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Neurological improvement in chronic ischemic stroke following surgical brain revascularization

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Abstract

50 patients suffering from completed ischemic stroke in the carotid territory for at least two months (17 mild, 31 moderate, 2 severe strokes) underwent extra-intracranial arterial bypass surgery. Neurological improvement was obtained in 43 cases; it persisted in time in 40 cases. Quantitative evaluation of motor performance in 21 patients showed that the degree of improvement was highly significant. Several factors strongly indicate a causal relation between surgical revascularization and neurological restoration. The positive surgical result is striclty dependent on correct patient selection and, in particular: i) on the documentation of local hemodynamic insufficiency; ii) on the occurrence of transient neurological (and to a certain extent EEG) improvement following hyperbaric oxygenation. The latter can also provide reliable information on the minimum degree of improvement to be expected from surgery.

Sommario

Cinquanta pazienti affetti da ictus ischemico stabilizzato nel territorio carotideo da almeno due mesi (17 ictus lievi, 31 moderati, 2 gravi) sono stati sottoposti ad anastomosi arteriosa microchirugica extra-intracranica. Miglioramento neurologico è stato ottenuto in 43 casi; esso è persistito nel tempo in 40 casi. Una valutazione quantitativa delle capacità motorie, eseguita in 21 pazienti, ha mostrato un’alta significatività del grado di miglioramento. Diversi fattori indicano un rapporto causale tra la rivascolarizzazione chirurgica ed il miglioramento neurologico. La positività del risultato chirurgico è strettamente dipendente dalla corretta selezione dei pazienti e, in particolare, i) dalla documentazione di una insufficienza emodinamica locale e ii) dalla dimostrazione di un miglioramento neurologico transitorio (e, entro certi limiti, elettroencefalografico) sottoponendo il paziente ad ossigenazione iperbarica. Quest’ultimo test consente anche un’attendibile previsione sull’entità del miglioramento minimo che ci si può attendere dal trattamento chirurgico.

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References

  1. Albert A.:La rieducazione neuromuscolare dell’emiplegico adulto. Roma, il Pensiero Scientifico, 258 pp, 1970

    Google Scholar 

  2. Andrews K., Brocklehurst J.C., Richards B., Kaycock P.J.:The rate of recovery from stroke and its measurement. Int. Rehab. Med., 3:155–161, 1981

    CAS  Google Scholar 

  3. Andrews B.T., Chater N.L., Weinstein P.R.:Extracranial-intracranial arterial bypass for MCA stenosis and occlusion. Operative results in 65 cases. J. Neurosurg, 62: 831–838, 1985

    CAS  PubMed  Google Scholar 

  4. Astrup J., Siesjo B.K., Symon L.:Thresholds in cerebral ischemia: the ischemic penumbra. Stroke 12:723–725, 1981

    CAS  PubMed  Google Scholar 

  5. Auer L.M., Oberbauer R.W., Clarici G., Pucher R.:Surgical treatment of cerebrovascular occlusive disease. A follow-up study. Acta Neurochir., 82:102–109, 1986.

    CAS  Google Scholar 

  6. Ausman J.I., Diaz F.G.:Critique of the extracranial-intracranial bypass study. Surg. Neurol. 26:218–221, 1986.

    CAS  PubMed  Google Scholar 

  7. Austin G.M. Ed:Microneurosurgical anastomoses for cerebral ischemia. CC. Thomas, Springfield Ill., 1976, 371 pg.

    Google Scholar 

  8. Austin G., Hayward W. Laffin D.:Modification of cerebral ischemia by microsurgical intracranial anastomosis. p. 281–294 in: G.H. Austin, ed.: Microneurosurgical Anastomoses for Cerebral Ischemia, C.C. Thomas Springfield, Ill. 1976

    Google Scholar 

  9. Awad I.A., Spetzler R.F.:Extracranial intracranial bypass surgery: a critical analysis in the light of the International Cooperative Study Neurosurg. 19:655–664, 1986

    CAS  Google Scholar 

  10. Bard G., Hirschberg G.G.:Recovery of voluntary motion in the upper extremity following hemiplegia. Arch. Phys. Med. Rehabil. 46:567–572, 1965

    CAS  PubMed  Google Scholar 

  11. Barnett M., Paoletti E., Flamm E., Brambilla G. (eds.):Cerebrovascular disease: new trends in surgical and medical aspects. Elserier, Amsterdam, 1981, 405 pp.

