Hemodynamic aspects in the aspect management of carotid-cavernous fistula

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✓ A method for intraoperative evaluation of the hemodynamic state in patients with carotid-cavernous fistula is described. Electromagnetic flow probes were applied on the internal carotid artery (ICA) in the neck and on the intracranial part of the artery distal to the fistula in five patients. Fistula “steal5 ranged from 90 to 975 ml/min. Forward flow rate in the intracranial portion of the ICA, distal to the fistula, was from 40 to 170 ml/min. The reverse flow rate during test occlusion of the ICA in the neck was between 35 and 60 ml/min. The ratio reverse flow/forward flow is assumed to give an indication of the collateral capacity of the cerebral vasculature and of the tolerance to trap ligation of the ICA. The pulsatile pattern of the intracranial ICA flow in this series varied considerably, and this parameter is also found to be of importance in the evaluation of the capacity of the collateral arterial system. The monitoring of cervical ICA flow proved to be a reliable way to supervise the procedure of plugging the fistula with flow-carried muscle emboli in conjunction with trap ligation.

Article Information

Address reprint requests to: Helge Nornes, M.D., Department of Neurosurgery, Rikshospitalet, Pilestredet 32, Oslo, Norway.

© AANS, except where prohibited by US copyright law.

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Figures

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    Drawing to show intraoperative placement of electromagnetic blood flow probes. PAC-posterior communicating artery; ACA-anterior cerebral artery.

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    Electromagnetic blood flow probes used, and their inner diameters.

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    Case 5. Graph showing intraoperative flow-to-pressure relationship during a period with markedly changing blood pressure. Blood pressure given as mean blood pressure.

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    Case 3. Tracings of intracranial ICA flow distal to the fistula. Zero checking with microtweezers. Reduced forward flow, zero flow, and finally reverse flow caused by gradual occlusion of the ICA in the neck. X = interruption of 30 seconds. Note that instantaneous flow is partly off scale in the middle sequence of the tracings. Corrections were made before the final sequence.

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    Case 3. Recording during gradual release of a Selverstone clamp after full occlusion for 60 seconds. Reverse, zero, and finally forward ICA flow is seen.

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    Case 4. Simultaneous recordings of ICA flow intracranially and in the neck. Graded occlusion with the Selverstone clamp followed by reopening after about 15 seconds. Q = period when fistula is fed from the ICA in the neck and from the circle of Willis. The same phenomenon is seen when the clamp is again opened.

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    Case 3. Recordings of ICA flow (neck) before arteriotomy (1), and after second (2) and third (3) embolus transportation. ZC = zero control by ICA clamping. Note change in calibration (x).

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    Final sequence of plugging procedure shown in Fig. 7. ZC = ICA clamped while introducing the muscle embolus. Recorded flow is the actual flow driving the sixth embolus into the fistula, securing full fistula occlusion.

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