Minimal Safe Arterial Blood Flow During Selective Antegrade Cerebral Perfusion at 20° Centigrade Ove Jonsson, MD, Arvid Morell, MS, Vitas Zemgulis, MD,

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Minimal Safe Arterial Blood Flow During Selective Antegrade Cerebral Perfusion at 20° Centigrade Ove Jonsson, MD, Arvid Morell, MS, Vitas Zemgulis, MD, PhD, Elin Lundström, MS, Thomas Tovedal, MS, Gunnar Myrdal Einarsson, MD, PhD, Stefan Thelin, MD, PhD, Håkan Ahlström, MD, PhD, Atle Björnerud, PhD, Fredrik Lennmyr, MD, PhD The Annals of Thoracic Surgery Volume 91, Issue 4, Pages 1198-1205 (April 2011) DOI: 10.1016/j.athoracsur.2010.12.066 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Experimental design. The blood flow was changed stepwise from 8-6-4-2-8 mL · kg−1 · min−1 in group 1 and kept at 6-6-6-6-6 mL · kg−1 · min−1 in group 2. The timing of the repeated magnetic resonance (MR) measurements is shown for each flow level, including perfusion- (red) and diffusion-weighted (blue) imaging and spectroscopy (grey). Markers indicate arterial blood gas (x) and protein S100β sampling (*). The baseline samples were collected immediately before the start of selective antegrade cerebral perfusion. The Annals of Thoracic Surgery 2011 91, 1198-1205DOI: (10.1016/j.athoracsur.2010.12.066) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Results for group 1 (■) and group 2 (□) with the last data set at 8/6 mL · kg−1 · min−1 (dashed grey). Relative lactate to creatine ratio at different flow levels (A) and lactate concentrations in blood (B). Relative changes of protein S100β concentrations (C). Prolongation of the mean transit time (MTT) of the gadolinium contrast agent in perfusion-weighted imaging demonstrating the coherence between flow settings and cerebral flow response (D). Mean arterial pressure (MAP) and mixed venous oxygen saturation (Svo2) across the experiment (E) and (F). * = p < 0.05. The Annals of Thoracic Surgery 2011 91, 1198-1205DOI: (10.1016/j.athoracsur.2010.12.066) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Magnetic resonance spectra collected at 5 flow levels for 1 subject, last dataset at 8 mL · kg−1 · min−1 (dashed grey). The peaks correspond to different metabolites and the amplitude of the peak to the metabolite concentration. The double peak representing lactate at 1.3 ppm increases during the experiment while the creatine peak at 3 ppm, used for normalization, remains constant. The Annals of Thoracic Surgery 2011 91, 1198-1205DOI: (10.1016/j.athoracsur.2010.12.066) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Four types of relative parametric images (rows) illustrating the regional distribution of the perfusion parameters for 2 subjects (columns). From top down the images reflect cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT) and time to peak (TTP). Left column subject display lateral differences in contrast to the symmetry of the subject in the right column; right hemisphere have reduced CBF and CBV while MTT and TTP are extended. Both data sets are from the second measurement for the subjects and acquired at 6 mL · kg−1 · min−1. The Annals of Thoracic Surgery 2011 91, 1198-1205DOI: (10.1016/j.athoracsur.2010.12.066) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions