title: Therapeutic strategies for patients with internal carotid or middle cerebral artery occlusion complicated by severe coronary artery disease.
abstract: OBJECTIVE
  Ischemic stroke is one of major complications of cardiac surgery. Although a current American Heart Association (AHA) guideline states that carotid endarterectomy is probably recommended before or concomitant to coronary artery bypass grafting (CABG) for the carotid stenosis, there is no report that analyzed optimal strategies in cardiac surgery for patients with total occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA). Therefore, this preliminary study was aimed to clarify whether preoperative blood flow measurements and prophylactic superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis could reduce the incidence of perioperative ischemic stroke during cardiac surgery in patients with total occlusion of the ICA or MCA.
  
  
  METHODS
  This prospective study included eight patients who were admitted to undergo cardiac surgery including CABG. All of them had total ICA or MCA occlusion on preoperative magnetic resonance (MR) examinations. Preoperative cerebral blood flow and its reactivity to acetazolamide were quantitatively determined in all eight patients using single photon emission computed tomography or positron emission tomography.
  
  
  RESULTS
  Preoperative blood flow measurements revealed that two (25%) of eight patients had normal cerebral hemodynamics because of well-developed collaterals. They safely underwent cardiac surgery. However, a marked impairment of cerebral perfusion reserve was identified in six (75%) of eight patients in the ipsilateral hemispheres. Of these, four patients underwent prophylactic STA-MCA anastomosis prior to CABG. Subsequently, they safely underwent CABG without perioperative ischemic stroke.
  
  
  CONCLUSIONS
  This is the first report suggesting that preoperative identification of hemodynamic compromise and prophylactic STA-MCA anastomosis may reduce perioperative ischemic stroke during cardiac surgery in patients with ICA or MCA occlusion, although further studies are needed to assess the validity.
authors.affiliation: Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
authors.forename: Masahito
authors.initials: M
authors.lastname: Kawabori
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kuroda
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Terasaka
authors.forename: Naoki
authors.initials: N
authors.lastname: Nakayama
authors.forename: Yoshiro
authors.initials: Y
authors.lastname: Matsui
authors.forename: Suguru
authors.initials: S
authors.lastname: Kubota
authors.forename: Masanori
authors.initials: M
authors.lastname: Nakamura
authors.forename: Katsuhiko
authors.initials: K
authors.lastname: Nakanishi
authors.forename: Fumiyuki
authors.initials: F
authors.lastname: Okamoto
authors.forename: Yoshinobu
authors.initials: Y
authors.lastname: Iwasaki
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000517:prevention & control / Q000601:surgery; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods; D002560:Cerebrovascular Circulation / Q000502:physiology; D001026:Coronary Artery Bypass / Q000379:methods; D003324:Coronary Artery Disease / Q000150:complications / Q000601:surgery*; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D020244:Infarction, Middle Cerebral Artery / Q000150:complications / Q000601:surgery*; D007431:Intraoperative Complications / Q000209:etiology / Q000517:prevention & control; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000592:standards