Selection of patients for extra-intracranial arterial bypass surgery based on rCBF measurements.

Extracranial intracranial arterial anastomosis is gaining acceptance as a form of treatment in selected cases with ischemic cerebrovascular disease. To establish indications for this operation and to provide an objective assessment of postoperative results, regional cerebral blood flow (rCBF) studies were performed in 110 patients with cerebrovascular insufficiency considered for extra-intracranial bypass surgery. The 133Xe intracarotid injection method with 16 externally placed detectors was used for measuring rCBF. Postoperatively, rCBF was measured in 40 patients. From these results our present criteria for surgery have evolved. The probability of a good postoperative result is best in patients who showed focal cerebral ischemia or a moderate general reduction of CBF with an additional ischemic focus. The operation is contraindicated in patients with either normal or severely reduced CBF values (less than 60% of normal).     

Measurement of regional cerebral blood flow and somatosensory evoked potentials in a canine model of hemispheric ischemia

Regional cerebral blood flow (rCBF) was studied using the radiolabeled microsphere technique in a canine model of hemispheric ischemia that others have previously examined morphologically with carbon perfusion. It was our goal to ascertain whether this ischemic model, which involves easily accessible occlusions of the ipsilateral circle of Willis, could produce reproducible and significant reduction of hemispheric cerebral blood flow. Seven animals underwent the surgical procedure with measurements of rCBF at base line, after arterial microdissection and brain retraction only, and finally after creation of the lesion. Simultaneous somatosensory evoked potential recordings were also obtained. Bilateral symmetrical flow decreases were referable to anesthetic normalization and maintenance alone before creation of the lesion. The arterial occlusions, however, produced further significant decreases in flow on the ipsilateral side only, sparing all contralateral structures and sparing the brain stem and cerebellum bilaterally. Evoked responses, which had shown no changes in latency or amplitude after dissection and retraction procedures, were completely abolished 15 minutes after the arterial occlusion. Control animals that underwent surgical positioning and anesthesia alone did not show concomitant decreases is rCBF. This model of open craniotomy and direct vascular occlusion is suitable for studies of cerebral ischemia where the therapeutic intervention proposed (such as cerebral revascularization) involves similar surgical manipulations. By this method, a standard and reproducible ischemic lesion is achieved through the surgical field without the need for exposure of the basilar artery.     

Blood flow and ischemia within traumatic cerebral contusions

OBJECTIVE: To provide evidence of irreversible ischemia in cerebral contusions among patients with severe traumatic brain injuries and to clarify the potential viability of tissue in the pericontusional zone, quantitative regional cerebral blood flow (rCBF) measurements obtained with the xenon-enhanced computed tomographic method were correlated with the areas of contusions, by using image fusion. METHODS: rCBF measurements obtained during the acute phase (mean, 2 d after injury; range, 0-10 d) were statistically correlated with the extent of tissue necrosis identified as focal atrophy on late follow-up computed tomographic scans (mean time after the xenon-enhanced computed tomographic cerebral blood flow investigation, 265 d; range, 30-1047 d). RESULTS: Seventeen patients exhibited 26 traumatic contusions. All contusions progressed to late focal atrophic areas on the follow-up computed tomographic scans. The rCBF values within the traumatic contusions ranged from 0.5 to 22.0 ml/100 g/min, with a mean of 5.9 +/- 5.9 ml/100 g/min. The contusions exhibited a specific rCBF profile, presenting as a core of severe lethal ischemia surrounded by variable but gradually increasing perfusion with increasing distance from the ischemic core. CONCLUSION: The ischemic profile of the contusions, with a pericontusional zone of low rCBF, presents the potential risk of secondary ischemic insults, similar to the risk in the ischemic penumbral zones surrounding areas of acute ischemic stroke.     

