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Chung Y, Nam SM, Lee SH, Kim K, Kang HS, Kim JE, Cho WS. Surgical Outcomes of Low-Flow Bypass Surgery in Intracranial Atherosclerotic Steno-Occlusive Diseases. Neurosurgery 2024:00006123-990000000-01155. [PMID: 38690884 DOI: 10.1227/neu.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/10/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The role of bypass surgery in intracranial atherosclerotic steno-occlusive diseases (ICADs) remains controversial. We aimed to analyze the surgical outcomes of bypass surgery in patients with the ICADs in a single tertiary institution. METHODS Among 1018 cases of low-flow bypass surgery between 2003 and 2022, 215 patients with the ICAD refractory to medical treatment were finally enrolled in this study. Clinical and radiological outcomes were retrospectively evaluated, with survival analyses. RESULTS All strokes, cerebral infarctions, and intracranial hemorrhages occurred in 12.1% (n = 26), 9.8% (n = 21), and 2.3% (n = 5), respectively, during the clinical follow-up of 54.6 ± 47.6 months (range, 0.6-237.8 months). Among all stroke events, 84.6% (n = 22) occurred within 30 postoperative days. The 2-year and 5-year cumulative risks of all strokes were 12.1% each. The mean modified Rankin Scale scores were 1.6 ± 1.1 (range, 0-5) preoperatively and 0.8 ± 1.2 (range, 0-6) at last (P < .01). The patency of direct bypass was 99.1% (n = 213) just before discharge and 96.3% (n = 184 of 191 patients with available tests) at the last angiographic follow-up of 27.0 ± 27.3 months (range, 2.3-97.3 months). All the patients with available data (n = 190) showed hemodynamic improvement on acetazolamide-challenged single-photon emission computed tomography with 99mTc-hexamethylpropyleneamine oxime during the follow-up of 38.6 ± 36.7 months (range, 2.3-158.6 months). CONCLUSION Low-flow bypass surgery showed acceptable treatment outcomes in the prevention of recurrent stroke.
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Affiliation(s)
- Yuwhan Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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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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Sebök M, Höbner LM, Fierstra J, Schubert T, Wegener S, Kulcsár Z, Luft AR, Regli L, Esposito G. Flow-augmentation STA-MCA bypass for acute and subacute ischemic stroke due to internal carotid artery occlusion and the role of advanced neuroimaging with hemodynamic and flow-measurement in the decision-making: preliminary data. Quant Imaging Med Surg 2024; 14:777-788. [PMID: 38223058 PMCID: PMC10784084 DOI: 10.21037/qims-23-876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/30/2023] [Indexed: 01/16/2024]
Abstract
Background A major clinical challenge is the adequate identification of patients with acute (<1 week) and subacute (1-6 weeks) ischemic stroke due to internal carotid artery (ICA) occlusion who could benefit from a surgical revascularization after a failure of endovascular and/or medical treatment. Recently, two novel quantitative imaging modalities have been introduced: (I) quantitative magnetic resonance angiography (qMRA) with non-invasive optimal vessel analysis (NOVA) for quantification of blood flow in major cerebral arteries (in mL/min), and (II) blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging to assess cerebrovascular reactivity (CVR). The aim of this study is to present our cohort of patients who underwent surgical revascularization in the acute and subacute phase of ischemic stroke as well as to demonstrate the importance of hemodynamic and flow assessment for the decision-making regarding surgical revascularization in patients with acute and subacute stroke and ICA-occlusion. Methods Symptomatic patients with acute and subacute ischemic stroke because of persistent ICA-occlusion despite optimal medical/endovascular recanalization therapy who were treated at the Neuroscience Clinical Center of the University Hospital Zurich underwent both BOLD-CVR and qMRA-NOVA to study the hemodynamic and collateral vessel status. Patients selected for surgical revascularization according to our previously published flowchart were included in this prospective cohort study. Repeated NOVA and BOLD-CVR investigations were done after bypass surgery as follow up as well as clinical follow up. Continuous BOLD-CVR and qMRA-NOVA variables were compared using paired Student t-test. Results Between May 2019 and September 2022, superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery was performed in 12 patients with acute and subacute stroke because of ICA-occlusion despite of optimal endovascular and/or medical treatment prior to the surgery. Impaired BOLD-CVR in the occluded vascular territory [MCA territory: ipsilateral vs. contralateral: -0.03±0.07 vs. 0.11±0.07 %BOLD/mmHgCO2, P<0.001] as well as reduced hemispheric flow with qMRA-NOVA (ipsilateral vs. contralateral: 228.00±54.62 vs. 384.50±70.99 mL/min, P=0.01) were measured indicating insufficient collateralization. Post-operative qMRA-NOVA showed improved hemispheric flow (via bypass) (pre-bypass vs. post-bypass: 236.60±76.45 vs. 334.20±131.33 mL/min, P=0.02) and the 3-month-follow-up with BOLD-CVR showed improved cerebral hemodynamics (MCA territory: pre-bypass vs. post-bypass: -0.01±0.05 vs. 0.06±0.03 %BOLD/mmHgCO2, P=0.02) in all patients studied. Conclusions Quantitative assessment with BOLD-CVR and qMRA-NOVA allows us to evaluate the pre- and post-operative cerebral hemodynamics and collateral vessel status in patients with acute/subacute stroke due to ICA occlusion who may benefit from surgical revascularization after failure of endovascular/medical treatment.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Lara Maria Höbner
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Tilman Schubert
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsár
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas R. Luft
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Yu LB, Shen M, Zhang Q, Zhang D. A Vessel Wall MRI Investigation in Patients With Moyamoya or Quasi-Moyamoya Disease: Diagnosis, Features, and Outcomes. J Craniofac Surg 2024; 35:e24-e28. [PMID: 37622552 DOI: 10.1097/scs.0000000000009681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/25/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND PURPOSE None of the previous studies have investigated the pathologic authenticity of affected arteries in moyamoya disease (MMD) and Quasi-MMD diagnosed by angiography. This study aimed to confirm the angiographic diagnosis of moyamoya as well as investigate the pathologic mechanisms in angiographically proven MMD and Quasi-MMD using high-resolution magnetic resonance imaging (MRI) in a large sample. METHODS We prospectively studied 116 patients who had angiographically proven MMD and Quasi-MMD. Each affected internal carotid artery, and middle cerebral artery was independently evaluated. In addition, clinical features and postoperative outcomes were compared between hemispheres with MMD and moyamoya syndrome (MMS). RESULTS Among 116 patients analyzed, 88 and 22 patients had angiographically proven MMD and Quasi-MMD, respectively. high-resolution magnetic resonance imaging confirmed bilateral MMD in 73 (83.0%) patients, 1 hemisphere with MMD and the other with intracranial atherosclerotic disease (ICAD) in 10 (11.4%) patients, and bilateral hemispheres with different vasculopathies in 5 (5.7%) patients. Detailed analysis of 204 affected hemispheres showed that several combinations of different vasculopathies were observed in the internal carotid artery and middle cerebral artery of the same hemisphere, such as ICAD-ICAD, ICAD-MMD, dissection-ICAD, and dissection-MMD. Hemispheres were assigned to MMD and MMS groups according to their vasculopathies. Transient ischemic attack occurred more frequently in hemispheres with MMD (48.1% versus 21.1%, P =0.024), whereas symptomatic ischemia was more common in hemispheres with MMS (57.9% versus 24.9%, P =0.002). However, postoperative cerebral infarction, symptom improvement and neo-formative collaterals showed no significant difference between hemispheres with MMD and MMS ( P >0.05). CONCLUSIONS Patients with angiographically proven MMD or Quasi-MMD needed more accurate evaluation combined with high-resolution magnetic resonance imaging. Highly selected patients with MMS might also obtain benefits from surgical revascularization.
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Affiliation(s)
- Le-Bao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Mi Shen
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease
- Department of Neurosurgery, Beijing Hospital, Beijing, China
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Khaw AV, Thiessen JD, St. Lawrence K, Pandey SK. The Quest of Characterizing Hemodynamic Failure in Patients With Cerebrovascular Disease. J Am Heart Assoc 2023; 12:e032657. [PMID: 38084748 PMCID: PMC10863759 DOI: 10.1161/jaha.123.032657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Alexander V. Khaw
- Department of Clinical Neurosciences, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Jonathan D. Thiessen
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Keith St. Lawrence
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Sachin K. Pandey
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
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Sebök M, van der Wouden F, Mader C, Pangalu A, Treyer V, Fisher JA, Mikulis DJ, Hüllner M, Regli L, Fierstra J, van Niftrik CHB. Hemodynamic Failure Staging With Blood Oxygenation Level-Dependent Cerebrovascular Reactivity and Acetazolamide-Challenged ( 15O-)H 2O-Positron Emission Tomography Across Individual Cerebrovascular Territories. J Am Heart Assoc 2023; 12:e029491. [PMID: 38084716 PMCID: PMC10863778 DOI: 10.1161/jaha.123.029491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Staging of hemodynamic failure (HF) in symptomatic patients with cerebrovascular steno-occlusive disease is required to assess the risk of ischemic stroke. Since the gold standard positron emission tomography-based perfusion reserve is unsuitable as a routine clinical imaging tool, blood oxygenation level-dependent cerebrovascular reactivity (BOLD-CVR) with CO2 is a promising surrogate imaging approach. We investigated the accuracy of standardized BOLD-CVR to classify the extent of HF. METHODS AND RESULTS Patients with symptomatic unilateral cerebrovascular steno-occlusive disease, who underwent both an acetazolamide challenge (15O-)H2O-positron emission tomography and BOLD-CVR examination, were included. HF staging of vascular territories was assessed using qualitative inspection of the positron emission tomography perfusion reserve images. The optimum BOLD-CVR cutoff points between HF stages 0-1-2 were determined by comparing the quantitative BOLD-CVR data to the qualitative (15O-)H2O-positron emission tomography classification using the 3-dimensional accuracy index to the randomly assigned training and test data sets with the following determination of a single cutoff for clinical application. In the 2-case scenario, classifying data points as HF 0 or 1-2 and HF 0-1 or 2, BOLD-CVR showed an accuracy of >0.7 for all vascular territories for HF 1 and HF 2 cutoff points. In particular, the middle cerebral artery territory had an accuracy of 0.79 for HF 1 and 0.83 for HF 2, whereas the anterior cerebral artery had an accuracy of 0.78 for HF 1 and 0.82 for HF 2. CONCLUSIONS Standardized and clinically accessible BOLD-CVR examinations harbor sufficient data to provide specific cerebrovascular reactivity cutoff points for HF staging across individual vascular territories in symptomatic patients with unilateral cerebrovascular steno-occlusive disease.
