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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 0:revneuro-2024-0028. [PMID: 38581271 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R Mayer
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - Harm J van der Horn
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Joshua Marquez
- 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C Stevenson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C William Shuttleworth
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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von Weitzel-Mudersbach P, Andersen G, Rosenbaum S. Low Morbidity after Extracranial-Intracranial Bypass Operation. The Danish Extracranial-Intracranial Bypass Study: A Nationwide Survey. Cerebrovasc Dis 2018; 45:252-257. [DOI: 10.1159/000489895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Patients with symptomatic atherosclerotic carotid artery occlusion (SACAO) have a high risk of a recurrent stroke. Extracranial-intracranial bypass (EC-IC bypass) has been shown not to improve outcome compared with medical treatment alone because long-term prevention of recurrent stroke in operated patients was offset by high perioperative stroke rates. We report our experience with EC-IC bypass operated at an experienced high-volume centre. Methods: We conducted a nationwide observational study of EC-IC bypass patients operated in the years 2007–2016 due to SACAO with ongoing clinical symptoms or progression on MRI and severe haemodynamic failure (SHF). Perioperative stroke and death within 30 days after the operation, ipsilateral stroke, bypass patency, transient ischaemic attack, and all-stroke events and deaths during long-term follow-up were registered prospectively. Results: EC-IC bypass was performed in 48 patients with SHF and SACAO. The mean age was 64 (45–83) years. The mean follow-up was 3.6 years. The stroke rate after 30 days was 4.2%. No further ipsilateral strokes occurred during follow-up. Clinical symptoms arrested in all patients. Bypass patency rate was 94%. Conclusions: The perioperative stroke rate in EC-IC bypass operation, performed at a highly experienced centre, was low. During long-term follow-up, no ipsilateral stroke occurred. Consequently, EC-IC-bypass should still be considered for selected patients with SACAO, if operation can be carried out in experienced centres with low perioperative morbidity.
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Dynamic Cerebrovascular and Intracranial Pressure Reactivity Assessment of Impaired Cerebrovascular Autoregulation in Intracranial Hypertension. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 122:255-60. [PMID: 27165917 DOI: 10.1007/978-3-319-22533-3_51] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We previously suggested that the discrepancy between a critical cerebral perfusion pressure (CPP) of 30 mmHg, obtained by increasing intracranial pressure (ICP), and 60 mmHg, obtained by decreasing arterial pressure, was due to pathological microvascular shunting at high ICP [1], and that the determination of the critical CPP by the static cerebral blood flow (CBF) autoregulation curve is not valid with intracranial hypertension. Here, we demonstrated that induced dynamic ICP reactivity (iPRx), and cerebrovascular reactivity (CVRx) tests accurately identify the critical CPP in the hypertensive rat brain, which differs from that obtained by the static autoregulation curve. Step changes in CPP from 70 to 50 and 30 mmHg were made by increasing ICP using an artificial cerebrospinal fluid reservoir connected to the cisterna magna. At each CPP, a transient 10-mmHg increase in arterial pressure was induced by bolus intravenous dopamine. iPRx and iCVRx were calculated as ΔICP/Δ mean arterial pressure (MAP) and as ΔCBF/ΔMAP, respectively. The critical CPP at high ICP, obtained by iPRx and iCVRx, is 50 mmHg, where compromised capillary flow, transition of blood flow to nonnutritive microvascular shunts, tissue hypoxia, and brain-blood barrier leakage begin to occur, which is higher than the 30 mmHg determined by static autoregulation.
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Abstract
Carotid occlusion is a disease that presents a difficult decision for the treating provider. Traditionally, many providers would opt for expectant management with risk factor reduction and supportive therapy. There is a growing body of literature however pointing to possible improved outcomes of more aggressive treatments, including reopening of the occluded carotid. In this review, we discuss the difficulties involved in diagnosing a patient presenting with symptomatic carotid occlusion, the natural history of the disease, and the emerging treatment options and paradigms of different institutions based on recent literature.
