Revascularisation of the Brain In  Acute Stroke
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Revascularisation of the Brain In Acute Stroke

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Brain revascularization in acute stroke situation. Results and indications.

Brain revascularization in acute stroke situation. Results and indications.

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Revascularisation of the Brain In  Acute Stroke Revascularisation of the Brain In Acute Stroke Presentation Transcript

  • REVASCULARISATION OF THE BRAIN IN ACUTE STROKE P. Pauliukas A. Mackevičius Vilnius University Emergency Hospital Department of Vascular Surgery
  • Brain blood flow levels 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
  • Patients distribution according to the brain ischemia 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 REVASCULARISATION
    • progressing stroke
    • non stable, fluctuating stroke
    • stroke resistant to the medical treatment
    • due to critical stenoses or occlusions of ICA
  •  
    • Carotid 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.
  • Results of brain revascularisation
  • 16% of patients have had critical stenoses of both internal carotid arteries ( ICA )
  • 23% of patients have had critical ICA stenosis on 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
  • CONCLUSIONS
  • 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 Hospital