6
Correlation ofregional cerebral blood flow and blood flow velocity in normal volunteers and patients with cerebro-vascular disease A. Hartm ann, F Ries. Y Tsuda*, H, Laqreze, R. Seiler"; P. Grolimund"" Neuro logisc he Uruvershätskllnik. BonnlFRG Neurochtrurgisc he Universitätsklinik. Bern . CIl··
Summary
Transeramal Doppler sonogra phy a nd measuremenl of regional cerebra l blood Ilow us ing the Xenon' Atnbalauon technique have been used simultaneously in 10 normal volunteers and 13 patients with acute-onset cerebrovasc ular disor ders during normocapn ia and during hyperventilatory hypocapnia . Hypoca pn ia led 10 a redu ctton or both blood Ilow and blood velocny in the territory of th e midd le cerebral artery. However. correlat ion was poor in most cases with respect: 1) to hemisphenc blood flow and flow velocity cver the midd le cereb ral artery (BFV), 2) cerebral blood flow (CBF) over th e middle cerebra l artery (MCA) and BFVand 31percern age changes of CBF over the MCA and BFV du ring hypocapn ia . In normals correlation usually was bet ter than in pa tients with cerebrovascular dtsorders. It was concluded that mea sur ement of BFVover the MCA usin g tran scranial Doppler sonography does not ref1ect either cereb ral ns su e perfu ston or ch anges of ussue perfu ston indu ced by alteratlon of COrcontent in the ertertal blood . Key-Words Tra nscra nial Doppler sonogra phy - Cerebral blood üow-Xenon !" inhalation -COz-reactivity
Korr ela tion von regional er Gehirndu r chblutun g und B1utßieß geschwindigk eit bei Normalp erson en und b ei Pa tie nten mit zerebrovaskulä r en Er kra nku ng en Bei 10 Normalpersonen und 13 Patienten mit akuten linksse itigen zerebrovaskulären Dur chbl utun gsstörungen wu rde sowoh l unter norm okapnischen wie auc h unter hyperv entiiatorischen hypoka pnischen Bedingungen die BlutJ1ießgeschwindig keit mit der transkraniellen Dopplers onogra ph ie un d die regionale Gehim durchblutung mit der Xenon-133-lnhalationstechntk simulta n gem essen . Unter hypokapnischen Bedingungen kam es zu einer Verm inderu ng der Hirn durchblutung (CBF) und BlutJ1ießgeschwindigkeit (BFG) im Territorium der A. cerebri med ia (ACM). Die Korrelation war für folgende Para meter unzu reic hend: 1. Hemisphärisch er CBF und BFG übe r der ACM. 2. CBF und BFG ü ber der MCA. 3. Prozentuale Verä nderu ng von CBF un d BFG üb er der ACM unt er hypokapn ischen Bedingungen. Bei Norm alpe rsonen wa r die Korrela tion in den me isten Fällen besser als bei Patienten mit zereb rova skulären Erkrankungen . Zusammenfassen d wu rd e festgestellt. daß die Messung der B1utJ1ießgeschwindigkeit üb er de r ACM weder die zerebra le Gewebep erfusio n noch Verä nderungen der Gewebeperfusion unter Verä nderung de r Cüj-Spannung im arterielle n Blut reflektiert.
Introducti on Transcranial uhrasound Dop pler sonography (TCD) is a non -Invasive method to estimate blood flow velocity in the ba sal parts of the arteries a rising from the
x eurochuurgta 34 (1991) 6-13 © Geo rg Thi erne Verlag Stungart - New Yor k
Ctrcle ofWiIlis . ind uding the siphon (3. 6). Cltntcal applica tio ns have been tried in a varie ty of cerebrovascular diseases in vasospasm following e .g. suba rachnoid hemcrrh age (2, 32), lntracranlal occlustve dtsea ses (28 , 291. arteriovenous malformations (20, 31), monitoring of carotid enda rterectomy (241 or ext rac ran ial-intracranial bypasssurgery (13). intracranial cir cula tory arrest (26) a nd moni toring during open h eart surgery with extracorporal cireul attcn (2 7).
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• Hecipiem ofthe Alexander von Humboldt Gesellschaft
Xeurochirurgia 34 (1991 J
Corretouon oj regiona/ cereörot bloodj7oU' and bloodj7oU' t'e1ocily
During alteratfon of the arterial partial pressure of carbon dioxide (Pa(O z) vascular resistance ls altered by ada ptation of the vascular diameter (25, 37). Measurement of rCBF using the non-traumatic method of Xenon'Atnh alauon {22} ls a ble to detect these rCBFchanges (36). Furthermore Ma rkwa lder et al. (21) have reported on alteration of blood flow velocity by chan ges of PaCOz using T(D . Btsnop et al. (8) have described a poor correlation for the absolute flow velocity in the middle cerebral artery (BFV) and hemispheric blood üow as measured by Xenon \31-inhalat ion-techniq ue in normals. However, they found a good correlanon for the reactivity index of BFV and e BFfollowing inhalation of5% ( Oz in air. In this study we have compared r(B F and BFV over the middle cerebra l artery in normal voluntee rs and patients with acute cerebrovascular diseases during normocapnta and hyperventilation. Inst rumen ta tion
al r(BF was measured usrng the Xenon' P. inhalation technique as described by Obrist et al. (22). A Cerebrogra ph 32 c (NOVO Instru ments, Denmark ) with 32 fixed detectors was used. The detectors with Nal-crystals of 3/4 inch size and a collimation of 20 mm were arranged in a heimet shape around the head ofthe patient. Identlcal posluons of the detectcrs in repeated or - as in this study - in prolonged protocols have been guaranteed by positioning the detector heimet with 2 light beams. Throughout the measurement the patients breathed via a mouth-plece connected to the cerebrograph. whilst the nose was closed by a clamp. Leakage was completely avoided and controlled by a special detector, positioned in the airway of the respiratory system.
