Carotid Compression Research Articles

Evaluation of cerebral autoregulation in dogs via transcranial color-coded duplex sonography and transient hyperemia testing.

To evaluate the changes in flow velocities of the middle cerebral artery before and after a carotid compression maneuver using transcranial color-coded duplex sonography (TCCD) in healthy anesthetized dogs under mechanical ventilation. Prospective study. University teaching hospital. Eleven healthy adult dogs. A 5-second carotid occlusion maneuver was performed to evaluate cerebral autoregulation (CA). After 10minutes of stable anesthesia, the middle cerebral artery was evaluated by TCCD. Dogs were positioned in sternal recumbency with the head raised to the level of the phlebostatic axis. The systolic peak velocity (Vp) was measured using pulsed Doppler mode. CA was evaluated through the transient hyperemia test (THT), which assesses changes in the Vp after a 5-second transient compression of the ipsilateral common carotid artery and is expressed as the ratio between the Vp flow before and after carotid compression. The Vp before and after carotid occlusion was compared using the Wilcoxon signed-rank test. The median Vp of the middle cerebral artery after the carotid compression maneuver was significantly higher than the median Vp before compression (median [interquartile range, IQR]: 47.7cm/s [34.3]vs64.1cm/s [24.4]; P=0.003). The median THT obtained was 1.20 (IQR: 0.37). The current study demonstrated a significant increase in the Vp of the middle cerebral artery after a 5-second temporary occlusion of the ipsilateral carotid artery in healthy anesthetized dogs under mechanical ventilation. These findings suggest that the noninvasive TCCD methodology could be valuable for assessing CA in dogs. Additional studies using this technique in neurocritical animals are required to confirm its usefulness.

Characteristics and treatment of epistaxis in nasopharyngeal carcinoma

ObjectivesTo analyze the risk factors and explore effective treatments for epistaxis in nasopharyngeal carcinoma (NPC) patients. MethodsFrom March 2006 to February 2020, 351 epistaxis patients visited our center and 195 patients meeting the inclusion criteria were enrolled in the study. Characteristics and treatments, including step-up hemostatic treatment (including medication, anterior ± posterior nostril packing, or further surgical hemostasis) and the CTPI emergency hemostasis method (including common carotid artery compression, tracheotomy / intubation, packing of nasal and nasopharynx, and interventional treatment), were analyzed. ResultsThe median total bleeding volume was 100.0 ml (range 20–4430 ml). 126 (64.6 %) and 69 (35.4 %) patients suffered from non-massive epistaxis and massive epistaxis. The 1-year overall survival (OS) rate was 60.1 % for patients with massive epistaxis and 97.3 % for those with non-massive epistaxis treated with step-up hemostatic treatment. Among patients with massive epistaxis, the 1-year OS rate was 80.0 % for those who received CTPI and 13.3 % for those who received step-up hemostatic treatment. ConclusionICA exposure and hemostasis failure was adverse prognostic factors for OS in NPC patients with epistaxis. The step-up hemostatic treatment is effective for controlling non-massive epistaxis. The CTPI emergency method might be an effective hemostasis treatment for NPC patients with massive epistaxis, especially those with PRNN and ICA exposure.

Is It Possible to Detect Return of Spontaneous Circulation during Chest Compression? Evaluation of a Novel Method: Carotid Artery Compression Ultrasound.