    Google Scholar 

  12. Carrol D.:The disability in hemiplegia caused by cerebrovascular disease. J. Chron. Dis., 15:179–189, 1982

    Google Scholar 

  13. Chater N., Popp J.:Microsurgical vascular bypass for occlusive cerebrovascular disease: review of 100 cases. Surg. Neurol., 6:115–118, 1976

    CAS  PubMed  Google Scholar 

  14. Conforti P., Tomasello F., Albanese V.:Evaluation of surgical revascularization. Pp. 385–394 in: M. Goldstein et al., eds.Advances in Neurology; vol. 24, New York, Raven Press, 1979.

    Google Scholar 

  15. Conforti P., Tomasello F., Albanese V.:Cerebral revascularization by microneurosurgical bypass. Piccin, Padova, 1984, 238 pp.

    Google Scholar 

  16. Day A.L., Roton A.L. Jr., Little J.R.:The Extracranial-Intracranial Bypass Study. Surg. Neurol., 26:222–226, 1986.

    CAS  PubMed  Google Scholar 

  17. De Renzi E., Ferrai C.:The Reporter’s Test: a sensitive test to detect expressive disturbances in aphasic, Cortex, 14: 279–293, 1978.

    PubMed  Google Scholar 

  18. De Renzi E., Faglioni P.:Normative data and screening power of a shortened version of the Token test. Cortex, 14: 41–49, 1978

    PubMed  Google Scholar 

  19. Deruty R.:Lanastomose extra-intracrânienne dans le traitement de l’ischémie cérébrale. Neurochirurgie, 29 175–190, 1983

    CAS  PubMed  Google Scholar 

  20. Dombovy M.L., Sandok B.A., Basford J.R.:Rehabilitation for stroke: a review. Stroke, 17:363–369, 1986

    CAS  PubMed  Google Scholar 

  21. Donaghy R.M.P.:Patch and bypass in microangional surgery. Pp. 75–86 in: R.M.P. Donaghy and M.G. Yasargil, eds.:Micro-vascular surgery. George Thieme Verlag, Stuttgart, 1967.

    Google Scholar 

  22. Donaghy R.M.P.:Evaluation of extracranial-intracranial blood flow diversion. (Pp 256–274 in: G.H. Austin, ed.:Microneurosurgical anastomoses for cerebal ischemia. C.C. Thomas, Springfield Ill., 1976.

    Google Scholar 

  23. Fein J.M., Reichman O.H. (eds.):Microvascular anastomoses for cerebral ischemia. New York, Springer-Verlag, 1978, 324 pp.

    Google Scholar 

  24. Gibbs J.M., Wise R.J.S., Thomas D.J., Mansfield A.M., Russell R.W.R.:Cerebral haemodynamic changes after extracranial-intracranial bypass surgery. J. Neurol. Neurosurg. Psychiat., 50:140–150, 1987.

    CAS  PubMed  Google Scholar 

  25. Gratzl O., Schmiedek P., Spetzler R.:Extracranial-intracranial arterial bypass for cerebral ischemia. Prog. Neurol. Surg. 9:1–29, 1978.

    Google Scholar 

  26. Greenhalgh R.M., Illingworth R.D., MC Fie R.D., Mills S.P., Perkin G.D., Clifford Rose F.:Extracranial to intracranial micro-revascularization for the treatment of completed ischemic stroke. Brit. med. J., 2:18–19, 1979.

    CAS  PubMed  Google Scholar 

  27. Gresham G.E.:Stroke outcome research. Stroke, 17: 358–360, 1986.

    CAS  PubMed  Google Scholar 

  28. Grunewald P., Lepage M., Mirom J.P., Froissart M., Galibat P.:Réflexions sur les anastomeses extra-intracrâniennes. A propos d’une série de 65 cas. Rev. Neurol., 135:467–471, 1979.

    CAS  PubMed  Google Scholar 

  29. Holbach K.H., Wassmann H., Bonatelli A.P.:A method to identify and treat reversible ischemic alterations of brain tissue. Pp. 169–176 in: P. Schmiedek (ed.):Microsurgery for stroke. New York, Springer-Verlag, 1977.

