Autologous Bone Marrow Stem Cell Transplantation for Neuronal Regeneration after Extracranial-Intracranial Bypass Surgery in Patients with Cerebral Infarction: Preliminary Report / 대한뇌혈관외과학회지

INTRODUCTION: Adult stem cells generate differentiated cells beyond their own tissue boundaries. To prove that stem cells derived from bone marrow is capable of therapeutic application in cerebral ischemic patients, we performed this study. MATERIAL AND METHOD: We transplanted adult stem cells derived from bone marrow of the patient's iliac bone to 5 patients with cerebral infarction. Of 5 patients, two patients had internal carotid artery occlusion, two patients had severe stenosis of the middle cerebral artery, remaining one patient had occlusion of the branch of the middle cerebral artery. At first, we performed extracranial-intracranial bypass surgery in all patients, and then implanted bone marrow stem cell in the infarcted brain and boder zone area directly under the microscopic navigator and also injected bone marrow stem cells through the grafted vessel to the infarcted area. Two weeks after bypass surgery, we confirmed the patency of bypass graft with external carotid angiography. In the same setting, mesenchymal stem cells acquired from autologous bone marrow were superselectively injected into the bypass graft via a microcatheter. Postoperative evaluation of the patients was decided to the neurological status and the degree of reduction of the high signal area on the T2 image of the postoperative MRI. RESULT: All patients who underwent bypass surgery with stem cell implantation had an uneventful postoperative course and showed some improvement of preoperative neurologic dysfunction. Postoperative significant improvement of cerebral vasoreactivity to acetazolamide was showed in all patients. On postoperative 3 months MRI, three patients showed significant reduction of the high signal area on the T2 image, and also improved neurological status on those patients. Other one patient showed moderate degree of the reduction of the high signal area on T2 image of the postoperative MRI, but neurological status of that patient slightly improved. Remaining one patient who showed poor circulation via bypass graft does neither reduction of the high signal area on T2 image of the postoperative MRI nor improvement of the neurological status of that patient. CONCLUSION: In patients of fixed cerebral infarction with major neurologic deficit, EC-IC bypass surgery is not effective, even though infarcted area filled by grafted vessel extensively. In those patients, autologous bone marrow stem cell implantation combined with bypass seems to be expect neuronal regeneration.

Complications of Extracranial-Intracranial Bypass Surgery / 대한뇌혈관외과학회지

OBJECTIVES: Extracranial-intracranial (EC-IC)bypass procedures have proved useful in selected patients with cerebral ischemia. We have experienced EC-IC bypass procedures in 85 patients with hemodynamic cerebral ischemia, moya moya and complicated aneurysm. In this study, complications after EC-IC bypass procedures was investigated. METHODS: Authors performed EC-IC bypass surgery for augmentation of cerebral blood flow in 85 patients for recent 7 years. Of 85 patients, the pathologic lesions were artherosclerotic hemodynamic cerebral ischemia in 60, moya moya in 14, complicated aneurysm in 9, and traumatic occlusion of the carotid artery in 2. An superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 67 cases and graft bypass with saphenous vein or radial artery in 18 cases. RESULTS: Of 85 patients who underwent bypass surgery, 63 had an uneventful postoperative course. Fifteen patients had hyperperfusion syndrome that included temporary neurologic deficit in 7, reperfusion hemorrhage in 3, seizure in 3, and neusea and vomiting in 2. Five patients had wound problems. Permanant neurologic deficit and complete obstruction of the preoperative stenotic lesion occured in one respectively. All patients except three cases of reperfusion hemorrhage and one case of permanent neurologic deficit recovered completely. Two of three cases of reperfusion hemorrhage and one case of permanent neurologic deficit recovered with minor neurologic deficit, and the remaining one case of reperfusion hemorrhage died. CONCLUSION: EC-IC bypass surgery is a reliable and reasonably safe method for establishing new pathways of collateral circulation to the brain. However, this operation can have potential complications by relative hyperperfusion of chronically hypoperfused and presumably dysautoregulated region, and new flow pattern after bypass. Bypass is deferred to 8 weeks till impaired autoregulation is restored after acute cerebral infarction. And blood pressure should be controlled closely throughout the immediate postoperative period.