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Affiliation(s)
- Martina Sebök
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | | | - Cäcilia Mader
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Athina Pangalu
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
- Department of NeuroradiologyUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Valerie Treyer
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Joseph Arnold Fisher
- Department of Anesthesia and Pain ManagementUniversity Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - David John Mikulis
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
- Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoOntarioCanada
| | - Martin Hüllner
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Luca Regli
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Jorn Fierstra
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
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Chang X, Ruan X, Ding J, Ma P, Yang G, Zhang R, Li Y, Na K, Xu H, Mu L, Zhang X, Tang Z. The efficacy of STA-MCA double anastomosis comparing to single anastomosis in chronic internal carotid artery occlusion patients. Clin Neurol Neurosurg 2023; 233:107947. [PMID: 37611351 DOI: 10.1016/j.clineuro.2023.107947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To investigate the efficacy of STA-MCA double-anastomosis and single-anastomosis in patients with cerebral hypoperfusion caused by chronic internal carotid artery occlusion(CICAO). METHODS In this retrospective study, data were collected from 19 patients with CICAO who underwent STA-MCA anastomosis at our hospital between January 2016 and January 2022, and they were divided into single anastomosis group and double anastomosis group according to the surgical method. The study collected general clinical data from both groups, including age, sex, lipid levels, blood pressure, glucose levels, smoking and alcohol consumption. Additionally, pre- and postoperative neurological function, cerebral hemodynamic parameters, and postoperative ischemic events were also recorded. By combining our study findings with the existing literature, a comparative analysis of the efficacy of single- and double-anastomosis in patients with CICAO was conducted. RESULTS Prior to surgical treatment,there were no statistically significant differences in cerebral hemodynamic parameters, including rob (0.65 ± 0.09 VS. 0.62 ± 0.04), rut (1.73 ± 0.40 VS. 1.99 ± 0.53), and rTMax (2.02 ± 0.49 VS. 1.72 ± 0.46), as well as neurofunctional scores, including modified Rankin Scale (MRS) (2.8 ± 1.03 VS. 2.4 ± 0.88) and National Institutes of Health Stroke Scale (NIHSS) (9.1 ± 5.08 VS. 8.3 ± 4.09) between the two groups. After operation, rCBF (single: 0.65 ± 0.09 VS.0.84 ± 0.08, p = 0.007; double: 0.62 ± 0.04 VS.1.08 ± 0.20, p = 0.001) were significantly increased in both groups, but the rMTT (1.99 ± 0.53 VS.1.27 ± 0.42, p = 0.0447) and rTMax (1.72 ± 0.46 VS.1.16 ± 0.16, p = 0.038) showed significant differences postoperatively only in the double-anastomosis group. The MRS (single: 1.8 ± 1.23, double: 1.7 ± 0.9) in both groups and the NIHSS (7.2 ± 5.11) in single-anastomosis group were not improved after surgery, while the NIHSS (8.3 ± 4.09 VS.4.4 ± 3.08, p = 0.037) in double-anastomosis group was improve significantly. In summary, the double-anastomosis group showed better improvement in rCBF and NIHSS scores compared to the single-anastomosis group.(ΔrCBF: 0.19±0.09 VS. 0.45±0.18, p=0.02, ΔNIHSS: 1.9±0.56 VS. 4±1.73, p=0.002). The cases were followed up for 20.3 ± 18.6 months, and there were no ischemic events in either group during the follow-up period. CONCLUSION STA-MCA revascularization can improve CBF in patients with hypoperfusion caused by CICAO, and prevent the reoccurrence of ischemic stroke effectively. Compared with single-anastomosis, double-anastomosis can provide more CBF and improve neurologic dysfunction.
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Affiliation(s)
- Xuying Chang
- Kunming Medical University, Kunming, Yunnan, China
| | | | - Jiangbo Ding
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People,s Hospital of Honghe Prefecture), Mengzi, Yunnan,China
| | - Peiyu Ma
- Department of surgery, The Second People's Hospita of Honghe Prefecture, Jianshui, Yunnan, China
| | - Guangwu Yang
- Kunming Medical University, Kunming, Yunnan, China
| | - Ruoyu Zhang
- Kunming Medical University, Kunming, Yunnan, China
| | - Yuhan Li
- Kunming Medical University, Kunming, Yunnan, China
| | - Kunpeng Na
- Kunming Medical University, Kunming, Yunnan, China
| | - Hang Xu
- Department of Pain,The First People's Hospital of Zhaotong, Zhaotong, Yunnan, China
| | - Linjie Mu
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xingkui Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhiwei Tang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
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Jo H, Lee SU, Jeong HG, Kim YD, Kim T, Sunwoo L, Ban SP, Bang JS, Kwon O, Oh CW. Long-term outcomes and quantitative radiologic analysis of extracranial-intracranial bypass for hemodynamically compromised chronic large artery occlusive disease. Sci Rep 2023; 13:3717. [PMID: 36879127 PMCID: PMC9988922 DOI: 10.1038/s41598-023-30874-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
This study aimed to demonstrate the effectiveness of nonemergent extracranial-to-intracranial bypass (EIB) in symptomatic chronic large artery atherosclerotic stenosis or occlusive disease (LAA) through quantitative analysis of computed tomography perfusion (CTP) parameters using RAPID software. We retrospectively analyzed 86 patients who underwent nonemergent EIB due to symptomatic chronic LAA. CTP data obtained preoperatively, immediately postoperatively (PostOp0), and 6 months postoperatively (PostOp6M) after EIB were quantitatively analyzed through RAPID software, and their association with intraoperative bypass flow (BF) was assessed. The clinical outcomes, including neurologic state, incidence of recurrent infarction and complications, were also analyzed. The time-to-maximum (Tmax) > 8 s, > 6 s and > 4 s volumes decreased significantly at PostOp0 and up through PostOp6M (preoperative, 5, 51, and 223 ml (median), respectively; PostOp0, 0, 20.25, and 143 ml, respectively; PostOp6M, 0, 7.5, and 148.5 ml, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). The postoperative improvement in the Tmax > 6 s and > 4 s volumes was significantly correlated with the BF at PostOp0 and PostOp6M (PostOp0, r = 0.367 (p = 0.001) and r = 0.275 (p = 0.015), respectively; PostOp6M r = 0.511 (p < 0.001) and r = 0.391 (p = 0.001), respectively). The incidence of recurrent cerebral infarction was 4.7%, and there were no major complications that produced permanent neurological impairment. Nonemergent EIB under strict operation indications can be a feasible treatment for symptomatic, hemodynamically compromised LAA patients.
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Affiliation(s)
- Hyunjun Jo
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
| | - Han-Gil Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Young-Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Oki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
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9
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Jo H, Seo D, Kim YD, Ban SP, Kim T, Kwon OK, Oh CW, Sunwoo L, Kim BJ, Han MK, Bae HJ, Lee SU, Bang JS. Quantitative radiological analysis and clinical outcomes of urgent EC-IC bypass for hemodynamic compromised patients with acute ischemic stroke. Sci Rep 2022; 12:8816. [PMID: 35614162 PMCID: PMC9132915 DOI: 10.1038/s41598-022-12728-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 05/03/2022] [Indexed: 12/30/2022] Open
Abstract
This study aimed to demonstrate the effectiveness of urgent extracranial-to-intracranial bypass (EIB) in acute ischemic stroke (AIS) through quantitative analysis of computed tomography perfusion (CTP) results using RAPID software. We retrospectively analyzed 41 patients who underwent urgent EIB for AIS under strict operation criteria. The quantitative data from CTP images were reconstructed to analyze changes in pre- and postoperative perfusion status in terms of objective numerical values using RAPID software. Short- and long-term clinical outcomes, including complications and neurological status, were also analyzed. Postoperatively, the volume of time-to-max (Tmax) > 6 s decreased significantly; it continued to improve significantly until 6 months postoperatively (preoperative, 78 ml (median); immediate postoperative, 23 ml; postoperative 6 months, 7 ml; p = 0.000). Ischemic core-penumbra mismatch volumes were also significantly improved until 6 months postoperatively (preoperative, 72 ml (median); immediate postoperative, 23 ml; postoperative 6 months, 5 ml; p = 0.000). In addition, the patients' neurological condition improved significantly (p < 0.001). Only one patient (2.3%) showed progression of infarction. Urgent EIB using strict indications can be a feasible treatment for IAT-ineligible patients with AIS due to large vessel occlusion or stenosis.
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Affiliation(s)
- Hyunjun Jo
- grid.222754.40000 0001 0840 2678Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-si, Korea
| | - Dongwook Seo
- grid.412674.20000 0004 1773 6524Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Deok Kim
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - Seung Pil Ban
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - Tackeun Kim
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - O-Ki Kwon
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - Chang Wan Oh
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - Leonard Sunwoo
- grid.31501.360000 0004 0470 5905Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Beom Joon Kim
- grid.31501.360000 0004 0470 5905Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Moon-Ku Han
- grid.31501.360000 0004 0470 5905Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Hee-Joon Bae
- grid.31501.360000 0004 0470 5905Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Si Un Lee
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
| | - Jae Seung Bang
- grid.31501.360000 0004 0470 5905Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Korea
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10
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Tsunoda S, Inoue T, Segawa M, Akabane A. One-stage Revascularization to the Ipsilateral Middle Cerebral Artery and Contralateral Anterior Cerebral Artery Territories. World Neurosurg 2022; 164:128-134. [PMID: 35504477 DOI: 10.1016/j.wneu.2022.04.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with multiple intracranial atherosclerotic stenoses often present with haemodynamic instability in two remote regions without a reciprocal vascular network. In this situation, revascularisation to each region may be required. METHODS In this report, two patients who had coexisting unilateral middle cerebral artery (MCA) and contralateral anterior cerebral artery (ACA) territory ischemia were treated by using ipsilateral superficial temporal artery (STA)-radial artery graft (RAG)-contralateral A3 bypass and ipsilateral STA-MCA bypass in one stage. RESULTS Postoperatively, the bypass conduit was well established and the patients' haemodynamic instability was improved. CONCLUSION In patients with severe haemodynamic instability in the remote unilateral MCA and contralateral ACA regions, as in our two cases, ipsilateral STA-MCA and ipsilateral STA-RAG-contralateral A3 bypasses in one stage can be a treatment option.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan.
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
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11
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Murai Y, Sekine T, Ishisaka E, Tsukiyama A, Kubota A, Matano F, Ando T, Nakae R, Morita A. Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study. Neurosurgery 2022; 90:426-433. [PMID: 35064659 DOI: 10.1227/neu.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited. OBJECTIVE To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass. METHODS Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI. RESULTS The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA. CONCLUSION Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases.
