Stellate ganglion block increases blood flow in the anastomotic artery after superficial temporal artery–middle cerebral artery bypass

Abstract

Editor—Superficial temporal artery–middle cerebral artery (STA-MCA) bypass has been used in patients with moyamoya disease and cerebral atherosclerotic disease.1Pandey P Steinberg GK Neurosurgical advances in the treatment of moyamoya disease.Stroke. 2011; 42: 3304-3310Crossref PubMed Scopus (99) Google Scholar, 2Cote R Caron JL Management of carotid artery occlusion.Stroke. 1988; 23: 25-29Google Scholar Stellate ganglion block (SGB) is a cervical sympathetic blockade technique used for a variety of syndromes involving vascular insufficiency and pain affecting the face, neck, and upper limbs. We present here the first case report demonstrating that SGB could improve the blood flow in the graft artery when applied after SGB-MCA bypass. A 160 cm, 44 kg, 77-yr-old male with pre-existing hypertension and cerebral infarction underwent right STA-MCA bypass for right internal cerebral artery occlusion and left internal cerebral artery stenosis. In the perioperative period, indocyanine green fluorescence angiography and Doppler echo showed adequate blood flow in the anastomotic artery. On postoperative day 8, magnetic resonance angiography (MRA) revealed very low blood flow in the STA; furthermore, the graft artery was not detected (Fig. 1a). We performed SGB in the patient with mepivacaine hydrochloride 1% 6 ml, using the landmark method at the anterior tubercle of the sixth cervical transverse process ipsilateral to the STA-MCA bypass, keeping the patient in the same posture without moving from the MRA bed for measurement of signal intensity changes on MRA. Thereafter, with the appearance of Horner's syndrome and increasing skin temperature of the right hand at 15 min after SGB, MRA showed an enlarged STA trunk, and the anastomotic artery was detected. Magnetic resonance angiography demonstrated 20% higher signal intensity in the MCA at the anastomotic lesion (Fig. 1b). During and after SGB, the patient's neurological status did not change. Stellate ganglion block is a feasible way to increase the blood flow in the STA.3Oh CKS Chung RK Lee H et al.Effect of stellate ganglion block on the cerebrovascular system.Anesthesiology. 2010; 113: 936-944Crossref PubMed Scopus (32) Google Scholar Stellate ganglion block decreases cerebral vascular tone without affecting autoregulation or the capacity of cerebral blood vessels to react to changes in carbon dioxide concentrations.4Gupta MM Bithal PK Dash HH Chaturvedi A Mahajan RP Effect of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography.Br J Anaeth. 2005; 95: 669-673Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar We applied SGB in our patient to increase the blood flow in the anastomotic lesion through the graft artery; we hypothesized that SGB could decrease cerebral vascular tone and prevent acute elevation of blood pressure in the MCA. The higher signal intensity in the STA and graft artery on MRA after SGB could be explained by the increased local blood flow. After SGB, signal intensity changes on MRA are mainly observed in the ipsilateral external cranial vessels and not in the ipsilateral internal cranial vessels, besides the ophthalmic artery.4Gupta MM Bithal PK Dash HH Chaturvedi A Mahajan RP Effect of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography.Br J Anaeth. 2005; 95: 669-673Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The higher signal intensity in the MCA after SGB in our patient indicated haemodynamic changes after the increase in blood flow in the anastomotic artery. Although increased MCA blood flow causes cerebral hyperperfusion in 18–24% patients after STA-MCA bypass for occlusive cerebrovascular disease,5Yamaguchi K Kawamata T Kawashima A Hori T Okada Y Incidence and predic­tive factors of cerebral hyperperfusion after extracranial–intracranial bypass for occlusive cerebrovascular didease.Neurosurgery. 2010; 67: 1548-1554Crossref PubMed Scopus (0) Google Scholar the increased STA blood flow in the graft artery did not cause cerebral hyperperfusion in our patient. This results in this patient emphasize the possible clinical application of SGB for improving blood flow in the graft artery and MCA after STA-MCA bypass without causing cerebral hyperperfusion. None declared.