Neurosurgery. 2010 Sep;67(3 Suppl Operative):ons102-7; discussion ons107.

The utility of using the bispectral index-Vista for detecting cross-clamping

decline in cerebral blood flow velocity.

Dahaba AA, Xue JX, Hua Y, Liu QH, Xu GX, Liu YM, Meng XF, Zhao GG, Rehak PH, Metzler H.

Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria.

Abstract

BACKGROUND: Patients undergoing carotid endarterectomy for extracranial internal carotid artery stenosis are at risk

of cerebral ischemia/hypoperfusion. Criterion recommended by European and American committees to determine

whether to place a shunt consisted of a decline in transcranial Doppler ultrasonography-measured middle cerebral artery

blood flow velocity (MCBFV) to < 30% to 40% of intraoperative preclamp value.

OBJECTIVE: To assess the discriminative power of the bispectral index (BIS)-Vista monitor for detecting a 40% decline

in MCBFV with cross-clamping.

METHODS: In 20 patients undergoing carotid endarterectomy under remifentanil/propofol anesthesia, BIS-Vista data,

MCBFV, and pulsatility index from bilaterally mounted BIS-Vista and transcranial Doppler monitors were continuously

recorded.

RESULTS: Coefficient of determination revealed good correlation (r = 0.763) between ipsilateral BIS-Vista and MCBFV

after cross-clamping. BIS-Vista exhibited a high discriminative power of 0.850 (95% confidence interval, 0.455-0.966)

area under the receiver-operating characteristic curve in detecting an ipsilateral 40% MCBFV decline. Two-way analysis

of variance (location by time) suggests that BIS-Vista exhibited a global decline; ie, both BIS-Vistas declined when 1

carotid on either side was clamped because there was no significant interhemispheric difference (P = .112) in mean BIS-

Vista values over time.

CONCLUSION: Although we demonstrated good correlation and high discriminative power of the BIS-Vista monitor in

depicting a MCBFV decline that could serve as indicator of decline in cerebral activity, BIS-Vista cannot be considered a

reliable indicator of cerebral ischemia/hypoperfusion that could replace transcranial Doppler monitoring to determine

whether a shunt is to be placed.

PMID: 20679941 [PubMed - indexed for MEDLINE]

Anesteziol Reanimatol. 2010 Mar-Apr;(2):19-23.

[Comparative assessment of various general anesthesia methods during

reconstructive operations on the carotid arteries].
[Article in Russian]

Neĭmark MI, Shmelev VV, Simagin VIu.

Abstract

Total intravenous anesthesia with diprivan and inhaled sevoflurane was assessed in 130 patients undergoing carotid

endartectomy. The parameters of hemodynamics and cerebral circulation and the markers of brain lesion were studied.

Sevoflurane anesthesia was shown to induce less depression of hemodynamic parameters and to maintain the more

optimal level of cerebral circulation, limiting brain ischemic and reperfusion lesions and causing a fewer number of

postoperative complications.

J Neurosurg Anesthesiol. 2010 Jul;22(3):207-13.

Cerebral pial vascular changes under propofol or sevoflurane anesthesia during

global cerebral ischemia and reperfusion in rabbits.

Ishiyama T, Shibuya K, Ichikawa M, Masamune T, Kiuchi R, Sessler DI, Matsukawa T.

Surgical Center, University of Yamanashi Hospital, Yamanashi, Japan. ishiyama@yamanashi.ac.jp

Abstract

BACKGROUND: Propofol and sevoflurane are commonly used anesthetics for neurosurgery. The aim of the study was

to compare the effects of propofol with sevoflurane on cerebral pial arteriolar and venular diameters during global brain

ischemia and reperfusion.

METHODS: Japanese white rabbits were anesthetized with propofol (n=11), sevoflurane (n=9), or the combination of

sevoflurane and intralipid (n=10). Global brain ischemia was induced by clamping the brachiocephalic, left common

carotid, and left subclavian arteries for 15 minutes. Pial microcirculation was observed microscopically through closed

cranial windows and measured using a digital-video analyzer. Measurements were recorded before clamping and

afterward for 120 minutes.

RESULTS: Plasma glucose and mean arterial blood pressure increased significantly during ischemia in the propofol-

anesthetized rabbits. During ischemia, pial arteriolar and venular diameters decreased significantly in all groups. After

unclamping, large and small, pial arteriolar and venular diameters increased temporarily and significant dilation was

observed in both sevoflurane groups. From 10 minutes after unclamping until the end of the study, large and small

arterioles returned to baseline diameters in the sevoflurane groups, but decreased significantly by 10% to 20% in the

propofol rabbits. Ischemia-induced adverse effects such as pulmonary edema and acute brain swelling were observed

primarily in propofol-anesthetized rabbits.

CONCLUSION: Propofol and sevoflurane acted differently on pial vessels during reperfusion after ischemic insult. Pial

arterioles and venules did not dilate immediately after reperfusion, and subsequently constricted throughout the

reperfusion period in propofol-anesthetized rabbits. In contrast, pial arterioles and venules dilated temporarily and

returned to baseline in sevoflurane-anesthetized rabbits.

Anesth Analg. 2001 Sep;93(3):560-5.

A comparison of sevoflurane, target-controlled infusion propofol, and

propofol/isoflurane anesthesia in patients undergoing carotid surgery: a quality
of anesthesia and recovery profile.

Godet G, Watremez C, El Kettani C, Soriano C, Coriat P.

Department of Anesthesiology, Pitié-Salpêtrière Hospital, Paris, France.

Abstract

In a prospective randomized study in patients undergoing carotid endarterectomy, we compared the hemodynamic

effects, the quality of induction, and the quality of recovery from a hypnotic drug for the induction of anesthesia with

sevoflurane, a target-controlled infusion (TCI) of propofol, or propofol 1.5 microg/kg followed by isoflurane. All patients

were premedicated with midazolam and received sufentanil 0.4 microg/kg at induction. The induction of anesthesia was

associated with a decrease in arterial blood pressure in all groups, but this was least pronounced in the Sevoflurane

group. There were similar a number of episodes of hypotension, hypertension, and tachycardia among groups, but the

incidence of bradycardia was less in the TCI group (P < 0.05) compared with the other groups. The duration of episodes

of hypotension was shorter (P < 0.05) in the TCI Propofol group (1.9 +/- 2.3 min) compared with the Sevoflurane group

(4.7 +/- 3.6 min). The duration of episodes of bradycardia was significantly lower (P < 0.05) in the TCI Propofol group

(0.1 +/- 0.5 min) in comparison with the Propofol Bolus group (2.5 +/- 3.9 min). Similar doses of vasoactive drugs were

used in all groups. The induction of anesthesia with sevoflurane was associated with inferior conditions for intubation in

comparison with both Propofol groups, although the time to intubation was faster in the Sevoflurane group (P < 0.05).

The recovery characteristics were similar in the three groups.

PMID: 11524318 [PubMed - indexed for MEDLINE]Free Article

Anesth Analg. 1997 Dec;85(6):1284-7.

 The effects of sevoflurane on cerebral hemodynamics during propofol
anesthesia.

Heath KJ, Gupta S, Matta BF.

Department of Anesthesia, Addenbrooke's Hospital, Cambridge, United Kingdom.

Abstract

We investigated the cerebral hemodynamic effects of 0.5 and 1.5 minimum alveolar anesthetic concentration (MAC)

sevoflurane during propofol anesthesia in 10 patients undergoing supratentorial tumor resection. All patients received a

standardized anesthetic, and their lungs were ventilated with a mixture of air and oxygen to produce mild hypocapnia.

Anesthesia was then maintained with a propofol infusion. Muscle relaxation was obtained by infusion of atracurium. A

transcranial Doppler probe was used to measure red cell flow velocity in the right middle cerebral artery (Vmca). A right-

sided jugular bulb catheter was inserted for sampling of jugular bulb blood. After a 30-min period of stabilization and

before the start of surgery, baseline arterial and jugular bulb blood samples were drawn to define the arterial-venous

oxygen content difference (AVDO2). Mean arterial pressure and Vmca were recorded. Sevoflurane (0.5 and 1.5 MAC) in

oxygen/air was then administered, and all measurements were repeated. Administration of sevoflurane at 0.5 MAC did

not change Vmca or AVDO2. Sevoflurane (1.5 MAC) did not change Vmca. There was an approximately 25% reduction

in AVDO2 (P < 0.05). This suggests that during propofol anesthesia, although 1.5 MAC sevoflurane does not increase

red blood cell velocity, there is a relative increase in flow with respect to metabolism. Administration of large-dose

sevoflurane may be associated with a degree of luxury perfusion. Implications: We investigated the cerebral

hemodynamic effects of sevoflurane in patients undergoing neurosurgery. Small-dose sevoflurane (1%) did not change

brain blood flow or oxygen consumption. Large-dose sevoflurane (3%) did not change flow velocity but reduced brain

oxygen consumption by 25%. Sevoflurane may provide a degree of luxury perfusion.

