revascularisation of the brain in acute stroke

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

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

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

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

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

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)

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.

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

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 )

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

Acute thrombosis of the critically stenosed right internal carotid artery ( emergency endarterectomy restored blood

flow ) and chronic occlusion of the left internal carotid artery

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 )

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 )

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

Distal autovenous shunt from the common carotid artery to the occluded left vertebral artery at the atlas level

CONCLUSIONSCONCLUSIONS

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.

Vilnius University Emergency Vilnius University Emergency HospitalHospital