Near Infrared Spectrophotometric Monitoring for Cerebral Ischemia during the Occlusion of the Internal Carotid Artery at CEA Kanji YAMANE 1 , Takeshi SHIMA 1 , Yoshikazu OKADA 1 , Masahiro NISHIDA 1 , Shinji OKITA 1 , Takashi HATAYAMA 1 , Akira YOSHIDA 2 1Department of Neurosurgery, Chugoku Rousai Hospital 2Department of Intensive Care Medicine, Chugoku Rousai Hospital Keyword: Carotid endarterectomy , Near infrared spectrophotometry , Cerebral ischemia , Collateral circulation pp.947-953
Published Date 1994/10/10
DOI https://doi.org/10.11477/mf.1436900918
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Near infrared spectrophotometry provides noninva-sively real-time information on cerebral oxygenation and cerebral blood volume. Using this method of spec-trophotometry we investigated the adequacy of collater-al circulation during cross-clamping of the internal carotid artery in patients who underwent carotid endar-terectomy. In 15 patients, oxy-hemoglobin, deoxy-hemoglobin and total hemoglobin were monitored con-tinuously by near infrared spectrophotometry at the ipsilateral frontal area on the operated side. Changes in these parameters following temporary cross-clamping of the internal carotid artery were evaluated. Most of the patients presented ischemic symptoms of verte-brobasilar circulation and affected upper extremities. In PTA of brachiocephalic lesions, one of the most for-midable complications is an embolism distal to the cen-tral nervous system. To prevent this complication, a vascular endoscope was used for visualization of the luminal surface of the stenotic lesions in 7 cases, and a protective balloon was used in 4 recent cases. The pro-tective balloon was used for transient occlusion of the artery to alter the flow direction so that the possible emboli might be forced to flow away to a less critical distal artery. In the distal protective balloon technique, the protective balloon was set so as to occlude the stenotic artery distally. Debris caused by PTA was aspirated and/or washed out to an extracranial artery with heparinized saline. In the proximal protective bal-loon technique, the protective balloon was set so as to occlude the stenotic artery proximally. Debris was washed out with blood flow caused by the induced steal phenomenon to an extracranial artery. In one case, in which there was stenosis in the left SA and at the left origin of the VA, kissing balloon technique was performed. Immediate post-PTA results were excellent and good in 21 cases, and poor in 3 cases including one in which the catheter could not be inserted to allow PTA to be performed. Follow-up angiography showed re-stenosis in 2 cases, and in one of them re-PTA was performed. No major complication was observed during PTA. No distal embolism was observed in any case. Vascular endoscopic observations showed the stenosed luminal surfaces before PTA were smooth and regular. No ulcer formation was observed. Therapeutic indica-tion of extracranial occlusive lesions based on our ex-perience was found in patients who had vertebrobasilar ischemic symptoms with more than 50% stenosis of VA bilaterally, or more than 50% stenosis of VA ipsilateral-ly, and aplasia or hyoplasia of VA and hypoplasia of VA at distal PICA contralaterally to the stenosis at the origin of VA. In SA stenosis, therapeutic indicaton was found in patients with ischemic symptoms of vertebro-basilar and/or upper extremity. Recent surgical techni-que for extracranial occlusive lesions is transposition of VA which has a low mortality and morbidity rate. Con-sidering the fact of invasive intervention associated with surgery and anesthesia, PTA is an alternative treat-ment. Recent reports and our experience indicate a high rate of success and rare occurrence of complications. Also safer PTA can be performed using some adjunc-tive procedures such as those mentioned in this report during PTA. The stump pressure of the internal carotid artery was mea-sured in every patient. Only the maximum decrease in oxy-hemoglobin during cross-clamping of the internal carotid artery correlated significantly with the stump pressure of the internal carotid artery. Changes in oxy-hemoglobin during cross-clamping of the internal caro-tid artery demonstrated three patterns; no change or minimally decreased (4 patients), decrease with recov-ery (4 patients), and decrease without recovery (7 patients). The stump pressure of the internal carotid artery in patients who had no recovery of their de-creased oxy-Hb was significantly lower than that in any other pattern (p<0.01, Mann-Whitney U analysis). Patients who experience decrease in oxy-Hb without recovery following cross-clamping of their internal carotid artery may have poor collateral circulation and therefore may develop cerebral ischemia.

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