Clinical implications of intraoperative infrared brain surface monitoring during superficial temporal artery–middle cerebral artery anastomosis in patients with moyamoya disease

Clinical article

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Object

Surgical revascularization for moyamoya disease prevents cerebral ischemic attacks by improving cerebral blood flow (CBF). Symptomatic cerebral hyperperfusion is a potential complication of this procedure, but its treatment is contradictory to that for ischemia. Because intraoperative techniques to detect hyperperfusion are still lacking, the authors performed intraoperative infrared monitoring in moyamoya disease using a novel infrared imaging system.

Methods

During superficial temporal artery–middle cerebral artery anastomosis in 25 patients (26 hemispheres) with moyamoya disease, the authors monitored the brain surface temperature intraoperatively with the IRIS-V infrared imaging system. The average gradation value change (indicating temperature change) was calculated using commercial software. Magnetic resonance imaging, MR angiography, and N-isopropyl-p-[123I]iodoamphetamine SPECT studies were performed routinely before and within 10 days after surgery.

Results

Patency of bypass, detailed local hemodynamics, and changes in cortical surface temperature around the anastomosis site were well recognized by the IRIS-V infrared imaging system in all cases. In the present study, 10 patients suffered transient neurological symptoms accompanied by an increase in CBF around the anastomosis site, recognized as symptomatic hyperperfusion. The increase in temperature was significantly higher in these patients. Intensive blood pressure control was undertaken, and free-radical scavengers were administered. No patient in the present study suffered a permanent neurological deficit.

Conclusions

Although the present method does not directly monitor surface CBF, temperature rise around the anastomosis site during surgery might be an indicator of postoperative hyperperfusion. Prospective evaluation with a larger number of patients is necessary to validate this technique.

Abbreviations used in this paper: CBF = cerebral blood flow; DW = diffusion weighted; EDMS = encephaloduromyosynangiosis; 123I-IMP = N-isopropyl-p-[123I]iodoamphetamine; MCA = middle cerebral artery; ROI = region of interest; STA = superficial temporal artery; TIA = transient ischemic attack.

Article Information

Address correspondence to: Atsuhiro Nakagawa, M.D., Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan. email: nakg_neurosurg@yahoo.co.jp.

Please include this information when citing this paper: published online May 8, 2009; DOI: 10.3171/2009.4.JNS08585.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photograph of the IRIS-V infrared imaging system in the operating theater. Inset: The infrared and charge-coupled device camera.

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    Case 1. Microscopic views of the surgical field around the anastomosis (inset, upper left) and intraoperative infrared monitoring showing changes in color of the STA (arrows) to white after temporary occlusion, indicating decrease in temperature (upper left) due to the absence of blood flow. Right after removal of the clip at 1 second, the color of the bypass transiently changed to white by cooled blood flow (upper right, arrowheads) and then changed to black (indicating an increase in temperature) at 2 seconds (lower left), indicating patency of the bypass. Note that the brain surface color around the anastomosis site (circle, lower right) did not significantly change throughout the process. F = frontal lobe; P = parietal lobe; T = temporal lobe; TC = temporary clip.

  • View in gallery

    Graph showing the relationship between time after removal of the temporary clip and changes of the average gradation value within the ROI around the anastomosis site as evaluated using imaging software in Case 1. The increase of gradation value after removal of the temporary clip was within 5 points, indicating no significant change in surface temperature.

  • View in gallery

    Case 2. Images obtained during intraoperative infrared monitoring disclosing changes in color in the color in the STA (arrows) to white after temporary occlusion (indicating decrease in temperature; upper left) due to the absence of blood flow. Immediately after removal of clip at 1 second, the color of the bypass changes to black (upper right), indicating the presence of blood flow. The area is even darker after 4 seconds (lower left). Note that the color of the brain surface around the anastomosis site (circle, lower right) gradually changes to black (indicating an increase in temperature).

  • View in gallery

    Graph showing the relationship between time after removal of the temporary clip and changes in average gradation value within the ROI around the anastomosis site as evaluated by imaging software in Case 2. There was a significant rise of gradation value after removal of the temporary clip, indicating significant change in surface temperature.

  • View in gallery

    The 123I-IMP-SPECT studies obtained preoperatively (upper), 1 day after surgery (center) and 8 days after surgery (lower). Note the focal intense increase in the CBF at the site of anastomosis (arrowheads in lower).

  • View in gallery

    Upper Left: Preoperative MR angiogram. Upper Right: Preoperative FLAIR study. Lower Left: Postoperative MR angiogram showing the apparently patent STA-MCA bypass (arrowheads). Lower Right: Postoperative FLAIR study showing high intensity signal around the site of anastomosis.

  • View in gallery

    Graph showing the differences in average gradation value within the ROI around the anastomosis site among 10 patients who had transient neurological deficits due to focal increase of CBF around the anastomosis site and 16 patients who did not, showing significant increase in gradation value (indirectly showing significant increase in surface cortical temperature) in the former group (up to 60 seconds after removal of the temporary clip). * p < 0.05; ** p < 0.05.

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