Objectives: To evaluate the diagnostic accuracy of carotid artery compression using a point-of-care ultrasound probe (POCUS-CAC) in reducing pulse check times and facilitating the detection of the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR) compared to manual palpation (MP). The secondary aim of the study is to assess the ability of POCUS-CAC to detect ROSC during ongoing chest compressions. Methods: This prospective study was conducted in a tertiary emergency department between January and June 2023. During CPR, POCUS-CAC was performed by placing a linear ultrasound probe transversely on the lateral neck to assess the compressibility of the carotid artery. Complete compression of the artery without any visible pulsation indicated no ROSC, while resistance to compression or partial compression suggested the presence of ROSC. Simultaneously, another clinician performed manual palpation of the femoral artery. The primary outcome assessed in this study was comparing ROSC detection between POCUS-CAC and traditional methods, and the secondary outcome was comparing the time taken to detect ROSC with each method, and the ability to detect ROSC during ongoing chest compressions. Results: The study included 41 cardiac arrest patients and analyzed 496 MP pulse and 1984 POCUS-CAC checks. The mean time to identify a pulse using POCUS-CAC was significantly shorter, at 2.3 (0.5-7.8, SD ± 1.2, 95% CI [2.25, 2.35]) s, compared to 4.7 (2.0-10.5, SD ± 1.8, 95% CI [4.54, 4.86]) s with MP (p = 0.004). Additionally, 52.9% of ROSC cases were detected earlier using POCUS-CAC, even during ongoing chest compressions. The sensitivity of POCUS-CAC was 100% (95% CI [80.5-100%]) and the specificity was 87.5% (95% CI [67.6-97.3%]). The POCUS-CAC method required less than 5 s in 99.996% of cases. Conclusions: POCUS-CAC significantly reduces pulse check times and enhances the early detection of ROSC during CPR, offering a reliable and rapid alternative to traditional manual palpation methods in emergency settings.

Assessing changes in regional cerebral hemodynamics in adults with a high-density full-head coverage time-resolved near-infrared spectroscopy device.

Cerebral oximeters have the potential to detect abnormal cerebral blood oxygenation to allow for early intervention. However, current commercial systems have two major limitations: (1)spatial coverage of only the frontal region, assuming that surgery-related hemodynamic effects are global and (2)susceptibility to extracerebral signal contamination inherent to continuous-wave near-infrared spectroscopy (NIRS). This work aimed to assess the feasibility of a high-density, time-resolved (tr) NIRS device (Kernel Flow) to monitor regional oxygenation changes across the cerebral cortex during surgery. The Flow system was assessed using two protocols. First, digital carotid compression was applied to healthy volunteers to cause a rapid oxygenation decrease across the ipsilateral hemisphere without affecting the contralateral side. Next, the system was used on patients undergoing shoulder surgery to provide continuous monitoring of cerebral oxygenation. In both protocols, the improved depth sensitivity of trNIRS was investigated by applying moment analysis. A dynamic wavelet filtering approach was also developed to remove observed temperature-induced signal drifts. In the first protocol ( years; five females, five males), hair significantly impacted regional sensitivity; however, the enhanced depth sensitivity of trNIRS was able to separate brain and scalp responses in the frontal region. Regional sensitivity was improved in the clinical study given the age-related reduction in hair density of the patients ( years; 14 females, 13 males). In five patients who received phenylephrine to treat hypotension, different scalp and brain oxygenation responses were apparent, although no regional differences were observed. The Kernel Flow has promise as an intraoperative neuromonitoring device. Although regional sensitivity was affected by hair color and density, enhanced depth sensitivity of trNIRS was able to resolve differences in scalp and brain oxygenation responses in both protocols.

The Promise, Mystery, and Perils of Stenting for Symptomatic Internal Jugular Vein Stenosis: A Case Series.