    Google Scholar 

  30. Holbach K.H., Wassmann H., Hoheluchter K.L., Jain K.K.:Differentiation between reversible and irreversible post-stroke changes in brain tissue: its relevance for cerebrovascular surgery. Surg. Neurol. 7:325–225, 1977

    CAS  PubMed  Google Scholar 

  31. Holbach K.H., Wassman H., Sanchez F.:EEG analysis for evaluating chronic cerebral ischemia treated by hyperbaric oxygenation and microneurosurgery. J. Neurol., 219: 227–240, 1978.

    Article  CAS  PubMed  Google Scholar 

  32. Ito Z., Hen K., Susuki A., Uemura K.:Selection of completed stroke patients, for STA-MCA anastomosis based on measurement of somatosensory evoked potentials and rCBF dynamics. Pp. 177–184 in: P. Schmiedek ed.:Microsurgery for stroke. New York, Springer-Verlag, 1977

    Google Scholar 

  33. Jacques S., Garner J.:Reversal of aphasia with superficial temporal artery to middle cerebral artery anastomosis. Surg. Neurol., 5:143–145, 1976

    CAS  PubMed  Google Scholar 

  34. Jongbloed L.:Prediction of function after stroke: a critical review. Stroke, 17:765–776, 1986

    CAS  PubMed  Google Scholar 

  35. Kapp J.K.:Neurological response to hyperbaric oxygen. A criteria for cerebral revascularization. Surg. Neurol.; 15: 43–46, 1981

    CAS  PubMed  Google Scholar 

  36. Katz S., Ford A.B., Chinn A.B., Newill U.A.:Prognosis after strokes. Part. II: Long term course of 159 patients. Medicine Balt. 45:236–246, 1966.

    Google Scholar 

  37. Kikuchi H., Karasawa J.:Clinical experience with STA-MCA anastomosis in 54 cases. Pp. 278–283 in: J.M. Fein, O.H. Reichman, eds.Microvascular anastomoses for cerebral ischemia. New York, Springer-Verlag, 1978

    Google Scholar 

  38. Kletter W.K.:The extra-intracranial bypass operation for prevention and treatment of stroke. New York. Springer-Verlag, pp. 166, 1979.

    Google Scholar 

  39. Koos W., Kletter G., Richling B., Schulster H.:Indications for and results of EIAB in patients with completed stroke. Pp. 131 in: H. Dietz, E. Metzel, C. Langmaid (eds):Neurological Surgery; Abstracts 7th Int. Congr. Neurol. Surg.; Neurochirurgia, Suppl., 1981.

  40. Kotila M., Waltimo O., Niemi M.L., Laaksonen R., Lempinen M.:The profile of recovery from stroke and factors influencing outcome. Stroke, 15:1039–1044, 1984.

    CAS  PubMed  Google Scholar 

  41. Lassen N.A., Symon L., Baron J.C. (eds.):Pénombre et ischémie cérébrale. London-Paris, J. Libbey, 1986, 130 pp.

    Google Scholar 

  42. Lehmann J.F., De Lauter B.J., Flower R.S., et al.:Stroke: does rehabilitation affect outcome? Arch. Phys. Med. Rehabil., 56:375–382, 1975.

    CAS  PubMed  Google Scholar 

  43. Maira G., Pola P., Ruggieri S., Savi L., Vignati A.:Pre and postoperative haemodynamic evaluation in patients with cerebral ischemic completed stroke. Giorn. It. Angiol., 1: 45–49, 1981.

    Google Scholar 

  44. Maira G., Rossi G.F., Anile C., Pola P., Vignati A., Agnoli A., Ruggeri S.:Cerebral functional and haemodynamic studies in view of surgical brain revascularization in the ischemic completed stroke. Pp. 339–350 in: H. Barnett, P. Paoletti, E. Flamm, G. Brambilla, eds.Cerebrovascular disease: New trends in surgical and medical aspects. Amsterdam, Elsevier, 1981.

