Diapositiva 1

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V Corso Nazionale Congiunto SIDV-GIUV
SINSEC Bertinoro 28 -31 Marzo 2007
Rivascolarizzazione Cerebrale Tecnica Chirurgica
Giuseppe Russo Responsabile UOSS
Cerebropatie Vascolari Acute UOSC
Neurochirurgia dUrgenza AORN A.Cardarelli -
Napoli
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Extracranial - Intracranial Bypass
EC-IC bypass was originally developed by Yasargil
and Yonekawa in 1977 as a safe means of direct
cerebral revascularization.
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
3
Extracranial - Intracranial Bypass
This methodology was called into question by the
EC-IC Bypass Study in 1985 which found the
procedure to be of no statistical benefit and
essentially discontinued as a treatment for
cerebral ischemia.
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
4
Extracranial - Intracranial Bypass
The procedure, however, continued to be used for
CBF replacement as an adjunct to parent vessel
sacrifice in patients with aneurysms and tumors
who had poor collateral circulation.
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
5
Extracranial - Intracranial Bypass
The EC/IC Bypass Study Group, 1985
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Extracranial - Intracranial Bypass
It is clearly impossible to reach a conclusion in
the matter without physiological studies of CBF
..
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Extracranial - Intracranial Bypass
Do abnormal cerebral hemodynamics identify a
stroke risk ?
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
8
Haemodynamic and Metabolic Responses to CPP
Reductions

• Three basic strategies
• paired rCBF measurements, with initial
  measurement obtained at rest and the second after
  provision of a cerebral vasodilatory stimulus
• measurement of rCBV alone or in combination with
  measurement of rCBF in the resting brain
• direct measurement of rOEF

Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
9
Haemodynamic and Metabolic Responses to CPP
Reduction
Increased OEF without increased CBV
Haemodynamic Failure Stage 2
Increased CBV indicates autoregulatory
vasodilation
Reductions in perfusion pressure within the
autoregulatory range
Derdeyn et al. Brain, 2002
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Inclusion criteria 1) Vascular imaging studies
demonstrating occlusion of one ICA 2) Vascular
imaging studies demonstrating less than 50
stenosis of the contralateral extracranial ICA 3)
A TIA or ischemic stroke in the hemispheric CA
territory of the occluded CA 4) Most recent
qualifying TIA or stroke must have occurred
within 120 days prior to the performance date of
PET 5) Modified Barthel Index score greater or
equal to 12/20 6) Age ranging between 18 and 85
years
RL. Grubb,WJ Powers, CP Derdeyn Neurosurg Focus
14 (3) 2003
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Sites were the recorded hemodynamic changes are
produced
Parenchimal
Can TCD Ultrasounds provide useful informations
in singling out the long-searched group of
patients elegible for cerebral bypass ?
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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CerebroVascular Reserve TCD recorded CO2
Reactivity Test
The increase of Blood Flow Velocity during
hypercapnia CO2 reactivity gives a measure of
the capacity of the intracerebral arterioles to
dilate further
G Russo, CA Lodi, M Ursino Neurological
Sciences, 2000
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Impaired CerebroVascular Reserve in left ICA
occlusion
R Vmca L Vmca p CO2
G Russo, CA Lodi, M Ursino Neurological
Sciences, 2000
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CerebroVascular Reserve Assessment Side to Side
Index
M Ursino, CA Lodi, G Russo - Journal of Vascular
Research 2000
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Vascular Brain Reserve
Paradoxical Responce
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Paradoxical Response explained by the model
ICA OCCLUDED SIDE
-
Maximal Vasodilated
CPP
Hypercapnia

VENOUS PRESSURE
CBV
Vasodilation

Reduced Pressure in the Willis
ICA OPEN SIDE
M Ursino, CA Lodi, G Russo - Journal of Vascular
Research 200037123-133
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Case Report
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Case Report
STA-MCA ByPass
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Case Report
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Case Report
Before STA-MCA bypass
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Brain Revascularization
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Bypass procedures for ICA reconstruction
Reconstruction of the ICA with the use of
interpositional SVGs (high flow EC-IC bypass)
for the management of giant aneurysms was
popularized by Sundt in the early 1980s
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Bypass procedures for ICA reconstruction
Skull Base, volume 15, number 1, 2005
E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Bypass procedures for ICA reconstruction
Skull Base, volume 15, number 1, 2005
E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Bypass procedures for ICA reconstruction
Skull Base, volume 15, number 1, 2005
E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Bypass procedures for ICA reconstruction
Perioperative Stroke Risk 7 - 15
Skull Base, volume 15, number 1, 2005
E. de Oliveira
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ELANA Excimer Laser Assisted Nonocclusive
Anastomosis
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ELANA Excimer Laser Assisted Nonocclusive
Anastomosis
Training Model in Vivo
Centro per le Biotecnologie
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ELANA Excimer Laser Assisted Nonocclusive
Anastomosis
Training Model in Vivo
Excimer Laser Assisted Non-occlusive
Anastomosis (ELANA). Our experience with a
training model in vivo. Russo G., Rotondo M.,
Punzo A., Di Napoli D. Journal Neurosurg Sci 51,
1 11-17, 2007
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ELANA Excimer Laser Assisted Nonocclusive
Anastomosis
PARTNER HOSPITALS Universitair Medisch
Centrum Utrecht - Holland Universitaetsklinikum
Mannheim Germany University Hospital Helsinky
- Finland Inselspital Bern Switzerland AORN
A.Cardarelli Napoli - Italy Kings College
Hospital London - UK St. Luke's-Roosevelt
Hospital New York - NY USA
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Giant Supraclinoid Carotid Aneurysm
First ELANA procedure in Italy May 2006
G.M. 22 yrs Left-handed Right Retro-orbital
Pulsating Headache
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Giant Supraclinoid Carotid Aneurysm
First ELANA procedure in Italy May 2006
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Giant Supraclinoid Carotid Aneurysm
First ELANA procedure in Italy May 2006
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ECA-MCA Excimer Laser Assisted Non-occlusive
Anastomosis
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ECA-MCA Excimer Laser Assisted Non-occlusive
Anastomosis
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Case n1 Five monthes follow-up
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Case n1 Five monthes follow-up
Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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ELANA Excimer Laser Assisted Nonocclusive
Anastomosis

• Dedicated Team
• Permanent Training
• More than 10 ELANA /year
• International Register
• National Register

Giuseppe Russo, Neurochirurgo - AORN
A.Cardarelli, Napoli
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Grazie !