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Intraoperative monitoring of cerebral cortical blood flow and middle cerebral artery pressure as a substitute for preoperative balloon test occlusion in patients with internal carotid artery aneurysms

  • Original Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

Balloon test occlusion (BTO) is a useful examination to evaluate the indications and methods for revascularization when treating unclippable internal carotid artery (ICA) aneurysms by parent artery occlusion. The purpose of the present study was to investigate the relationship between intraoperative monitoring of cerebral cortical blood flow (CoBF) and middle cerebral artery (MCA) pressure during surgical parent artery occlusion and the findings of BTO.

Methods

Eleven patients with an ICA aneurysm in the cavernous portion underwent preoperative BTO with brain perfusion single-photon emission tomography. CoBF was monitored intraoperatively in all patients using a laser Doppler probe. The lowest CoBF during test occlusion of the ICA under functioning superficial temporal artery-middle cerebral artery (STA-MCA) bypass was determined, and the ratio of the value to the CoBF immediately before test occlusion of the ICA was calculated in the frontal and temporal lobes. When the CoBF ratio in the frontal or temporal lobe was less than 0.9, high-flow bypass grafting was added. The MCA pressure was also measured by temporarily occluding the proximal STA.

Results

Of the 11 patients undergoing STA-MCA bypass, 5 patients underwent concomitant high-flow bypass grafting. Significant differences in the cerebrovascular reserve based on SPECT during BTO, CoBF, and the MCA pressure ratio during surgery were observed when comparing the two groups.

Conclusions

Intraoperative monitoring of CoBF and MCA pressure may be useful, along with preoperative BTO, for patients with unclippable ICA aneurysms.

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Abbreviations

BTO:

Balloon test occlusion

CoBF:

Cerebral cortical blood flow

STA-MCA:

Superficial temporal artery-middle cerebral artery

High-flow bypass:

External carotid artery-middle cerebral artery bypass using interposition of a saphenous vein graft

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Acknowledgements

This work was partly supported by a Grant-in-Aid for Strategic Medical Science Research (S1491001, 2014-2018) from the Ministry of Education, Culture, Sports, Science, and Technology of Japan.

Funding

No funding was received for this research.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan

    Yoshitaka Kubo, Takahiro Koji, Kenji Yoshida & Kuniaki Ogasawara

  2. Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan

    Ryushi Kondo

Authors
  1. Yoshitaka Kubo
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  2. Takahiro Koji
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  3. Ryushi Kondo
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  4. Kenji Yoshida
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  5. Kuniaki Ogasawara
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Corresponding author

Correspondence to Yoshitaka Kubo.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

For this type of study, formal consent is not required.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Comments

In this manuscript the authors investigate the reliability of two intraoperative methods, cerebral cortical blood flow (CoBF) and middle cerebral artery (MCA) pressure, in assessing the cerebrovascular reserve after internal carotid artery (ICA) occlusion by comparing the results with balloon test occlusion (BTO) findings.

The authors showed that continuous intraoperative measurements of both CoBF and MCA pressure during ICA occlusion test may help to identify flow needing replacement, along with preoperative BTO results.

This is a valuable work that attempt to provide an immediate tool to select the optimal revascularization strategy: BTO is not always performable in emergent settings of ruptured aneurysm and has not always proven foolproof in averting ischemia after vessel sacrifice, and alternative flow replacement assessment techniques are still evolving.

As the authors stated, though, CoBF measurements are limited to the area under the probe and may underestimate change in perfusion to the surrounding territory at risk.

The ultrasonic flow probe, another intraoperative technique that directly measures blood flow within cerebral vessels, has already been proven reliable in the assessment of cerebral flow demand in the needs of ICA sacrifice, 1 with good long-term results. 2

It would be of interest to investigate the relationship of the CoBF with actual cerebral vessel flow deficit in the setting of flow demand assessment.

Nevertheless, this preliminary study provides further insights into the flow replacement assessment, in an ongoing effort to ensure the optimal revascularization strategy selection.

1. Amin-Hanjani S, Alaraj A, Charbel FT (2010) Flow replacement bypass for aneurysm: decision-making using intraoperative blood flow measurements. Acta Neurochir 152:1021–1032.

2. Rustemi O, Amin-Hanjani S, Shakur SF, Du X, Charbel FT (2016) Donor selection in flow replacement bypass surgery for cerebral aneurysm: quantitative analysis of long-term native donor flow sufficiency. Neurosurgery 78:332–342.

Denise Brunozzi

Fady T Charbel

Illinois, USA

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Kubo, Y., Koji, T., Kondo, R. et al. Intraoperative monitoring of cerebral cortical blood flow and middle cerebral artery pressure as a substitute for preoperative balloon test occlusion in patients with internal carotid artery aneurysms. Acta Neurochir 160, 1129–1137 (2018). https://doi.org/10.1007/s00701-018-3469-0

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  • DOI: https://doi.org/10.1007/s00701-018-3469-0

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