Neurophysiologic monitoring to assure delivery of retrograde cerebral perfusion

Ganzel, Brian L.; Edmonds, Harvey L.; Pank, J. R.; Goldsmith, L. Jane

doi:10.1016/s0022-5223(97)70234-4

Cited by 75 publications

(36 citation statements)

References 16 publications

(1 reference statement)

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“…As RCP would have to arterialize the venous space first, one would expect significant true retrograde perfusion to have a much more dramatic effect on rSO 2 than that found. 51 Intraoperative fundoscopy allows direct visualization of regional cerebral circulation in real-time.…”

Section: Is There Evidence That Rcp Perfuses the Brain In Humans?mentioning

confidence: 99%

“…55,56 In our own studies, we have demonstrated that reversal of flow is detectable in two-thirds of patients undergoing RCP, but the velocity is low in many cases. This low flow signal may be undetectable unless filtering is abolished 51 and this makes TCD an unreliable monitoring tool. 56 TCD cannot be applied in all patients due to the lack of an acoustic window in the squamous temporal bone.…”

Section: Is There Evidence That Rcp Perfuses the Brain In Humans?mentioning

confidence: 99%

“…Clearly, during surgery undertaken with a marked head-down operating table tilt, appropriate zeroing of transducers to correctly measure pressure at the level of the brain is essential. However, Ganzel et al 51 have shown that with intensive intraoperative monitoring, RCP can be safely used with higher pressures dependent on demonstration of a reversed Doppler flow signal in the middle cerebral artery. Using multimodality neurophysiological monitoring, they found no evidence of cerebral oedema during RCP if the pressure was kept at 25 mmHg in the SVC in a series of 30 patients.…”

Section: Rcp Driving Pressurementioning

confidence: 99%

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Retrograde cerebral perfusion: clinical and experimental aspects

Wong

Bonser

1999

Perfusion

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Section: Is There Evidence That Rcp Perfuses the Brain In Humans?mentioning

confidence: 99%

Section: Is There Evidence That Rcp Perfuses the Brain In Humans?mentioning

confidence: 99%

Section: Rcp Driving Pressurementioning

confidence: 99%

See 1 more Smart Citation

Retrograde cerebral perfusion: clinical and experimental aspects

Wong

Bonser

1999

Perfusion

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“…Although a number of modalities, such as near-infrared spectroscopy and transcranial cerebral oximetry, have been introduced to monitor the brain during aortic arch operations, no single technique has proven to be a perfect monitoring tool. A method of physiological monitoring, intraoperative electroencephalography (EEG), was introduced by Ganzel and colleagues in 1997 [10]. The viewpoint is that maximal cerebral protection is achieved at temperatures suicient to induce electrocerebral inactivity on EEG, under the assumption that maximal suppression of cerebral metabolic activity is achieved at electrocerebral inactivity [2,11].…”

Section: Introductionmentioning

confidence: 99%

Intraoperative Electroencephalography During Aortic Arch Surgery

Murashita¹

2017

Electroencephalography

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Since its introduction, deep hypothermic circulatory arrest has been widely used for cerebral protection during aortic arch surgery. The use of electroencephalogram plays an important role in intraoperative neurophysiologic monitoring. Systemic cooling to the point of electrocerebral inactivity has been thought to ensure optimal neuroprotection from the ischemic injury during circulatory arrest. Therefore, electroencephalogram can guide surgeons to induce deep hypothermic circulatory arrest at an optimal timing. In the meantime, along with the advent of adjunctive cerebral perfusion techniques, there is a certain trend that circulatory arrest is induced at higher degrees than traditional deep hypothermic approach, called moderate hypothermic circulatory arrest. The role of electroencephalogram in this approach has not been well established yet, but some studies suggested the importance of intraoperative electroencephalogram in this approach as well. Electroencephalogram is also utilized in emerging operative techniques called hybrid arch repair. To conclude, intraoperative use of electroencephalogram can greatly contribute to cerebral protection in the ield of aortic arch surgery, and surgeons should be familiar with its mechanism, indication, and interpretation.

