Rivascolarizzazione Cerebrale Tecnica Chirurgica Rivascolarizzazione Cerebrale Tecnica Chirurgica...

Rivascolarizzazione Cerebrale

Tecnica Chirurgica

Rivascolarizzazione Cerebrale

Tecnica ChirurgicaGiuseppe Russo

Responsabile UOSS “Cerebropatie Vascolari Acute”

UOSC Neurochirurgia d’Urgenza

AORN “A.Cardarelli” - Napoli

V Corso Nazionale Congiunto

SIDV-GIUV SINSEC

Bertinoro 28 -31 Marzo 2007

Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

EC-IC bypass was originally developed by Yasargil

and Yonekawa in 1977 as a safe means of direct

cerebral revascularization.

Extracranial - Intracranial BypassExtracranial - Intracranial Bypass


This methodology was called into question by the EC-IC Bypass Study in 1985 which found the procedure

to be of no statistical benefit and essentially discontinued as a treatment for cerebral ischemia.




The procedure, however, continued to be used for

CBF replacement as an adjunct to parent vessel sacrifice in patients with aneurysms and tumors who had poor collateral circulation.

The EC/IC Bypass Study Group, 1985The EC/IC Bypass Study Group, 1985The EC/IC Bypass Study Group, 1985The EC/IC Bypass Study Group, 1985


Most distal angiography lesion of 1337 Partecipants

Middle cerebral arteryMiddle cerebral artery

Stenosis Stenosis 14.4 %14.4 % OcclusionOcclusion 12.1 %12.1 %

Internal Carotid arteryInternal Carotid artery

Stenosis (above C2)Stenosis (above C2) 15.4 %15.4 % Occlusion, no symptomsOcclusion, no symptoms 37.0 % 37.0 % Occlusion, recurrent symptomsOcclusion, recurrent symptoms 21.1 %21.1 %

It is clearly impossible to reach a It is clearly impossible to reach a

conclusion in the matter without conclusion in the matter without

physiological studies of CBF …..physiological studies of CBF …..


Do abnormal cerebral hemodynamics identify a stroke risk ?

n.n. CBF AssesmentCBF Assesment poor poor CVRCVR adequate adequate CVRCVR

Yonas et al Yonas et al (1985)(1985)

6688

stable xenon CTstable xenon CT & & acetazolamideacetazolamide 36 %36 % 4.4 %4.4 %

Kleiser & Kleiser & Widder Widder (1992)(1992)

8811

TCD TCD and inhaled and inhaled COCO22 21 %21 %

Silvestrini et Silvestrini et al al (1994)(1994)

3322

TCD TCD and inhaled and inhaled COCO22 24 %24 %

Grubb Grubb (1998)(1998)

8899

PETPET - OEF - OEF26.5 %26.5 % 5.3 %5.3 %



Derdeyn et al. – Brain, 2002 after Powers et al., 1987Derdeyn et al. – Brain, 2002 after Powers et al., 1987

1. Increased OEF in the territory of an occluded carotid artery often occurs in the absence of a measurable elevation in CBV. 2. Patients who have both increased OEF and increased CBV, are at much higher risk for subsequent ipsilateral stroke.

Haemodynamic and Metabolic ResponsesHaemodynamic and Metabolic Responsesto CPP Reductionsto CPP ReductionsHaemodynamic and Metabolic ResponsesHaemodynamic and Metabolic Responsesto CPP Reductionsto CPP Reductions

Three basic strategiesThree basic strategies

1. paired rCBF measurements, with initial measurement obtained at rest and the second after provision of a cerebral vasodilatory stimulus

2. measurement of rCBV alone or in combination with measurement of rCBF in the resting brain

3. direct measurement of rOEF


Derdeyn et al. Brain, 2002Derdeyn et al. Brain, 2002 Derdeyn et al. Brain, 2002Derdeyn et al. Brain, 2002

