Transcranial Doppler Ultrasound Recording with Compression ... - NCBI

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... of the North American Skull Base Society, Lake Buena Vista, Florida, February 27-March 3, 1991 Reprint ... right X) 1993 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. ... sound (TDU) recording has been developed as a new ... loon occlusion was carried out in the six remaining pa-.
J. Maurer M.D., K. Ungersbock, M.D., R.G. Amedee, M.D., FA.C.S., W.J. Mann, M.D., FA.C.S., and A. Perneczky, M.D.

Transcranial Doppler Ultrasound

Recording

with

in Patients

Compression Test with

Tumors

Involving the Carotid Arteries

In some patients with advanced tumors of the skull patients.' To avoid these severe problems, it is important to base and neck computed tomography (CT), magnetic res- obtain information about this risk preoperatively. Different diagnostic procedures have been used to onance imaging (MRI), and ultrasound imaging show that the carotid artery is surrounded or infiltrated by tumor. For identify patients with a risk for neurologic complications the planning of the therapeutic strategy (especially if sur- after ligation of one carotid artery. The most simple but gery is anticipated), it is important to know if this vessel is least useful procedure is the manual compression of the potentially resectable. Depending on the collateral circu- carotid artery with clinical observation of the patient for lation to the brain at the circle of Willis, obliteration or at least 10 minutes.2 Other commonly used procedures are resection of the common or internal carotid artery (ICA) compression of the carotid artery with electroencephalographic monitoring, cerebral angiography with occlusion can cause severe neurologic complications. When the vessel is ligated, complications such as hemiparesis, hemi- eventually combined with electroencelphalography, and plegia, aphasia, or even death can occur in 5 to 30% of measurement of cerebral blood flow with intraoperative Skull Base Surgery, Volume 3, Number 1, January 1993 From the Departments of Otohinolaryngology and Neurosurgery, University of Mainz, Mainz, Germany, and the Department of Otolaryngology-Head and Neck Surgery, iblane University Medical Center, New Orleans, Louisiana Presented at The Second Annual Meeting of the North American Skull Base Society, Lake Buena Vista, Florida, February 27-March 3, 1991 Reprint requests: Dr. Amedee, Tilane University Medical Center, Department of Otolaryngology, 1430 Tblane Ave., New Orleans, LA 70112-2699 Copy11 right X) 1993 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.

SKULL BASE SURGERYNOLUME 3, NUMBER 1 JANUARY 1993

ICA stump pressure registration. In spite of cerebral angiography and electroencephalographic monitoring with carotid artery compression and intraoperative registration of the ICA, 6% of patients will have severe neurologic complications, including a reported 2% mortality.3 A complication rate of 8% was observed when performing arterial angiography with balloon occlusion prior to operative management of tumors involving the ICA. However, these complications were not severe or permanent.4 In neurologic and neurosurgical diagnostics of cerebrovascular pathologic conditions transcranial Doppler ultrasound (TDU) recording has been developed as a new diagnostic tool during the last several years. We currently present our first experience with this technique in patients in whom unilateral resection or ligation of the common or ICA would possibly be necessary intraoperatively.

segment of the ICA. In seven patients angiography with balloon occlusion was performed because the results of TDU were inconclusive in determining the resectability of the common carotid artery or ICA.

RESULTS

In three patients with metastatic tumors of the neck extending down to the supraclavicular fossa, complete compression of the carotid artery was not possible and therefore the examination could not be performed in these patients. The remaining 28 patients showed immediately after compression of the ipsilateral carotid artery a diminution of the blood flow velocity in the MCA to varying degrees. This diminution was between 25 and 90% of the flow velocity under normal conditions. In 12 patients we found a rapid reestablishment of the flow velocity in the MATERIALS AND METHODS MCA within 5 to 22 seconds, reaching 90% or more of the velocity under normal conditions (sufficient recovery, Thirty-one patients with various tumors of the skull Fig. 1). In nine patients under compression, a significant base and neck were included in this study (Table 1). In recovery of the flow velocity in the MCA could not be these patients CT or MRI, or both, with routine ultrasound observed and it did not reach 50% of the value under examinations preoperatively could not completely rule out normal conditions (insufficient recovery, Fig. 2). In seven or predict the necessity for surgical manipulation of the patients the recovery under compression was between 50 common carotid artery or ICA. This group of patients was and 90% of the value under normal conditions (questionthen assessed using TDU as a noninvasive means of exam- able recovery, Fig. 3). ination. This involved the use of a pulsed Doppler system In four patients with sufficient recovery of the flow with an emitted ultrasonic frequency of 2 mHz and a burst velocity, ligation or resection of the ICA was performed repetition rate between 5 and 20 kHz. For the examination, without neurologic complications. In the remaining eight the transducer was applied to the temporal bone region patients with sufficient recovery, the carotid was neither because this is usually the thinnest bony area of the skull ligated or resected. In those patients with an insufficient and here the attenuation of ultrasonic energy is relatively recovery, ligation or resection was not performed and in low. The blood flow velocity of the middle cerebral artery some cases surgery was not even a treatment option. One (MCA) was determined under normal conditions and with patient with a giant aneurysm of the ICA with a questionmanual compression of the ipsilateral carotid artery. The able recovery of the flow velocity in the MCA under blood flow velocity of the MCA under normal and com- compression had a ligation of the artery. In this patient pressed conditions was used as an indicator to determine angiography with balloon occlusion was attempted but the cerebral cross-flow. Before and after the test, complete was impossible for technical reasons. Fourteen days after occlusion of the internal carotid artery was controlled by the operation, the patient showed severe neurologic comdetermination of the blood flow velocity in the intracranial plication and eventually died. An angiography with balloon occlusion was carried out in the six remaining patients with a questionable recovery of the flow velocity in the MCA. One of these cases was judged to have a suffiTable 1. Demographics of Patients Studied cient collateralization following angiography. For the Using Transcranial Doppler Ultrasound other five patients, the angiography confirmed the lack of No. collateral flow and enhanced the chances for severe neuroSex logic complications following ligation or resection. Male 17 Female 14 Age range (yr) Tumor types Metastatic neck tumors Various primary tumors of skull base Intracranial meningiomas Giant internal carotid artery aneurysms Paranasal sinus adenocarcinoma Middle ear squamous cell carcinoma 12

