Presentation is loading. Please wait.

Presentation is loading. Please wait.

Rivascolarizzazione Cerebrale Tecnica Chirurgica Rivascolarizzazione Cerebrale Tecnica Chirurgica Giuseppe Russo Responsabile UOSS Cerebropatie Vascolari.

Similar presentations


Presentation on theme: "Rivascolarizzazione Cerebrale Tecnica Chirurgica Rivascolarizzazione Cerebrale Tecnica Chirurgica Giuseppe Russo Responsabile UOSS Cerebropatie Vascolari."— Presentation transcript:

1 Rivascolarizzazione Cerebrale Tecnica Chirurgica Rivascolarizzazione Cerebrale Tecnica Chirurgica Giuseppe Russo Responsabile UOSS Cerebropatie Vascolari Acute UOSC Neurochirurgia dUrgenza AORN A.Cardarelli - Napoli V Corso Nazionale Congiunto SIDV-GIUV SINSEC Bertinoro Marzo 2007

2 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli EC-IC bypass was originally developed by Yasargil and Yonekawa in 1977 as a safe means of direct cerebral revascularization. Extracranial - Intracranial Bypass

3 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli This methodology was called into question by the EC-IC Bypass Study in 1985 which found the procedure to be of no statistical benefit and essentially discontinued as a treatment for cerebral ischemia. Extracranial - Intracranial Bypass

4 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Extracranial - Intracranial Bypass The procedure, however, continued to be used for CBF replacement as an adjunct to parent vessel sacrifice in patients with aneurysms and tumors who had poor collateral circulation.

5 The EC/IC Bypass Study Group, 1985 Extracranial - Intracranial Bypass Most distal angiography lesion of 1337 Partecipants Middle cerebral artery Middle cerebral artery Stenosis 14.4 % Stenosis 14.4 % Occlusion 12.1 % Occlusion 12.1 % Internal Carotid artery Stenosis (above C2) 15.4 % Stenosis (above C2) 15.4 % Occlusion, no symptoms 37.0 % Occlusion, no symptoms 37.0 % Occlusion, recurrent symptoms 21.1 % Occlusion, recurrent symptoms 21.1 %

6 It is clearly impossible to reach a conclusion in the matter without physiological studies of CBF ….. Extracranial - Intracranial Bypass

7 Do abnormal cerebral hemodynamics identify a stroke risk ? n. CBF Assesment poor CVR adequate CVR Yonas et al (1985) 68 stable xenon CT & acetazolamide 36 % 4.4 % Kleiser & Widder (1992) 81 TCD and inhaled CO 2 21 % Silvestrini et al (1994) 32 TCD and inhaled CO 2 24 % Grubb (1998) 89 PET - OEF 26.5 % 5.3 % Extracranial - Intracranial Bypass Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

8 Derdeyn et al. – Brain, 2002 after Powers et al., Increased OEF in the territory of an occluded carotid artery often occurs in the absence of a measurable elevation in CBV. 2. Patients who have both increased OEF and increased CBV, are at much higher risk for subsequent ipsilateral stroke. Haemodynamic and Metabolic Responses to CPP Reductions Haemodynamic and Metabolic Responses to CPP Reductions Three basic strategies 1.paired rCBF measurements, with initial measurement obtained at rest and the second after provision of a cerebral vasodilatory stimulus 2.measurement of rCBV alone or in combination with measurement of rCBF in the resting brain 3.direct measurement of rOEF Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

9 Derdeyn et al. Brain, 2002 Increased CBV indicates autoregulatory vasodilation Reductions in perfusion pressure within the autoregulatory range Increased OEF without increased CBV Increased OEF without increased CBV Haemodynamic Failure Stage 2 Haemodynamic Failure Stage 2 Haemodynamic and Metabolic Responses to CPP Reduction Haemodynamic and Metabolic Responses to CPP Reduction

10 RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus 14 (3): 2003 RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus 14 (3): 2003 Inclusion criteria 1) Vascular imaging studies demonstrating occlusion of one ICA 2) Vascular imaging studies demonstrating less than 50% stenosis of the contralateral extracranial ICA 3) A TIA or ischemic stroke in the hemispheric CA territory of the occluded CA 4) Most recent qualifying TIA or stroke must have occurred within 120 days prior to the performance date of PET 5) Modified Barthel Index score greater or equal to 12/20 6) Age ranging between 18 and 85 years Inclusion criteria 1) Vascular imaging studies demonstrating occlusion of one ICA 2) Vascular imaging studies demonstrating less than 50% stenosis of the contralateral extracranial ICA 3) A TIA or ischemic stroke in the hemispheric CA territory of the occluded CA 4) Most recent qualifying TIA or stroke must have occurred within 120 days prior to the performance date of PET 5) Modified Barthel Index score greater or equal to 12/20 6) Age ranging between 18 and 85 years

11 Parenchimal Sites were the recorded hemodynamic changes are produced Can TCD Ultrasounds provide useful informations in singling out the long-searched group of patients elegible for cerebral bypass ? Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