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Critical cerebral perfusion pressure at high intracranial pressure measured by induced cerebrovascular and intracranial pressure reactivity. Crit Care Med 2015; 42:2582-90. [PMID: 25289933 DOI: 10.1097/ccm.0000000000000655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The lower limit of cerebral blood flow autoregulation is the critical cerebral perfusion pressure at which cerebral blood flow begins to fall. It is important that cerebral perfusion pressure be maintained above this level to ensure adequate cerebral blood flow, especially in patients with high intracranial pressure. However, the critical cerebral perfusion pressure of 50 mm Hg, obtained by decreasing mean arterial pressure, differs from the value of 30 mm Hg, obtained by increasing intracranial pressure, which we previously showed was due to microvascular shunt flow maintenance of a falsely high cerebral blood flow. The present study shows that the critical cerebral perfusion pressure, measured by increasing intracranial pressure to decrease cerebral perfusion pressure, is inaccurate but accurately determined by dopamine-induced dynamic intracranial pressure reactivity and cerebrovascular reactivity. DESIGN Cerebral perfusion pressure was decreased either by increasing intracranial pressure or decreasing mean arterial pressure and the critical cerebral perfusion pressure by both methods compared. Cortical Doppler flux, intracranial pressure, and mean arterial pressure were monitored throughout the study. At each cerebral perfusion pressure, we measured microvascular RBC flow velocity, blood-brain barrier integrity (transcapillary dye extravasation), and tissue oxygenation (reduced nicotinamide adenine dinucleotide) in the cerebral cortex of rats using in vivo two-photon laser scanning microscopy. SETTING University laboratory. SUBJECTS Male Sprague-Dawley rats. INTERVENTIONS At each cerebral perfusion pressure, dopamine-induced arterial pressure transients (~10 mm Hg, ~45 s duration) were used to measure induced intracranial pressure reactivity (Δ intracranial pressure/Δ mean arterial pressure) and induced cerebrovascular reactivity (Δ cerebral blood flow/Δ mean arterial pressure). MEASUREMENTS AND MAIN RESULTS At a normal cerebral perfusion pressure of 70 mm Hg, 10 mm Hg mean arterial pressure pulses had no effect on intracranial pressure or cerebral blood flow (induced intracranial pressure reactivity = -0.03 ± 0.07 and induced cerebrovascular reactivity = -0.02 ± 0.09), reflecting intact autoregulation. Decreasing cerebral perfusion pressure to 50 mm Hg by increasing intracranial pressure increased induced intracranial pressure reactivity and induced cerebrovascular reactivity to 0.24 ± 0.09 and 0.31 ± 0.13, respectively, reflecting impaired autoregulation (p < 0.05). By static cerebral blood flow, the first significant decrease in cerebral blood flow occurred at a cerebral perfusion pressure of 30 mm Hg (0.71 ± 0.08, p < 0.05). CONCLUSIONS Critical cerebral perfusion pressure of 50 mm Hg was accurately determined by induced intracranial pressure reactivity and induced cerebrovascular reactivity, whereas the static method failed.
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Lee SB, Huh PW, Kim DS, Yoo DS, Lee TG, Cho KS. Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke. Clin Neurol Neurosurg 2013; 115:1238-44. [DOI: 10.1016/j.clineuro.2012.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 11/20/2012] [Accepted: 11/24/2012] [Indexed: 01/20/2023]
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Fujimoto S, Toyoda K, Inoue T, Jinnouchi J, Kitazono T, Okada Y. Changes in superficial temporal artery blood flow and cerebral hemodynamics after extracranial–intracranial bypass surgery in moyamoya disease and atherothrombotic carotid occlusion. J Neurol Sci 2013; 325:10-4. [DOI: 10.1016/j.jns.2012.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 11/04/2012] [Accepted: 11/06/2012] [Indexed: 11/29/2022]
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Jussen D, Horn P, Vajkoczy P. Aspirin Resistance in Patients with Hemodynamic Cerebral Ischemia Undergoing Extracranial-Intracranial Bypass Surgery. Cerebrovasc Dis 2013; 35:355-62. [DOI: 10.1159/000348649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/23/2012] [Indexed: 11/19/2022] Open