Physiological function after middle cerebral artery occlusion in rabbits with neovascularization of the brain by transposed omentum

The effect of brain neovascularization by omental transposition on somatosensory evoked potentials and on regional cerebral blood flow (rCBF) measured by hydrogen clearance was evaluated in rabbits exposed to experimental ischemia after occlusion of the middle cerebral artery (MCA). After MCA occlusion, the animals with brains neovascularized by transposed omentum showed a mild drop of rCBF accompanied by normal patterns of somatosensory evoked potentials elicited by sciatic stimulation. In the control animals, the evoked cortical electrical activity drastically decreased in amplitude immediately after arterial occlusion and fell to zero one-half hour later. The decay of bioelectrical activity in these rabbits was associated inevitably with a major drop in the rCBF. Morphological examination, as well as the functional data, indicate that omental transposition in animals exposed to experimental ischemia minimizes the occurrence of cerebral infarction because the neovascularization is capable of maintaining the local blood flow for at least 1 hour; therefore, the cortical electrical activity is preserved totally. In the light of these results, the authors suggest that this surgical technique can also be utilized in human beings who are affected by transient ischemic attacks to prevent more serious consequences.     

Polyamine and prostaglandin markers in focal cerebral ischemia

This study examines the pathophysiology of stroke secondary to focal cerebral ischemia. The interaction of arachidonic acid metabolites and polyamines, a class of ubiquitous ornithine-derived molecules with important membrane effects on edema, Ca++-dependent endocytosis, platelet function, and prostaglandin (PG) formation, are correlated with regional changes in H2 clearance, cerebral blood flow (rCBF), ischemic edema, and somatosensory evoked responses (SSERs) after middle cerebral artery (MCA) occlusion. Thirty cats were studied up to 3 hours before and 6 hours after right MCA occlusion. Four areas of brain showing different levels of perfusion after MCA occlusion were sampled for tissue levels of PGs: 6-keto-PGF1 alpha, PGE2, and as well as thromboxane B2 (TXB2), ornithine decarboxylase activity (ODC) (a measure of polyamine activity) and gravimetric determination of cerebral edema. After right MCA occlusion, right hemisphere SSER amplitude decreased and interpeak latency increased markedly. rCBF was distributed into zones of dense, partial, and no ischemia ranging from 12.6 to 59.4 ml/100 g/minute. Ischemic edema was distributed inversely to rCBF and was increased in areas of dense ischemia (85.2 +/- 0.5%) and ischemia (82.7 +/- 0.7%), but not in partially ischemic or control areas. 6-Keto-PGF1 alpha (1257.3 pg/mg), PGE2 (1628.5 pg/mg), and TXB2 (1572.8 pg/mg) were all significantly (P less than 0.05) increased in areas of partial ischemia that had not yet developed edema. ODC levels were significantly elevated (3812 pmole/g/hour, P less than 0.05) and increased with time in areas of slightly denser ischemia that showed an intermediate increase in edema, but not the presence of infarction. This is the first demonstration that ODC, the rate-limiting enzyme for polyamine synthesis, is stimulated by cerebral ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of hyperacute stroke using perfusion computed tomography

Evaluation of the cerebral circulation dynamics in patients with stroke soon after onset is extremely important for planning the optimum treatment. Perfusion computed tomography (CT) was evaluated in 118 patients with stroke within 10 hours of onset in whom initial CT showed no ischemic change. The mean transit time (MTT), cerebral blood flow (CBF), and cerebral blood volume (CBV) perfusion CT maps were visually evaluated in three slices covering the body of the lateral ventricle, the basal ganglia, and the pons, and the ratios of the values in regions of interest (ROIs) in the ischemic lesion and the symmetrical location in the opposite hemisphere were calculated (ROI ratio of regional (r) MTT, rCBF, and rCBV). The location of occlusion was confirmed by angiography performed on the same day in 106 cases and the location of infarction by later magnetic resonance (MR) imaging. MTT maps correctly identified 44 of 46 cases of ischemia in the carotid system, 20 of 29 cases of ischemia in the vertebrobasilar system, and 11 of 35 cases of ischemia in perforator regions. Eight cases could not be identified by perfusion CT, angiography, or MR imaging. The ROI ratios at the upper boundary of infarction (n = 18) were: rCBF 0.574 +/- 0.220 (mean +/- SD) and rCBV 0.972 +/- 0.276, and at the lower boundary of non-infarction (n = 24) were: rCBF 0.504 +/- 0.247 and rCBV 0.815 +/- 0.169; showing a statistical significance of p = 0.348 for CBF and p = 0.026 for CBV (unpaired t-test). The perfusion CT MTT maps correlated well with the angiographical findings for the carotid system, but poorly for the vertebrobasilar system and the perforator regions. A rCBF ratio of 0.5 and rCBV ratio of 0.9 were established for the boundaries of ischemia.     