Increased CBV indicates autoregulatory vasodilation

Reductions in perfusion pressure within the autoregulatory range

Increased OEF Increased OEF without increased CBVwithout increased CBVIncreased OEF Increased OEF without increased CBVwithout increased CBV

Haemodynamic FailureHaemodynamic FailureStage 2Stage 2Haemodynamic FailureHaemodynamic FailureStage 2Stage 2

Haemodynamic and Metabolic ResponsesHaemodynamic and Metabolic Responsesto CPP Reductionto CPP ReductionHaemodynamic and Metabolic ResponsesHaemodynamic and Metabolic Responsesto CPP Reductionto CPP Reduction

http://brain.oupjournals.org/cgi/content/full/125/3/595/AWF047F1

http://brain.oupjournals.org/cgi/content/full/125/3/595/AWF047F3

RL. Grubb,WJ Powers, CP Derdeyn RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus 14 (3): 2003Neurosurg Focus 14 (3): 2003

RL. Grubb,WJ Powers, CP Derdeyn RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus 14 (3): 2003Neurosurg Focus 14 (3): 2003

Inclusion criteriaInclusion criteria1) Vascular imaging studies demonstrating occlusion of one ICA

2) Vascular imaging studies demonstrating less than 50% stenosis of the contralateral extracranial ICA

3) A TIA or ischemic stroke in the hemispheric CA territory of the occluded CA

4) Most recent qualifying TIA or stroke must have occurred within 120 days prior to the performance date of PET

5) Modified Barthel Index score greater or equal to 12/20

6) Age ranging between 18 and 85 years

Inclusion criteriaInclusion criteria1) Vascular imaging studies demonstrating occlusion of one ICA

2) Vascular imaging studies demonstrating less than 50% stenosis of the contralateral extracranial ICA

3) A TIA or ischemic stroke in the hemispheric CA territory of the occluded CA

4) Most recent qualifying TIA or stroke must have occurred within 120 days prior to the performance date of PET

5) Modified Barthel Index score greater or equal to 12/20

6) Age ranging between 18 and 85 years

Parenchimal

Sites were the recorded hemodynamic changes are produced

Sites were the recorded hemodynamic changes are produced

Can TCD Ultrasounds provide

useful informations in singling

out the “long-searched” group of

patients elegible for cerebral

bypass ?

Can TCD Ultrasounds provide

useful informations in singling

out the “long-searched” group of

patients elegible for cerebral

bypass ?


G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000

CerebroVascular Reserve CerebroVascular Reserve TCD recorded CO2 Reactivity TestCerebroVascular Reserve CerebroVascular Reserve

TCD recorded CO2 Reactivity Test

reference value: 3.5 % ± 0.9 mmHg

L VmcaR Vmca

p CO2

The increase of Blood Flow Velocity during hypercapnia “CO2 reactivity”

gives a measure of the capacity of the intracerebral arterioles to dilate further

The increase of Blood Flow Velocity during hypercapnia “CO2 reactivity”

gives a measure of the capacity of the intracerebral arterioles to dilate further

R Vmca

L Vmca

p CO2

R Vmca

L Vmca

p CO2

Impaired CerebroVascular ReserveImpaired CerebroVascular Reservein in leftleft ICA occlusion ICA occlusion

Impaired CerebroVascular ReserveImpaired CerebroVascular Reservein in leftleft ICA occlusion ICA occlusion

G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000

M Ursino, CA Lodi, G Russo - Journal of Vascular Research 2000

CerebroVascular Reserve AssessmentCerebroVascular Reserve Assessment Side to Side IndexSide to Side Index

CerebroVascular Reserve AssessmentCerebroVascular Reserve Assessment Side to Side IndexSide to Side Index

0

1020

30

40

5060

70

8090

100

110

120130

140

Subjects n°

Rel

ativ

e C

O2

Rea

ctiv

ity

Ind

ex (

%)

0

1020

30

40

5060

70

8090

100

110

120130

140

Subjects n°

Rel

ativ

e C

O2

Rea

ctiv

ity

Ind

ex (

%)

