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Impact of cervical internal carotid clamping and radial artery graft bypass on cortical arterial perfusion pressure during craniotomy

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Abstract

Strategic cervical internal carotid occlusion is employed either temporarily or permanently in various neurosurgical procedures. The aim of the present study was to assess changes in cortical arterial pressure during cervical internal carotid cross-clamping before and after the placement of radial artery (RA) graft bypass in the treatment of complex carotid artery aneurysms. Perfusion pressure of the middle cerebral artery (MCA) was assessed in 22 patients with complex carotid aneurysm treated with RA graft bypass. Regional cerebral blood flow was assessed postoperatively using single-photon computed tomography. Mean cortical blood pressure (mcBP) was found to be 48.2 ± 24.2 and 97.0 ± 24.0 % of baseline after clamping the cervical internal carotid artery and opening the RA graft bypass, respectively. Cerebral perfusion pressure estimated by the mcBP failed to sustain a critical limit of greater than 70 mmHg under craniotomy in 16 out of 20 (80 %) patients. There was an inverse correlation in mcBP between the baseline and after the placement of the RA graft bypass (r = 0.66, P < 0.005). Postoperative regional cerebral blood flow in the MCA territory on the ipsilateral side of the aneurysm was 97 ± 7 % of that of the contralateral side after internal carotid artery (ICA) ligation combined with RA graft bypass. Substantial pressure reductions in cerebral cortical arteries were observed during the cervical internal carotid cross-clamping. Perfusion pressure in peripheral cortical arteries after the placement of the RA graft bypass was comparable to the state before ICA clamping.

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Acknowledgements

The author thanks Dr. N. Kobayashi, Dr. R. Tanikawa, and K. Takizawa for performing the surgery and for their guidance throughout the course of this investigation.

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Authors and Affiliations

  1. Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, North 15 West 7, Kita, 060-8638, Japan

    Ken Kazumata, Shunsuke Terasaka & Kiyohiro Houkin

  2. Sapporo Teishinkai Hospital, Sapporo, Japan

    Hiroyasu Kamiyama

  3. Akita Blood Vessel and Research Institute, Akita, Japan

    Tatsuya Ishikawa

  4. Sapporo Azabu Neurosurgical hospital, Sapporo, Japan

    Toshitaka Nakamura

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  1. Ken Kazumata
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Correspondence to Ken Kazumata.

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Comments

Tarek A Rayan and Fady T Charbel, Chicago, USA

The primary objective of this article was to assess changes in cortical arterial pressures occurring with cervical internal carotid artery clamping before and after EC–IC bypass procedures using a radial artery graft for a high-flow conduit for the treatment of complex carotid artery aneurysms.

The authors describe a novel idea for the measurement of cortical arterial pressure during the technique used to perform a STA–MCA–RA–ECA bypass procedure. A double-insurance bypass has been employed by performing a STA–MCA bypass prior to the RA–MCA anastomosis for securing the minimal blood flow requirements during the anastomosis and preventing any ischemic insult on the event of graft occlusion. Cortical blood pressure was measured via one branch of the STA anastomosed with the MCA before and during ICA clamp and after RA graft bypass between ECA and MCA.

The authors state a logical rational for performing a double-insurance bypass, outlying the relevant ischemic complications occurring with patients having an abrupt occlusion of their ICA due to hemodynamic insufficiency without immediate reduction in regional cerebral blood flow, with reduced perfusion pressures undetectable by BTO.

Using this simple technique, for the first time, the blood-carrying capacity of the RA graft was assessed in terms of cortical arterial perfusion pressure. The authors found an inverse correlation in corrected mean perfusion pressure between the baseline and after the placement of the RA bypass. It also demonstrated an average of 52 % reduction in cortical perfusion pressure and a substantial decrease in CPP (<70 mmHg) during ICA clamp in 80 % of patients. The study concluded that blood flow in the RA graft was comparable to that of the ICA as measured by cortical arterial pressure, which they confirmed postoperatively with regional blood flow studies.

There are some concerns, patients in the present report underwent RA graft bypass regardless of the degree of collateral circulation in the event of carotid occlusion. As expected, it revealed a diverse range of reductions in perfusion pressure in cerebral cortical arteries. This, accompanied with patients having a wide age range, from 24–81, makes small number of patients a relatively incoherent group that respond differently to hemodynamic insufficiency.

With the bias that comes with a retrospective study, this article still cannot be used to guide the selection process of appropriate candidates for EC–IC bypass because the comparison of cortical pressures is achieved only after the bypass has been performed. However, the present investigation is clinically relevant because the severity of ischemia during abrupt carotid cross-clamping assessed directly by cortical perfusion pressure without selecting patients based on BTO is an investigation that an application of an EC–IC bypass could specifically provide.

The authors state that the EC–RA–MCA bypass is considered an ideal vascular reconstruction that can replace the ICA in terms of cerebral hemodynamics. However, our studies of bypass surgeries for proximal carotid aneurysms using “flow replacement” algorithms by implementing the “cut flow index” showed different conclusions. The flow bypass concept aims for optimal revascularization strategies to directly match graft flow to demand on a case-by-case basis, compensating the “flow deficit” in efferent vessels of aneurysms. Using this concept, the traditional decision between high-flow and low flow-bypass becomes less relevant.

Results showed that STA–MCA bypasses compensated this deficit efficiently in most cases, without the need of a RA interposition graft. This has the advantages of in situ pedicle grafts such as greater patency rates, better longevity, and the need for only one anastomosis. In the case of diminutive STA, a saphenous vein graft was used for the bypass instead of RA because of preferred tissue handling and ease of harvesting with less morbidity. Replacing the full hemispheric flow, it allowed prolonged temporary clipping and ultimately permitting direct aneurysm clipping after suction–decompression without carotid sacrifice.

The article continues to provide a valuable input for further understanding the complex hemodynamics of cerebral blood flow, showing that cortical perfusion pressure potentially reveals impaired cerebral hemodynamics in the middle cerebral artery territory where no substantial decrease is identified by CBF studies and confirming that preoperative assessment of rCBF alone may not be sufficient when therapeutic IC ligation is necessary. The technique is helpful in detecting any deterioration in cerebral blood flow during the procedure itself, allowing a rapid and prompt response to rectify decreased flow measurements.

Overall, the paper reconfirms the importance and success of bypass surgeries in restoring blood flow to the brain efficiently. Authors are to be congratulated on their novel idea for graft flow measurement in terms of cortical arterial perfusion pressure.

Akitsugu Kawashima, Chiba, Japan

This article evaluates the cortical arterial perfusion pressure in cases of complex aneurysms treated with ECA–RA–MCA bypass. The authors measured cortical artery pressure directly through the connected bypass graft. They found a serious reduction in cortical arterial pressure during ICA clamping that was sufficiently compensated by the blood flow from RA graft bypass, therefore advocating the necessity of universal bypass approach in cases of therapeutic acute ICA occlusion. Data for the cortical arterial pressure through the graft in larger number of cases of large/giant ICA aneurysms are very valuable. This procedure can be also useful for a continuous monitoring during surgery. It is remarkable that their data indicated the existence of larger numbers of patients who need reconstruction of blood flow in the therapeutic acute ICA occlusion than data from former studies based on balloon test occlusion.

The authors also described that the superiority of universal bypass approach based on the extent of reduction of mean cortical arterial perfusion pressure. There were some “good baseline ratio cases after carotid clamping” in their data, while the authors’ emphasis was based on the change of cortical arterial perfusion pressure after carotid clamping. What probably is important is not to evaluate only the mean perfusion pressure, but to also have a case-by-case evaluation. For example, it may be estimated which cases are really in need for a high-flow bypass by using this procedure intraoperatively, the same as by intraoperative blood flow measurement using ultrasonic flow meter1 before placing the high flow bypass.

References

1. Amin-Hanjani S, Alaraj A, Charbel FT. Flow replacement bypass for aneurysms: decision-making using intraoperative blood flow measurements. Acta neurochirurgica. 2010;152:1021–1032; discussion 1032

Albert van der Zwan, Utrecht, The Netherlands

This clearly written paper is nicely demonstrating peripheral hemodynamic effects of constructing a high-flow radial artery EC–IC bypasses for temporary or permanent ICA replacement on cerebral perfusion pressure and even cortical perfusion pressure. The authors, for the first time, measure the pressure in the peripheral cortical arteries after placing a smaller distal STA–MCA bypass for protection followed by a high flow RA bypass procedure for replacing the ICA. The substantial pressure reductions they observe during the clamping of the ICA before the opening of the RA bypass and the restoration of these parameters demonstrate several important issues: First, the STA–MCA bypass is, in most cases, not able to replace the full capacity of the ICA as could be expected. There are no tools to identify patients in which the STA is capable of doing this, although intraoperative flow measurements could help in some cases. Second, these results again demonstrate that BTO tests in their full varieties used are not reliable enough to identify all cases for safe ligation of the ICA only.

In addition, the high variability of the systolic CBP, diastolic CBP, mean CBP, CPP, and to baseline ratios as demonstrated in this study again underlines the lack of knowledge we have in each specific patient on leptomeningeal collateral capacity. Stump pressures measured in the used timeframes will also not help us in this as the authors also delineated. Although this study suggests that an extra (low flow?) EC–IC bypass could help in avoiding ischemia during the creation of any high-flow replacement bypass, it still remains unsure to what extent this is necessary or helpful in each specific patient. In addition, both conventional bypass techniques (STA–MCA bypass and RA bypass) have the same drawbacks of temporal occlusion of the recipient vessel, inducing temporal ischemia by the technique itself. Although in the majority of cases (like in this study), this seems to be safe; although several brain protection measurements as cardiac arrest etc. are described, it remains unclear for which patient groups this is save enough. This paper anyhow measures that at least even the conventional temporal clamping of the ICA to make a protective bypass possible is at itself already a clear risk. It is for that reason that since 1993, our group developed the excimer laser-assisted non-occlusive anastomosis technique (ELANA), and more than 400 patients have been treated with this technique in Europe and the US. Yet, it is still unknown whether this is necessary in all cases considering our lack of knowledge on the variable capacity leptomeningeal anastomoses. For this reason, in our department, we prefer to walk on the safe side. Therefore, studies like this are very useful in gaining more knowledge on peripheral hemodynamics, leptomeningeal capacity, and individual compensatory abilities to help us in future decisions to be made in treating these difficult cases. We believe that also perioperative and intraoperative flow studies combined with predictive mathematical vascular models could help us further for a better understanding of cerebral hemodynamics.

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Kazumata, K., Kamiyama, H., Ishikawa, T. et al. Impact of cervical internal carotid clamping and radial artery graft bypass on cortical arterial perfusion pressure during craniotomy. Neurosurg Rev 37, 493–500 (2014). https://doi.org/10.1007/s10143-014-0545-7

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