The Chronological changes in the cerebral blood flow and cerebral metabolic rate for glucose in the ischemic rabbit brain

Chronological changes in regional cerebral blood flow (rCBF) and in the regional cerebral metabolic rate for glucose (rCMRGlu) were studied by a double tracer autoradiographic method in regions of local ischemia in rabbit brains. Local ischemia was produced by cautery of the bilateral vertebral artery, followed several days later by cautery of the left middle cerebral artery through a transorbital approach and ligation of the left common carotid artery. Autoradiography was performed, 2 hours, 6 hours, and 4 days after occlusion, by a double tracer method involving the use of 14C-iodo-antipyrine and 18F-fluoro-deoxyglucose. Absolute rCBF values were estimated by Sakurada's method and rCMRGlu values by Hutchins' formula. Histological examination was performed concurrently with the rCBF and rCMRGlu study. Mildly ischemic lesions (rCBF of 25 to 40 ml/100 g/min) were detected in the superior portion of the left frontal lobe, the left parietal lobe, and the left occipital lobe. Severely ischemic lesions (rCBF below 25 ml/100 g/min) were found in the lateral part of the left frontal lobe, the left temporal lobe, and the left caudate nucleus. In the mildly ischemic regions, rCMRGlu decreased in proportion to the decrease in rCBF. That is, matched low perfusion was observed, but there were no histological abnormalities. In severe ischemia the situation was quite different. Two hours after occlusion, most areas showed a decrease in rCMRGlu in proportion to the decrease in rCBF. However, 6 hours after occlusion, rCMRGlu decreased nonuniformly: in some places the decrease was dramatic and in others, rCMRGlu residue was found. Four days after occlusion, the reduction in rCMRGlu was again proportional to the rCBF decrease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nonhyperemic blood flow restoration and brain edema in experimental focal cerebral ischemia

The effect of suppression of postischemic reactive hyperemia on the blood-brain barrier (BBB) and ischemic brain edema after temporary focal cerebral ischemia was studied in cats under ketamine and alpha-chloralose anesthesia. Regional cerebral blood flow (rCBF) was measured by a thermal diffusion method and a hydrogen clearance method. The animals were separated into three groups. In Group A, the left middle cerebral artery (MCA) was occluded for 6 hours. In Group B, the MCA was occluded for 3 hours and then reperfused for 3 hours; postischemic hyperemia was suppressed to the preischemic level by regulating the degree of MCA constriction. In Group C, the MCA was occluded for 3 hours and reperfused for 3 hours without suppressing the postischemic reactive hyperemia. The brain was removed and cut coronally at the site of rCBF measurement. The degree of ischemic edema was assessed by gravimetry in samples taken from the coronal section and correlated with the degree of BBB disruption at the corresponding sites, evaluated by densitometric determination of Evans blue discoloration. The findings showed that 1) ischemic edema was significantly exacerbated by postischemic hyperemia during reperfusion in parallel with the degree of BBB opening to serum proteins, and 2) suppression of postischemic hyperemia significantly reduced the exacerbation of ischemic edema and BBB opening. These findings indicate that blood flow may be restored without significant exacerbation of postischemic edema by the suppression of postischemic hyperemia in focal cerebral ischemia.     

Cerebral arteriovenous malformations. 2. A study of cerebral hemodynamics

Regional cerebral blood flow (rCBF) in 16 patients with cerebral AVM was measured using 133-Xe inhalation cerebrograph, and in 3 patients rCBF was measured using stable xenon enhanced CT. Neurological status and angiographical findings were studied in the connection with rCBF measurement. RCBF in almost patients with hemorrhagic episodes was low in the frontal area (frontal depression). The larger the size of nidus is, the higher the shunt flow through nidus is, therefore, there were no significant difference of mean rCBF between the affected and non-affected hemisphere independently of the size of nidus. But in the area adjacent to AVM nidus, particularly the nidus over 20 cm3 of volume, surrounding ischemic focus was noticed. And it was thought that brain swelling due to the normal perfusion pressure break through may occur when the nidus over 20 cm3 was removed. The reduction of rCBF of the non-affected cerebral hemisphere was noticed in the cases with nearly medical seated AVM and the rCBF reduction of the non-affected or affected hemisphere was noticed in the cases with posterior fossa AVM. There was similarity between the results concerning the hemodynamic status obtained by 133-Xe inhalation cerebrograph and stable xenon enhanced CT. But 133-Xe inhalation cerebrograph was less useful for estimation of cerebral hemodynamics than the stable xenon enhanced CT, because overestimation of rCBF was noticed in 133-Xe inhalation cerebrograph.     