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Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Tetsuro Sekine
- Department of Radiology, Musashi-Kosugi Hospital, Nippon Medical School, Kanagawa, Japan
| | - Eitaro Ishisaka
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Atsushi Tsukiyama
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Asami Kubota
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Takahiro Ando
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
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12
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Extracranial–Intracranial Bypass for Cerebral Ischemia. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Tsunoda S, Inoue T, Segawa M, Okubo S, Akabane A. Revascularization to the ACA: effectiveness and variation of the STA-RAG-A3 bonnet bypass. Acta Neurochir (Wien) 2021; 163:3483-3493. [PMID: 34495406 DOI: 10.1007/s00701-021-04986-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effectiveness of bypass surgery in patients with atherothrombotic ischemia in the anterior cerebral artery (ACA) domain remains unclear. In this study, three cases with ischemia in the ACA territory underwent revascularization surgery using superficial temporal artery (STA)-radial artery graft (RAG)-A3 (pericallosal artery) bonnet bypass. Herein, we discuss the effectiveness and variations of this approach. METHODS Among 182 consecutive patients with atherothrombotic ischemic stroke admitted to the NTT Medical Center, Tokyo, from April 2017 to May 2021, three patients with hemodynamic insufficiency in the extensive ACA territory beyond the recent infarct area were treated using STA-RAG-A3 bonnet bypass. RESULTS One patient with bilateral severe cerebral blood flow (CBF) deficiency required additional A3-A3 and STA-middle cerebral artery single bypass in conjunction with STA-RAG-A3 bypass. There were no complications associated with the surgical procedure. The patients' hemodynamic study results and neurocognitive performances improved dramatically after surgery. CONCLUSION Our results suggest the efficacy of STA-RAG-A3 bypass for atherothrombotic ACA ischemia. However, because the number of cases was too small to generalize our results, more cases and thorough pre- and postoperative hemodynamic studies are necessary to prove the validity of the approach.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan.
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Higashigotanda, Shinagawa-ku, Tokyo, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
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14
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Sekine T, Murai Y, Orita E, Ando T, Takagi R, Amano Y, Matano F, Iwata K, Ogawa M, Obara M, Kumita S. Cross-Comparison of 4-Dimensional Flow Magnetic Resonance Imaging and Intraoperative Middle Cerebral Artery Pressure Measurements Before and After Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery. Neurosurgery 2021; 89:909-916. [PMID: 34460923 DOI: 10.1093/neuros/nyab305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The hemodynamic changes after superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery are unclear. OBJECTIVE To clarify the hemodynamics by comparing flow parameters obtained by 4-dimensional (4D) flow magnetic resonance imaging (MRI) and intraoperative MCA pressure measurement. METHODS We recruited 23 patients who underwent STA-MCA bypass surgery for internal carotid artery (ICA) or MCA stenosis. We monitored intraoperative MCA, STA, and radial artery (RA) pressure. All patients underwent 4D flow MRI preoperatively and 3 wk after surgery to quantify the blood flow volume (BFV) of the ipsilateral ICA (BFViICA), contralateral ICA (BFVcICA), basilar artery (BFVBA), ipsilateral STA (BFViSTA), and contralateral STA (BFVcSTA). The sum of intracranial BFV was defined as BFVtotal. We compared BFV parameters and intraoperative pressure. RESULTS BFViSTA significantly increased after surgery (P < .001). BFViICA and BFVBA significantly decreased after surgery (BFViICAP = .005; BFVBAP = .02). No significant difference was observed between BFVcICA before and after surgery. As a result, BFVtotal postoperatively increased by 6.8%; however, no significant difference was observed. Flow direction at M1 changed from antegrade to unclear after surgery in 5 patients. Intraoperative MCA pressure and MCA/RA pressure ratio significantly increased after surgery (P < .001). We found a stronger positive correlation between MCA pressure increase ratio and BFVtotal increase ratio in patients with lower pre-MCA pressure (r = 0.907, P < .001). CONCLUSION The visual and quantitative assessment of 4D flow MRI revealed that intracranial blood flow changes complementarily after STA-MCA bypass surgery. 4D flow MRI may detect the improvement of cerebral perfusion pressure.
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Affiliation(s)
- Tetsuro Sekine
- Department of Radiology, Nippon Medical School, Tokyo, Japan.,Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Erika Orita
- Department of Radiology, Nippon Medical School, Tokyo, Japan
| | - Takahiro Ando
- Department of Radiology, Nippon Medical School, Tokyo, Japan
| | - Ryo Takagi
- Department of Radiology, Nippon Medical School, Tokyo, Japan.,Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Amano
- Department of Radiology, Nippon Medical School, Tokyo, Japan.,Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Kotomi Iwata
- Department of Radiology, Nippon Medical School, Tokyo, Japan
| | - Masashi Ogawa
- Department of Radiology, Nippon Medical School, Tokyo, Japan
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15
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Cai S, Fan H, Peng C, Wu Y, Yang X. The comparison of STA-MCA bypass and BMT for symptomatic internal carotid artery occlusion disease: a systematic review and meta-analysis of long-term outcome. Chin Neurosurg J 2021; 7:17. [PMID: 33814006 PMCID: PMC8020543 DOI: 10.1186/s41016-021-00236-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery is now being widely used in moyamoya disease, and its therapeutic value in SICAO remains divergent. METHODS A systematic search was performed in PubMed, EMBASE, and Cochrane Databases in Feb. 2020 and updated in Jun. 2019. We have strict inclusion and exclusion criteria. Cochrane Bias Risk Assessment Tool was used to assess the quality of included RCTs. Review Manager 5.3 was used for analysis results in terms of comparing the STA-MCA bypass and BMT. For dichotomous variable outcomes, risk ratios (RRs) and 95% confidence intervals (95%CIs) were calculated for the assessment. RESULTS The total patient cohort consisted of 2419 patients, of whom 1188 (49.1%) patients had been grouped in STA-MCA bypass and 1231 (50.9%) patients had been divided into the BMT group. Mean follow-up of included patients was 29 months. The RR of the seven studies was 1.01, and the 95% confidence interval was .89-1.15, with statistical significance, Z = .13, P = .89, sustaining that STA-MCA bypass was not superior to BMT in symptomatic carotid artery occlusion disease. CONCLUSIONS STA-MCA bypass and BMT were associated with similar rates of a composite of long-term stroke. And the risk of long-term overall stroke was mildly higher with BMT. At present, each patient should receive more precise treatment, by reasonably assessing the individual differences of each patient to reduce the recurrence rate of stroke.
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Affiliation(s)
- Shifei Cai
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Hao Fan
- Department of Neuroophthalmology, Tianjin Medical University Eye Hospital, Tianjin, 300052, China
| | - Chao Peng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Yuzhang Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China.
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16
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Okuma Y, Hirotsune N, Shinozaki K, Yagi T, Kegoya Y, Sotome Y, Matsuda Y, Sato Y, Tanabe T, Muraoka K, Nishino S. Near-Infrared Spectroscopy Might Help Prevent Onset of Cerebral Hyperperfusion Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1269:63-67. [PMID: 33966196 DOI: 10.1007/978-3-030-48238-1_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cerebral hyperperfusion syndrome (CHS) is a rare but fatal perioperative complication after surgical correction of carotid stenosis. Despite numerous treatment options for preventing CHS, it does occur in some patients. We developed the outlet gate technique (OGT), in which the embolic balloon was deflated gradually in accordance with the ratio of oxygen saturation measured by a brain oximeter of the ipsilateral brain region to that in the contralateral region. Between June 2017 and May 2018, 39 patients with carotid stenosis underwent endovascular carotid revascularization procedures; of these, 20 underwent the procedure with the OGT. CBO was measured five times in those 20 patients: before the procedure, with the embolic protection device (EPD) on, with the EPD off, during the procedure, and after the procedure. Preventive treatment options were used more frequently in these patients, and although their surgical status seemed more complicated, perioperative complications were not increased. There were almost significant differences between CBO values except between those during and after the procedure with the OGT. This showed that the OGT allowed for stabilization of the CBO and thus has the potential to prevent CHS.
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Affiliation(s)
- Yu Okuma
- Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA. .,Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan.
| | - Nobuyuki Hirotsune
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Koichiro Shinozaki
- Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA
| | - Tsukasa Yagi
- Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA
| | - Yasuhito Kegoya
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yuta Sotome
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yuki Matsuda
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yu Sato
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Tomoyuki Tanabe
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Kenichiro Muraoka
- Department of Neurological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Shigeki Nishino
- Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY, USA
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17
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Fan AP, An H, Moradi F, Rosenberg J, Ishii Y, Nariai T, Okazawa H, Zaharchuk G. Quantification of brain oxygen extraction and metabolism with [ 15O]-gas PET: A technical review in the era of PET/MRI. Neuroimage 2020; 220:117136. [PMID: 32634594 PMCID: PMC7592419 DOI: 10.1016/j.neuroimage.2020.117136] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/15/2020] [Accepted: 07/01/2020] [Indexed: 12/31/2022] Open
Abstract
Oxygen extraction fraction (OEF) and the cerebral metabolic rate of oxygen (CMRO2) are key cerebral physiological parameters to identify at-risk cerebrovascular patients and understand brain health and function. PET imaging with [15O]-oxygen tracers, either through continuous or bolus inhalation, provides non-invasive assessment of OEF and CMRO2. Numerous tracer delivery, PET acquisition, and kinetic modeling approaches have been adopted to map brain oxygenation. The purpose of this technical review is to critically evaluate different methods for [15O]-gas PET and its impact on the accuracy and reproducibility of OEF and CMRO2 measurements. We perform a meta-analysis of brain oxygenation PET studies in healthy volunteers and compare between continuous and bolus inhalation techniques. We also describe OEF metrics that have been used to detect hemodynamic impairment in cerebrovascular disease. For these patients, advanced techniques to accelerate the PET scans and potential synthesis with MRI to avoid arterial blood sampling would facilitate broader use of [15O]-oxygen PET for brain physiological assessment.
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Affiliation(s)
- Audrey P Fan
- Department of Radiology, Stanford University, Stanford, CA, USA; Department of Biomedical Engineering and Department of Neurology, University of California Davis, Davis, CA, USA.
| | - Hongyu An
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Farshad Moradi
- Department of Radiology, Stanford University, Stanford, CA, USA
| | | | - Yosuke Ishii
- Department of Radiology, Stanford University, Stanford, CA, USA; Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, CA, USA
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18
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Gunawardena M, Rogers JM, Stoodley MA, Morgan MK. Revascularization surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion. J Neurosurg 2020; 132:415-420. [PMID: 30738386 DOI: 10.3171/2018.9.jns181075] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust. METHODS Consecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter. RESULTS From 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%-6.6%). CONCLUSIONS Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.