Cerebral venous outflow disorders (CVDs) secondary to internal jugular vein (IJV) stenosis are becoming an increasingly recognized cause of significant cognitive and functional impairment in patients. There are little published data on IJV stenting for this condition. This study aims to report on procedural success. A single-center retrospective analysis was performed on patients with CVD that underwent IJV stenting procedures. From 2019 to 2023, 29 patients with CVD underwent a total of 33 IJV stenting procedures. Most patients (20; 69%) had an underlying connective tissue disorder diagnosis. The mean age of the included patients was 36.3 years (SD 12.4), 24 were female (82.8%), and all were Caucasian except for 2 patients (27; 93.0%). Twenty-eight procedures (85%) involved isolated IJV stenting under conscious sedation, whereas 5 procedures (15%) involved IJV stenting and concomitant transverse sinus stenting under general anesthesia. Thirteen (39%) patients underwent IJV stenting after open IJV decompression and styloidectomy. Three patients had stents placed for stenosis below the C1 tubercle, one of which was for carotid compression. Periprocedural complications occurred in 11 (33%), including intracardiac stent migration in 1 patient, temporary shoulder pain/weakness in 5 (15%), and persistent and severe shoulder pain/weakness in 2 patients (6%). Approximately 75% of patients demonstrated improvement after stenting although only 12 patients (36%) had durable improvement over a mean follow-up of 4.5 months (range 6 weeks-3.5 years). Our experience, along with early published studies, suggests that there is significant promise to IJV revascularization techniques in these patients; however, stenting carries a high complication rate, and symptom recurrence is common. Most neurointerventionalists should not be performing IJV stenting unless they have experience with these patients and understand technical nuances (stent sizing, anatomy, patient selection), which can maximize benefit and minimize risk.

Analysis of the history of the search for methods of protecting the brain during operations on the internal carotid artery

The review covers the first studies of the vessels of the brain. The history of the emergence and development of the doctrine of protecting the brain during operations on the carotid arteries is given. Experience has been accumulated in the development of the doctrine of surgical protection of the brain during primary operations on the carotid arteries and compression of the carotid arteries. The analysis of existing and existing methods was carried out. Based on the above analysis, ways of further development of methods of protecting the brain during operations on the carotid arteries are shown.

Impaired cerebrovascular reactivity correlates with reduced retinal vessel density in patients with carotid artery stenosis: Cross-sectional, single center study.

The cerebral and retinal circulation systems are developmentally, anatomically, and physiologically interconnected. Thus, we hypothesized that hypoperfusion due to atherosclerotic stenosis of the internal carotid artery (ICA) can result in disturbances of both cerebral and retinal microcirculations. We aimed to characterize parameters indicating cerebrovascular reactivity (CVR) and retinal microvascular density in patients with ICA stenosis, and assess if there is correlation between them. In this cross-sectional study the middle cerebral artery (MCA) blood flow velocity was measured by transcranial Doppler (TCD) and, simultaneously, continuous non-invasive arterial blood pressure measurement was performed on the radial artery by applanation tonometry. CVR was assessed based on the response to the common carotid artery compression (CCC) test. The transient hyperemic response ratio (THRR) and cerebral arterial resistance transient hyperemic response ratio (CAR-THRR) were calculated. Optical coherence tomography angiography (OCTA) was used to determine vessel density (VD) on the papilla whole image for all (VDP-WIall) and for small vessels (VDP-WIsmall). The same was done in the peripapillary region: all (VDPPall), and small (VDPPsmall) vessels. The VD of superficial (VDMspf) and deep (VDMdeep) macula was also determined. Significance was accepted when p<0.05. Twenty-four ICA stenotic patients were evaluated. Both CVR and retinal VD were characterized. There was a significant, negative correlation between CAR-THRR (median = -0.40) and VDPPsmall vessels (median = 52%), as well as between VDPPall vessels (median = 58%), and similar correlation between CAR-THRR and VDP-WIsmall (median = 49.5%) and between VDP-WIall (median = 55%). The significant correlation between impaired cerebrovascular reactivity and retinal vessel density in patients with ICA stenosis suggests a common mechanism of action. We propose that the combined use of these diagnostic tools (TCD and OCTA) helps to better identify patients with increased ischemic or other cerebrovascular risks.