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Schubert GA, Seiz M, Czabanka M, Thomé C. Perfusion Characteristics in Chronic Cerebrovascular Insufficiency : An Anatomically and Clinically Oriented XeCT Analysis of Cerebrovascular Atherosclerotic Disease. Transl Stroke Res 2011; 3:122-9. [PMID: 24323758 DOI: 10.1007/s12975-011-0107-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/21/2011] [Accepted: 09/21/2011] [Indexed: 10/17/2022]
Abstract
Xenon-enhanced computed tomography (XeCT) allows quantification of hemodynamic insufficiency in the setting of cerebrovascular atherosclerotic disease (CAD). However, data regarding the relationship between hemodynamic indices [cerebral blood flow (CBF) and cerebrovascular reserve capacity (CVRC)] and normal subjects (with aging) and pathology (progression of CAD or development of stroke symptoms) are limited. In this study, we analyzed 103 consecutive patients undergoing XeCT according to age, anatomical location and disease severity. We stratified anatomically defined ROIs according to a classification system that observes the presence of proximal stenosis (class I vs. class II/III) as well as the presence of neurological symptoms (class II vs. III); CBF, CVRC and hemodynamic stress distribution were calculated. Supratentorial CBF decreases significantly with age, but not infratentorially. Cortical CVRC remains stable over time. Our classification of disease severity correlated highly significantly with a decrease in supratentorial CBF and CVRC, though CVRC is less sensitive to age-related changes. Regression analysis delineated a CVRC of 34% to discriminate between ROI classes. Age-dependent perfusion characteristics in normal vascular territories were characterized. In CAD, CVRC remains the most sensitive parameter. A simplified classification of ROIs according to disease severity correlates well with established markers for hemodynamic insufficiency. It may facilitate comparison of different pathologies such as CAD and Moyamoya disease and will be the focus of further studies.
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Yamaguchi K, Kawamata T, Kawashima A, Hori T, Okada Y. Incidence and Predictive Factors of Cerebral Hyperperfusion After Extracranial-Intracranial Bypass for Occlusive Cerebrovascular Diseases. Neurosurgery 2010; 67:1548-54; discussion 1554. [DOI: 10.1227/neu.0b013e3181f8c554] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Although many studies of postoperative cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy have been reported, there are few reports related to extracranial-intracranial (EC-IC) bypass for atherosclerotic occlusive cerebrovascular diseases.
OBJECTIVE:
To examine the incidence of cerebral hyperperfusion and CHS after EC-IC bypass and to investigate predictive factors.
METHODS:
Fifty consecutive patients undergoing EC-IC bypass for atherosclerotic occlusive cerebrovascular diseases were studied. Immediately after bypass surgery, resting regional cerebral blood flow was determined under continuous sedation, and postoperative hyperperfusion was evaluated according to the definitions as follows: > 50% increase in regional cerebral blood flow compared with the contralateral side (method 1) and > 100% increase in corrected regional cerebral blood flow compared with preoperative values (method 2). Logistic regression analysis was conducted to determine the effect of multiple variables on postoperative hyperperfusion.
RESULTS:
Transient symptoms of CHS were observed in 3 patients. Cerebral hyperperfusion was detected in 12 patients (24%) as defined by method 1 and in 9 patients (18%) by method 2. Postoperative hyperperfusion occurred significantly more frequently in patients with the steal phenomenon (regional cerebral vasoreactivity ≤ 0%; P = .001 by method 1 and P = .001 by method 2) and correlated with impaired preoperative regional cerebral vasoreactivity (P < .001). Logistic regression analysis revealed that the steal phenomenon was a significant risk factor for hyperperfusion as defined by both methods 1 (P = .009) and 2 (P = .03).
CONCLUSION:
The incidence of cerebral blood flow-assessed postoperative hyperperfusion after EC-IC bypass for atherosclerotic occlusive cerebrovascular diseases was not rare. Post EC-IC bypass CHS could be reduced by continuous, strict blood pressure control under sedation.
