Linear response of collateral cerebral perfusion pressure during carotid clamping

Phenylephrine is frequently used to increase systemic arterial pressure during carotid endarterectomy. However, little is known of its effect on collateral cerebral perfusion pressure, particularly in patients with high collateral cerebral vascular resistance who are at increased risk of cerebral ischemia during carotid clamping. We tested the hypothesis that this subset of patients can have collateral perfusion pressure, and hence collateral cerebral blood flow, increased in a predictable way by elevating systemic arterial pressure. We measured mean systemic arterial pressure ( P a), jugular venous pressure ( P v), and mean carotid back pressure ( P c), and calculated collateral cerebral perfusion pressure ( P = P c - P v) and the ratio of collateral to ipsilateral hemisphere cerebral vascular resistance ( R c R h ) in 18 patients with low P. Initial measurements were P a = 84 ± 8.8 (mm Hg, mean ± SD), P v = 7.8 ± 3.9, P c = 26 ± 5.1, P = 18 ± 4.5 and R c R h = 3.4 ± 1.15 . During phenylephrine infusion, P a = 108 ± 11, P c = 32 ± 6.5, and P = 24 ± 7.2, increases of 29, 23, and 33%, respectively ( P < 0.05). Unchanged were P v = 8.2 ± 4.1 (5%) and R c R h = 3.5 ± 1.30 (3%) ( P > 0.8). The latter two findings indicate that cerebral perfusion pressure and mean systemic arterial pressure are linearly related according to the fluid mechanics equation governing these parameters: P a = P( R c R h + 1) + P v . These results support the use of phenylephrine to increase collateral blood flow during carotid endarterectomy in patients with low cerebral perfusion pressure.