Assessment of cerebral autoregulatory function and inter-hemispheric blood flow in older adults with internal carotid artery stenosis using transcranial Doppler sonography-based measurement of transient hyperemic response after carotid artery compression

Unhealthy vascular aging promotes atherogenesis, which may lead to significant internal carotid artery stenosis (CAS) in 5 to 7.5% of older adults. The pathogenic factors that promote accelerated vascular aging and CAS also affect the downstream portion of the cerebral microcirculation in these patients. Primary treatments of significant CAS are eversion endarterectomy or endarterectomy with patch plasty. Factors that determine adequate hemodynamic compensation and thereby the clinical consequences of CAS as well as medical and surgical complications of carotid reconstruction surgery likely involve the anatomy of the circle of Willis (CoW), the magnitude of compensatory inter-hemispheric blood flow, and the effectiveness of cerebral microcirculatory blood flow autoregulation. This study aimed to test two hypotheses based on this theory. First, we hypothesized that patients with symptomatic and asymptomatic CAS would exhibit differences in autoregulatory function and inter-hemispheric blood flow. Second, we predicted that anatomically compromised CoW would associate with impaired inter-hemispheric blood flow compensation. We enrolled older adults with symptomatic or asymptomatic internal CAS (>70% NASCET criteria; n = 46) and assessed CoW integrity by CT angiography. We evaluated transient hyperemic responses in the middle cerebral arteries (MCA) after common carotid artery compression (CCC; 10 s) by transcranial Doppler sonography (TCD). We compared parameters reflecting autoregulatory function (e.g., transient hyperemic response ratio [THRR], return to baseline time [RTB], changes of vascular resistance) and inter-hemispheric blood flow (residual blood flow velocity). Our findings revealed that CAS was associated with impaired cerebral vascular reactivity. However, we did not observe significant differences in autoregulatory function or inter-hemispheric blood flow between patients with symptomatic and asymptomatic CAS. Moreover, anatomically compromised CoW did not significantly affect these parameters. Notably, we observed an inverse correlation between RTB and THRR, and 49% of CAS patients exhibited a delayed THRR, which associated with decreased inter-hemispheric blood flow. Future studies should investigate how TCD-based evaluation of autoregulatory function and inter-hemispheric blood flow can be used to optimize surgical techniques and patient selection for internal carotid artery revascularization.

Eagle Syndrome with Internal Carotid Artery Compression causing Recurred Syncope: A Case Report.

We herein report a 54-year-old man with eagle syndrome who presented with repeated episodes of syncope, especially after moving his head to a downward position. Computed tomography with contrast revealed a bilateral elongated styloid process. The left internal carotid artery was obviously compressed by the left elongated styloid processes. A transcranial Doppler examination detected a significantly decreased blood flow velocity in the left middle cerebral artery when the patient slightly lowered his head position. After surgery, the positional cerebral blood flow alteration disappeared. No further similar syncope episodes have been reported to date.

DEATH DUE TO DELAYED COMPLICATION IN HANGING - A CASE REPORT

Hanging is one of the most common methods of painless suicide in India. Hanging is a form of asphyxia which is caused by the suspension of the body by a ligature encircling the neck, where the constricting force is the weight of the body. In most cases of hanging cases, the death of the individual occurs immediately or the usual average period is about 3 to 5 minutes. Causes of death in case of hanging are asphyxia, venous congestion, cerebral ischemia, carotid compression or fracture of vertebrae resulting in penetration into the spinal cord. In this article, the authors report a rare case of a 19-year-old male individual, who attempted suicide by hanging, survived for 7 days in ICU in an unconscious state and then died after the best efforts of the ICU team. Delayed death in hanging can be due to aspiration pneumonia, oedematous or haemorrhagic swelling of pharyngeal tissues or aryepiglottic folds, emphysema, infections, oedema of the larynx, lungs and brain pathology like an abscess, hypoxic encephalopathy, infarction and softening. In post-mortem examination, the doctor must remove the ligating material after carefully preserving the knot, and look for any marks of injury or struggle that may suggest the violence leading to strangulation. Prolonged resuscitative measures must be tried in all the victims of attempted hanging, and a guarded prognosis must be described.

Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula

ABSTRACT Purpose To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF). Materials and methods Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome. Results A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months. Conclusion The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.

Assessing the Sensitivity of Multi-Distance Hyperspectral NIRS to Changes in the Oxidation State of Cytochrome C Oxidase in the Brain.

Near-infrared spectroscopy (NIRS) measurements of tissue oxygen saturation (StO2) are frequently used during vascular and cardiac surgeries as a non-invasive means of assessing brain health; however, signal contamination from extracerebral tissues remains a concern. As an alternative, hyperspectral (hs)NIRS can be used to measure changes in the oxidation state of cytochrome c oxidase (ΔoxCCO), which provides greater sensitivity to the brain given its higher mitochondrial concentration versus the scalp. The purpose of this study was to evaluate the depth sensitivity of the oxCCO signal to changes occurring in the brain and extracerebral tissue components. The oxCCO assessment was conducted using multi-distance hsNIRS (source-detector separations = 1 and 3 cm), and metabolic changes were compared to changes in StO2. Ten participants were monitored using an in-house system combining hsNIRS and diffuse correlation spectroscopy (DCS). Data were acquired during carotid compression (CC) to reduce blood flow and hypercapnia to increase flow. Reducing blood flow by CC resulted in a significant decrease in oxCCO measured at rSD = 3 cm but not at 1 cm. In contrast, significant changes in StO2 were found at both distances. Hypercapnia caused significant increases in StO2 and oxCCO at rSD = 3 cm, but not at 1 cm. Extracerebral contamination resulted in elevated StO2 but not oxCCO after hypercapnia, which was significantly reduced by applying regression analysis. This study demonstrated that oxCCO was less sensitive to extracerebral signals than StO2.

Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation

AimTo identify whether a novel pulse check technique, carotid artery compression using an ultrasound probe, can reduce pulse check times compared to manual palpation (MP). MethodsThis prospective study was conducted in an emergency department between February and December 2021. A physician applied point-of-care ultrasound–carotid artery compression (POCUS-CAC) and assessed the carotid artery compressibility and pulsatility by probe compression during rhythm check time. Another clinician performed MP of the femoral artery. The primary outcome was the difference in the average time for pulse assessment between POCUS-CAC and MP. The secondary outcomes included the time difference in each pulse check between methods, the proportion of times greater than 5 s and 10 s, and the prediction of return of spontaneous circulation (ROSC) during ongoing chest compression. Results25 cardiac arrest patients and 155 pulse checks were analyzed. The median (interquartile range) average time to carotid pulse identification per patient using POCUS-CAC was 1.62 (1.14–2.14) s compared to 3.50 (2.99–4.99) s with MP. In all 155 pulse checks, the POCUS-CAC time to determine ROSC was significantly shortened to 0.44 times the MP time (P < 0.001). The POCUS-CAC approach never exceeded 10 s, and the number of patients who required more than 5 s was significantly lower (5 vs. 37, P < 0.001). Under continuous chest compression, six pulse checks predicted the ROSC. ConclusionsWe found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in cardiac arrest patients.