During background recording (30 sec in the first and 5 min in the following study) the patient breathed via the Cerebrograph from and tnto room atr. This phase was followed by the so-called saturaü on phase. durin g which the patient breathed from and to an Sditre- alrb ag conta ining 25- 30 mCi Xenon!" for 60 sec. After this period the patient breathed via the Cerebrograph from arid into room air for 10 min to record desat uration. The Nal-crystals recorded increase and decrease of Xenon llJ - activity in the cranial tissue throughout the total study. Recirculation or Xenon':" was estima ted by recordi ng ofth e endexpiratory activity, stnce the concentranon of endtidal Xenon \31 is similar to that of the arteria l system (15, 22). All cranial curves which did not achieve a count of 1000/0.5 sec (counting interval) al the initial peak, were discarded from calculation. This occurred in only a few
instances. Endtidal Xenon'Aconcentra uon was conunu ously recorded. Endexpiratory COr concentration (volume %) was continuously recorded by a capn ogra pb and followed on a plotter to control regular breath ing. COr volume% was recalculated to PaC0 2 by using the formula. PaCO _ 2
eoz Val% 100
x Pm
where Pm Is the at mospherie pressure in mmll g. This value then was eorr eeted by a multiplying faetor whieh depends on the calibrati ng atmosphenc pressure (760 mmHg). It may be ass umed that endtidal PaC0 2 resembles PaC0 2 (10). if lung function Is normal. This was confirmed by prevlous studies OS). All data were stored on line on a computer (pOP 1103 V) and the original head curves subjected to biexponential analysis and further ealculation ofthe followtng par ameters: 1) Initial slope Index (151.sec' "): 151represents primarily but not exclusively flow from the fast perfused tissue. It is defined as the monoexponential slope between the 30th and the 90th sec of the clearanee eurve whieh ts deconvoluted from the biexponential analysis. 2) Mean tissue llow (CBF 15; ml ·l00 g_l. mtn"). It is a modification of the height-over-are a curve. extra polated till the 15lh min (23). The calculation is performed on the original curve eorrected for background. recireulation and delayed starr fit time (19). The mean grey-white matter partition eoeffi cient was used for calculaticn ofCBF 15. 3) Fast matter ücw (Fl ; ml · 100 g"! . min- I ) : Fl repr ese nts flow from the fast perfused eompa rtment. For calculation of Fl from the biexponential calculauon of the original curve a partition coefficient for the grey matter was used. esumate d according to the hemoglobin concentratio n. During the protoeol blood pressure was repeate dty measured using the Hiva-Rocci-method. b) BFV was measured by Te D using the TC 2-64 (EM E, Überlingen, FRG)as developed by Aa slid et al. (3). This method is based on a pulsed ultrasound emtsston (2 MHz), focused by a polystyrene acoustic lens at an optimal depth of 45 to 50 mm with an emitting area of a bout 1,5 em . The maximal energy emission 0 00 mw/cm-I respects the tolerable maximum as far as possible btologfcal side-effects are eoncerned (5).The focal resolution depends greatly on the skull thtckness and structu re (11) and is assumed to be 6 mm laterall y and lOm m axlally. The focal depth may be altered from 25 to 155 mm at 5 mm-steps. The Doppler frequency shift depends on the insonation angle, emission Irequency and ultrasound velocity in the tissue: The insonation or the MCA ls performed through the thin part of the temporal bone r'ultrasound window") and its angle is determined by the bone configuration and the vessel course. A sharp angle Ibetween 0 and 30 degreesl reduces the maximum er ror to less than 15 % (3). In case of an tnsonation of the horizontal segrnent of the MCA this error is reduced even more,as the optimal ultrasound signal for a defined vessel segment regularly is obtained from only one and the same small insonalion area .
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Regional cerebral blood Ilow (rCBF) depends on metahohe demand, blood cheracterlsttcs . geometrie param eters of the vessels and the propu lsive forces. Since blood velocity in the proximal part oft he intracranial vascular system determ ines rCBFin the distal capillary system only to a limited extent. TeD might not always be able to rellect tissue perfusion. However. ifth e vascular erossecnon changes without alteration of the other parameters both blood Ilow end velocity ofthe blood stream are modified.
7
A. Hartmann. R Ries. Y Tsudn, 1/. Lagreze , R. Sei/er. P. Grolimund
Xel/rochirl/ryiu 34 (19 91J
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•
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~
l Fic. 1 ContIl'UOUS Iecol' ~ 01 ~lplI' alory ~ and ende'KPWatoryXe " _ concentrallOrt The flg.leadsfrom ogtrtto Jett ReglNr breatlw'l& dum&steadys ateon tne nght
cant hemispherie differences. as only the left MCA could be constdered during CBF registration. In CVD pauents. the same procedure was performed, except that BFVoft he MCA was regtsiered on the side of vascular lesion. During CSF measurement. the ultrasound probe was placed on the temporal bone througb Ihe replacement of one detector in the detector heimet and held in a fixed postnon for 15 min before CBF measurement onset, thus getung the mean reference BFV t- 100%) by registration of the optima l ultrasound signal in a 5 min Interval. Durtng CBF measu rement. TCDregistration was performed every minute including Ihe immediately rollowtng 10min. In the curve of BF\' alteration by hyperventilation. the lo.....est mea n. systolic and diastolic BF\' values during the first 5 mtn ofthe voluntary hyperventllaticn were considered for BF\' change compared to the individual reference value t- 100%). Pallen ts
sodeeod dum& 'iOIuntaryIlyperverItllatlOl1 onlhe Ieft sc e 01 tre flg.Hypefvent.. Iß IatIOl1 wasstartehimdurc hbl utu nKbt-im Menschen mit O e~ ible n Wä rmeleilsonden. ~er \"t'nant 37 (19661 173- 175 lJishop. C. C. H, . .\1. Inso//. S.I'OI/"efl. I). RUfI .,\". I•. HrtJIl'se: EITect of inl n nal ca rotid anel)' occlusion on mlddll' cereb ra l a n ery blood Oow st rest in response to hype rcap nia , La neet 11%6) 7 13-7 19 lJishop. C. C. R.• S. Pau'ell, IJ. /f u f /. /../. L. IJrou'se: Trllnsc ra nial Doppler mess ureme nt or midd le cere bral artel)' blood Oow "'elocity: a \'a lidatio n study . Stroke 11 (19861913 - 9 15 8u rti. N. K.• R. K. Alber!: Nonin\'lIsive monitoring of lIneria l hlood gases. Chest 83 11 983 1666-670 Gro/imund. P.: Trans miss ion of ultra sound Ihr ol,lgh the tempora l bone. In: R. Aaslid led.l Transeranial Doppler Sonograph)". Spri nKI'r. lle idelberg 1986. 10-21 Ua/sey. 1./1. .11. A . .\/r/JrJuyll. S. Gl'lmon : Transcranial Doppler a nd rCBF compa red in carotid enda rterKtomy. Stro ke 17 119861 1206-1208 Uardl'rs. 11.• J. Gif$OOc/t: Tran scrlnial Doppler sonogra phy a nd ils ap plicatio n in extracranW - inlrlcr aniaJ b)-plss surgery. ~ I'ur. H I'~Irt"h 7119851129-1 41 HOrpl'r. A. .\/.: ~ inter-mationship bet....l'E'n pCO! a nd blood pn"SSurein the regu laLionof blood ßow Ihrol,lgh the «'"-,brai corte x. Acta Sl'urol. ~nd. t4 0%5194 -1 03 lIor/1IIonn.A.. R. r . Kumm~r: Diealrlumat ische Messung der regionakon Gl'himdu rchblu tung : Met hode und ZU\·l'rlass igkl'ils priirunK. Fortschr. Neuro!. Psychill. 50 11982151-68 lIor/mann. A .• 11. Log""zl'. Y. Tsuda : Cl'rl'brll blood now in ag inK I nd in patienlS with and without risk fadors for cerl'bro\'aseu lar diSl'aSt', Futu ra Publ.• lnc. ~l t. KISCO. Nl'w York 1987 lIe"""rici.ll.. W. Rauu nberg. G, Sitze' . 11. Sr hu'Orfz: Trllnse ra nial Doppler ultr asou nd for the llssess ment of intra cranial a rtel)' Oo\\" ve[ocity - pan 1. Sl,lrg. ~el,lro l, 27119871439- 448
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12
Kt ty. S. S., C. F. Schmidt: EITl"ct5ofacti\'e un d passive hypervenulalion on cereeret blood ücw. ce rebra l OX)"l{t'n consum ption. ca nliac ou tpUl. and b100d pressure of normel ~'oung men. J. Cltn. luves t. 25 119461107- 119 l' Lindegaard. K. F.. S. J . BaUt. R. Aa$fid. H ,\'ornf'$: Doppler diagnosis or intracranial artery ocdusiv'l' diserders. J. Seurol . f'eurosurg . Ps~·chial . 49 (1986) 510- 518 JIII Lindegaorrl K. F., S. J. BaUt, P. Grolimllnd. R. Aa.slid. P. HIlbf'r . H Sornf'.: Assessment o f intra cra nial hemedynamic in eereuc anl'r)" diSE'a~ by transcranlal Dopple r uhrasound . J . Xeurosurg. 63 (1985) 890-898 1'1 .lforb ro ldt r, T. .\1., P. Grolimund. R, W. Seder, F. Ro fh. R. Aaslid: Dependency orblood I\ow \'elocit~' in the midd le rerebral artery on end-uda l earben dicxide panial pressu re - a transc ranial uhra sou nd Doppler study. J . ce ree. Blood Flow ~It'tab . 4 119841 3611-372 zz Obri.s/, IV. D,. H, K. Thomson. H S. I\ "ong t l 01.: Rt'gional cereb ral blood now esumaied by 133-Xt'non ·l nhalat ion . Stro ke 6 0 9751 245-256 Jl Obri$/. IV. 0 .. W. /i. Wilkinso n: The noninvaslve 133 Xenon method : Evaluation ortndtces.Cerebral circulation. Excerpte med. (E1se"ie r) (19791 119 - 124 U Padaya chee. T. S. R. G, Goslin.q. C. C. R.lJish op. K. G. Bilmolld. N. L. 8 rou's f': Monno nn g middle ce reb ral artery blood velochy duemg carotid endart er ectomy. a-n. J. Surg. 73 (1986198- 100 ZJ r anerson. 1. L. i r.. A, lI eyma n. L. L. lJoll ry. R, W. Frrgll$on: Th resh old or response ofthe cerebra l vesse ls of ma n 10 incrt'ase in blood ca rbon dioxide . J. D in. Inn ·sl. 341 1955 11857 -1864 l'lo Rit $. F.. D..\ roskop p: Value orT CD for dt'lt'rm ina tion ofbrain dt'ath . Hn pressl rr Rit$, F., 11. '\! urdoy, M. Eicht, P. L Kirchhoff: So ninusi"t' a!;Sl"SSmf'n l of intracra nia l ht' modynamiC'S pa ramMers during t:l:lraco rpo",a l circulation. Springer Publ.lin prt'SS1 ZI Ringtlstf'in. E. B.: llltraschalldiagnoslik am "enebro ba s ili re n K",isla ur. Teil 11: Transnuchalr Diagnosr intra kra n it'ller "ert t'brobasiliirer StenOSt'n mit Hilfe e ines neuarugen Impulssc ha U-Dop p\(>r·S)"stf'ms. UltraschaU 611985160-67 ,. Rin~l.s/f'in. E. B.. H, Zrumer. G. KOI'bmochtr. F. 1'l"lllflnghoflTransk ranielle Dopplf'r·Sonogra ph ie dt' r him,·t'rsorgt'nd t'n Anerif'n: Alrau mat isehe Diagn ostik von StenOSt'n und VerschtiisSE'ndes Ka roliss~-phons und der A. ('('rebri mt'd ia . St'n"f'narzt 56 (198 51 2%-306 1&
• Risbf'rg. J.: Regional cere bral blood Ile w measurements by 133 Xenon Inhalation: ~l ethodology a nd a pplications in neuropsychelogy and ps)'Chiatr}' . Brain a nd Uinguage 9 1198016 -34 J I Schtrart::. A., .\ 1. Ht nnt ric;: f'oni n\'asivr transe ramal Dopple r uhrasound in inlracranialangiomas.1'>t'urology 36( 19861626-635 JZ Seiler. R. W . P. Grotimllnd. R. All$Urf. P.lluber. lI_,,"orne$: Rt'lation or cerebral vasespasm l"'aluatt'd by transeramal Dopple r ultrasound 10 dinic.al grade and CT·\isuali1:t'd subarachnoid ht'morrlagr. J. xeurcsurg. 11986) " Shopi",. IV.. A. J. l\ 'o.ssf'r monn. 1. L. Patlf'rson : u umen cere brcva scu lar response time 10 l"'aluation of al'tt'rial urban d ioxide tension . Asth.:-':eurol .13(1%51130-138 M Shf'n bn. H. A., P. Xrwok. B, GolllboJ!f't o/.:"Ihe effects of aging . an en oscjercsrs. an d hype rtension upon the cereb ral etrculatlon. J . Clln. luvest. 32 (19531459 - 465 n Tominaga. S.. S. St rondgoard. K. Uf'mllfO. K.lIo. T. KU fSUl OU'fl. X, A. I_ass t>n. T. Sakamllro : Cerebrovascutar COl rea ctivuy in no rmotensive an d hyp ertensive men . Stro ke 7119761507- 5 10 3l> Tsuda. Y.. A. lJartmann : Hyperfrontal distri butio n of regicnal cerebra t blood Ilöw a nd vascular COl -rt'llctivity in norm als and disturba nces in lschc mlc cere brova scular dtsorders . Acta Radio logiea (in press ) J1 Wasst>rmann. A. 1., J. C. Patlt rsrm: Tha ccrebrel vascular responsc to red ucuon in a rteria l car bon dioxtde renston. J, C1i n . Invest. 40 (196 111297 -1 30 3 :111 Wf'('h slf'r. L. R., A. H. Ropper. J, P. Kistlf'r: Tra nsc ra nia l Doppler in cere brovasc ula r disease . Stro ke 17 (1986190 5-912
Prof. Or. A. llartmann :-':eurologische Univ.-K1ini k Sigmund·F",ud-Slr. 25 5300 Bonn lIFRG
13
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Xe /lroc hi ru rgi a 3 4 (1991)
Correl a /ton of regirJ/lalcereb ral bloodj1ou' u n d blood j10w f'efocily
Correlation ofregional cerebral blood flow and blood flow velocity in normal volunteers and patients with cerebro-vascular disease A. Hartm ann, F Ries. Y Tsuda*, H, Laqreze, R. Seiler"; P. Grolimund"" Neuro logisc he Uruvershätskllnik. BonnlFRG Neurochtrurgisc he Universitätsklinik. Bern . CIl··
Summary
Transeramal Doppler sonogra phy a nd measuremenl of regional cerebra l blood Ilow us ing the Xenon' Atnbalauon technique have been used simultaneously in 10 normal volunteers and 13 patients with acute-onset cerebrovasc ular disor ders during normocapn ia and during hyperventilatory hypocapnia . Hypoca pn ia led 10 a redu ctton or both blood Ilow and blood velocny in the territory of th e midd le cerebral artery. However. correlat ion was poor in most cases with respect: 1) to hemisphenc blood flow and flow velocity cver the midd le cereb ral artery (BFV), 2) cerebral blood flow (CBF) over th e middle cerebra l artery (MCA) and BFVand 31percern age changes of CBF over the MCA and BFV du ring hypocapn ia . In normals correlation usually was bet ter than in pa tients with cerebrovascular dtsorders. It was concluded that mea sur ement of BFVover the MCA usin g tran scranial Doppler sonography does not ref1ect either cereb ral ns su e perfu ston or ch anges of ussue perfu ston indu ced by alteratlon of COrcontent in the ertertal blood . Key-Words Tra nscra nial Doppler sonogra phy - Cerebral blood üow-Xenon !" inhalation -COz-reactivity