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Affiliation(s)
- Kohji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Akitsugu Kawashima
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomokatsu Hori
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Computed Tomographic Angiography in Evaluation of Superficial Temporal to Middle Cerebral Artery Bypass. J Comput Assist Tomogr 2010; 34:437-9. [DOI: 10.1097/rct.0b013e3181cfbca2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patel HC, Mcnamara IR, Al-Rawi PG, Kirkpatrick PJ. Improved cerebrovascular reactivity following low flow EC/IC bypass in patients with occlusive carotid disease. Br J Neurosurg 2010; 24:179-84. [DOI: 10.3109/02688690903536603] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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YOSHIMURA S, EGASHIRA Y, ENOMOTO Y, YAMADA K, YANO H, IWAMA T. Superficial Temporal Artery to Middle Cerebral Artery Double Bypass Via a Small Craniotomy -Technical Note-. Neurol Med Chir (Tokyo) 2010; 50:956-9. [DOI: 10.2176/nmc.50.956] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Shinichi YOSHIMURA
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
| | - Yusuke EGASHIRA
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
| | - Yukiko ENOMOTO
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
| | - Kiyofumi YAMADA
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
| | - Hirohito YANO
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
| | - Toru IWAMA
- Department of Neurosurgery, Graduate School of Medicine, Gifu University
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Garrett MC, Komotar RJ, Starke RM, Merkow MB, Otten ML, Sciacca RR, Connolly ES. The efficacy of direct extracranial-intracranial bypass in the treatment of symptomatic hemodynamic failure secondary to athero-occlusive disease: a systematic review. Clin Neurol Neurosurg 2009; 111:319-26. [PMID: 19201526 DOI: 10.1016/j.clineuro.2008.12.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Revised: 12/16/2008] [Accepted: 12/19/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The 1985 International Extracranial-Intracranial (EC-IC) Bypass Trial failed to show a benefit following surgery in patients with varying degrees of angiographic ICA stenosis. More recent studies using modern technology to identify appropriate candidates, however, have generated promising findings. As a result, controversy exists regarding the role of this technique in the treatment of symptomatic athero-occlusive disease. To this end, we performed a systematic review and quantitative analysis of the literature to determine if a subset of patients with symptomatic hemodynamic failure secondary to athero-occlusive disease may benefit from direct EC-IC bypass. METHODS We performed a MEDLINE (1985-2007) database search using the following keywords, singly and in combination: EC-IC bypass, hemodynamic failure and misery perfusion. Additional studies were identified manually by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files. Our literature search divided studies into three categories: natural history of patients with stage I hemodynamic failure (16 studies, 2320 patients), natural history of patients with stage II hemodynamic failure (3 studies 163 patients), and outcomes of patients with hemodynamic failure treated by EC-IC bypass (23 studies 506 patients). RESULTS Patients with severe stage I and stage II hemodynamic failure are at higher risk of cerebral infarction than those with mild disease (p=.014, OR 1.17-4.08 and p=0.10, OR 0.89-3.63, respectively). Additionally, patients with severe hemodynamic failure respond better to surgery than those with mild disease (p=0.03, OR 0.16-0.92). CONCLUSIONS Patients with severe hemodynamic failure secondary to athero-occlusive disease appear to benefit from direct EC-IC bypass surgery. As a result, the conclusions of the 1985 International EC-IC Bypass Trial may not be applicable to this subset of patients. A randomized clinical trial involving this patient population is warranted.
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Affiliation(s)
- Matthew C Garrett
- Department of Neurosurgery, Columbia University, New York, NY 10032, United States
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Garrett MC, Komotar RJ, Merkow MB, Starke RM, Otten ML, Connolly ES. The extracranial-intracranial bypass trial: implications for future investigations. Neurosurg Focus 2008; 24:E4. [PMID: 18275299 DOI: 10.3171/foc/2008/24/2/e4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The 1985 International Extracranial-Intracranial (EC-IC) Bypass Trial failed to show a surgical benefit of EC-IC bypass in patients with varying degrees of angiographic stenosis. This study was limited by the technology available at the time it was conducted. In the 20 years since, there has been considerable progress in imaging techniques that now enable the identification of a subset of stroke patients with hemodynamic ischemia. In the present study, the authors review the relevant literature and propose a reevaluation of the benefits of the EC-IC bypass procedure using these new imaging techniques. The authors reviewed the admission criteria for the EC-IC Bypass Trial in the light of more recently discovered neurovascular physiology and showed that the imaging criteria used in that trial are not physiologically adequate. A MED-LINE (1985-2007) database search for EC-IC case studies was conducted, and additional studies were identified manually by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files.
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Affiliation(s)
- Matthew C Garrett
- Department of Neurosurgery, Columbia University, New York, New York 10032, USA
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Levy EI, Yonas H. Cerebral Revascularization for Cerebral Ischemia and Stroke Prevention in Patients with Atherosclerotic Occlusive Disease: Defining the Population That Benefits. Neurosurg Clin N Am 2001. [DOI: 10.1016/s1042-3680(18)30038-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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