Total

20-72 12 11 4 2 1 1 31

DISCUSSION Doppler sonography was first used in the diagnostic evaluation of extracranial vessels. With the continuous wave principle machines used for this purpose, vessel identification was very difficult. Therefore, these types of machines were not suitable for intracranial vessel identi-

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Patient-Nr. _ Onset of compression B 5-22s after onset Figure 1. Sufficient recovery: The flow velocity in the middle cerebral artery (MCA) under compression for these patients with a sufficient recovery reached 90% or more of the flow velocity under normal conditions. Blood flow velocity in the MCA in percent of the value under normal conditions. Black columns: onset of compression of the ipsilateral carotid artery. Shaded columns: after 5 to 20 seconds under compression.

fication or examination.56 Moreover, the ultrasoundemitting frequencies used, between 5 and 10 mHz, were not suitable for penetration of the skull bones.7 The invention of pulsed Doppler systems with an ultrasonic emitting frequency of 2 mHz allowed for the safe identification and critical examination of intracranial vessels.7 With compression testing (which in its simplest form has been in

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clinical use since the beginning of the century), it becomes possible to judge the cerebral cross-flow potential of the patient before a therapeutic ligation or resection of the common carotid artery or ICA is performed.8 Cerebral angiography without temporary occlusion is of little diagnostic value for establishing the presence of cerebral collateralization.' Cerebral angiography with

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Patient-Nr. 30s after onset _ Onset of compression Figure 2. Insufficient recovery: No reestablishment of the flow velocity in the middle cerebral artery (MCA) under compression in patients with insufficient recovery. Blood flow velocity in the MCA in percent of the value under normal conditions. Black columns: onset of compression of the ipsilateral carotid artery. Shaded columns: after 30 seconds under compression.

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Figure 3. Questionable recovery: Reestablishment of the flow velocity in the middle cerebral artery (MCA) but 90% never reached in patients with questionable recovery. Blood flow velocity in the MCA in percent of the value under normal conditions. Black columns: onset of compression of the ipsilateral carotid artery. Shaded columns: after 30 seconds under compression.

temporary balloon occlusion and TDU with compression

of similar value for establishing preoperative cerebral collateralization. However, arteriography represents an invasive method with associated risks such as vessel intimal injury, air embolus, thrombus formation, and cardiac arrhythmias.9 Another potential risk of angiography is cerebral ischemia. Most of these risks are not associated with TDU.10 There is a possibility for the separation of atheromatous plaques during the compression test, but such plaques can be excluded by precompression ultrasonography in the region. II Additional advantages of TDU recording with compression testing are that it can be repeated at any time with good reproducibility of the measured flow velocities.'2 TDU recording with compression testing in vascular surgery is used as a method for the evaluation of the intraoperative clamping risk.2,23'14 In these studies it was reported to be a valid method for recognizing highrisk patients in whom obliteration of the ICA might lead to considerable decrease in flow velocity of the ipsilateral MCA. With compression, 40 to 60% of the flow velocity in the MCA under normal conditions was regarded as the inferior limit for the predictability of neurologic complications.2,13,14 If the flow velocity in the MCA under ipsilateral carotid compression reaches 90% or more of the value under normal conditions, there is probably no hemodynamic risk associated with ligation or resection of the carotid artery.2"13"14 These values are also valid in skull base and neck tumors involving the carotid artery. The TDU recording with compression testing cannot be accomplished in all patients. In some patients with extensive neck tumors complete compression of the caare