A Cut Above the Rest: The Historic Perspectives of Circumcision and Anesthesia

Introduction: Circumcision is the oldest known recorded surgical procedure dating to at least 4000 BCE and held religious, cultural, and military significance. Preputial resection connoted contrasting meanings among different cultures; in some, circumcision was and remains an important transtion into infancy and then adulthood. In Bronze Age and early Egyptian cultures, however, circumcision was performed on vanquished enemies and improved upon the morbidity and mortality of phallic resectoin as a war trophy. The circumcision of Jesus was a significant subject for many Medieval and Renaissance artists who often portrated the event as an allegroical commentary on contemporary socio-political events. While there has been much literature, anthropological analysis, and art on circumcision, little is known about the anesthesia provided to those undergoing the procedure, especially those for whom the act was not a punitive militaristic procedure. We aimed to identify descriptions of the anesthesia provided to patients or victims undergoing circumcision and how the anesthesia may have evolved into the modern techniques used in the modern era. Sources and Methods: We performed a literature review via PubMed journal articles, texts, and historical discussions detailing the evolution of circumcision and accompanying anesthesia throughout history. Results: Earliest records of circumcision described religious rather than scientific rationale, marking a boy’s ascension to manhood. Documentation of the earliest practices of anesthesiology are relevant to urology through these traditions. Circumcision is first noted in Egyptian temple hieroglyphics dated to 4000 BCE, depicting young men restrained with a priest performing the cut wielding a knife. As early as 2500 BCE, circumcision in ancient Egypt was the first known surgical procedure utilizing anesthesia. A mixture rendered from calcium carbonate and acetic acid formed carbon dioxide on the prepuce resulting in the first rendition of cryo-analgesia. Egypt was not the only culture performing circumcision during this time period. Assyrian records dating back to 400 BCE describe a similar methodology, but also transcribed another primitive method of anesthesia. Assyrians utilized digital compression of the carotid arteries to produce anesthetic effects of both altered consciousness and decreased procedural pain. Carotid compression was commonplace enough that it influenced the language for which the carotid blood vessels are described in both Greek and Russian with translation as “The Artery of Sleep.” The Jewish tradition of brit milah utilizes a few drops of wine in the mouth of the infant, both as a form of analgesia and symbolic of the sealed covenant. It is hypothesized that the sugar interacts with the opiate receptors in the brain which is enhanced by the suckling action, providing comfort. Conclusions: Since their earliest documented history, anesthetic techniques have contributed to and been intertwined with the practices of circumcision.

Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma.

Pediatric oropharyngeal trauma is common. Although most cases resolve uneventfully, there have been reports of internal carotid artery injury leading to devastating neurovascular sequelae. There is significant controversy regarding the utility of CT angiography (CTA) in children with seemingly minor oropharyngeal trauma. The goal of this study was to appraise changes in diagnosis and treatment based on CTA results. A comprehensive search of PubMed, Embase, CINAHL, Scopus, the Cochrane Ear, Nose and Throat Disorders Group Trials Register, and the ClinicalTrials.gov database was performed following PRISMA guidelines. The search yielded 5,078 unique abstracts, of which 8 articles were included. A total of 662 patients were included, with 293 having any CT head/neck imaging, and 255 with CTA. Eleven injuries/abnormalities of the carotid were found on CTAs, comprising edema around the carotid (n=8), potential intimal tear (n=1), carotid spasm (n=1), and carotid compression (n=1). The pooled proportion of imaging findings on CTA that could lead to changes in clinical management was 0.00 (95% CI 0.00-0.43). Angiography was obtained in 10 patients, in 6 cases due to abnormal CTA. Angiography identified 1 patient with vessel spasm and two patients with carotid intima disruption without thrombus. No patient underwent vascular repair or suffered cerebrovascular injury. Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes. N/A Laryngoscope, 133:457-466, 2023.

What you need to know about: arterial cerebrovascular syndromes caused by static or dynamic musculoskeletal compression.

Compressive syndromes of the cervical arteries caused by musculoskeletal structures include bow hunter's syndrome, beauty parlour stroke syndrome, carotid compression by the hyoid bone, carotid compression by the digastric muscle and Eagle syndrome. They are a rare but increasingly recognised group of syndromes, so a high level of suspicion is needed so the diagnosis is not missed. The diagnosis is typically based on a combination of clinical history and advanced imaging investigations. Compression of the arteries may be static (only provoked by compression) or dynamic (exaggerated by movement), and this should be considered when selecting imaging studies. Symptoms resulting from vertebrobasilar insufficiency or ischaemia of areas supplied by the internal carotid artery are caused by compression of the vertebral artery and the internal carotid artery respectively. Surgical procedures are the preferred treatment for most of these syndromes.