Relationship between cerebral blood flow and oxygen metabolism, and extracellular glucose and lactate concentrations during middle cerebral artery occlusion and reperfusion: a microdialysis and positron emission tomography study in nonhuman primates

OBJECT: Changes in lactate and glucose levels in the brain may be used to monitor a dynamic ischemic process. The authors related extracellular concentrations of glucose and lactate to regional cerebral blood flow (rCBF) and cerebral metabolic rate of oxygen (CMRO2) in a model of ischemia. METHODS: Transient (2 hours) middle cerebral artery occlusion (MCAO) was performed in eight macaque monkeys. Extracellular measurements of glucose and lactate levels using microdialysis (two probes in each brain) and sequential positron emission tomography measurements were performed during MCAO and reperfusion. Glucose and lactate levels were related to rCBF and CMRO2 as well as the pathophysiological categories of severe ischemia and penumbra. In probe regions characterized by severe ischemia, there were significant changes in glucose and lactate levels and the lactate/glucose ratio. In probe regions distinguished by penumbra, only lactate levels increased significantly and, in general, the changes were smaller and transient. This difference between severe ischemic and penumbral regions was significant for all microdialysis parameters. There was a significant correlation between glucose, and CBF and CMRO2. Lactate concentration was correlated with CMRO2. CONCLUSIONS: Extracellular glucose levels might be limited by rCBF, whereas lactate levels were more related to CMRO2. Lactate concentration is a better marker of irreversible ischemia than glucose concentration, although near-zero levels of glucose during MCAO probably signals near-complete cessation of rCBF. In situations with elevated lactate levels, glucose may help to discriminate between partial and severe ischemia.     

Continuous monitoring of regional cerebral blood flow during temporary arterial occlusion in aneurysm surgery

OBJECT: Temporary arterial occlusion (TAO) during aneurysm surgery carries the risk of ischemic sequelae. Because monitoring of regional cerebral blood flow (rCBF) may limit neurological damage, the authors evaluated a novel thermal diffusion (TD) microprobe for use in the continuous and quantitative assessment of rCBF during TAO. METHODS: Following subcortical implantation of the device at a depth of 20 mm in the middle cerebral artery or anterior cerebral artery territory, rCBF was continuously monitored by TD microprobe (TD-rCBF) throughout surgery in 20 patients harboring anterior circulation aneurysms; 46 occlusive episodes were recorded. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The mean subcortical TD-rCBF decreased from 27.8+/-8.4 ml/100 g/min at baseline to 13.7+/-11.1 ml/100 g/min (p < 0.0001) during TAO. The TD microprobe showed an immediate exponential decline of TD-rCBF on clip placement. On average, 50% of the total decrease was reached after 12 seconds, thus rapidly indicating the severity of hypoperfusion. Following clip removal, TD-rCBF returned to baseline levels after an average interval of 32 seconds, and subsequently demonstrated a transient hyperperfusion to 41.4+/-18.3 ml/l 00 g/min (p < 0.001). The occurrence of postoperative infarction (15%) and the extent of postischemic hyperperfusion correlated with the depth of occlusion-induced ischemia. CONCLUSIONS: The new TD microprobe provides a sensitive, continuous, and real-time assessment of intraoperative rCBF during TAO. Occlusion-induced ischemia is reliably detected within the 1st minute after clip application. In the future, this may enable the surgeon to alter the surgical strategy early after TAO to prevent ischemic brain injury.     