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rotid artery is not possible. We had three such patients in whom the compression test could not be performed. In patients in whom it is impossible to find a suitable bone window in the temporal area, the examination becomes impossible, but our study did not include such a patient. 'S The diagnostic value related to neurologic complications after carotid ligation is similar for the three examination methods in use today. These methods are: (1) the electroencephalographic monitoring during carotid compression, (2) cerebral angiography with occlusion, and (3) TDU recording with compression test.3912 None of these methods can exclude complications caused by other hemodynamic factors, such as a distal stump emboli of the ICA. Our results demonstrate the advantages of preoperative evaluation using TDU recording with compression testing in skull base and neck tumors. It is possible to identify the patients with a high probability of tolerating carotid ligation or resection without hemodynamic complications. These are the patients with a flow velocity in the MCA with ipsilateral carotid compression of 90% or more of the flow velocity under normal conditions. In our study 39% (12 of 31) of the patients were in this group. Moreover, it is possible to identify patients with a high risk of neurologic complications after carotid manipulation due to insufficient cerebral collaterlization. In these patients the flow velocity in the MCA remained under 50% of the flow velocity under normal conditions with carotid compression. 29% (9 of 31) of the patients in this study were in this group. In the remaining 32% (10 of 31), a determinate result could not be established because of incomplete compression of the carotid artery (3 of 10) or

TUMORS OF THE CAROTID ARTERIES-MAURER ET AL

because the flow velocity in the MCA under carotid compression did not allow for determination of cerebral collateralization (7 of 10). In this study a safe assessment of the cerebral collateralization as determined by TDU recording with compression testing was possible in 68% of the patients. The need for more expensive or invasive diagnostic proceedings was thus avoided. If the TDU recording is not able to determine the hemodynamic situation, other diagnostic tools like angiography, electroencephalographic monitoring, or measurement of the cerebral blood flow should be used.

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REFERENCES 12. 1. Jawad K, Miller JD, Wyper, DJ, Rowan JO: Measurement of CBF and carotid artery pressure compared with cerebral angiographie in assessing collateral blood supply after carotid ligation. J Neurosurg 46:185-196, 1977 2. Dandy WE: The location of the conscious center in the brain-the corpus striatum. Johns Hopkins Hosp Bull 79:34-58, 1946 3. Burmeister W, Dorrler J, Maurer PC: Transcranielles DopplerMonitoring in der Karotischirurgie - Was bringt der intraluminale Shunt? In Widder B (ed): Transkranielle DopplerSonographie bei zerebrovaskularen Erkrankugen. Berlin: Springer-Verlag, 1986, pp 82-85 4. Andrews JC, Valvanis A, Fisch U: Management of the internal carotid artery in surgery of the skull base. Laryngoscope 99: 1224-1229, 1989 5. Eden A: Physikalische und technische Grundlagen der transcraniellen Dopplersonographie. In Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: Springer-Verlag, 1986, pp 2-7 6. Reutern von GM, Kapp H: The capabilities of ultrasonic diag-

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nostic procedures in cerebrovaskular disease. In Hartmann, Hager (eds): Cerebral Blood Flow and Metabolism Measurement. Berlin: Springer-Verlag, 1985, pp 546-555 Aaslid R, Markwalder TM, Nornes H: Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57:769-774, 1982 Webster JE, Gurdjian: Carotid artery compression as employed both in the past and in the present. J Neurosurg 15:372-384, 1957 Vries de EJ, Sekhar LN, Horton JA, Eibling DE, Janecka IP, Schramm VL, Yonas H: A new method to predict safe resection of the internal carotid artery. Laryngoscope 100:85-88, 1990 Rautenberg W, Schwartz A, Hennerici M: Transcranieele Dopplersonographie wahrend der cerebralen angiographie. In Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: Springer-Verlag, 1986, pp 144-154 Winter R, Hohagen F, Kaiser W, Reuther R: Reproduzierbarkeit transcranieller dopplersonographischer Messungen. In Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: Springer-Verlag, 1986, pp 21-24 Budingen HJ, Hoffman C, Knippschild J, Staudacher TH, Zeides A, Grogler FM: Transkranielle Dopplersonographie bei Karotisoperationen. In: Widder B (ed): Transkranielle DopplerSonographie bei zerebrovaskularen Erkrankungen. Berlin: SpringerVerlag, 1986, pp 86-91 Paulat K, Widder B: Praoperative Bestimimung des Clamping Risikos und Vorhersage des Stumpfdruckes in der Karotischirurgie. In: Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: SpringerVerlag, 1986, pp 96-99 Pfadenhauer K, Weber H, Loeprecht: Transkranielles DopplerMonitoring in der Karotischirurgie-Eine vergleichende Untersuchung unter Berucksichtigung der Ergenbnisse des EEGTrend-Analyzers und der Stumpfdruckmessung. In Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: Springer-Verlag, 1986, pp 92-95 Reutern von GM: Stellenwert der transcraniellen Doppler-Sonographie aus der Sicht des Neurologen. In: Widder B (ed): Transkranielle Doppler-Sonographie bei zerebrovaskularen Erkrankungen. Berlin: Springer-Verlag, 1986, pp 168-173

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