Cerebral Hyperperfusion Syndrome following the Excision of a Mycotic Aneurysm with Superficial Temporal Artery-to-Middle Cerebral Artery Bypass: Case Report

The authors report a rare case of cerebral hyperperfusion syndrome (HPS) following the excision of a mycotic aneurysm with superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass. A 74-year-old woman with infective endocarditis presented with progressive cerebral infarction and subarachnoid hemorrhage due to a mycotic aneurysm, which was excised with a STA-MCA bypass. Postoperatively, the patient developed HPS that was considered to be exacerbated by a previous ischemic event. Therefore, cerebral hemodynamics should be evaluated before bypass surgery to prevent subsequent hyperperfusion.     

幼猪深低温体外循环最适区域性脑灌注流量的实验研究

目的探索幼猪在深低温体外循环中的最适区域性脑灌注（RCP）流量,为先天性心脏病（先心病）小儿患者术中脑保护策略提供理论基础。方法20只健康幼猪,年龄23．7±2．1d,体重6．4±0．6kg,采用随机数字表法分为4组,每组各5例。对照组为单纯深低温停循环（DHCA组）;实验组按不同RCP流量分为3组：RCP25组,流量为25．9±3．0ml（kg·min）;RCP50组,流量为49．7士1．8ml／（kg·rain）;RCP80组,流量为79．5±0．9ml／（kg·min）;通过检测血浆中建立CPB前（T1）、DHCA或RCP前（T2）、RCP结束后10min（T3）、停机前（T4）、CPB结束后1h（Ts）以及2h（T5）6个时间点检测血浆中的S-100β蛋白、神经元特异性烯醇化酶（NSE）的浓度、脑氧摄取率（CEOz）及大脑皮质半胱天冬氨酸酶3（caspase3）的含量,评估不同RCP流量的脑保护效果。结果各组幼猪血浆中S-100β蛋白和NSE的浓度于T4时明显升高,并于T5时达到高峰（P〈0．05）;RCP50组血浆中S-100β蛋白和NSE的浓度从T4时开始明显低于DHCA组和RCP80组（P〈O．05）,与RCP2。组相比,其差异无统计学意义（P〉0．05）。各组CEO2在T1时差异无统计学意义（P〉0．05）,在T2时明显降低（P％0．05）。DHCA组、RCPzs组和RCP50组的CEO2在T3时开始升高,RCP20组在T3时稍微下降,但其差异无统计学意义（P〉0．05）;从T4开始,RCP25组和RCPj。组的CEO。与DHcA组和RCP80组更接近于基础值（T1）（P〈0．05）。大脑皮质中caspase3的含量在3种不同流量的RCP组明显低于DHCA组（F=23．54,P〈0．01）,其中RCP25组及RCP5。组明显低于RCP80组（F=23．54,P〈0．01）,而RCP2s组与RCP50组的caspase3含量差异无统计学意义（P〉0．05）。结论在我们建立的幼猪深低温体外循环模型中,RCP最适灌注流量为25～50ml／（kg·rain）,并且趋向于50ml／（kg·rain）。     

Distal Superficial Temporal Artery to Proximal Posterior Cerebral Artery Bypass by Posterior Oblique Transzygomatic Subtemporal Approach

This article investigates the possibility for the distal superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) direct bypass by subtemporal oblique posterior transzygomatic approach. Five adult cadaveric specimens were dissected. Cadeveric dissection protocol was approved by the Research Ethics Committee. A preauricular vertical skin incision was made, the trunk of STA was identified, and bifurcation, frontal, and parietal branches of the STA were followed distally. Posterior zygomatic arch osteotomy and microcraniotomy were then performed, and the dura was opened. The temporal lobe was retracted, interpeduncular and ambient cisterns were opened, and the P2 segment of the PCA was exposed. Parietal branch of STA and P2 segment of the PCA was anastomosed. The average length of the transected STA from the bifurcation and the zygomatic arch were 47.3 ± 2.1 mm and 71.4 ± 2.3 mm, respectively. The mean calibers of the parietal and frontal branch of the STA at this distance were 1.6 ± 0.1 and 1.4 ± 0.2, respectively. The mean diameter of the P2 was 2.1 ± 0.2 mm. Because of the calibers of the parietal branch of the STA and proximal PCA are over 1.5 mm and 2.0 mm, respectively, this direct end-to-side bypass technique may be a reasonable alternative in suitable cases.     

“Reverse” Bypass Using a Naturally Formed “Bonnet” Superficial Temporal Artery in Symptomatic Common Carotid Artery Occlusion: A Case Report

We herein describe a patient with symptomatic common carotid artery occlusion who underwent a reverse superficial temporal artery (STA)-middle cerebral artery (MCA) single bypass using a naturally formed “bonnet” STA. The surgical procedure was performed without difficulty, and no further neurological deterioration was observed after surgery. In practice, this case highlights that the reverse STA-MCA bypass can be achieved safely and less invasively using a naturally formed “bonnet” STA.     

多层螺旋CT冠状动脉成像在冠心病诊断中的临床应用

近年来,冠心病(coronary artery disease,CAD)在我国的发病率明显增高,早期诊断、早期治疗尤为重要。随着计算机断层成像(CT)技术的迅速发展,多层螺旋CT(multidetector-row computed tomography,MDCT)逐步成为冠心病筛查和诊断的首选检查方法。现就MDCT的发展概况、钙化积分、检测冠状动脉狭窄程度、斑块评价、解剖变异显示、旁路血管评价、冠状动脉支架术后评价、心肌灌注、心功能分析等方面的临床应用进行综述     

Virtual Three-dimensional Computed Tomography Assessment of the Gastric Pouch Following Laparoscopic Roux-Y Gastric Bypass

Background The construction of the gastric pouch during surgery is largely based on the prevailing dogma of Roux-Y gastric bypass (RYGB) surgery. The scarce data that exist suggest that the smaller the gastric pouch, the greater the weight loss after surgery. Current estimations of pouch volume have inherent limitations. We describe the use of virtual three-dimensional computed tomography (3D CT) to assess pouch volume in the immediate postoperative period. Methods We performed 3D CT on three patients 1 day after laparoscopic RYGB using a 16-channel multidetector CT scan. Effervescent granules were administered, along with 1 oz of water, orally to achieve gastric pouch distension. Transaxial images were transferred to the 3D workstation (Vitrea, Vital Images, Inc.) and endoluminal views of the gastric pouch were generated with perspective volume rendering. Pouch area was also measured from the standard postoperative upper gastrointestinal (UGI) contrast study. Results All three patients were female, with a mean preoperative body mass index (BMI) of 43.7 kg/m² and a mean age of 44.3 years. Mean pouch height was 4.07 cm, mean pouch width was 3.79 cm, and mean pouch depth was 2.1 cm. The mean calculated pouch volume was 31.6 cm³. The calculated pouch area using 3D CT was statistically indistinct from the pouch area calculated using the UGI study (15.2 cm² vs 16.9 cm²; p = 0.549.) Conclusion For the first time, we describe the use of 3D CT to accurately measure postoperative pouch volume. In addition, we were able to confirm the utility of area (postoperative UGI) as an accurate surrogate for pouch volume.     

Significance of Cerebral Blood Flow Analysis in the Acute Stage after Revascularization Surgery for Moyamoya Disease

Moyamoya disease is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by steno-occlusive changes at the terminal portion of the internal carotid artery, either bilaterally or unilaterally, and an abnormal vascular network at the base of the brain. Surgical revascularization such as extracranial-intracranial (EC-IC) bypass is the preferred procedure for moyamoya disease. Despite the favorable long-term outcome, cerebral infarction and hyperperfusion syndrome are potential complications of this procedure, which can lead to neurological deterioration in the acute stage. In light of the similar clinical presentations between perioperative ischemia and hyperperfusion, it is essential to attempt a prompt cerebral blood flow (CBF) measurement in the acute stage after EC-IC bypass for moyamoya disease to differentiate these distinct pathologies, because the management of cerebral ischemia and hyperperfusion is contradictory to each other. Routine CBF analysis by single-photon emission computed tomography and/or magnetic resonance imaging not only facilitated a safer perioperative management but also provided important information about dynamic pathology of the hemodynamic conversion in the acute stage after revascularization surgery for moyamoya disease. We represent the current status of CBF analysis during the perioperative period of revascularization surgery for moyamoya disease, and sought to discuss its significance and efficacy to avoid surgical complications.     

