Improved cerebrovascular reactivity following low flow EC/IC bypass in patients with occlusive carotid disease

Abstract

Patients with major cerebral artery occlusive disease can suffer cerebral hypoperfusion and be at an increased risk of future strokes. EC/IC bypass has been shown to reduce this risk. Patients with cerebral hypoperfusion, and who are at risk of haemodynamic ischaemia, can be identified by the use of xenon computerised tomography (XeCT) to demonstrate severe impairment of the cerebrovascular reserve (CVR). We report our series on the effect of low flow EC/IC bypass on CVR in patients with symptomatic cerebral haemodynamic ischaemia. Thirteen patients with clinical and radiological features of cerebral hypoperfusion were assessed with acetazolamide activated XeCT. Pre- and postoperative regional cerebral blood flow (rCBF) and CVR were assessed. The change in CVR from pre- to post surgery was calculated (%CVR). Values were compared using ANOVA and Student's paired t-test. Unless otherwise stated, values are given as mean ± standard error of the mean. Statistical significance was taken at p < 0.05.

Pre-operative symptomatic hemisphere CBF was 38 ± 2 mls/100g/min compared to 40 ± 3.2 mls/100 g/min in the asymptomatic hemisphere, with the greatest difference observed in the MCA territory (38.6 ± 2 cf 45.4 ± 3.2 mls/100g/min). Baseline CBF was not significantly improved post EC/IC bypass. However CVR was significantly improved in the symptomatic hemisphere post-operatively (p = 0.015), with the greatest increase (28%) seen in the MCA territory (p = 0.0105). First, 85% of patients had either an improvement in symptoms or no further symptoms. There was a 93% graft patency and no operative mortality. Low flow EC/IC bypass can improve CVR in patients with symptomatic cerebral ischaemia in the presence of occlusive carotid disease. However, therapy must be individualised, with careful patient selection and minimal surgical morbidity.

Key Words:

• EC/IC bypass
• cerebrovascular reactivity
• carotid occlusion
• Xenon CT scanning
• cerebral blood flow

Acknowledgements

We would like to thank Mrs C. L. Turner for performing the postoperative transcranial colour coded duplex ultrasonography, and Dr H. K. Richards for statistical advice.

Conflicts of Interest: P. G. Al-Rawi was funded by The Stroke Association UK. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.