Korr ela tion von regional er Gehirndu r chblutun g und B1utßieß geschwindigk eit bei Normalp erson en und b ei Pa tie nten mit zerebrovaskulä r en Er kra nku ng en Bei 10 Normalpersonen und 13 Patienten mit akuten linksse itigen zerebrovaskulären Dur chbl utun gsstörungen wu rde sowoh l unter norm okapnischen wie auc h unter hyperv entiiatorischen hypoka pnischen Bedingungen die BlutJ1ießgeschwindig keit mit der transkraniellen Dopplers onogra ph ie un d die regionale Gehim durchblutung mit der Xenon-133-lnhalationstechntk simulta n gem essen . Unter hypokapnischen Bedingungen kam es zu einer Verm inderu ng der Hirn durchblutung (CBF) und BlutJ1ießgeschwindigkeit (BFG) im Territorium der A. cerebri med ia (ACM). Die Korrelation war für folgende Para meter unzu reic hend: 1. Hemisphärisch er CBF und BFG übe r der ACM. 2. CBF und BFG ü ber der MCA. 3. Prozentuale Verä nderu ng von CBF un d BFG üb er der ACM unt er hypokapn ischen Bedingungen. Bei Norm alpe rsonen wa r die Korrela tion in den me isten Fällen besser als bei Patienten mit zereb rova skulären Erkrankungen . Zusammenfassen d wu rd e festgestellt. daß die Messung der B1utJ1ießgeschwindigkeit üb er de r ACM weder die zerebra le Gewebep erfusio n noch Verä nderungen der Gewebeperfusion unter Verä nderung de r Cüj-Spannung im arterielle n Blut reflektiert.
Introducti on Transcranial uhrasound Dop pler sonography (TCD) is a non -Invasive method to estimate blood flow velocity in the ba sal parts of the arteries a rising from the
x eurochuurgta 34 (1991) 6-13 © Geo rg Thi erne Verlag Stungart - New Yor k
Ctrcle ofWiIlis . ind uding the siphon (3. 6). Cltntcal applica tio ns have been tried in a varie ty of cerebrovascular diseases in vasospasm following e .g. suba rachnoid hemcrrh age (2, 32), lntracranlal occlustve dtsea ses (28 , 291. arteriovenous malformations (20, 31), monitoring of carotid enda rterectomy (241 or ext rac ran ial-intracranial bypasssurgery (13). intracranial cir cula tory arrest (26) a nd moni toring during open h eart surgery with extracorporal cireul attcn (2 7).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
• Hecipiem ofthe Alexander von Humboldt Gesellschaft
Xeurochirurgia 34 (1991 J
Corretouon oj regiona/ cereörot bloodj7oU' and bloodj7oU' t'e1ocily
During alteratfon of the arterial partial pressure of carbon dioxide (Pa(O z) vascular resistance ls altered by ada ptation of the vascular diameter (25, 37). Measurement of rCBF using the non-traumatic method of Xenon'Atnh alauon {22} ls a ble to detect these rCBFchanges (36). Furthermore Ma rkwa lder et al. (21) have reported on alteration of blood flow velocity by chan ges of PaCOz using T(D . Btsnop et al. (8) have described a poor correlation for the absolute flow velocity in the middle cerebral artery (BFV) and hemispheric blood üow as measured by Xenon \31-inhalat ion-techniq ue in normals. However, they found a good correlanon for the reactivity index of BFV and e BFfollowing inhalation of5% ( Oz in air. In this study we have compared r(B F and BFV over the middle cerebra l artery in normal voluntee rs and patients with acute cerebrovascular diseases during normocapnta and hyperventilation. Inst rumen ta tion
al r(BF was measured usrng the Xenon' P. inhalation technique as described by Obrist et al. (22). A Cerebrogra ph 32 c (NOVO Instru ments, Denmark ) with 32 fixed detectors was used. The detectors with Nal-crystals of 3/4 inch size and a collimation of 20 mm were arranged in a heimet shape around the head ofthe patient. Identlcal posluons of the detectcrs in repeated or - as in this study - in prolonged protocols have been guaranteed by positioning the detector heimet with 2 light beams. Throughout the measurement the patients breathed via a mouth-plece connected to the cerebrograph. whilst the nose was closed by a clamp. Leakage was completely avoided and controlled by a special detector, positioned in the airway of the respiratory system.