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Affiliation(s)
| | - Jeffrey M Rogers
- 2Department of Clinical Medicine, Macquarie University; and.,3Faculty of Health Sciences, University of Sydney, New South Wales, Australia
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19
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Rice CJ, Cho SM, Taqui A, Moore NZ, Witek AM, Bain MD, Uchino K. Early versus Delayed Extracranial-Intracranial Bypass Surgery in Symptomatic Atherosclerotic Occlusion. Neurosurgery 2020; 85:656-663. [PMID: 30239897 DOI: 10.1093/neuros/nyy411] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/02/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical trials of extracranial-intracranial (EC-IC) bypass surgery studied patients in subacute and chronic stage after ischemic event. OBJECTIVE To investigate the short-term outcomes of EC-IC bypass in progressive acute ischemic stroke or recent transient ischemic attacks. METHODS The study was a retrospective review at a single tertiary referral center from 2008 to 2015. Inclusion criteria consisted of EC-IC bypass within 1 yr of last ischemic symptoms ipsilateral to atherosclerotic occlusion of internal carotid or middle cerebral artery. Early bypass group who underwent surgery within 7 d of last ischemic symptoms were compared to late bypass group who underwent surgery >7 d from last ischemic symptom. The primary endpoint was perioperative ischemic or hemorrhagic stroke or intracranial hemorrhage within 7 d of surgery. RESULTS Of 126 patients who underwent EC-IC bypass during the period, 81 patients met inclusion criteria, 69 (85%) persons had carotid artery occlusion, 7 (9%) had proximal MCA occlusion, and 5 (6%) had both. Early surgery had a 31% (9/29) perioperative stroke rate compared to 11.5% (6/52) of patients undergoing late bypass (P = .04). Of patients with acute stroke within 7 d of surgery, 41% (7/17) had perioperative stroke within 7 d (P = .07). Six of nine patients (67%) with blood pressure dependent fluctuation of neurologic symptoms had perioperative stroke (P = .049). CONCLUSION EC-IC bypass in setting of acute symptomatic stroke within 1 wk may confer higher risk of perioperative stroke. Patients undergoing expedited or urgent bypass for unstable or fluctuating stroke symptoms might be at highest risk for perioperative stroke.
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Affiliation(s)
- Cory J Rice
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sung-Min Cho
- Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ather Taqui
- Department of Vascular Neurology, Novant Health System, Charlotte, North Carolina
| | - Nina Z Moore
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alex M Witek
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mark D Bain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Alvi MA, Rinaldo L, Kerezoudis P, Rangel-Castilla L, Bydon M, Cloft H, Lanzino G. Contemporary trends in extracranial-intracranial bypass utilization: analysis of data from 2008 to 2016. J Neurosurg 2019; 133:1821-1829. [PMID: 31731270 DOI: 10.3171/2019.8.jns191401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The impact of FDA approval of flow-diversion technology for the treatment of supraclinoid internal carotid artery aneurysms and the publication of the Carotid Occlusion Surgery Study, both of which occurred in 2011, on the utilization of extracranial-intracranial (EC-IC) bypasses is not known. METHODS The National Inpatient Sample (NIS) was queried for hospitalizations for EC-IC bypass performed from 2008 to 2016. Diagnoses of interest included an unruptured intracranial aneurysm (UIA), subarachnoid hemorrhage (SAH), carotid occlusive disease (COD), and moyamoya disease. The authors assessed trends in EC-IC bypass utilization for these diagnoses and the incidence of adverse discharges, defined as discharge to locations other than home, and the rate of mortality. RESULTS A total of 1640 EC-IC bypass procedures were performed at 558 hospitals during the study period, with 1148 procedures at 448 hospitals performed for a diagnosis of interest. The most frequent surgical indication was moyamoya disease (65.7%, n = 754), followed by COD (23.2%, n = 266), SAH (3.2%, n = 37), and a UIA (7.9%, n = 91). EC-IC bypass utilization for COD decreased from 0.21 per 100 admissions of COD in 2010 to 0.09 per 100 admissions in 2016 (p = 0.023). The frequency of adverse discharges increased during the study period from 22.3% of annual admissions in 2008 to 31.2% in 2016 (p = 0.030) when analysis was limited to procedures performed for a diagnosis of interest. Per volume, the top 5th percentile of hospitals, on average, performed 18.4 procedures (SD 13.2) per hospital during the study period, compared to 1.3 procedures (SD 1.3) that were performed in hospitals within the bottom 95th percentile. The rate of adverse discharges was higher at low-volume institutions when compared to that at high-volume institutions (33.8% vs 28.7%; p = 0.029). Over the study period, the authors noted a trend toward a reduced percentage of total surgical volume performed at high-volume hospitals (p < 0.001). CONCLUSIONS The authors observed a decrease in the utilization of EC-IC bypass for COD during the study period. An increase in the rate of adverse discharges was also noted, coinciding with more procedures being performed at lower-volume centers.
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Affiliation(s)
| | | | | | | | | | - Harry Cloft
- 2Radiology, Mayo Clinic, Rochester, Minnesota
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21
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White TG, Abou-Al-Shaar H, Park J, Katz J, Langer DJ, Dehdashti AR. Cerebral revascularization after the Carotid Occlusion Surgery Study: what candidates remain, and can we do better? Neurosurg Focus 2019; 46:E3. [DOI: 10.3171/2018.11.focus18536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVECerebral revascularization for carotid occlusion was previously a mainstay procedure for the cerebrovascular neurosurgeon. However, the 1985 extracranial-intracranial bypass trial and subsequently the Carotid Occlusion Surgery Study (COSS) provided level 1 evidence via randomized controlled trials against bypass for symptomatic atherosclerotic carotid occlusion disease. However, in a small number of patients optimal medical therapy fails, and some patients with flow-limiting stenosis develop a perfusion-dependent neurological examination. Therefore it is necessary to further stratify patients by risk to determine who may most benefit from this intervention as well as to determine perioperative morbidity in this high-risk patient population.METHODSA retrospective review was performed of all revascularization procedures done for symptomatic atherosclerotic cerebrovascular steno-occlusive disease. All patients undergoing revascularization after the publication of the COSS in 2011 were included. Perioperative morbidity and mortality were assessed as the primary outcome to determine safety of revascularization in this high-risk population. All patients had documented hypoperfusion on hemodynamic imaging.RESULTSAt total of 35 revascularization procedures were included in this review. The most common indication was for patients with recurrent strokes, who were receiving optimal medical therapy and who suffered from cerebrovascular steno-occlusion. At 30 days only 3 perioperative ischemic events were observed, 2 of which led to no long-term neurological deficit. Immediate graft patency was good, at 94%. Long term, no further strokes or ischemic events were observed, and graft patency remained high at 95%. There were no factors associated with perioperative ischemic events in the variables that were recorded.CONCLUSIONSCerebral revascularization may be done safely at high-volume cerebrovascular centers in high-risk patients in whom optimal medical therapy has failed. Further research must be done to develop an improved methodology of risk stratification for patients with symptomatic atherosclerotic cerebrovascular steno-occlusive disease to determine which patients may benefit from intervention. Given the high risk of recurrent stroke in certain patients, and the fact that patients fail medical therapy, surgical revascularization may provide the best method to ensure good long-term outcomes with manageable up-front risks.
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Affiliation(s)
| | | | | | - Jeffrey Katz
- 3Neurology, North Shore University Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell; and
| | - David J. Langer
- 2Department of Neurosurgery, Lenox Hill Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
| | - Amir R. Dehdashti
- Departments of 1Neurosurgery and
- 2Department of Neurosurgery, Lenox Hill Hospital, Barbara and Donald Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
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22
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Comparison of Quantitative and Qualitative Oxygen Extraction Fraction (OEF) in Acute Stroke Patients with Large Vessel Occlusion. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019. [PMID: 30178322 DOI: 10.1007/978-3-319-91287-5_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
The superficial temporal artery-middle cerebral artery bypass (STA-MCA) bypass surgery developed by Donaghy and Yarsagil in 1967 provided relief for patients with acute stroke and large vessel occlusive vascular disease. Early reports showed low morbidity and good outcomes. However, a large clinical trial in 1985 reported a failure of extracranial-intracranial (EC/IC) bypass to show benefit in reducing the risk of stroke compared to best medical treatment. Problems with the study included cross overs to surgery from best medical treatment, patients unwilling to be randomized and chose EC/IC surgery, and loss of patients to follow-up. Most egregious is the fact that the study did not attempt to identify and select the patients at high risk for a second stroke. Based on these shortcomings of the EC/IC bypass study, a carotid occlusion surgery study (COSS) was proposed by Dr. William Powers and colleagues using qualitative hemispheric oxygen extraction fraction (OEF) by positron emission tomography (PET) between the contralateral and ipsilateral hemispheres with a ratio of 1.16 indicative of hemodynamic compromise. To increase patient enrollment, several compromises were made mid study. First. The ratio threshold was lowered to 1.12 and the level of occlusion in the carotid reduced from 70% to 60%. Despite these compromises the study was closed for futility, apparently because the stroke rate in the medically treated group was too low. Thus, the question as to the benefit of EC/IC bypass surgery remains unresolved. In our NIH funded study Quantitative Occlusive Vascular Disease Study (QUOVADIS), we used quantitative OEF to evaluate stroke risk and compared it to the qualitative count-rate ratio method used in the COSS study and found that these two methods did not identify the same patients at increased risk for stroke, which may explain the reason for the failure of the COSS study as our results show that qualitative OEF ratios do not identify the same patients as quantitative OEF.
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23
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Hwang YH, Kwon YS, Lee YH. STA-Distal ACA Bypass Using a Contralateral STA Interposition Graft for Symptomatic ACA Stenosis. J Cerebrovasc Endovasc Neurosurg 2018; 20:191-197. [PMID: 30397592 PMCID: PMC6199401 DOI: 10.7461/jcen.2018.20.3.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 09/05/2018] [Accepted: 09/21/2018] [Indexed: 11/23/2022] Open
Abstract
Intracranial arterial stenosis usually occurs due to atherosclerosis and is considered the most common cause of stroke worldwide. Although the effectiveness of bypass surgery for ischemic stroke is controversial, the superficial temporal artery to the middle cerebral artery bypass for ischemic stroke is a common procedure. In our report, a 50-year-old man presented with sudden-onset left side weakness and dysarthria. An angiogram showed significant stenosis in the junction of the right cavernous-supraclinoid internal carotid artery and right pericallosal artery. Symptoms altered between improvement and deterioration. Magnetic resonance imaging showed a repeated progression of anterior cerebral artery (ACA) infarction despite maximal medical therapy. We performed a STA-ACA bypass with contralateral STA interposition. Postoperative course was uneventful with no further progression of symptoms. Thus, bypass surgery may be considered in patients with symptomatic stenosis or occlusion of the ACA, especially when patients present progressive symptoms despite maximal medical therapy.