    Google Scholar 

  45. Maira C., Ruggieri S., Fazio F., Vignati A., Agnoli A.:99Tc computerized quantitative dynamic serial scintigraphy in evaluation of extra-intracranial anastomosis. Pp 167–169 in: A. Bes, G. Geraud, eds.:Circulation cérébrale. Paris, Masson, 1980.

    Google Scholar 

  46. Maira G., Rossi G.F., Vignati A., Anile C., Fernandez E., Agnoli A., Ruggeri S.:Haemodynamic events and failure of the extra-intracranial arterial anastomosis. Pp. 169–176 in: J.S. Meyer, H. Lechner, M. Reivich, E.O. Ott, eds. mcerebral vascular disease 4. Amsterdam-Oxford-Princenton, Excerpta Medica, 1983.

    Google Scholar 

  47. Mehdorn M., Hoffmann W.F., Chater N.K.:Microneurosurgical arterial by-pass for cerebral ischemia. Pp. 350–356 in: S.J. Peerless, G.W. Mc Cormick, eds.: Microsurgery for cerebral ischemia. New York, Springer-Verlag, 1980.

    Google Scholar 

  48. Merei T.F., Bodosi M.:Microsurgical anastomosis for cerebral ischemia in ninety patients. Pp. 264–270 in: P. Schmiedek, eds.: Microsurgery for stroke. New York, Springer-Verlag, 1977.

    Google Scholar 

  49. Mitzukami M., Kin H., Sakuta Y., Nishilima M., Araki G.:Cortical arterial pressure in occlusive cerebrovascular disease and results of by-pass surgery. Pp. 233–239 in: P. Schmiedek, ed.:Microsurgery for Stroke.New York, Springer Verlag.1977.

    Google Scholar 

  50. Perless S.J., McCormick C.A. (eds).:Microsurgery for cerebral ischemia. New York, Springer-Verlag, 1980, 372 pp.

    Google Scholar 

  51. Reichmann O.H., Anderson R.E., Roberts T.S. Heilbrum M.P.:The treatment of intracranial occlusive cerebrovascular disease by STA-Cortical MCA anastomosis. Pp. 31–46 in: H. Handa ed.:Microneurosurgery. Tokyo, Igaku Shoin Ltd., 1975.

    Google Scholar 

  52. Roski R., Spetzler R.F., Owen M., Chandar K., Shall J.G., Nulsen F.W.:Reversal of seven-year old defect with extracranial-intracranial arterial anastomosis. Surg. Neurol. 10:267–168, 1978.

    CAS  PubMed  Google Scholar 

  53. Rossi G.F., Maira G.:Surgical revascularization and brain function following “completed” stroke. Pp. 217–238 in: A.W. Wilkinson, ed.:Investigation of brain function. New York, Plenum Publ. Co., 1981.

    Google Scholar 

  54. Rossi G.F., Maira G., Pola P., Vignati A.:Restoration of brain function through surgical revascularization in the stroke patient. Pp. 101–109 in: J. Eccles, M. Dimitrijevic, eds:Recent achievements in restorative neurology: upper motor neuron functions and dysfunctions. Basel, Karger, 1985.

    Google Scholar 

  55. Rossi G.F., Maira G., Vignati A., Agnoli A., Ruggeri S.:Extra-intracranial arterial anastomosis in ischemic completed stroke. Pp. 76–79 in: J.S. Meyer, W. Lechner, M. Reivicim, E.O. Ott, A. Aranibar, eds.:Cerebral Vascular disease 3. Amsterdam, Elsevier, 1980.

    Google Scholar 

  56. Schmiedek P. (ed.):Microsurgery for stroke. New York, Springer-Verlag, 1977, 291 pp.

    Google Scholar 

  57. Sivenius J., Pyörälä K., Heinonen O.P., Salonen J.T., Riekkinen P.:The significance of intensity of rehabilitation of stroke. A controlled trial. Stroke 16:928–931, 1985

    CAS  PubMed  Google Scholar 

  58. Skilberck C.E., Wade D.T., Hewer R.L., Wood V.A.:Recovery after stroke. J. Neurol. Neurosurg. Psych. 46:5–8. 1983.

    Google Scholar 

  59. Skyhoj Olsen T., Bruhn P., Oberg G.:Existe-t-il une prénombre ischémique chronique? Pp. 123–127 in: N.A. Lassen, L. Symon, J.C. Barron, eds.:Pénombre et ischémie cérébrale. London-Paris, John Libbey, 1986.

