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Rivascolarizzazione Cerebrale Tecnica Chirurgica

V Corso Nazionale Congiunto SIDV-GIUV SINSEC Bertinoro 28 -31 Marzo 2007. Rivascolarizzazione Cerebrale Tecnica Chirurgica. Giuseppe Russo Responsabile UO SS “Cerebropatie Vascolari Acute” UOSC Neurochirurgia d’Urgenza AORN “A.Cardarelli” - Napoli.

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Rivascolarizzazione Cerebrale Tecnica Chirurgica

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  1. V Corso Nazionale Congiunto SIDV-GIUV SINSEC Bertinoro 28 -31 Marzo 2007 Rivascolarizzazione Cerebrale Tecnica Chirurgica Giuseppe Russo Responsabile UOSS “Cerebropatie Vascolari Acute” UOSC Neurochirurgia d’Urgenza AORN “A.Cardarelli” - Napoli

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

  3. Extracranial - Intracranial Bypass 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. Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  4. 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. Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  5. Most distal angiography lesion • of 1337 Partecipants • Middle cerebral artery • Stenosis 14.4 % • Occlusion 12.1 % • Internal Carotid artery • Stenosis (above C2) 15.4 % • Occlusion, no symptoms 37.0 % • Occlusion, recurrent symptoms21.1 % Extracranial - Intracranial Bypass The EC/IC Bypass Study Group, 1985

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

  7. Extracranial - Intracranial Bypass Do abnormal cerebral hemodynamics identify a stroke risk ? Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  8. 1. 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. Derdeyn et al. – Brain, 2002 after Powers et al., 1987 Haemodynamic and Metabolic Responses to CPP Reductions • Three basic strategies • paired rCBF measurements, with initial measurement obtained at rest and the second after provision of a cerebral vasodilatory stimulus • measurement of rCBV alone or in combination with measurement of rCBF in the resting brain • direct measurement of rOEF Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

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

  10. 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 RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus 14 (3): 2003

  11. Sites were the recorded hemodynamic changes are produced Parenchimal 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. L Vmca R Vmca p CO2 reference value: 3.5 % ± 0.9 mmHg CerebroVascular Reserve TCD recorded CO2 Reactivity Test The increase of Blood Flow Velocity during hypercapnia “CO2 reactivity” gives a measure of the capacity of the intracerebral arterioles to dilate further G Russo, CA Lodi, M Ursino – Neurological Sciences, 2000

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

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

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

  16. Paradoxical Response explained by the “model” ICA OCCLUDED SIDE - Maximal Vasodilated CPP Hypercapnia + VENOUS PRESSURE CBV Vasodilation + Reduced Pressure in the Willis ICA OPEN SIDE M Ursino, CA Lodi, G Russo - Journal of Vascular Research 2000;37:123-133

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

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

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

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

  21. High flow graft Low flow STA-MCA bypass 15 – 25 ml/min 70 – 180 ml/min Brain Revascularization Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  22. Bypass procedures for ICA reconstruction 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 1980’s Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

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

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

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

  26. Bypass procedures for ICA reconstruction Perioperative Stroke Risk 7 - 15 % Skull Base, volume 15, number 1, 2005 E. de Oliveira Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  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 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 Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

  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 First ELANA procedure in Italy – May 2006 G.M. 22 yrs Left-handed Right Retro-orbital Pulsating Headache Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

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

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

  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 Giuseppe Russo, Neurochirurgo - AORN “A.Cardarelli”, Napoli

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

  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. Grazie !

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