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Affiliation(s)
- Yoon Ha Hwang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sub Kwon
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yun Ho Lee
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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24
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Donahue MJ, Achten E, Cogswell PM, De Leeuw FE, Derdeyn CP, Dijkhuizen RM, Fan AP, Ghaznawi R, Heit JJ, Ikram MA, Jezzard P, Jordan LC, Jouvent E, Knutsson L, Leigh R, Liebeskind DS, Lin W, Okell TW, Qureshi AI, Stagg CJ, van Osch MJP, van Zijl PCM, Watchmaker JM, Wintermark M, Wu O, Zaharchuk G, Zhou J, Hendrikse J. Consensus statement on current and emerging methods for the diagnosis and evaluation of cerebrovascular disease. J Cereb Blood Flow Metab 2018; 38:1391-1417. [PMID: 28816594 PMCID: PMC6125970 DOI: 10.1177/0271678x17721830] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/26/2017] [Accepted: 06/10/2017] [Indexed: 01/04/2023]
Abstract
Cerebrovascular disease (CVD) remains a leading cause of death and the leading cause of adult disability in most developed countries. This work summarizes state-of-the-art, and possible future, diagnostic and evaluation approaches in multiple stages of CVD, including (i) visualization of sub-clinical disease processes, (ii) acute stroke theranostics, and (iii) characterization of post-stroke recovery mechanisms. Underlying pathophysiology as it relates to large vessel steno-occlusive disease and the impact of this macrovascular disease on tissue-level viability, hemodynamics (cerebral blood flow, cerebral blood volume, and mean transit time), and metabolism (cerebral metabolic rate of oxygen consumption and pH) are also discussed in the context of emerging neuroimaging protocols with sensitivity to these factors. The overall purpose is to highlight advancements in stroke care and diagnostics and to provide a general overview of emerging research topics that have potential for reducing morbidity in multiple areas of CVD.
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Affiliation(s)
- Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, USA
| | - Eric Achten
- Department of Radiology and Nuclear Medicine, Universiteit Gent, Gent, Belgium
| | - Petrice M Cogswell
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frank-Erik De Leeuw
- Radboud University, Nijmegen Medical Center, Donders Institute Brain Cognition & Behaviour, Center for Neuroscience, Department of Neurology, Nijmegen, The Netherlands
| | - Colin P Derdeyn
- Department of Radiology and Neurology, University of Iowa, Iowa City, IA, USA
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Audrey P Fan
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Rashid Ghaznawi
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeremy J Heit
- Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University, CA, USA
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Peter Jezzard
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Jouvent
- Department of Neurology, AP-HP, Lariboisière Hospital, Paris, France
| | - Linda Knutsson
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Richard Leigh
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | | | - Weili Lin
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas W Okell
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Adnan I Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
| | - Charlotte J Stagg
- Oxford Centre for Human Brain Activity, University of Oxford, Oxford, UK
| | | | - Peter CM van Zijl
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Jennifer M Watchmaker
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Max Wintermark
- Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University, CA, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Greg Zaharchuk
- Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University, CA, USA
| | - Jinyuan Zhou
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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25
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Ausman JI, Liebeskind DS, Gonzalez N, Saver J, Martin N, Villablanca JP, Vespa P, Duckwiler G, Jahan R, Niu T, Salamon N, Yoo B, Tateshima S, Buitrago Blanco MM, Starkman S. A review of the diagnosis and management of vertebral basilar (posterior) circulation disease. Surg Neurol Int 2018; 9:106. [PMID: 29930872 PMCID: PMC5991286 DOI: 10.4103/sni.sni_373_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/26/2017] [Indexed: 12/28/2022] Open
Abstract
We have reviewed the English literature published in the last 70 years on Diseases of the Vertebral Basilar Circulation, or Posterior Circulation Disease (PCD). We have found that errors have been made in the conduct and interpretation of these studies that have led to incorrect approaches to the management of PCD. Because of the difficulty in evaluating the PC, the management of PCD has been incorrectly applied from anterior circulation disease (ACD) experience to PCD. PCD is a common form of stroke affecting 20-40% patients with stroke. Yet, the evidence is strong that the Anterior Circulation (AC) and Posterior Circulations (PC) differ in their pathology, in their clinical presentations, in the rapidity of development of symptoms, in optimal imaging methods, and in available treatments. There appears to be two categories of patients who present with PCD. The first, acute basilar artery occlusion has a more rapid onset. The diagnosis must be made quickly and if imaging proves a diagnosis of Basilar Artery Occlusion (BAO), the treatment of choice is Interventional removal of the basilar artery thrombosis or embolus. The second category of PCD and the most commonly seen PCD disease process presents with non-specific symptoms and early warnings of PCD that now can be related to ischemic events in the entire PC vessels. These warning symptoms and signs occur much earlier than those in the AC. IA angiography is still the gold standard of diagnosis and is superior in definition to MR and CT angiography which are commonly used as a convenient screening imaging tool to evaluate PCD but are both inferior to IA angiography in definition for lesions below 3-4 mm. In at least two reported studies 7T MR angiography appears superior to other imaging modalities and will become the gold standard of imaging of PCD in the future. Medical treatments applied to the ACD have not been proven of value in specific forms of PCD. Interventional therapy was promising but of unproven value in Randomized Controlled Trials (RCT) except for the treatment of Basilar Artery Occlusion (BAO). Surgical revascularization has been proved to be highly successful in patients, who are refractory to medical therapy. These studies have been ignored by the scientific community basically because of an incorrect interpretation of the flawed EC-IC Bypass Trial in 1985 as applying to all stroke patients. Moreover, the EC-IC Bypass Study did not include PCD patients in their study population, but the study results were extrapolated to patients with PCD without any scientific basis. This experience led clinicians to an incorrect bias that surgical treatments are of no value in PCD. Thus, incorrectly, surgical treatments of PCD have not been considered among the therapeutic possibilities for PCD. QMRA is a new quantitative MR technique that measures specific blood flow in extra and intracranial vessels. QMRA has been used to select those patients who may benefit from medical, or interventional, or surgical treatment for PCD based on flow determinations with a high success rate. QMRA accurately predicts the flows in many large and small vessels in the PC and AC and clearly indicates that both circulations are intimately related. From medical and surgical studies, the longer one waits for surgical treatment the higher the risk of a poor outcome results. This observation becomes obvious when the rapidity of development of PCD is compared with ACD. Recent advances in endovascular therapy in the treatment of acute basilar thrombosis is a clear sign that early diagnosis and treatment of PCD will reduce the morbidity and mortality of these diseases. In this review it is evident that there are multiple medical and surgical treatments for PCD depending upon the location of the lesion(s) and the collateral circulation demonstrated. It is clear that the AC and PC have significant differences. With the exception of the large population studies from Oxford England, the reported studies on the management of PCD in the literature represent small selected subsets of the universe of PC diseases, the information from which is not generalizable to the universe of PCD patients. At this point in the history of PCD, there are not large enough databases of similar patients to provide a basis for valid randomized studies, with the exception of the surgical studies. Thus, a high index of suspicion of the early warning symptoms of PCD should lead to a rapid individual clinical assessment of patients selecting those with PCD. Medical, interventional, and/or surgical treatments should be chosen based on knowledge presented in this review. Recording the results in a national Registry on a continuing basis will provide the data that may help advance the management of PCD based on larger data bases of well documented patient information to guide the selection of future therapies for PCD treatments. It is also clear that the management of patients within the complex of diseases that comprise PCD should be performed in centers with expertise in the imaging, medical, interventional and surgical approaches to diseases of the PCD.
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Affiliation(s)
- James I. Ausman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David S. Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Neurovascular Imaging Research Core, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nestor Gonzalez
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jeffrey Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil Martin
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - J. Pablo Villablanca
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Paul Vespa
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Tianyi Niu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Bryan Yoo
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Manuel M. Buitrago Blanco
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Sidney Starkman
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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26
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[Revascularization experience and results in ischaemic cerebrovascular disease: Moyamoya disease and carotid occlusion]. Neurocirugia (Astur) 2018; 29:170-186. [PMID: 29550248 DOI: 10.1016/j.neucir.2018.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/24/2018] [Accepted: 01/31/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Cerebral revascularization techniques are an indispensable tool in the current armamentarium of vascular neurosurgeons. We present revascularization surgery experience and results in both moyamoya disease and occlusive cerebral ischaemia. PATIENTS AND METHODS Patients with ischaemic occlusive disease and moyamoya disease who underwent microsurgical revascularization between October 2014 and September 2017 were analysed. RESULTS In the study period, 23 patients with occlusive ischaemic disease underwent microsurgical revascularization. Three patients presented with serious postoperative complications (2 intraparenchymal haemorrhages in the immediate postoperative period and one thrombosis of the femoral artery). All patients, except one, achieved normalization of the cerebral hemodynamic reserve (CHR) in the SPECT study. Twenty patients had a good neurological result, with no ischaemic recurrence of the revascularized territory. Among patients with moyamoya, 20 had moyamoya disease and 5 had moyamoya syndrome with unilateral involvement. Five patients were treated at paediatric age. Haemorrhagic onset occurred in 2 patients. The CHR study showed hemodynamic compromise in all patients. Cerebral SPECT at one year showed resolution of the hemodynamic failure in all patients. There have been 4 postoperative complications (acute subdural hematoma, two subdural collections and one dehiscence of the surgical wound). No patient presented with neurological worsening at 6 and 12months of follow-up. CONCLUSIONS Cerebral revascularization through end-to-side anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery is an indisputable technique in the treatment of moyamoya disease and possibly in a subgroup of patients with symptomatic occlusive ischaemic cerebrovascular disease.
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Fierstra J, van Niftrik C, Warnock G, Wegener S, Piccirelli M, Pangalu A, Esposito G, Valavanis A, Buck A, Luft A, Bozinov O, Regli L. Staging Hemodynamic Failure With Blood Oxygen-Level–Dependent Functional Magnetic Resonance Imaging Cerebrovascular Reactivity. Stroke 2018; 49:621-629. [DOI: 10.1161/strokeaha.117.020010] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/03/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
Abstract
Background and Purpose—
Increased stroke risk correlates with hemodynamic failure, which can be assessed with (
15
O-)H
2
O positron emission tomography (PET) cerebral blood flow (CBF) measurements. This gold standard technique, however, is not established for routine clinical imaging. Standardized blood oxygen-level–dependent (BOLD) functional magnetic resonance imaging+CO
2
is a noninvasive and potentially widely applicable tool to assess whole-brain quantitative cerebrovascular reactivity (CVR). We examined the agreement between the 2 imaging modalities and hypothesized that quantitative CVR can be a surrogate imaging marker to assess hemodynamic failure.
Methods—
Nineteen data sets of subjects with chronic cerebrovascular steno-occlusive disease (age, 60±11 years; 4 women) and unilaterally impaired perfusion reserve on Diamox-challenged (
15
O-)H
2
O PET were studied and compared with a standardized BOLD functional magnetic resonance imaging+CO
2
examination within 6 weeks (8±19 days). Agreement between quantitative CBF- and CVR-based perfusion reserve was assessed. Hemodynamic failure was staged according to PET findings: stage 0: normal CBF, normal perfusion reserve; stage I: normal CBF, decreased perfusion reserve; and stage II: decreased CBF, decreased perfusion reserve. The BOLD CVR data set of the same subjects was then matched to the corresponding stage of hemodynamic failure.
Results—
PET-based stage I versus stage II could also be clearly separated with BOLD CVR measurements (CVR for stage I 0.11 versus CVR for stage II −0.03;
P
<0.01). Hemispheric and middle cerebral artery territory difference analyses (ie, affected versus unaffected side) showed a significant correlation for CVR impairment in the affected hemisphere and middle cerebral artery territory (
P
<0.01,
R
2
=0.47 and
P
=0.02,
R
2
= 0.25, respectively).
Conclusions—
BOLD CVR corresponded well to CBF perfusion reserve measurements obtained with (
15
O-)H
2
O-PET, especially for detecting hemodynamic failure in the affected hemisphere and middle cerebral artery territory and for identifying hemodynamic failure stage II. BOLD CVR may, therefore, be considered for prospective studies assessing stroke risk in patients with chronic cerebrovascular steno-occlusive disease, in particular because it can potentially be implemented in routine clinical imaging.
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Affiliation(s)
- Jorn Fierstra
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Christiaan van Niftrik
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Geoffrey Warnock
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Susanne Wegener
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Marco Piccirelli
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Athina Pangalu
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Giuseppe Esposito
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Antonios Valavanis
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Alfred Buck
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Andreas Luft
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Oliver Bozinov
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- From the Departments of Neurosurgery (J.F., C.v.N., G.E., O.B., L.R.), Neuroradiology (M.P., A.V.), Neurology (S.W., A.L.), Pharmacology and Toxicology (G.W.), and Nuclear Medicine (A.B.), Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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Xu B, Li C, Guo Y, Xu K, Yang Y, Yu J. Current understanding of chronic total occlusion of the internal carotid artery. Biomed Rep 2017; 8:117-125. [PMID: 29435269 PMCID: PMC5776422 DOI: 10.3892/br.2017.1033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 01/08/2023] Open
Abstract
At present, there is limited understanding of chronic total occlusion (CTO) of the internal carotid artery (ICA). Therefore, the present report collected related cases from PubMed and reviewed the literature. Cerebral vessels may form collateral circulation immediately or gradually following CTO of the ICA. The natural history of CTO of the ICA includes a variety of outcomes, all of which are biased toward a non-benign progressive process and are characterized by insufficient cerebral perfusion, embolus detachment and cognitive dysfunction. The majority of cases of CTO of the ICA require treatment. In early studies, the results of external-ICA bypass were unsatisfactory, while recanalization is now considered the only viable option. The current treatment indications mainly depend on the degree of injury to the cerebrovascular reserve and the extent to which the oxygen extraction fraction is increased. The length, height and duration of ICA occlusion are also relevant, though more frequently, the condition depends on multiple factors. Endovascular interventional recanalization, carotid endarterectomy (CEA) and hybrid surgery may be conducted in a select group of patients. As novel materials are developed, the success rate of simple recanalization may gradually increase; however, hybrid surgery may be more representative of the current trend, as advanced CEA can remove carotid atherosclerosis plaques, thus reducing the technological demands of the subsequent interventional recanalization. There are many complications that may result from recanalization following CTO of the ICA, including hyperperfusion and technical errors; therefore, the operation must be conducted carefully. If the recanalization is successful, it typically results in a stable improvement of patient condition in the long term. However, despite these conclusions, more studies are required in the future to further improve current understanding of CTO of the ICA.
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Affiliation(s)
- Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Lin A, Rawal S, Agid R, Mandell DM. Cerebrovascular Imaging: Which Test is Best? Neurosurgery 2017; 83:5-18. [DOI: 10.1093/neuros/nyx325] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 05/12/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
Optimal diagnosis and characterization of cerebrovascular disease requires selection of the appropriate imaging exam for each clinical situation. In this review, we focus on intracranial arterial disease and discuss the techniques in current clinical use for imaging the blood vessel lumen and blood vessel wall, and for mapping cerebral hemodynamic impairment at the tissue level. We then discuss specific strategies for imaging intracranial aneurysms, arteriovenous malformations, dural arterial venous fistulas, and arterial steno-occlusive disease.
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Affiliation(s)
- Amy Lin
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Sapna Rawal
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Ronit Agid
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Mandell
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
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Maddula M, Sprigg N, Bath PM, Munshi S. Cerebral misery perfusion due to carotid occlusive disease. Stroke Vasc Neurol 2017; 2:88-93. [PMID: 28959496 PMCID: PMC5600014 DOI: 10.1136/svn-2017-000067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 11/06/2022] Open
Abstract
Purpose Cerebral misery perfusion (CMP) is a condition where cerebral autoregulatory capacity is exhausted, and cerebral blood supply in insufficient to meet metabolic demand. We present an educational review of this important condition, which has a range of clinical manifestations. Method A non-systematic review of published literature was undertaken on CMP and major cerebral artery occlusive disease, using Pubmed and Sciencedirect. Findings Patients with CMP may present with strokes in watershed territories, collapses and transient ischaemic attacks or episodic movements associated with an orthostatic component. While positron emission tomography is the gold standard investigation for misery perfusion, advanced MRI is being increasingly used as an alternative investigation modality. The presence of CMP increases the risk of strokes. In addition to the devastating effect of stroke, there is accumulating evidence of impaired cognition and quality of life with carotid occlusive disease (COD) and misery perfusion. The evidence for revascularisation in the setting of complete carotid occlusion is weak. Medical management constitutes careful blood pressure management while addressing other vascular risk factors. Discussion The evidence for the management of patients with COD and CMP is discussed, together with recommendations based on our local experience. In this review, we focus on misery perfusion due to COD. Conclusion Patients with CMP and COD may present with a wide-ranging clinical phenotype and therefore to many specialties. Early identification of patients with misery perfusion may allow appropriate management and focus on strategies to maintain or improve cerebral blood flow, while avoiding potentially harmful treatment.
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Affiliation(s)
- Mohana Maddula
- Acute Stroke Unit, Tauranga Hospital, Tauranga, New Zealand
| | - Nikola Sprigg
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Sunil Munshi
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Refractory Symptomatic Intracranial Atherosclerotic Stenosis. World Neurosurg 2017; 104:74-81. [PMID: 28434956 DOI: 10.1016/j.wneu.2017.04.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate blood flow changes after bypass surgery for refractory symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS We examined a cohort of consecutive patients with symptomatic ICAS. Superficial temporal artery-middle cerebral artery (MCA) bypass was performed in refractory patients with poor perfusion. Angiograms were graded systematically for antegrade, collateral, and bypass flow, and clinical variables were collected preoperatively, at 7 days postoperatively, and 3, 6, and 12 months postoperatively. RESULTS Among 185 consecutive cases with ICAS, 15 patients who were unsuitable for or did not respond to the best medical therapy or stenting underwent bypass surgery. No patients had new ischemic deficits within 7 days postoperatively. The mean follow-up period was 30.2 ± 12.3 months. Within this period, all anastomoses were patent by methods of ultrasound or computed tomography angiography. In 2 patients, stenotic lesions exhibited early postoperative occlusion conversion at 7 days on digital subtraction angiography. In 2 patients, stenotic lesions showed progression of occlusion at 6 and 8 months. The 2 lesions with early occlusion were both located in the MCA. The extent of retrograde blood flow via bypass anastomosis was correlated with early occlusion conversion. CONCLUSIONS For refractory ICAS in patients with compromised hemodynamics, direct bypass might induce early occlusion of a stenotic area. MCA lesions may have a greater tendency toward early occlusion conversion.
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Matano F, Murai Y, Tanikawa R, Kamiyama H, Tateyama K, Tamaki T, Mizunari T, Mizumura S, Kobayashi S, Teramoto A, Morita A. Intraoperative middle cerebral artery pressure measurements during superficial temporal artery to middle cerebral artery bypass procedures in patients with cerebral atherosclerotic disease. J Neurosurg 2016; 125:1367-1373. [DOI: 10.3171/2015.10.jns151305] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
No previous study has monitored middle cerebral artery (MCA) pressure during the superficial temporal artery (STA)-MCA bypass procedure for cerebral atherosclerotic disease. In this paper, the authors describe their method of monitoring MCA pressure and report their initial data on intraoperative MCA pressure and its relationship with hemodynamics prior to and after the bypass procedures.
METHODS
The results from a total of 39 revascularization procedures performed between 2004 and 2014 were analyzed. The patient group included 27 men and 12 women, and their mean age at surgery was 67.6 years (range 39–83 years). The authors investigated the MCA pressure via the STA during STA-MCA bypass procedures. After one branch of the STA was anastomosed to the MCA, the other branch was connected to an arterial line, and a clip was placed temporally on the main STA trunk to monitor the pre-anastomosis MCA pressure. Simultaneously, the radial artery (RA) pressure was determined before removing the temporal clip to measure the post-anastomosis MCA pressure. The relationship between MCA pressures and single photon emission computed tomography findings and the risk factors for hyperperfusion after STA-MCA bypass were analyzed.
RESULTS
The MCA/RA (%) pressure was significantly correlated with that of the resting stenotic/normal side cerebral blood flow (CBF) ratio (%) in the linear regression analysis (slope 1.200, r2 = 0.3564, F = 20.49, p < 0.0001). The intraoperative MCA pressure was 39.3% of RA pressure in patients with Powers' Stage 2 cerebral atherosclerotic disease. After 1 branch of the STA was anastomosed, the intraoperative MCA pressure increased to 75.3% of the RA pressure. The rate of increase in pressure was significantly correlated with the increase in the STA diameter in the linear regression analysis (slope 2.59, r2 = 0.205, F = 9.549, p = 0.0038). Hyperperfusion occurred in 2 cases. When mean values for these 2 patients were compared with those for the 37 patients without hyperperfusion, significant differences were found in the stenotic/normal side CBF ratio (p = 0.0001), pre-anastomosis MCA pressure (p = 0.02), rate of increase in pressure (p = 0.02), pre-anastomotic MCA/RA pressure ratio (p = 0.01), vascular reserve (p = 0.0489), and STA diameter (p = 0.0002).
CONCLUSIONS
The measurement of intraoperative MCA pressure may be a useful technique to assess cerebral perfusion and for predicting the risk of hyperperfusion. Monitoring MCA pressure is recommended during STA-MCA bypass procedures for atherosclerotic disease.