Possibility of Middle Meningeal Artery-to-Petrous Internal Carotid Artery Bypass: An Anatomic Study

The possibility of creating a middle meningeal artery (MMA)-to-petrous internal carotid artery (ICA) bypass was investigated in six cadavers (bilaterally). Such a procedure could be used to treat patients with high cervical vascular lesions and those with tumors of the infratemporal fossa invading the high cervical ICA. After a frontotemporal craniotomy, the foramen spinosum and foramen ovale were exposed extradurally. Immediately posterior to the foramen ovale and medial to the foramen spinosum, the petrous portion of the ICA was exposed with a diamond-tipped drill. The MMA was lifted from its groove, and a sufficient length was transected to perform a bypass with the petrous ICA medially. The mean width of the MMA at the site of anastomosis was 2.3 +/- 0.35 mm. The mean length of MMA from the foramen spinosum to the site of the anastomosis was 9.6 +/- 1.7 mm. Based on these measurements, width and length of MMA appear to be sufficient for a bypass with petrous ICA.     

Efficacy of Superficial Temporal Artery-Middle Cerebral Artery Double Anastomoses in a Patient with Rapidly Progressive Moyamoya Disease: Case Report

Moyamoya disease can be associated with a rapidly progressive course in young patients. This report describes a patient with moyamoya disease who experienced rapid disease progression, resulting in cerebral infarction and a wide area of diminished cerebral perfusion. Double superficial temporal artery (STA)-middle cerebral artery (MCA) anastomoses were utilized to immediately increase cerebral perfusion in the affected area. This case involved a 5-year-old girl who had been diagnosed with moyamoya disease and had undergone STA-MCA anastomosis with indirect bypass in the right hemisphere at the age of 3. At the time of presentation, magnetic resonance (MR) imaging showed cerebral infarction at the left frontal lobe, and MR angiography showed rapidly progressive narrowing of the left MCA that had not been present 3 months prior. N-isopropyl-p-[I123] iodoamphetamine single-photon emission computed tomography (IMP-SPECT) showed markedly decreased uptake in the left hemisphere. She underwent emergent STA-MCA double anastomoses with indirect bypass on the left side. IMP-SPECT showed marked increase in uptake in the left hemisphere. The anterior cerebral artery (ACA) territory adjacent to the cerebral infarction also showed increased uptake on the SPECT. Postoperatively, there were no clinical or radiographic indications of ischemic or hemorrhagic complications. Double anastomoses are effective in quickly and significantly increasing blood flow. The postoperative course in this case was uneventful. Double anastomoses are a surgical option for patients with moyamoya disease who show rapid disease progression, even in those in the acute phase of cerebral infarction.     

异丙酚对体外循环后早期脑氧代谢的影响

目的观察异丙酚对体外循环(CPB)后早期脑氧代谢的影响. 方法 25例低温CPB下行瓣膜置换术患者,随机分成异丙酚(P)组和咪唑安定(M)组,分别于CPB前(T1)、复温5 min(T2)、CPB结束后15 min(T3)、 30 min(T4)和60 min(T5)观察SjO2、 CEO2、 Da-vO2, Da-vCO2和PH差等指标. 结果 P组SjO2在T1～T5均显著高于M组;T3时相SjO2<60%者P组仅1例患者,少于M组的5例(P<0.05);各组内Da-vO2在T2、T3均低于T1,P组于T4恢复至T1水平,M组需至T5才恢复至T1水平. 结论异丙酚对CPB后早期脑氧供需障碍有一定的改善作用.     

Venous Reddening as a Possible Sign of Hyperperfusion after Superficial Temporal Artery-Middle Cerebral Artery Anastomosis for Moyamoya Disease: Case Report

Here we report a case of moyamoya disease in which cortical veins reddened after superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis, following postoperative hyperperfusion. A 37-year-old man with moyamoya disease suffered cerebral infarction in his right hemisphere. Single photon emission computed tomography (SPECT) showed impaired cerebral blood flow (CBF) in both cerebral hemispheres. The patient underwent STA-MCA anastomosis in the right cerebral hemisphere. During operation, soon after declamping the STA, cortical veins near the anastomosis site changed its color from blue to red. This change was repeatable by clamping and declamping of the STA. Postoperative SPECT and computed tomography (CT) demonstrated increased CBF and subarachnoid hemorrhage at the anastomosis site, suggesting the occurrence of postoperative hyperperfusion. By strictly controlling the patient''s blood pressure, the syndrome resolved 1 week after the operation. We propose that the venous reddening after STA-MCA anastomosis may be a sign of postoperative hyperperfusion.     