During background recording (30 sec in the first and 5 min in the following study) the patient breathed via the Cerebrograph from and tnto room atr. This phase was followed by the so-called saturaü on phase. durin g which the patient breathed from and to an Sditre- alrb ag conta ining 25- 30 mCi Xenon!" for 60 sec. After this period the patient breathed via the Cerebrograph from arid into room air for 10 min to record desat uration. The Nal-crystals recorded increase and decrease of Xenon llJ - activity in the cranial tissue throughout the total study. Recirculation or Xenon':" was estima ted by recordi ng ofth e endexpiratory activity, stnce the concentranon of endtidal Xenon \31 is similar to that of the arteria l system (15, 22). All cranial curves which did not achieve a count of 1000/0.5 sec (counting interval) al the initial peak, were discarded from calculation. This occurred in only a few
instances. Endtidal Xenon'Aconcentra uon was conunu ously recorded. Endexpiratory COr concentration (volume %) was continuously recorded by a capn ogra pb and followed on a plotter to control regular breath ing. COr volume% was recalculated to PaC0 2 by using the formula. PaCO _ 2
eoz Val% 100
x Pm
where Pm Is the at mospherie pressure in mmll g. This value then was eorr eeted by a multiplying faetor whieh depends on the calibrati ng atmosphenc pressure (760 mmHg). It may be ass umed that endtidal PaC0 2 resembles PaC0 2 (10). if lung function Is normal. This was confirmed by prevlous studies OS). All data were stored on line on a computer (pOP 1103 V) and the original head curves subjected to biexponential analysis and further ealculation ofthe followtng par ameters: 1) Initial slope Index (151.sec' "): 151represents primarily but not exclusively flow from the fast perfused tissue. It is defined as the monoexponential slope between the 30th and the 90th sec of the clearanee eurve whieh ts deconvoluted from the biexponential analysis. 2) Mean tissue llow (CBF 15; ml ·l00 g_l. mtn"). It is a modification of the height-over-are a curve. extra polated till the 15lh min (23). The calculation is performed on the original curve eorrected for background. recireulation and delayed starr fit time (19). The mean grey-white matter partition eoeffi cient was used for calculaticn ofCBF 15. 3) Fast matter ücw (Fl ; ml · 100 g"! . min- I ) : Fl repr ese nts flow from the fast perfused eompa rtment. For calculation of Fl from the biexponential calculauon of the original curve a partition coefficient for the grey matter was used. esumate d according to the hemoglobin concentratio n. During the protoeol blood pressure was repeate dty measured using the Hiva-Rocci-method. b) BFV was measured by Te D using the TC 2-64 (EM E, Überlingen, FRG)as developed by Aa slid et al. (3). This method is based on a pulsed ultrasound emtsston (2 MHz), focused by a polystyrene acoustic lens at an optimal depth of 45 to 50 mm with an emitting area of a bout 1,5 em . The maximal energy emission 0 00 mw/cm-I respects the tolerable maximum as far as possible btologfcal side-effects are eoncerned (5).The focal resolution depends greatly on the skull thtckness and structu re (11) and is assumed to be 6 mm laterall y and lOm m axlally. The focal depth may be altered from 25 to 155 mm at 5 mm-steps. The Doppler frequency shift depends on the insonation angle, emission Irequency and ultrasound velocity in the tissue: The insonation or the MCA ls performed through the thin part of the temporal bone r'ultrasound window") and its angle is determined by the bone configuration and the vessel course. A sharp angle Ibetween 0 and 30 degreesl reduces the maximum er ror to less than 15 % (3). In case of an tnsonation of the horizontal segrnent of the MCA this error is reduced even more,as the optimal ultrasound signal for a defined vessel segment regularly is obtained from only one and the same small insonalion area .
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Regional cerebral blood Ilow (rCBF) depends on metahohe demand, blood cheracterlsttcs . geometrie param eters of the vessels and the propu lsive forces. Since blood velocity in the proximal part oft he intracranial vascular system determ ines rCBFin the distal capillary system only to a limited extent. TeD might not always be able to rellect tissue perfusion. However. ifth e vascular erossecnon changes without alteration of the other parameters both blood Ilow end velocity ofthe blood stream are modified.