Pre- and Postoperative Cerebral Haemodynamic Assessments and Multidisciplinary Team Management for Patients Undergoing Cerebral Revascularization Procedures: 2 Case Reports

Background: Cerebrovascular bypasses are complex neurosurgical procedures with specific indications. Surgical risks and outcome are associated with the type of bypass intended and patient&rsquo;s underlying conditions. A multidisciplinary team approach is therefore pivotal in the management of these bypass patients. Objective: The aim of this study is to provide an overview of the perioperative haemodynamic assessments and management of patients undergoing cerebral revasculaization with 2 illustrative cases. Case Report: Case 1: A 40-year-old male with cerebrovascular occlusive condition and recurrent transient ischaemic attacks (TIA&rsquo;s) affecting his left side. Preoperative computed tomography (CT) brain perfusion and carbon dioxide (CO2) inhalation technique revealed poor cerebrovascular reserve (CVR) in the right middle cerebral artery (MCA) territory. The patient underwent a right superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. Case 2: A 56-year-old female with a left giant cavernous sinus aneurysm presented with left-sided intractable facial pain. Preoperative cerebral digital subtraction angiography (DSA) with carotid compression test revealed inadequate collateral circulation. She underwent a high flow, common carotid-middle cerebral artery bypass with saphenous vein graft and trapping of the giant aneurysm. Results: Case 1: Postoperative computed tomography angiography (CTA) brain scan on day 1 confirmed graft patency. The patient improved rapidly in strength of the left arm and right leg. CT brain perfusion scan at 3 months showed improved brain perfusion and CVR. Case 2: Postoperative CTA brain on day 1 confirmed graft patency. On day 3 post-operatively, she developed self-limiting left-sided ophthalmoplegia, which completely resolved by 6 weeks. CTA brain at 5 months showed patency of the bypass graft. There was no further facial pain or ophthalmoplegia at the last follow-up. Conclusion: Although many new surgical techniques had been developed, the outcome for patients undergoing bypass surgery remains highly dependent on multidisciplinary teamwork, detailed preoperative haemodynamic assessment, patient selection and perioperative care. Keywords: Cerebrovascular bypass; EC-IC bypass; STA-MCA bypass; Cerebral ischaemia; Cerebrovacular reserve; Balloon occlusion test

Failed endovascular therapy for acute internal carotid artery occlusion from pituitary apoplexy: illustrative case

BACKGROUNDLarge pituitary adenomas can rarely cause compression of the cavernous internal carotid artery (ICA) due to chronic tumor compression or invasion. Here, the authors present a case of pituitary apoplexy causing acute bilateral ICA occlusion with resultant stroke. Our middle-aged patient presented with sudden vision loss and experienced rapid deterioration requiring intubation. Computed tomography (CT) angiography revealed a large pituitary mass causing severe stenosis of the bilateral ICAs. CT perfusion revealed a significant perfusion delay in the anterior circulation. The patient was taken for cerebral angiography, and balloon angioplasty was attempted with no improvement in arterial flow. Resection of the tumor was then performed, with successful restoration of blood flow. Despite restoration of luminal patency, the patient experienced bilateral ICA infarcts.OBSERVATIONSPituitary apoplexy can present as an acute stroke due to flow-limiting carotid compression. Balloon angioplasty is ineffective for the treatment of this type of compression. Surgical removal of the tumor restores the flow and luminal caliber of the ICA.LESSONSPituitary apoplexy can be a rare presentation of acute stroke and should be managed with immediate surgical decompression rather than attempted angioplasty in order to restore blood flow and prevent the development of cerebral ischemia.