Cerebral Blood Flow Velocities After Subarachnoid Haemorrhage in Relation to the Amount of Blood Clots in the Initial Computed Tomography

Summary  In 72 patients with acute subarachnoid haemorrhage (SAH) the relationship between the amount of subarachnoid blood clots detected by initial cranial computed tomography (CCT) up to 48 hours after bleeding and the later development of vasospasm, established by blood flow velocity measurement with transcranial Doppler ultrasound (TCD) was investigated. The serial Doppler examinations started within the first 72 hours after SAH and were carried out every second day up to three weeks. Each Doppler recording was accompanied by a neurological examination. Patients classified as Hunt and Hess grade V were excluded from the study. All patients with remarkable brain oedema in CCT or with intracranial pressure above 25 mmHg were also excluded. Because of the well known age-dependence of vasospasm after SAH, two age groups were formed.  A statistically significant correlation (p>0.05) between blood flow velocities and blood load after SAH was not found. The mean age of the investigated 72 individuals was 48.9 years (14 up to 76 years). 47 patients were younger than 56 years. Linear regression analysis indicated a correlation with a quite low significance level (r=0.350, p<0.025) between TCD blood flow velocities and blood load in CCT in these younger subjects. No significant correlation (p>0.05) between these two variables could be established in the 25 patients older than 55 years. In a second step an intra-individual comparison of side-to-side differences in TCD and CCT was made. There were no significant differences in blood flow velocities between subjects with or without side-to-side differences in cisternal blood load.  It is concluded that the amount of blood visible on initial CCT after SAH is not a powerful predictor of cerebral blood flow velocities measured by TCD.     

Is Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Imaging Cost-effective in Prostate Cancer: An Analysis Informed by the proPSMA Trial

BackgroundBefore integrating prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) into routine care, it is important to assess if the benefits justify the differences in resource use.ObjectiveTo determine the cost-effectiveness of PSMA-PET/CT when compared with conventional imaging.Design, setting, and participantsA cost-effectiveness analysis was developed using data from the proPSMA study. proPSMA included patients with high-risk prostate cancer assigned to conventional imaging or ⁶⁸Ga-PSMA-11 PET/CT with planned health economics data collected. The cost-effectiveness analysis was conducted from an Australian societal perspective.Intervention⁶⁸Ga-PSMA-11 PET/CT compared with conventional imaging (CT and bone scan).Outcome measurements and statistical analysisThe primary outcome from proPSMA was diagnostic accuracy (nodal and distant metastases). This informed a decision tree analysis of the cost per accurate diagnosis.Results and limitationsThe estimated cost per scan for PSMA PET/CT was AUD$1203, which was less than the conventional imaging cost at AUD$1412. PSMA PET/CT was thus dominant, having both better accuracy and a lower cost. This resulted in a cost of AUD$959 saved per additional accurate detection of nodal disease, and AUD$1412 saved for additional accurate detection of distant metastases. The results were most sensitive to variations in the number of men scanned for each ⁶⁸Ga-PSMA-11 production run. Subsequent research is required to assess the long-term costs and benefits of PSMA PET/CT-directed care.ConclusionsPSMA PET/CT has lower direct comparative costs and greater accuracy compared to conventional imaging for initial staging of men with high-risk prostate cancer. This provides a compelling case for adopting PSMA PET/CT into clinical practice.Patient summaryThe proPSMA study demonstrated that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) better detects disease that has spread beyond the prostate compared with conventional imaging. Our analysis shows that PSMA PET/CT is also less costly than conventional imaging for the detection of disease spread.This research was presented at the European Association of Nuclear Medicine Scientific Meeting in October 2020.     

Anatomy Relationship around Internal Carotid Artery in the Endoscopic Surgery of Nasopharynx: A Study Based on Computed Tomography Angiography

Objective Anatomic knowledge is needed to avoid injury to internal carotid artery (ICA) during the endoscopic surgery around nasopharynx and its surrounding space. Design We prospectively studied the computed tomography angiography (CTA) data of 28 patients with image processing software. Special attention was given to ICA and various landmarks around nasopharynx. Results The anatomic relationship between ICA and different landmarks around nasopharynx was clearly presented in three-dimension. The fossa of Rosenmuller is the nearest point of the nasopharyngeal cavity to ICA. The opening of the Vidian canal in the middle cranial fossa could be either above, below, or at the level of the horizontal segment of petrous ICA. The pharyngeal trunk of the ascending pharyngeal artery can also be clearly identified in most reconstructed CTA images. Multiple anatomic relationships were also quantified. Conclusions Reconstructed CTA can provide key anatomic information for a safe and accurate endoscopic dissection around nasopharynx.     