Effect of mannitol on cerebral blood flow and microcirculation during experimental middle cerebral artery occlusion

Regional cerebral blood flow (rCBF) was measured during and after a 2-3 hour occlusion period of the middle cerebral artery (MCA) in cats with the hydrogen clearance technique. The effects of mannitol upon rCBF were studied. Transient hypotension during occlusion dropped the blood flow to near zero on the occluded side, leading to postischemic hypoperfusion. Mannitol failed to modify blood flow during the occlusion period, but was effective in preventing any further decrease of blood flow during hypotension. Animals receiving mannitol had an improved postischemic recovery of blood flow. The correlation of ischemic severity and postischemic brain damage and the effects of mannitol on these parameters are discussed.     

Evaluation of patients undergoing extra-intracranial arterial bypass surgery based on CT-scanning and neurophysiological studies

Summary In order to evaluate short-term effects of extra-intracranial arterial bypass procedure (EIAB) on cerebral function, we performed neurophysiological studies, combined with CT-evaluation, on 17 patients undergoing EIAB, pre- and postoperatively.CT helps to define, on a morphological basis, the extent of ischemic brain damage, and is, in some cases, a valuable tool in preoperatively assessing chances for a recovery.EEG shows, 2 weeks after surgery, in 50% of the patients after completed stroke, worsening of ischemic lesions as a result of reduced intraoperative cerebral perfusion and/or temporary occlusion of the recipient cortical vessel.Amongst somatosensory evoked potentials (SEP), and relative and absolute response periods (RPrel/ RPabs), RP abs and RPrel seem to have the highest potential in predicting later outcome in patients with TIA/RIND, while no correlation could be found between neurophysiological data and later clinical course for the completed stroke group (Table II).Dedicated to Professor K. J. Zülch on the occasion of his 70th birthday.     

Treatment of acute focal cerebral ischemia and recirculation with d-propranolol

The purpose of the investigation was to evaluate the effects of d-propranolol upon temporary cerebral ischemia followed by a period of reperfusion, that is, a situation analogous to major cerebral artery embolization. Twenty adult cats, lightly anesthesized with nitrous oxide, underwent 4 hours of right middle cerebral artery (MCA) occlusion and 2 hours of recirculation. Ten cats were untreated and 10 cats received d-propranolol, the weak beta-blocking isomer of racemic (d,l) propranolol. The d-propranolol was infused directly into the right carotid artery at doses of 2 mg/kg, given as a bolus immediately before MCA occlusion, and 0.33 mg/kg/hour, given continuously for 6 hours beginning immediately after MCA occlusion. Systemic arterial blood pressure was similar in both groups, but heart rate was transiently reduced in the treated group immediately after the bolus injection of d-propranolol and MCA occlusion. Regional cerebral blood flow (rCBF), measured by the xenon-133 clearance technique, was not significantly different in the ischemic, right hemisphere. Electroencephalographic (EEG) activity changes in the ischemic, right hemisphere were similar in both groups, but there was significant deterioration of EEG activity in the left, nonischemic hemisphere of untreated cats after MCA reopening. Swelling of the ischemic, right hemispheres was similar in both groups and more severe than in previous studies wherein there was no recirculation phase. Carbon perfusion and blood-brain barrier changes were also similar. The results of the study failed to show a protective effect despite theoretical beneficial actions of d-propranolol. Also, the study demonstrated that d-propranolol does not have a detrimental effect upon rCBF in acute focal cerebral ischemia.     