12 G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000 CerebroVascular Reserve TCD recorded CO 2 Reactivity Test CerebroVascular Reserve TCD recorded CO 2 Reactivity Test reference value: 3.5 % ± 0.9 mmHg L Vmca R Vmca p CO 2 The increase of Blood Flow Velocity during hypercapnia CO 2 reactivity gives a measure of the capacity of the intracerebral arterioles to dilate further The increase of Blood Flow Velocity during hypercapnia CO 2 reactivity gives a measure of the capacity of the intracerebral arterioles to dilate further

13 R Vmca L Vmca p CO2 Impaired CerebroVascular Reserve in left ICA occlusion Impaired CerebroVascular Reserve in left ICA occlusion G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000

14 M Ursino, CA Lodi, G Russo - Journal of Vascular Research 2000 CerebroVascular Reserve Assessment Side to Side Index Side to Side Index CerebroVascular Reserve Assessment Side to Side Index Side to Side Index Healthy Subjects ICA occlusione

15 Vascular Brain Reserve Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Paradoxical Responce

16 M Ursino, CA Lodi, G Russo - Journal of Vascular Research 2000;37: Paradoxical Response explained by the model Paradoxical Response explained by the model Hypercapnia CBVCBV Reduced Pressure in the Willis Reduced Pressure in the Willis VENOUSPRESSUREVENOUSPRESSURE + Vasodilation Vasodilation CPPCPP + - ICAOCCLUDEDSIDE ICAOPENSIDE Maximal Vasodilated

17 Case Report Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

18 Case Report Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli STA-MCA ByPass

19 Case Report Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

20 Case Report Before STA-MCA bypass 20 days after STA-MCA bypass Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

21 Brain Revascularization 15 – 25 ml/min Low flow STA-MCA bypass High flow graft 70 – 180 ml/min Distal Flow Increase Proximal Flow Replacement ICA Reconstruction

22 Reconstruction of the ICA with the use of interpositional SVGs (high flow EC-IC bypass) for the management of giant aneurysms was popularized by Sundt in the early 1980s Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Bypass procedures for ICA reconstruction Bypass procedures for ICA reconstruction

23 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Bypass procedures for ICA reconstruction Bypass procedures for ICA reconstruction Skull Base, volume 15, number 1, 2005 E. de Oliveira

24 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Bypass procedures for ICA reconstruction Bypass procedures for ICA reconstruction Skull Base, volume 15, number 1, 2005 E. de Oliveira

25 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Bypass procedures for ICA reconstruction Bypass procedures for ICA reconstruction Skull Base, volume 15, number 1, 2005 E. de Oliveira

26 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Bypass procedures for ICA reconstruction Bypass procedures for ICA reconstruction Skull Base, volume 15, number 1, 2005 E. de Oliveira Perioperative Stroke Risk %

27 ELANA Excimer Laser Assisted Nonocclusive Anastomosis Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

28 ELANA Excimer Laser Assisted Nonocclusive Anastomosis Training Model in Vivo Centro per le Biotecnologie Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

29 ELANA Excimer Laser Assisted Nonocclusive Anastomosis Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Training Model in Vivo Excimer Laser Assisted Non-occlusive Anastomosis (ELANA). Our experience with a training model in vivo. Russo G., Rotondo M., Punzo A., Di Napoli D. Journal Neurosurg Sci 51, 1: 11-17, 2007

30 ELANA Excimer Laser Assisted Nonocclusive Anastomosis PARTNER HOSPITALS Universitair Medisch Centrum Utrecht - Holland Universitaetsklinikum Mannheim – Germany University Hospital Helsinky - Finland Inselspital Bern – Switzerland AORN A.Cardarelli Napoli - Italy Kings College Hospital London - UK St. Luke's-Roosevelt Hospital New York - NY USA Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

31 Giant Supraclinoid Carotid Aneurysm G.M. 22 yrs Left-handed Right Retro-orbital Pulsating Headache First ELANA procedure in Italy – May 2006

32 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Giant Supraclinoid Carotid Aneurysm First ELANA procedure in Italy – May 2006

33 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Giant Supraclinoid Carotid Aneurysm First ELANA procedure in Italy – May 2006

34 ECA-MCA Excimer Laser Assisted Non-occlusive Anastomosis Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

35 ECA-MCA Excimer Laser Assisted Non-occlusive Anastomosis Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

36 Case n°1 – Five monthes follow-up

37 Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli Case n°1 – Five monthes follow-up

38 ELANA Excimer Laser Assisted Nonocclusive Anastomosis Dedicated Team Permanent Training More than 10 ELANA /year International Register National Register Giuseppe Russo, Neurochirurgo - AORN A.Cardarelli, Napoli

39


Download ppt "Rivascolarizzazione Cerebrale Tecnica Chirurgica Rivascolarizzazione Cerebrale Tecnica Chirurgica Giuseppe Russo Responsabile UOSS Cerebropatie Vascolari."

Similar presentations


Ads by Google