    Google Scholar 

  60. Spetzler R.F., Roski R.A., Zabramski J.:Middle cerebral artery perfusion pressure in cerebrovascular occlusive disease. Stroke, 14:552–555, 1983.

    CAS  PubMed  Google Scholar 

  61. Stephens Jr. H.W.:Microsurgical anastomoses of ten patients in a community hospital. Pp. 227–243 in: G.H. Austin, ed.:Microneurosurgical anastomoses for cerebral ischemia. Springfield, Ill. C.C. Thomas, 1976.

    Google Scholar 

  62. Sundt T.M., Whisnant J.P., Fode N.C., Piepgras D.G., Houser D.W.:Results, complications and follow-up of 415 by pass operations for occlusive disease of the carotid system Mayo Clin. Proc. 60:230–240, 1985.

    PubMed  Google Scholar 

  63. The EC/IC Bipass study group:Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N. Engl. J. Med. 313:1191–1200, 1985.

    Google Scholar 

  64. Tsuda Y., Kimura K., Iwata Y., Hayakawa T., Etani H., Fukunaga R., Yoneda S., Abe H.:Improvement of cerebral blood flow and/or CO 2 reactivity after superficial temporal artery-middle cerebral artery bypass in patients with transient ischemic attacks and watershed-zone infarctions. Surg. Neurol. 22:595–604, 1984.

    CAS  PubMed  Google Scholar 

  65. Veering M.M., Jonkman E.J., Poortvliet D.C.J., De Weerd A.W., Tans J.T.J., John E.R.:The effect of reconstructive vascular surgery on clinical status, quantitative EEG and cerebral blood flow in patients with cerebral ischemia. A three months follow-up study in operated and unoperated patients. EEG clin. Neurophysiol. 64:383–393, 1986.

    Article  CAS  Google Scholar 

  66. Wade D.T., Hewer R.L.:Functional abolition after stroke: measurement, natural history and prognosis. J. Neurol. Neurosurg. Psychiat. 50:177–182, 1987.

    CAS  PubMed  Google Scholar 

  67. Wade D.T., Wood V.A., Hewer R.L.:Recovery after stroke. The first 3 months. J. Neurol. Neurosurg. Psychiat., 48:7–13, 1985.

    CAS  PubMed  Google Scholar 

  68. Weinstein P.R., Rodriguez Y., Baena R., Chater N.L.:Results of extracranial-intracranial arterial by-pass for intracranial internal carotid artery stenosis: review of 150 cases. Neurosurg. 15:787–794, 1984.

    CAS  Google Scholar 

  69. Yasargil M.G.:Experimental small vessel surgery in the dog including patching and grafting of cerebral vessels and the formation of functional extra-intracranial shunts. Pp. 87–126 in R: R.M.P. DONAGHY and M.G. YASARGIL, eds.:Microvascular surgery: Stuttgart, Georg-Thieme Verlag: 1967.

    Google Scholar 

  70. Yonekawa Y., Yasargil M.G.:Extra-intracranial anastomosis: clinical and technique aspects. Pp. 47–48 in: H. Lrayenbhul ed.:Advances and technical standards in neurosurgery, vol. 3, 1976.

  71. Yonekura M., Austin G., Hayward D.:Long-term evaluation of cerebral blood flow, transient ischemic attacks and stroke after STA-MCA anastomosis. Surg. Neurol., 18: 123–130, 1982.

    CAS  PubMed  Google Scholar 

  72. Zamponi A., Gabriele P., Cecconi V.:La valutazione motoria dell’emiplegico con la Scala di Albert, Riv. Neurobiol., 9:34–49, 1980.

    Google Scholar 

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  1. Istituto di Neurochirurgia Policlinico A. Gemelli, Università Cattolica, Largo A. Gemelli, 8-00168, Roma

    Rossi G. F., Maira G., Vignati A. & Puca A.

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Rossi, G.F., Maira, G., Vignati, A. et al. Neurological improvement in chronic ischemic stroke following surgical brain revascularization. Ital J Neuro Sci 8, 465–475 (1987). https://doi.org/10.1007/BF02334603

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