Protection of focal cerebral ischemia by alkalinization of systemic pH

OBJECT: It has been demonstrated in many studies that intracellular brain acidosis during cerebral ischemia is a significant factor in perpetuating the cycle of cellular dysfunction leading to neuronal injury. The purpose of this study was to determine whether preischemic administration of alkalotic agents could reduce neuronal injury after focal cerebral ischemia. METHODS: Fifteen fasted rabbits under 1.0% halothane anesthesia were randomized into three groups: Group 1 rabbits were ischemic controls (n = 5) that underwent 4 hours of focal cerebral ischemia. Groups 2 and 3 rabbits underwent a paradigm similar to that of Group 1, except that they were pretreated with either sodium bicarbonate or Carbicarb at similar buffering capacities. Intracellular brain pH (pH(i)), regional cortical blood flow (rCBF), and intrinsic reduced nicotinamide adenine dinucleotide (NADH) fluorescence were measured with in vivo fluorescence imaging. At the end of each experiment, infarct volume expressed as a percentage of hemispheric volume was measured by triphenyltetrazolium chloride staining. RESULTS: Preischemic alkalinization did not alter brain pH(i), rCBF, or NADH fluorescence. After 4 hours of ischemia, brain pH(i), rCBF, NADH fluorescence, and infarct volume measured 6.40 +/- 0.09 (mean +/- standard error), 11 +/- 2 ml/100 g/min, 165 +/- 8% of baseline control, and 37 +/- 3% in ischemic controls, respectively. In Group 2 animals treated with sodium bicarbonate, brain pH(i), rCBF, NADH fluorescence, and infarct volume improved significantly (P < 0.05, analysis of variance) to 6.74 +/- 0.08, 24 +/- 6 ml/100 g/min, 137 +/- 6% of baseline control, and 22 +/- 4%, respectively. Group 3 Carbicarb animals demonstrated improvements in brain pH(i), rCBF, and NADH fluorescence, with a significant reduction in infarct volume. CONCLUSION: These findings suggest that pretreatment with alkalinizing agents may be a useful intervention to provide intraoperative cerebral protection from ischemic injury.     

Diagnosis of hemodynamic compromise in patients with chronic cerebral ischemia; measurement of cerebral blood volume (CBV) with 99mTc-RBC SPECT

To evaluate the efficacy of tests for selecting patients with hemodynamic compromise, measurement of cerebral blood volume (CBV) with 99mTc-RBC single photon emission computed tomography (SPECT) was performed in thirteen patients with occlusive cerebrovascular disease, and was compared with results obtained by 133Xe SPECT and acetazolamide (Diamox) test. All patients in our study suffered TIA, RIND, or minor complete stroke. Cerebral angiography demonstrated severe stenosis or occlusion in the ipsilateral internal carotid artery or middle cerebral artery, although plain CT scan or MRI revealed no or, if any, only localized infarcted lesions. Regional cerebral blood volume (rCBV) was measured with 99mTc-RBC SPECT and regional cerebral blood flow (rCBF) was measured with 133Xe SPECT before and after intravenous injection of 10 - 12 mg/kg acetazolamide (Diamox). Our results suggest that the ipsilateral rCBV/rCBF (mean transit time) is a more sensitive index of the cerebral perfusion reserve than the use of only rCBV or rCBF of the ipsilateral hemisphere. Also, the ipsilateral rCBV/rCBF is significantly correlated (r = -0.72) with the Diamox reactivity of rCBF, which is considered to represent the cerebral vasodilatory capacity in patients with chronic cerebral ischemia. Postoperative SPECT study revealed remarkable improvement of ipsilateral rCBV/rCBF and Diamox reactivity in four patients who underwent EC/IC bypass surgery to improve the hemodynamic compromise. In conclusion, our results suggest that the measurement of rCBV/rCBF with 133Xe SPECT and 99mTc-RBC SPECT is useful for detecting the hemodynamic compromise in patients with occlusive cerebrovascular disease.     

Regional CBF, intraventricular pressure, and cerebral metabolism in patients with ruptured intracranial aneurysms

Regional cerebral blood flow (rCBF), cerebral metabolic rate of oxygen (CMRO2), intraventricular pressure, and lactate/pH levels in the cerebrospinal fluid (CSF) were measured in 38 patients with ruptured intracranial aneurysms between the 3rd and 13th day after subarachnoid hemorrhage (SAH). Angiography was performed following the rCBF study and the degree of vasospasm was measured on the angiograms. The patients were graded clinically according to the system of Hunt and Hess. Cerebral vasospasm significantly influenced rCBF: global reductions and focal changes (ischemia, hyperemia, and tissue peaks) were commonly associated with vasospasm. Patients with severe diffuse spasm always had global ischemia (21 +/- 5 ml/100 gm/min), and cerebral infarctions were demonstrated subsequently, The CMRO2 was more reduced than rCBF, indicating an uncoupling between flow and metabolism. This relative luxury perfusion was associated with CSF lactic acidosis and intracranial hypertension. The arteriovenous difference of oxygen was equally reduced in all categories of patients, probably due to the primary insult of SAH. The CMRO2 decreased concomitantly with arterial caliber, indicating a secondary impairment of cerebral metabolism due to vasospasm.     

