revascularisation of the brain in acute stroke
DESCRIPTION
Brain revascularization in acute stroke situation. Results and indications.TRANSCRIPT
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REVASCULARISATION OF THE REVASCULARISATION OF THE BRAIN IN ACUTE STROKEBRAIN IN ACUTE STROKE
P. Pauliukas
A. Mackevičius
Vilnius University Emergency Hospital Vilnius University Emergency Hospital Department of Vascular SurgeryDepartment of Vascular Surgery
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Brain blood flow levelsBrain blood flow levels
0
10
20
30
40
50
60
t
ml\ 100g\ min
Normal brain perfusion
Reversible ischemia
Non reversible ischemia
Jones et al., 1981 Heiss & Rosner, 1983
“Stroke. A practical guide to management” Warlow et al 1996
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Patients distribution according to the brain ischemia time
• 4 hours 8 patients
• 5 - 23 hours 17 patients
• 1 day 10 patients
• 2 days 7 patients
• 3 - 6 days 12 patients
• one week 12 patients
61
5
Total number of patients 66: 50 men and 16 women
Vertebrobasilarstroke
Carotid artery
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Patients distribution according to the brain Patients distribution according to the brain ischemia clinical expression depthischemia clinical expression depth
1. Mild neurological deficit 18 patients
2. Moderate neurological deficit: hemiparesis (with partial aphasia in case of left ICA lesion) 24 patients
3. Severe neurological deficit: hemiplegia (with total aphasia in case of left ICA lesion) without loss of consciousness 19 patients
By I. Portnoi
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INDICATIONS FOR BRAIN INDICATIONS FOR BRAIN REVASCULARISATIONREVASCULARISATION
• progressing stroke
• non stable, fluctuating stroke
• stroke resistant to the medical treatment
due to critical stenoses or occlusions of ICA
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56
34
0
3
7
14
0
3
11
5
I ischemia depth II ischemia depth III ischemia depth
Neurological situation of operated patients
TIA crescendo (5 patients) Fluctuating stroke (12 patients)
Progressing stroke (21 patients) Stable stroke (23 patients)
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46
15
Patients distribution according to ischemia nature
Hypoperfusion
Cardioembolia
Carotid operationsCarotid operations
• Endarterectomy - 47 patients;
• Embolectomy - 9 patients:a) from the bifurcation - 3 patients;
b) from the ICA - 6 patients;
• ECA reconstruction - 2 patients;
• CA revision - 3 patients.
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72
135
16
5053
0
25
16
6 8 5 6 4
21
per cent
Excellent(28%)
Good (41%) No changes(15%)
Bad (6%) Died (10%)
I ischemia depth II ischemia depth III ischemia depth
Results of brain revascularisationResults of brain revascularisation
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16% of patients have had critical stenoses of both 16% of patients have had critical stenoses of both internal carotid arteries ( ICA )internal carotid arteries ( ICA )
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23% of patients have had critical ICA stenosis 23% of patients have had critical ICA stenosis on one side and ICA occlusion on the other sideon one side and ICA occlusion on the other side
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Acute thrombosis of the critically stenosed right internal carotid artery ( emergency endarterectomy restored blood
flow ) and chronic occlusion of the left internal carotid artery
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Aplasia of the right vertebral artery and loop with kink of the left vertebral artery ( v/b stroke cleared after reconstruction, using internal shunt, of the kinked left vertebral artery )
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Critical stenosis of the left ICA, loop with kink of the right vertebral artery and steal through the left cervical ascendens artery ( left subclavian and vertebral artery are occluded at their origins )
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Critical stenosis of the left ICA, loop with kink of the right vertebral artery and steal through the left cervical ascendens artery ( left subclavian and left vertebral arteries are occluded ). The same
patient as in previous slide
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Distal autovenous shunt from the common carotid artery to the occluded left vertebral artery at the atlas level
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CONCLUSIONSCONCLUSIONS
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Good and even excellent results can be achieved if strict rules are adjusted to the
surgical treatment:• Only critical stenoses or occlusions of ICA should be operated;
• The shorter brain ischemia, the better revascularisation results;
• Arterial hypotension is detrimental before and during the operation,
therefore light artificial arterial hypertension is desirable untill the
blood flow to the brain is restored;
• Intraarterial carotid shunt must be used routinely in cases of acute
stroke;
• Heparin administration is dangerous and should be avoided after the
successful brain revascularisation.
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Vilnius University Emergency Vilnius University Emergency HospitalHospital