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“…8 Clinical studies measuring transcranial Doppler flow, subdural laser Doppler flow, retinal angiography, and radioactive tracers suggest that RCP, may provide cerebral blood flow sufficient to support cerebral metabolism, at least in some patients. [9][10][11][12][13] Anatomic variations in the internal jugular vein (ie, presence or absence of valves and competence of valves) may play a role in whether RCP actually provides brain perfusion. It has been difficult to address this question using animal models because the cerebral venous anat- ACP involves selectively circulating blood to the brain via the arch vessels while the remainder of the body is in circulatory arrest.…”

mentioning

confidence: 99%

Cerebral Protection During Surgery of the Aortic Arch

Soong

Uysal

Reich

2001

Semin Cardiothorac Vasc Anesth

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The most significant challenge in surgical repair of the aortic arch (transverse thoracic aorta) is to protect the brain from ischemic injury. During the portion of the procedure when the brachiocephalic vessels are attached to a graft, there is an obligatory interruption in the normal path of circulation to the brain. Various strategies are used to overcome the potential for brain injury during discontinuity between the aorta and the cerebral circulation. These include deep hypothermic circulatory arrest, retrograde cerebral perfusion, and selective anterograde cerebral perfusion. Pharmacologic adjuncts to these procedures are also used to further enhance brain protection. This review addresses the relative merits of these techniques as means of cerebral protection. Copyright © 2001 by W.B. Saunders Company.Hypothermia has been the mainstay of cerebral protection against global ischemic injury for more than 2 decades. Although the underlying mechanism of hypothermia-induced brain protection is unclear, it is almost certainly related to a reduction in the cerebral metabolic rate for oxygen (CMR02), which is in proportion to the degree of brain cooling. Other potential mechanisms of cerebral protection include decreased toxic neurotransmitter release during ischemia and amelioration of oxidative stress during reperfusion.Cerebral hypothermia may be accomplished using both cardiopulmonary bypass (CPB) with a heat exchanger and surface cooling. The optimal rate of cooling is controversial. Some centers use maximal cooling, in which the bath temperature is as low as 4°C with perfusate temperatures of approximately 10°C. Other centers limit the gradient between esophageal and blad-I der temperature to <10°C by gradually lowering the bath and perfusate temperatures. The use of a-stat versus pH-stat blood gas management during hypothermic CPB is also controversial. The addition of carbon dioxide gas during pH-stat management induces cerebral vasodilation. In older patients with atherosclerotic disease, this may result in a greater embolic load to the brains However, in patients who have cyanotic congenital heart disease with bronchopulmonary collateral vessels, cerebral vasodilation may be advantageous in preventing pulmonary stealing of cerebral blood flow. Although there are data on coronary artery bypass surgery, there are no outcome data to support the choice of a-stat versus pH-stat gas management in aortic arch surgery.An important clinical question is at what point it is safe to begin circulatory arrest for the period required for the surgical repair. Many institutions use duration of cooling and/or temperatures measured in various body cavities as their criteria for initiating circulatory arrest. A minimum of 30 minutes of cooling during CPB is commonly required to prevent upward drift of temperature during circulatory arrest. Circulatory arrest is typically initiated only after temperatures in the range of 12 to 18°C, measured at esophageal, urinary bladder, nasopharyngeal, tympanic membrane, and rectal si...

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Neurophysiologic monitoring to assure delivery of retrograde cerebral perfusion

Cited by 75 publications

References 16 publications

Retrograde cerebral perfusion: clinical and experimental aspects

Retrograde cerebral perfusion: clinical and experimental aspects

Intraoperative Electroencephalography During Aortic Arch Surgery

Cerebral Protection During Surgery of the Aortic Arch

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