Regional cerebral blood flow in patients with ruptured intracranial aneurysms.

Eighty-five studies of regional cerebral blood flow (rCBF) were performed on 49 patients with ruptured intracranial aneurysms. The changes in rCBF were analyzed under various pathophysiological conditions, The degree of flow abnormalities correlated well with the clinical severity of neurological deficits. All of the patients with diffuse vasospasm of severe grade, to less than half of their control value, showed focal areas of decreased flow below 30 ml/100 gm/min, in addition to a reduction in mean CBF. The relief or disappearance of vasospasm in angiograms was followed by the increase of rCBF in the ischemic focus and mean CBF. Marked reduction in rCBF was found in patients with intracerebral hematoma and ventricular dilatation. Impaired CO2 response and autoregulation were found in patients with severe neurological deficits, a severe degree of vasospasm and marked depression of CBF. In this series direct operation was delayed in patients with impaired vascular reactivity as well as marked decrease of mean CBF below 30 ml/100 gm/min; good clinical results were obtained in thses patients.     

Correlation of Regional Cerebral Blood Flow with Ischemic Electroencephalographic Changes during Sevoflurane-Nitrous Oxide Anesthesia for Carotid Endarterectomy

Background: Carotid endarterectomy necessitates temporary unilateral carotid artery occlusion. Critical regional cerebral blood flow (rCBF) has been defined as the rCBF below which electroencephalographic (EEG) changes of ischemia occur. This study determined the rCBF50, the rCBF value at which 50% of patients will not demonstrate EEG evidence of cerebral ischemia with carotid cross-clamping.

Methods: Fifty-two patients undergoing elective carotid end-arterectomy were administered 0.6-1.2% (0.3-0.6 minimum alveolar concentration) sevoflurane in 50% nitrous oxide (N2 O). A 16-channel EEG was used for monitoring. The washout curves from intracarotid133 Xenon injections were used to calculate rCBF before and at the time of carotid occlusion by the half-time (t1/2) technique. The quality of the EEG with respect to ischemia detection was assessed by an experienced electroencephalographer.

Results: Ischemic EEG changes developed in 5 of 52 patients within 3 min of carotid occlusion at rCBFs of 7, 8, 11, 11, and 13 ml [center dot] 100 g sup -1 [center dot] min sup -1. Logistic regression analysis was used to calculate an rCBF50 of 11.5 +/- 1.4 ml [center dot] 100 g sup -1 [center dot] min sup -1 for sevoflurane. The EEG signal demonstrated the necessary amplitude, frequency, and stability for the accurate detection of cerebral ischemia in all patients within the range of 0.6-1.2% sevoflurane in 50% N2 O.     

Regional effects of craniotomy on cerebral circulation and metabolism: PET study on the un-ruptured aneurysmal surgery

Regional effects of craniotomy on cerebral circulation and metabolism, such as regional cerebral blood flow (rCBF), regional cerebral oxygen consumption (rCMRO2), regional oxygen extraction fraction (rOEF), and regional cerebral blood volume (rCBV) were examined by a PET (positron emission tomography) study concerning surgery that was performed on unruptured aneurysm patients. Eight patients with intracranial un-ruptured aneurysms were studied pre- and post-operatively by the 15O labelled-gas steady-state method, using HEADTOME-III. All patients underwent aneurysmal surgery performed by the transsylvian approach. There was a significant increase in the mean OEF values taken from the whole-brains of 8 patients, but there was not a significant change in CBF, CMRO2 or CBV. The increase in OEF was caused by decrease of O2 content, which was caused by post-operative decrease in the Hb value. So, this OEF increase was not the direct effect of craniotomy. In 2 patients, the rCBF and rCMRO2, in the fronto-temporal region (where craniotomy was performed) increased post-operatively. This regional effect suggests transient reactive hyperemia following compressive ischemia during the operative procedure, and metabolic demands for recovery of brain function. In 2 other patients, who had relatively low rCBFs during the pre-operative study, rCBF and rCMRO2 in the bi-frontal region had decreased more at the post-operative study. This change appears to have been caused by removal of cerebrospinal fluid and depression of the frontal lobe. From this study, it becomes evident that the regional effect of craniotomy on cerebral circulation and metabolism is not so great, when adequate microsurgical techniques are used.