7
A. Hartmann. R Ries. Y Tsudn, 1/. Lagreze , R. Sei/er. P. Grolimund
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cant hemispherie differences. as only the left MCA could be constdered during CBF registration. In CVD pauents. the same procedure was performed, except that BFVoft he MCA was regtsiered on the side of vascular lesion. During CSF measurement. the ultrasound probe was placed on the temporal bone througb Ihe replacement of one detector in the detector heimet and held in a fixed postnon for 15 min before CBF measurement onset, thus getung the mean reference BFV t- 100%) by registration of the optima l ultrasound signal in a 5 min Interval. Durtng CBF measu rement. TCDregistration was performed every minute including Ihe immediately rollowtng 10min. In the curve of BF\' alteration by hyperventilation. the lo.....est mea n. systolic and diastolic BF\' values during the first 5 mtn ofthe voluntary hyperventllaticn were considered for BF\' change compared to the individual reference value t- 100%). Pallen ts
sodeeod dum& 'iOIuntaryIlyperverItllatlOl1 onlhe Ieft sc e 01 tre flg.Hypefvent.. Iß IatIOl1 wasstartehimdurc hbl utu nKbt-im Menschen mit O e~ ible n Wä rmeleilsonden. ~er \"t'nant 37 (19661 173- 175 lJishop. C. C. H, . .\1. Inso//. S.I'OI/"efl. I). RUfI .,\". I•. HrtJIl'se: EITect of inl n nal ca rotid anel)' occlusion on mlddll' cereb ra l a n ery blood Oow st rest in response to hype rcap nia , La neet 11%6) 7 13-7 19 lJishop. C. C. R.• S. Pau'ell, IJ. /f u f /. /../. L. IJrou'se: Trllnsc ra nial Doppler mess ureme nt or midd le cere bral artel)' blood Oow "'elocity: a \'a lidatio n study . Stroke 11 (19861913 - 9 15 8u rti. N. K.• R. K. Alber!: Nonin\'lIsive monitoring of lIneria l hlood gases. Chest 83 11 983 1666-670 Gro/imund. P.: Trans miss ion of ultra sound Ihr ol,lgh the tempora l bone. In: R. Aaslid led.l Transeranial Doppler Sonograph)". Spri nKI'r. lle idelberg 1986. 10-21 Ua/sey. 1./1. .11. A . .\/r/JrJuyll. S. Gl'lmon : Transcranial Doppler a nd rCBF compa red in carotid enda rterKtomy. Stro ke 17 119861 1206-1208 Uardl'rs. 11.• J. Gif$OOc/t: Tran scrlnial Doppler sonogra phy a nd ils ap plicatio n in extracranW - inlrlcr aniaJ b)-plss surgery. ~ I'ur. H I'~Irt"h 7119851129-1 41 HOrpl'r. A. .\/.: ~ inter-mationship bet....l'E'n pCO! a nd blood pn"SSurein the regu laLionof blood ßow Ihrol,lgh the «'"-,brai corte x. Acta Sl'urol. ~nd. t4 0%5194 -1 03 lIor/1IIonn.A.. R. r . Kumm~r: Diealrlumat ische Messung der regionakon Gl'himdu rchblu tung : Met hode und ZU\·l'rlass igkl'ils priirunK. Fortschr. Neuro!. Psychill. 50 11982151-68 lIor/mann. A .• 11. Log""zl'. Y. Tsuda : Cl'rl'brll blood now in ag inK I nd in patienlS with and without risk fadors for cerl'bro\'aseu lar diSl'aSt', Futu ra Publ.• lnc. ~l t. KISCO. Nl'w York 1987 lIe"""rici.ll.. W. Rauu nberg. G, Sitze' . 11. Sr hu'Orfz: Trllnse ra nial Doppler ultr asou nd for the llssess ment of intra cranial a rtel)' Oo\\" ve[ocity - pan 1. Sl,lrg. ~el,lro l, 27119871439- 448
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Kt ty. S. S., C. F. Schmidt: EITl"ct5ofacti\'e un d passive hypervenulalion on cereeret blood ücw. ce rebra l OX)"l{t'n consum ption. ca nliac ou tpUl. and b100d pressure of normel ~'oung men. J. Cltn. luves t. 25 119461107- 119 l' Lindegaard. K. F.. S. J . BaUt. R. Aa$fid. H ,\'ornf'$: Doppler diagnosis or intracranial artery ocdusiv'l' diserders. J. Seurol . f'eurosurg . Ps~·chial . 49 (1986) 510- 518 JIII Lindegaorrl K. F., S. J. BaUt, P. Grolimllnd. R. Aa.slid. P. HIlbf'r . H Sornf'.: Assessment o f intra cra nial hemedynamic in eereuc anl'r)" diSE'a~ by transcranlal Dopple r uhrasound . J . Xeurosurg. 63 (1985) 890-898 1'1 .lforb ro ldt r, T. .