HF01-09 A CUT ABOVE THE REST: HISTORIC PERSPECTIVES OF CIRCUMCISION AND ANESTHESIA

You have accessJournal of UrologyHistory of Urology Forum I (HF01)1 Sep 2021HF01-09 A CUT ABOVE THE REST: HISTORIC PERSPECTIVES OF CIRCUMCISION AND ANESTHESIA Ellen Lutnick, Kyle Waisanen, and Kevin Pranikoff Ellen LutnickEllen Lutnick More articles by this author , Kyle WaisanenKyle Waisanen More articles by this author , and Kevin PranikoffKevin Pranikoff More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001992.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To explore the origins of circumcision and the use of anesthesia along the journey. METHODS: Literature review via PubMed journal articles, texts, and historical discussion detailing the evolution of circumcision and accompanying anesthesia throughout history. RESULTS: Earliest records of circumcision described religious rather than scientific rationale, marking a boy’s ascension to manhood. Documentation of the earliest practices of anesthesiology are relevant to urology through these traditions. Circumcision is first noted in Egyptian temple hieroglyphics dated to 4000 BCE, depicting young men restrained with a priest performing the cut wielding a knife. As early as 2500 BCE, circumcision in ancient Egypt was the first known surgical procedure utilizing anesthesia. A mixture rendered from calcium carbonate and acetic acid formed carbon dioxide on the prepuce resulting in the first rendition of cryo-analgesia. Egypt was not the only African culture performing circumcision during this time period. Assyrian records dating back to 400 BCE describe a similar methodology, but also transcribed another primitive method of anesthesia. Assyrians utilized digital compression of the carotid arteries to produce anesthetic effects of both altered consciousness and decreased procedural pain. Carotid compression as anesthesia was commonplace enough that it influenced the language for which the carotid blood vessels are described in both Greek and Russian with translation as “The Artery of Sleep”. As the practice was adopted by the Israelites, infant circumcision was acknowledged on the eighth day of life representative of the covenant between God and Abram. It is considered that this shift may have been related to a pubescent male’s ability to refuse the religious covenant on the basis of the painful procedure, while an infant is unable to object. The Jewish tradition of brit milah utilizes a few drops of wine in the mouth of the infant, both as a form of analgesia and symbolic of the sealed covenant. It is hypothesized that the sugar interacts with the opiate receptors in the brain which is enhanced by the suckling action, providing comfort. Today, approximately 1 of 3 males worldwide are circumcised, with 55% of physicians performing infant circumcision choosing not to utilize any form of anesthesia, citing lack of necessity and anesthetic risk. CONCLUSIONS: Since their earliest documented history, anesthetic techniques have contributed to and been intertwined with the practices of circumcision. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e230-e230 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ellen Lutnick More articles by this author Kyle Waisanen More articles by this author Kevin Pranikoff More articles by this author Expand All Advertisement Loading ...

Manual Carotid Compression is a Viable Alternative for Reduction of Cerebral Microemboli.

Stroke is a devastating complication of cardiovascular surgeries, and the risk is particularly high for those requiring cardiopulmonary bypass (CPB). Embolic particles generated during the unclamping of the aortic cross-clamp may enter the cerebral circulation, lodging in small vessels. External manual compression of the carotid arteries is a non-invasive technique that has been proposed for cerebral protection during CPB procedures but is not widely deployed. The aim of this study is to assess the potential for cerebral emboli reduction with carotid compression using an in vitro model. Experiments were performed with a glass aortic arch model in a mock cardiovascular circuit. Small fluorescent particles were released into the circulation with and without carotid compression, and the particles visualized in the aortic midplane. The number of particles in the aorta and arch branch vessels were counted from the images before, during and following the release of carotid compression for durations of 10, 15 and 20s. A gamma variate function was fit to the data to describe the bolus dynamics. Carotid compression for 10 s reduces the number of embolic articles entering the carotid arteries by over 75%. A compression duration of 15-20s does not result in greater particle reduction than one of 10s. Brief compression of the common carotid arteries during cardiovascular interventions has the potential to dramatically reduce the number of cerebral emboli and should be investigated further.