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Affiliation(s)
| | - Yasuo Murai
- 1Department of Neurological Surgery, Nippon Medical School
| | - Rokuya Tanikawa
- 2Department of Neurosurgery, Teishinkai Hospital, Sapporo, Japan
| | | | | | | | | | - Sunao Mizumura
- 3Department of Radiology, Toho University Omori Medical Center, Tokyo; and
| | | | - Akira Teramoto
- 1Department of Neurological Surgery, Nippon Medical School
| | - Akio Morita
- 1Department of Neurological Surgery, Nippon Medical School
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Ma Y, Gu Y, Tong X, Wang J, Kuai D, Wang D, Ren J, Duan L, Maimaiti A, Cai Y, Huang Y, Wang X, Cao Y, You C, Yu J, Jiao L, Ling F. The Carotid and Middle cerebral artery Occlusion Surgery Study (CMOSS): a study protocol for a randomised controlled trial. Trials 2016; 17:544. [PMID: 27852286 PMCID: PMC5111211 DOI: 10.1186/s13063-016-1600-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/13/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion with haemodynamic insufficiency are at high risk for recurrent stroke when treated medically. METHODS The Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS) trial is an ongoing, government-funded, prospective, multicentre, randomised controlled trial. The CMOSS will recruit 330 patients with symptomatic ICA or MCA occlusion (parallel design, 1:1 allocation ratio) and haemodynamic insufficiency. Participants will be allocated to best medical treatment alone or best medicine plus extracranial-intracranial (EC-IC) bypass surgery. The primary outcome events are all strokes or deaths occurring between randomisation and 30 days post operation or post randomisation and ipsilateral ischaemic stroke within 2 years. Recruitment will be finished by December 2016. All the patients will be followed for at least 2 years. The trial is scheduled to complete in 2019. DISCUSSION The CMOSS will test the hypothesis that EC-IC bypass surgery plus best medical therapy reduces subsequent ipsilateral ischaemic stroke in patients with symptomatic ICA or MCA occlusion and haemodynamic cerebral ischaemia. This manuscript outlines the rationale and the design of the study. CMOSS will allow for more critical reappraisal of the EC-IC bypass for selected patients in China. TRIAL REGISTRATION NCT01758614 with ClinicalTrials.gov. Registered on 24 December 2012.
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Affiliation(s)
- Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fu Dan University, No. 12 Mid Wulumuqi Road, Shanghai, 200040, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Huanhu Hospital, No. 6 Jizhao Road, Tianjin, 300350, China
| | - Jiyue Wang
- Department of Neurosurgery, Brain Hospital, No. 45 Huashan Road, LiaoCheng, Shandong, 252000, China
| | - Dong Kuai
- Department of Neurosurgery, The 1st Affiliated Hospital of ShanXi Medical University, No. 85 South Jiefang Road, Taiyuan, Shanxi, 030001, China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Jun Ren
- Department of Neurosurgery, The 2nd Affiliated Hospital of LanZhou University, No. 80 Cuiyingmen Road, Lanzhou, Gansu, 730030, China
| | - Lian Duan
- Department of Neurosurgery, The 307 Hospital of PLA, No. 8 Dongda Street, Beijing, 100071, China
| | - Aili Maimaiti
- Department of Neurosurgery, The 1st Affiliated Hospital of XinJiang Medical University, No. 137 South Liyushan Road, Wulumuqi, Xinjiang Uyghur Autonomous Region, 830054, China
| | - Yiling Cai
- Department of Neurology, The 306 Hospital of PLA, No. 9 Anxiangbeili, Beijing, 100101, China
| | - Yujie Huang
- Department of Neurosurgery, Drum Tower Hospital, Medical School of Nanjing University, No. 321 Zhongshan Road, Nanjing, Jiangsu, 210008, China
| | - Xiaojian Wang
- Department of Neurosurgery, The 1st Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 650101, China
| | - Yi Cao
- Department of Neurosurgery, The 2nd Affiliated Hospital of Kunming Medical University, No. 324 Dianmian Road, Kunming, Yunnan, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37 Guoxue Street, Chengdu, Sichuan, 610041, China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, Hubei, 430030, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
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The masaryk hospital extracranial–intracranial bypass study. Neurosurg Rev 2016; 40:53-57. [DOI: 10.1007/s10143-016-0746-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 03/31/2016] [Accepted: 04/09/2016] [Indexed: 11/25/2022]
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35
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Long-term patency of superficial temporal artery to middle cerebral artery bypass for cerebral atherosclerotic disease: factors determining the bypass patent. Neurosurg Rev 2016; 39:655-61. [DOI: 10.1007/s10143-016-0736-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 03/06/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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36
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Goode SD, Altaf N, Munshi S, MacSweeney STR, Auer DP. Impaired Cerebrovascular Reactivity Predicts Recurrent Symptoms in Patients with Carotid Artery Occlusion: A Hypercapnia BOLD fMRI Study. AJNR Am J Neuroradiol 2016; 37:904-9. [PMID: 27012300 DOI: 10.3174/ajnr.a4739] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 09/01/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A key factor in predicting recurrent ischemic episodes in patients with carotid artery occlusion is the presence of hemodynamic impairment. There is, however, no consensus on how to best assess this risk in terms of imaging modalities or thresholds used. Here we investigated whether a predefined threshold of hemispheric asymmetry in hypercapnia fMRI predicts recurrent symptoms in patients with carotid artery occlusion. MATERIALS AND METHODS We studied 23 patients (2 women) with a mean age of 67.5 ± 9 years. Patients were assessed for recurrent ischemic events until lost to follow-up, study end, death, or recurrent ischemic event. Hypercapnia fMRI was used to assess the cerebrovascular reserve and quantify the percentage signal change in GM in the MCA territory and the hemispheric asymmetry index. Kaplan-Meier survival analysis and log-rank tests were performed to assess differences between patients with normal or abnormal hemispheric indices. RESULTS The median follow-up was 20 months. During this period, 8 patients experienced recurrent events, and 15 did not. The percentage signal change in GM in the MCA territory was significantly decreased in those patients with recurrent events compared with those without (2.39 ± 0.22 versus 2.70 ± 0.42, P = .032). The normal hemispheric index predicted event-free survival during follow-up (median, 20 months) for both the combined outcome (recurrent events and/or death, log-rank, P = .034) and recurrent retinal or ipsilateral ischemic events only (log-rank, P = .012). CONCLUSIONS The hemispheric asymmetry index derived from hypercapnia fMRI showed hemodynamic impairment in more than half of the studied patients with carotid occlusion, and those patients showed a higher risk of recurrent ischemic symptoms.
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Affiliation(s)
- S D Goode
- From the Sheffield Vascular Institute (S.D.G.), Northern General Hospital, Sheffield, UK Department of Vascular Surgery (S.D.G., N.A., S.T.R.M.), Queens Medical Centre, Nottingham, UK Department of Radiological Sciences (S.D.G., N.A., D.P.A.), Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.
| | - N Altaf
- Department of Vascular Surgery (S.D.G., N.A., S.T.R.M.), Queens Medical Centre, Nottingham, UK Department of Radiological Sciences (S.D.G., N.A., D.P.A.), Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
| | - S Munshi
- Department of Stroke Medicine (S.M.), Nottingham City Hospital, Nottingham, UK
| | - S T R MacSweeney
- Department of Vascular Surgery (S.D.G., N.A., S.T.R.M.), Queens Medical Centre, Nottingham, UK
| | - D P Auer
- Department of Radiological Sciences (S.D.G., N.A., D.P.A.), Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.
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Esposito G, Amin-Hanjani S, Regli L. Role of and Indications for Bypass Surgery After Carotid Occlusion Surgery Study (COSS)? Stroke 2016; 47:282-90. [DOI: 10.1161/strokeaha.115.008220] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/20/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Giuseppe Esposito
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
| | - Sepideh Amin-Hanjani
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
| | - Luca Regli
- From the Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland (G.E., L.R.); and Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute (S.A.-H.)
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Chang FC, Luo CB, Lirng JF, Lin CJ, Lee HJ, Wu CC, Hung SC, Guo WY. Endovascular Management of Post-Irradiated Carotid Blowout Syndrome. PLoS One 2015; 10:e0139821. [PMID: 26439632 PMCID: PMC4595276 DOI: 10.1371/journal.pone.0139821] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 09/17/2015] [Indexed: 12/28/2022] Open
Abstract
Purpose To retrospectively evaluate the clinical and technical factors related to the outcomes of endovascular management in patients with head-and-neck cancers associated with post-irradiated carotid blowout syndrome (PCBS). Materials and Methods Between 2000 and 2013, 96 patients with PCBS underwent endovascular management. The 40 patients with the pathological lesions located in the external carotid artery were classified as group 1 and were treated with embolization. The other 56 patients with the pathological lesions located in the trunk of the carotid artery were divided into 2 groups as follows: group 2A comprised the 38 patients treated with embolization, and group 2B comprised the 18 patients treated with stent-graft placement. Fisher’s exact test was used to examine endovascular methods, clinical severities, and postprocedural clinical diseases as predictors of outcomes. Results Technical success and immediate hemostasis were achieved in all patients. The results according to endovascular methods (group 1 vs 2A vs 2B) were as follows: technical complication (1/40[2.5%] vs 9/38[23.7%] vs 9/18[50.0%], P = 0.0001); rebleeding (14/40[35.0%] vs 5/38[13.2%] vs 7/18[38.9%]), P = 0.0435). The results according to clinical severity (acute vs ongoing PCBS) were as follows: technical complication (15/47[31.9%] vs 4/49[8.2%], P = 0.0035); rebleeding (18/47[38.3%] vs 8/49[16.3%], P = 0.0155). The results according to post-procedural clinical disease (regressive vs progressive change) were as follows: alive (14/21[66.7%] vs 8/75[10.7%], P<0.0001); survival time (34.1±30.6[0.3–110] vs 3.6±4.0[0.07–22] months, P<0.0001). Conclusion The outcomes of endovascular management of PCBS can be improved by taking embolization as a prior way of treatment, performing endovascular intervention in slight clinical severity and aggressive management of the post-procedural clinical disease.
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Affiliation(s)
- Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
- * E-mail:
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Han-Jui Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Chih-Chun Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Sheng-Che Hung
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
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YAMAUCHI H. Evidence for Cerebral Hemodynamic Measurement-based Therapy in Symptomatic Major Cerebral Artery Disease. Neurol Med Chir (Tokyo) 2015; 55:453-9. [PMID: 26041631 PMCID: PMC4628196 DOI: 10.2176/nmc.ra.2015-0071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 11/21/2022] Open
Abstract
In patients with atherosclerotic internal carotid artery or middle cerebral artery occlusive disease, chronic reduction in cerebral perfusion pressure (chronic hemodynamic compromise) increases the risk of ischemic stroke and can be detected by directly measuring hemodynamic parameters. However, strategies for selecting treatments based on hemodynamic measurements have not been clearly established. Bypass surgery has been proven to improve hemodynamic compromise. However, the benefit of bypass surgery for reducing the stroke risk in patients with hemodynamic compromise is controversial. The results of the two randomized controlled trials were inconsistent. Hypertension is a major risk factor for stroke, and antihypertensive therapy provides general benefit to patients with symptomatic atherosclerotic major cerebral artery disease. However, the benefit of strict control of blood pressure for reducing the stroke risk in patients with hemodynamic compromise is a matter of debate. The results of the two observational studies were different. We must establish strategies for selecting treatments based on hemodynamic measurements in atherosclerotic major cerebral artery disease.