Healthy Subjects ICA occlusioneHealthy Subjects ICA occlusione

Vascular Brain ReserveVascular Brain ReserveVascular Brain ReserveVascular Brain Reserve


Paradoxical ResponceParadoxical ResponceParadoxical ResponceParadoxical Responce

M Ursino, CA Lodi, G Russo - Journal of Vascular Research 2000;37:123-133

Paradoxical Responseexplained by the “model”

Paradoxical Responseexplained by the “model”

HypercapniaHypercapniaHypercapniaHypercapnia

CBVCBVCBVCBV

Reduced PressureReduced Pressurein the Willisin the Willis

Reduced PressureReduced Pressurein the Willisin the Willis

VENOUS VENOUS PRESSUREPRESSUREVENOUS VENOUS

PRESSUREPRESSURE

++ Vasodilation Vasodilation Vasodilation Vasodilation

CPPCPPCPPCPP

++

--

ICAICAOCCLUDED OCCLUDED

SIDESIDE

ICAICAOCCLUDED OCCLUDED

SIDESIDE

ICAICAOPEN OPEN SIDESIDE

ICAICAOPEN OPEN SIDESIDE

Maximal VasodilatedMaximal Vasodilated

Case Report Case Report Case Report Case Report

0

20

40

60

80

100

120

140

7/ 7/ 98 30/ 9/ 00 11/ 3/ 02 15/ 5/ 05Re

lati

ve

CO

2 R

ea

cti

vit

y In

de

x


Case ReportCase ReportCase ReportCase Report


STA-MCA ByPassSTA-MCA ByPass


Before STA-MCA bypass

0

20

40

60

80

100

120

140

Rela

tiv

e C

V R

eserve In

dex

20 days after STA-MCA bypass



Brain RevascularizationBrain Revascularization

15 – 25 ml/min

Low flow STA-MCA bypass

High flow graft

70 – 180 ml/min

Distal Flow Increase

Proximal

Flow Replacement

ICA Reconstruction

Reconstruction of the ICA with the use of interpositional SVGs

(high flow EC-IC bypass) for the management of giant

aneurysms was popularized by Sundt

in the early 1980’s


Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction



Skull Base, volume 15, number 1, 2005 E. de Oliveira



Skull Base, volume 15, number 1, 2005 E. de Oliveira

Perioperative Stroke Risk 7 - 15 %

ELANAExcimer Laser Assisted Nonocclusive Anastomosis



Training Model in Vivo

Centro per le BiotecnologieGiuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli



Training Model in Vivo

Excimer Laser Assisted Non-occlusive Anastomosis (ELANA). Our experience with a training model in vivo. Russo G., Rotondo M., Punzo A., Di Napoli D. Journal Neurosurg Sci 51, 1: 11-17, 2007


PARTNER HOSPITALS Universitair Medisch CentrumUtrecht - Holland

UniversitaetsklinikumMannheim – Germany

University HospitalHelsinky - Finland

Inselspital Bern – Switzerland

AORN A.CardarelliNapoli - Italy

Kings College HospitalLondon - UK

St. Luke's-Roosevelt Hospital New York - NY USA



Giant Supraclinoid Carotid Aneurysm

G.M. 22 yrs G.M. 22 yrs

Left-handedLeft-handed

Right Retro-orbital Pulsating HeadacheRight Retro-orbital Pulsating Headache

First ELANA procedure in Italy – May 2006First ELANA procedure in Italy – May 2006


Giant Supraclinoid Carotid Aneurysm

First ELANA procedure in Italy – May 2006First ELANA procedure in Italy – May 2006

ECA-MCA Excimer Laser Assisted Non-occlusive Anastomosis



Case n°1 – Five monthes follow-upCase n°1 – Five monthes follow-up


• Dedicated Team

• Permanent Training

• More than 10 ELANA

/year

• International Register

• National Register

• Dedicated Team

• Permanent Training

• More than 10 ELANA

/year

• International Register

• National Register


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