\1., P. Grolimund. R, W. Seder, F. Ro fh. R. Aaslid: Dependency orblood I\ow \'elocit~' in the midd le rerebral artery on end-uda l earben dicxide panial pressu re - a transc ranial uhra sou nd Doppler study. J . ce ree. Blood Flow ~It'tab . 4 119841 3611-372 zz Obri.s/, IV. D,. H, K. Thomson. H S. I\ "ong t l 01.: Rt'gional cereb ral blood now esumaied by 133-Xt'non ·l nhalat ion . Stro ke 6 0 9751 245-256 Jl Obri$/. IV. 0 .. W. /i. Wilkinso n: The noninvaslve 133 Xenon method : Evaluation ortndtces.Cerebral circulation. Excerpte med. (E1se"ie r) (19791 119 - 124 U Padaya chee. T. S. R. G, Goslin.q. C. C. R.lJish op. K. G. Bilmolld. N. L. 8 rou's f': Monno nn g middle ce reb ral artery blood velochy duemg carotid endart er ectomy. a-n. J. Surg. 73 (1986198- 100 ZJ r anerson. 1. L. i r.. A, lI eyma n. L. L. lJoll ry. R, W. Frrgll$on: Th resh old or response ofthe cerebra l vesse ls of ma n 10 incrt'ase in blood ca rbon dioxide . J. D in. Inn ·sl. 341 1955 11857 -1864 l'lo Rit $. F.. D..\ roskop p: Value orT CD for dt'lt'rm ina tion ofbrain dt'ath . Hn pressl rr Rit$, F., 11. '\! urdoy, M. Eicht, P. L Kirchhoff: So ninusi"t' a!;Sl"SSmf'n l of intracra nia l ht' modynamiC'S pa ramMers during t:l:lraco rpo",a l circulation. Springer Publ.lin prt'SS1 ZI Ringtlstf'in. E. B.: llltraschalldiagnoslik am "enebro ba s ili re n K",isla ur. Teil 11: Transnuchalr Diagnosr intra kra n it'ller "ert t'brobasiliirer StenOSt'n mit Hilfe e ines neuarugen Impulssc ha U-Dop p\(>r·S)"stf'ms. UltraschaU 611985160-67 ,. Rin~l.s/f'in. E. B.. H, Zrumer. G. KOI'bmochtr. F. 1'l"lllflnghoflTransk ranielle Dopplf'r·Sonogra ph ie dt' r him,·t'rsorgt'nd t'n Anerif'n: Alrau mat isehe Diagn ostik von StenOSt'n und VerschtiisSE'ndes Ka roliss~-phons und der A. ('('rebri mt'd ia . St'n"f'narzt 56 (198 51 2%-306 1&
• Risbf'rg. J.: Regional cere bral blood Ile w measurements by 133 Xenon Inhalation: ~l ethodology a nd a pplications in neuropsychelogy and ps)'Chiatr}' . Brain a nd Uinguage 9 1198016 -34 J I Schtrart::. A., .\ 1. Ht nnt ric;: f'oni n\'asivr transe ramal Dopple r uhrasound in inlracranialangiomas.1'>t'urology 36( 19861626-635 JZ Seiler. R. W . P. Grotimllnd. R. All$Urf. P.lluber. lI_,,"orne$: Rt'lation or cerebral vasespasm l"'aluatt'd by transeramal Dopple r ultrasound 10 dinic.al grade and CT·\isuali1:t'd subarachnoid ht'morrlagr. J. xeurcsurg. 11986) " Shopi",. IV.. A. J. l\ 'o.ssf'r monn. 1. L. Patlf'rson : u umen cere brcva scu lar response time 10 l"'aluation of al'tt'rial urban d ioxide tension . Asth.:-':eurol .13(1%51130-138 M Shf'n bn. H. A., P. Xrwok. B, GolllboJ!f't o/.:"Ihe effects of aging . an en oscjercsrs. an d hype rtension upon the cereb ral etrculatlon. J . Clln. luvest. 32 (19531459 - 465 n Tominaga. S.. S. St rondgoard. K. Uf'mllfO. K.lIo. T. KU fSUl OU'fl. X, A. I_ass t>n. T. Sakamllro : Cerebrovascutar COl rea ctivuy in no rmotensive an d hyp ertensive men . Stro ke 7119761507- 5 10 3l> Tsuda. Y.. A. lJartmann : Hyperfrontal distri butio n of regicnal cerebra t blood Ilöw a nd vascular COl -rt'llctivity in norm als and disturba nces in lschc mlc cere brova scular dtsorders . Acta Radio logiea (in press ) J1 Wasst>rmann. A. 1., J. C. Patlt rsrm: Tha ccrebrel vascular responsc to red ucuon in a rteria l car bon dioxtde renston. J, C1i n . Invest. 40 (196 111297 -1 30 3 :111 Wf'('h slf'r. L. R., A. H. Ropper. J, P. Kistlf'r: Tra nsc ra nia l Doppler in cere brovasc ula r disease . Stro ke 17 (1986190 5-912
Prof. Or. A. llartmann :-':eurologische Univ.-K1ini k Sigmund·F",ud-Slr. 25 5300 Bonn lIFRG
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Xe /lroc hi ru rgi a 3 4 (1991)
Correl a /ton of regirJ/lalcereb ral bloodj1ou' u n d blood j10w f'efocily