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Affiliation(s)
- Hiroshi YAMAUCHI
- Division of PET Imaging, Shiga Medical Centre Research Institute, Moriyama, Shiga
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Kataoka H, Miyamoto S, Ogasawara K, Iihara K, Takahashi JC, Nakagawara J, Inoue T, Mori E, Ogawa A. Results of Prospective Cohort Study on Symptomatic Cerebrovascular Occlusive Disease Showing Mild Hemodynamic Compromise [Japanese Extracranial-Intracranial Bypass Trial (JET)-2 Study]. Neurol Med Chir (Tokyo) 2015; 55:460-8. [PMID: 26041628 PMCID: PMC4628197 DOI: 10.2176/nmc.oa.2014-0424] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to determine the true threshold of cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) for subsequent ischemic stroke without extracranial-intracranial (EC-IC) bypass surgery in patients with hemodynamic ischemia due to symptomatic major cerebral arterial occlusive diseases. Patients were categorized based on rest CBF and CVR into four subgroups as follows: Group A, 80% < CBF < 90% and CVR < 10%; Group B, CBF < 80% and 10% < CVR < 20%; Group C, 80% < CBF < 90% and 10% < CVR < 20%; and Group D, CBF < 90% and 20% < CVR < 30%. Patients were followed up for 2 years under best medical treatment by the stroke neurologists. Primary and secondary end points were defined as all adverse events and ipsilateral stroke recurrence respectively. A total of 132 patients were enrolled. All adverse events were observed in 9 patients (3.5%/year) and ipsilateral stroke recurrence was observed only in 2 patients (0.8%/year). There was no significant difference among the four subgroups in terms of the rate of both primary and secondary end points. Compared with the medical arm of the Japanese EC-IC bypass trial (JET) study including patients with CBF < 80% and CVR < 10% as a historical control, the incidence of ipsilateral stroke recurrence was significantly lower in the present study. Patients with symptomatic major cerebral arterial occlusive diseases and mild hemodynamic compromise have a good prognosis under medical treatment. EC-IC bypass surgery is unlikely to benefit patients with CBF > 80% or CVR > 10%.
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Affiliation(s)
- Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
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Chui J, Manninen P, Sacho RH, Venkatraghavan L. Anesthetic Management of Patients Undergoing Intracranial Bypass Procedures. Anesth Analg 2015; 120:193-203. [DOI: 10.1213/ane.0000000000000470] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Risk Profile In Extracranial/Intracranial Bypass Surgery—The Role of Antiplatelet Agents, Disease Pathology, and Surgical Technique In 168 Direct Revascularization Procedures. World Neurosurg 2014; 82:672-7. [DOI: 10.1016/j.wneu.2013.06.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/04/2013] [Accepted: 06/28/2013] [Indexed: 11/20/2022]
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Horie N, Fukuda Y, Izumo T, Hayashi K, Suyama K, Nagata I. Indocyanine green videoangiography for assessment of postoperative hyperperfusion in moyamoya disease. Acta Neurochir (Wien) 2014; 156:919-26. [PMID: 24627037 DOI: 10.1007/s00701-014-2054-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 02/26/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative cerebral hyperperfusion (HP) is a notable complication that occurs more frequently in moyamoya disease (MMD) than in atherosclerosis. This study aimed to clarify the characteristics of intraoperative indocyanine green (ICG) videoangiography in MMD and atherosclerotic disease in terms of postoperative HP. METHODS This prospective study included 47 patients with 60 sides that underwent superior temporal artery (STA)-middle cerebral artery (MCA) single bypass. ICG videoangiography was performed after revascularization. The ICG time intensity curve was recorded in the STA, proximal MCA, distal MCA, and superficial Sylvian vein, and the angiographic differences among adult MMD, pediatric MMD, and atherosclerosis were analyzed. RESULTS Twenty-two patients (27 sides) had adult MMD, 14 patients (22 sides) had pediatric MMD, and 11 patients (11 sides) had atherosclerosis. Postoperative HP was significantly higher in adult MMD (40.7 %) than in pediatric MMD (18.2 %) and atherosclerosis (0 %). Adult MMD with HP was associated with a longer ICG peak time (P < 0.001). There was no correlation between the ICG peak time and preoperative cerebral blood flow or vascular reserve. The ratio of the vessel caliber was also higher in adult MMD with HP (P < 0.001). CONCLUSIONS ICG videoangiography provides different characteristics of bypass flow among adult MMD, pediatric MMD, and atherosclerosis. Poor run-off and stagnation of blood flow from the STA might contribute to postoperative HP in MMD. The occurrence of postoperative HP in MMD could depend on two factors: donor STA size and poor run-off and integrity of the blood brain barrier in the recipient MCA.
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Affiliation(s)
- Nobutaka Horie
- Department of Neurosurgery, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan,
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Gupta A, Baradaran H, Schweitzer AD, Kamel H, Pandya A, Delgado D, Wright D, Hurtado-Rua S, Wang Y, Sanelli PC. Oxygen extraction fraction and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2014; 35:250-5. [PMID: 23945227 DOI: 10.3174/ajnr.a3668] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Increased oxygen extraction fraction on PET has been considered a risk factor for stroke in patients with carotid stenosis or occlusion, though the strength of this association has recently been questioned. We performed a systematic review and meta-analysis to summarize the association between increased oxygen extraction fraction and ipsilateral stroke risk. MATERIALS AND METHODS A comprehensive literature search was performed. We included studies with baseline PET oxygen extraction fraction testing, ipsilateral stroke as the primary outcome, and at least 1 year of follow-up. A meta-analysis was performed by use of a random-effects model. RESULTS After screening 2158 studies, 7 studies with 430 total patients with mean 30-month follow-up met inclusion criteria. We found that 6 of 7 studies were amenable to meta-analysis. Although 4 of the 6 studies independently did not reach statistical significance, meta-analysis revealed a significant positive relationship between abnormal oxygen extraction fraction and future ipsilateral stroke, with a pooled OR of 6.04 (95% CI, 2.58-14.12). There was no statistically significant difference in OR in the subgroup analyses according to testing method or disease site. CONCLUSIONS Abnormal oxygen extraction fraction remains a powerful predictor of stroke in carotid stenosis or occlusion and is a valuable reference standard to compare and validate MR imaging-based measures of brain oxygen metabolism. However, there is a need for further evaluation of oxygen extraction fraction testing in patients with high-grade but asymptomatic carotid disease.
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Affiliation(s)
- A Gupta
- From the Departments of Radiology (A.G., H.B., A.D.S., Y.W., P.C.S.)
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Reynolds MR, Derdeyn CP, Grubb RL, Powers WJ, Zipfel GJ. Extracranial-intracranial bypass for ischemic cerebrovascular disease: what have we learned from the Carotid Occlusion Surgery Study? Neurosurg Focus 2014; 36:E9. [DOI: 10.3171/2013.10.focus13427] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracranial-intracranial (EC-IC) arterial bypass has been used in the treatment of various neurosurgical pathologies including skull base tumors requiring sacrifice of a large intracranial artery; complex intracranial aneurysms requiring trapping; and distal revascularization, moyamoya disease, and symptomatic cerebrovascular stenoocclusive disease. The latter indication has been the subject of intense investigations in several large randomized controlled trials, most recently the Carotid Occlusion Surgery Study (COSS). In the present literature review and synthesis, the authors examine the current evidence available for EC-IC arterial bypass for the treatment of ischemic cerebrovascular disease including both extracranial carotid artery occlusive disease and intracranial atherosclerotic disease. They focus particular attention on EC-IC arterial bypass for the treatment of symptomatic hemodynamic cerebral ischemia and how lessons learned from the COSS might guide future investigations into the treatment of this disease.
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Affiliation(s)
| | - Colin P. Derdeyn
- 1Departments of Neurological Surgery,
- 2Radiology, and
- 3Neurology, Washington University School of Medicine, St. Louis, Missouri; and
| | | | - William J. Powers
- 4Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gregory J. Zipfel
- 1Departments of Neurological Surgery,
- 2Radiology, and
- 3Neurology, Washington University School of Medicine, St. Louis, Missouri; and
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Mansour O, Schumacher M, Farrag MA, Abd-Allah F. Intracranial Atherosclerosis: The Natural History and Management Strategies. WORLD JOURNAL OF CARDIOVASCULAR DISEASES 2014; 04:350-360. [DOI: 10.4236/wjcd.2014.47044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Kazumata K, Yokoyama Y, Sugiyama T, Asaoka K. Occipital-posterior cerebral artery bypass via the occipital interhemispheric approach. Surg Neurol Int 2013; 4:90. [PMID: 23956933 PMCID: PMC3740606 DOI: 10.4103/2152-7806.114975] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/31/2013] [Indexed: 11/04/2022] Open
Abstract
Background: The unavailability of the superficial temporal artery (STA) and the location of lesions pose a more technically demanding challenge when compared with conventional STA-superior cerebellar or posterior cerebral artery (PCA) bypass in vascular reconstruction procedures. To describe a case series of patients with cerebrovascular lesions who were treated using an occipital artery (OA) to PCA bypass via the occipital interhemispheric approach. Methods: We retrospectively reviewed three consecutive cases of patients with cerebrovascular lesions who were treated using OA-PCA bypass. Results: OA-PCA bypass was performed via the occipital interhemispheric approach. This procedure included: (1) OA-PCA bypass (n = 1), and combined OA-posterior inferior cerebellar artery and OA-PCA saphenous vein interposition graft bypass (n = 1) in patients with vertebrobasilar ischemia; (2) OA-PCA radial artery interposition graft bypass in one patient with residual PCA aneurysm. Conclusions: OA-PCA bypass represents a useful alternative to conventional STA-SCA or PCA bypass.
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Affiliation(s)
- Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Powers WJ, Clarke WR, Adams HP, Derdeyn CP, Grubb RL. Commentary: Extracranial-intracranial bypass for stroke in 2012: response to the critique of the carotid occlusion surgery study "It was déjà vu all over again". Neurosurgery 2013; 71:E772-6. [PMID: 22899445 DOI: 10.1227/neu.0b013e318268c7d3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Amin-Hanjani S, Barker FG, Charbel FT, Connolly ES, Morcos JJ, Thompson BG. Extracranial-Intracranial Bypass for Stroke—Is This the End of the Line or a Bump in the Road? Neurosurgery 2012; 71:557-61. [DOI: 10.1227/neu.0b013e3182621488] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
The results of the recently published Carotid Occlusion Surgery Study, which failed to show a benefit of extracranial-intracranial (EC-IC) bypass over medical therapy in patients with symptomatic hemodynamically significant carotid occlusion, have been interpreted by some as the end of the line for EC-IC bypass in the management of stroke. Despite being carefully conceived and executed, several aspects of the trial design, study population, and underlying assumptions deserve further examination to determine how best to translate these results into clinical practice. Although a general expansion of EC-IC bypass use in this population would not be supported by the trial results, a select subset of patients with medically refractory hemodynamic symptoms may well benefit from surgery performed with sufficiently low perioperative morbidity. The potential for beneficial functional or cognitive impact of revascularization also remains under investigation. Limited application and further study with an eye to future developments, rather than complete abandonment, is warranted.
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