Prolonged Antegrade Cerebral Perfusion via Right Axillary Artery (≥60 min) Does Not Affect Early Outcomes in a Repair of Type A Acute Aortic Dissection

Purpose: We aim to investigate whether the duration of antegrade cerebral perfusion (ACP) via right axillary artery with an 8-mm prosthetic graft affects early outcomes in a repair of type A acute aortic dissection (AAD).Methods: Over the 24 months from April 2010, a repair of AAD under ACP via the right axillary artery and mild hypothermic circulatory arrest (rectum temperature, 28–30°C) was performed in 34 patients. Mean age was 64.5 ± 13.7 years of age. Preoperative shock status was in three due to cardiac tamponade. Organ malperfusion occurred in 11 patients preoperatively. Mean follow-up period was 9.6 ± 8.4 months and follow-up rate was 100%.Results: Hospital mortality rate was 8.8%. No newly required hemodialysis and new onset of temporary or permanent neurologic deficits were present in survivors. There were no statistically significant differences of mortality rate, new onset of permanent or temporary neurologic deficits and distal organ dysfunction between ACP duration <60 min and ≥60 min. The 12-month survival was 84.4% ± 6.4%. And, freedom from aorta-related events at 12 and 18 months were 100% ± 0.0% and 88.9% ± 10.5%, respectively.Conclusions: The duration of ACP via right axillary artery does not affect early outcomes following a repair of AAD.     

Three-Dimensional Computed Tomography Analysis of the Posterior Tibial Slope in 100 Knees

Background

The posterior tibial slope (PTS) is an important consideration in knee arthroplasty. However, there is still no consensus for the optimal slope. The objectives of this study were (1) to reliably determine the native PTS in this population using 3-dimensional computed tomography scans and (2) to determine the normal reference range for PTS in this population.

The Relationship Between Cerebral Blood Flow Velocities and the Amount of Blood Clots in Computed Tomography After Subarachnoid Haemorrhage

127 patients with aneurysmal subarachnoid haemorrhage (SAH) were analyzed for the relationship between the amount of blood clots as detected by initial computed tomography (CT) up to 48 hours after SAH and changes of blood flow velocities as measured using transcranial Doppler ultrasonography (TCD). All patients were operated on within 72 hours after SAH. Patients who presented with remarkable brain oedema or with pathological intracranial pressure (ICP) due to mass effects of a haematoma, and who were in a poor neurological condition classified according to Hunt-Hess as grade V were excluded from this study. Serial TCD examination of the middle cerebral arteries (MCA) and anterior cerebral arteries (ACA) started within 48 hours after SAH and were performed daily up to three weeks. A statistically significant correlation between blood load designated according to Fisher's grading as group CT I-CT IV and mean flow velocities (MFV) was found in groups CT I, II, and III. High values of MFV in MCA examinations were noted in patients with severe SAH (group CT III)--161 cm/s, and low values in patients without SAH (group CT I)--119 cm/s. Patients with haematocephalus and/or haematoma without a mass effect (group CT IV) had lower blood flow velocities than patients with severe SAH (group CT III) but values were higher than in patients without SAH (group CT I). The number of days for which MFV in the MCA was > 120 cm/s and was statistically (p < 0.05) correlated with the amount of blood clots as observed in the respective CT (in group CT I, II, and III). MFV values in the anterior cerebral artery (ACA) were lower than those obtained in the middle cerebral artery (MCA) in all groups. Statistically significant (p < 0.05) differences were noted between groups CT I and CT III (first and third week) and between groups CT I and CT IV (third week). If the SAH was extensive in the CT scan, pathological values of MFV > 90 cm/s were observed in ACA, and this was more pronounced in group CT III than in group CT IV. Blood flow velocities obtained via TCD were registered to compare side-to-side differences and particularly high differences were observed in patients with severe SAH. It is concluded that the amount of blood clots in the initial computed tomography after SAH is significantly correlated with cerebral blood flow velocity measurements by TCD.