees of autoregulatory vasodilation of small distal arterioles.12 Powers 10 and Powers et al 11 proposed a 2-stage classification of hemodynamic impairment in patients with CVD. In stage I (autoregulatory vasodilation), autoregulation reduces cerebral vascular resistance. CBF and oxygen extraction fraction (OEF) are not significantly changed. Increases of cerebral blood volume (CBV) and mean transit time (MTT) are 2 parameters that reflect this initial phase of compensatory autoregulatory vasodilation. Further decreases of CPP beyond cerebral autoregulatory vasodilation capacity eventually result in stage II (autoregulatory failure), characterized by decreases of CBF and increases of OEF. When the CBF decreases, neurons increase the fraction of oxygen extracted from the blood to maintain normal neurologic function. ...

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“…17 Additionally, SSYLVIA documented a high restenosis rate at 6 months. Because of the limited experience with high-grade MCA stenoses, symptomatic patients with perfusion failure may need to await further prospective evaluation of available treatments, including conventional or modified extracranial-intracranial bypass surgery 18,19 and angioplasty with or without stenting on an individual compassionate basis.…”

Section: Schumacher Et Al Histopathological Mca Findings After Angiopmentioning

confidence: 99%

Histopathological Evaluation of Middle Cerebral Artery After Percutaneous Intracranial Transluminal Angioplasty

Schumacher

Tanji

Mangla

et al. 2003

Stroke

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

Cited by 63 publications

References 53 publications

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries

The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia

Histopathological Evaluation of Middle Cerebral Artery After Percutaneous Intracranial Transluminal Angioplasty

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