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abstract abstract abstract 20 20

Anesthesiology. 1993 Oct;79(4):704-9.

Effects of sevoflurane on cerebral circulation and metabolism in patients with

ischemic cerebrovascular disease.

Kitaguchi K, Ohsumi H, Kuro M, Nakajima T, Hayashi Y.

Department of Anesthesiology, National Cardiovascular Center, Osaka, Japan.

Abstract

BACKGROUND: Sevoflurane is a newly developed volatile anesthetic that has a low blood-gas partition coefficient. The

effects of sevoflurane on the cerebral circulation or metabolism in humans have not been studied. The authors examined

the cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRO2) during sevoflurane anesthesia. The

carbon dioxide response and autoregulation of cerebral circulation were also examined.

METHODS: Ten patients with ischemic cerebrovascular disease undergoing extra-intracranial artery anastomosis were

studied. Cerebral blood flow and CMRO2 were determined by the Kety-Schmidt method using argon. These procedures

were performed during the inhalation of 33% N2O, 33% argon, and oxygen with 1.5% sevoflurane (0.88 minimum

alveolar concentration). To examine the relationship of CBF to a change in PaCO2, CBF was measured repeatedly at

steady state PaCO2, of 40, 35, and 45 mmHg. Furthermore, CBF was measured before and after an increase in mean

arterial pressure (MAP) caused by intravenous infusion of methoxamine to determine the relationship between CBF and

MAP.

RESULTS: Cerebral blood flow and CMRO2 were 28 +/- 4 ml x 100 g-1 x min-1 and 1.34 +/- 0.23 ml x 100 g-1 x min-1,

respectively. Cerebral blood flow was found to vary directly with PaCO2 alteration. The slope of the regression line

between PaCO2 and CBF was 1.29 ml x 100 g-1 x min-1 x mmHg-1. On the other hand, CBF was constant throughout

the elevation of MAP with vasopressor.

 CONCLUSIONS: Both carbon dioxide response and cerebral autoregulation were well maintained under 0.88 MAC

sevoflurane anesthesia in patients with ischemic cerebrovascular disease.

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abstract abstract abstract 20 20

Rev Esp Anestesiol Reanim. 2004 Dec;51(10):568-75.

[Comparison of 4 techniques for general anesthesia for carotid endarterectomy:

inflammatory response, cardiocirculatory complications, and postoperative
analgesia].

[Article in Spanish]

Longás Valién J, Guerrero Pardos LM, Gonzalo González A, Infantes Morales M, Rodríguez Zazo A, Abengochea Beisty

JM.
Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario Miguel Servet, Zaragoza.

jalonva@terra.es

Abstract

OBJECTIVE: [corrected] To study the analgesia, hemodynamic stability and inflammatory response in patients

undergoing carotid endarterectomy under different types of general anesthesia.

MATERIALS AND METHODS: A comparison of 80 patients randomized to 4 groups: group 1, maintenance with

sevoflurane at a minimum alveolar concentration (MAC) of 1; group 2, sevoflurane at MAC 1.5; group 3, remifentanil;

group 4, propofol. Variables studied were hemodynamic alterations during and after surgery, level of postoperative

analgesia, differential white cell counts, levels of interleukin-6 (IL-6), and clinical signs and symptoms of systemic

inflammatory response syndrome in the first 24 hours after surgery.

RESULTS: The incidences of episodes of intraoperative hypertension were 60% in group 1, 65% in group 2, 50% in

group 3, and 60% in group 4. The incidences of episodes of intraoperative hypotension were 85% in group 1, 80% in

group 2, 80% in group 3, and 75% in group 4. Patients in groups 3 and 4 had higher incidences of systemic inflammatory

response syndrome (p<0.05) in the first 24 hours after surgery and higher levels of IL-6 (p<0.05). Postoperative

analgesia was similar in all 4 groups.

CONCLUSIONS: Increased levels of IL-6 in peripheral blood and of systemic inflammatory response syndrome were

found in the early postoperative period in groups that did not receive halogenated gases. Hemodynamic stability and

analgesia were similar in all groups, however.