rivascolarizzazione cerebrale tecnica chirurgica rivascolarizzazione cerebrale tecnica chirurgica...
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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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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.
Extracranial - Intracranial BypassExtracranial - Intracranial Bypass
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Extracranial - Intracranial BypassExtracranial - Intracranial Bypass
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
Extracranial - Intracranial BypassExtracranial - Intracranial Bypass
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 …..
Extracranial - Intracranial BypassExtracranial - Intracranial Bypass
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 %
Extracranial - Intracranial BypassExtracranial - Intracranial Bypass
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
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 ?
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Case ReportCase ReportCase ReportCase Report
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
STA-MCA ByPassSTA-MCA ByPass
Case ReportCase ReportCase ReportCase Report
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Case ReportCase ReportCase ReportCase Report
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction
Skull Base, volume 15, number 1, 2005 E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction
Skull Base, volume 15, number 1, 2005 E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction
Skull Base, volume 15, number 1, 2005 E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Bypass procedures for ICA Bypass procedures for ICA reconstructionreconstruction
Skull Base, volume 15, number 1, 2005 E. de Oliveira
Perioperative Stroke Risk 7 - 15 %
ELANAExcimer Laser Assisted Nonocclusive Anastomosis
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
ELANAExcimer Laser Assisted Nonocclusive Anastomosis
Training Model in Vivo
Centro per le BiotecnologieGiuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
ELANAExcimer Laser Assisted Nonocclusive Anastomosis
Giuseppe 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
ELANAExcimer Laser Assisted Nonocclusive Anastomosis
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Giant Supraclinoid Carotid Aneurysm
First ELANA procedure in Italy – May 2006First ELANA procedure in Italy – May 2006
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
ECA-MCA Excimer Laser Assisted Non-occlusive Anastomosis
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Case n°1 – Five monthes follow-upCase n°1 – Five monthes follow-up
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli
Case n°1 – Five monthes follow-upCase n°1 – Five monthes follow-up
ELANAExcimer Laser Assisted Nonocclusive Anastomosis
• 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
Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli