Failure of a Saphenous Vein Extracranial Intracranial Bypass Graft to Protect against Bilateral Middle Cerebral Artery Ischemia after Carotid Artery Occlusion Case Report

Failure of a Saphenous Vein Extracranial Intracranial Bypass Graft to Protect against Bilateral... AbstractOBJECTIVE AND IMPORTANCE:We present the case of a patient who experienced bilateral middle cerebral artery infarctions after Hunterian ligation and trapping of a ruptured right cavernous aneurysm, despite a high-flow extracranial-intracranial bypass. This is a rare complication, and it highlights the need for further refinements in our understanding of the hemodynamic insufficiency created by major vessel sacrifice.CLINICAL PRESENTATION:The patient was a 59-year-old woman who experienced multiple episodes of massive epistaxis before undergoing angiography, which revealed left internal carotid artery occlusion and an irregular right cavernous aneurysm. The patient was then transferred to our center for treatment. The patient was neurologically intact at presentation, and her epistaxis was controlled by nasal packing.INTERVENTION:The patient underwent an extracranial-intracranial bypass from the external carotid artery to the M2 segment of the right middle cerebral artery, followed by trapping of the aneurysm. Despite evidence of graft patency, the patient experienced bilateral middle cerebral artery distribution infarctions after surgery.CONCLUSION:Although extracranial-intracranial bypasses protect the majority of patients who undergo carotid artery ligation from ischemic complications, this case demonstrates that hemodynamic insufficiency can occur even with a high-flow saphenous vein graft. Better ways to quantitate the hemodynamic needs of the brain after major vessel sacrifice may facilitate matching of the revascularization strategy to the specific needs of each patient, thus further reducing the likelihood of ischemic complications. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Failure of a Saphenous Vein Extracranial Intracranial Bypass Graft to Protect against Bilateral Middle Cerebral Artery Ischemia after Carotid Artery Occlusion Case Report

Failure of a Saphenous Vein Extracranial Intracranial Bypass Graft to Protect against Bilateral Middle Cerebral Artery Ischemia after Carotid Artery Occlusion Case Report

artery ligation, ischem ic co m p licatio n s Failure of a Saphenous Vein Extracranial resulting from h e m o d y n a m ic insuffi­ ciency are still occasionally seen (4, 5). Intracranial Bypass Graft to Protect W e present the case of a patient w ho suffered a rare but significant c o m p lic a ­ against Bilateral Middle Cerebral Artery tion resulting from the failure of a high- flow venou s b y p ass graft to protect Ischemia after Carotid Artery Occlusion against cerebral ischem ia associated with carotid artery ligation. O n the basis Case Report of this case, w e draw attention to alter­ native strategies that m ight have b e n e ­ fited this patient and to the need for increased u n d erstan d in g of the h e m o ­ Bernard R. Bendok, M.D., Ali Murad, M.D., d ynam ic insufficiency that can be c re ­ Christopher C. Getch, M.D., H. Hunt Batjer, M.D. ated by m ajor vessel sacrifice. Department of Neurological Surgery, Northwestern University Medical School, Chicago, Illinois CASE REPO RT T h e patient w as a 59-year-old, right- handed w o m a n w h o presented to a n ­ OBJECTIVE AND IM PO R T A N C E: W e present the case of a patient who other hospital w ith m ajor arterial e p i­ staxis, w hich w as treated w ith local experienced bilateral middle cerebral artery infarctions after Hunterian packing. The patient returned 1 w eek ligation and trapping of a ruptured right cavernous aneurysm, despite a later for p ack in g rem oval, at w h ich time high-flow extracranial-intracranial bypass. This is a rare complication, m assive arterial epistaxis occurred. and it highlights the need for further refinements in our understanding of Intranasal balloo n s w ere im m ed iately the hemodynamic insufficiency created by major vessel sacrifice. placed by an otolaryngologist. D ia g n o s­ CLINICAL PRESENTATIO N: The patient was a 59-year-old woman who tic evaluation, including cerebral an g io ­ experienced multiple episodes of...
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Publisher
Oxford University Press
Copyright
© Published by Oxford University Press.
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1097/00006123-199908000-00032
Publisher site
See Article on Publisher Site

Abstract

AbstractOBJECTIVE AND IMPORTANCE:We present the case of a patient who experienced bilateral middle cerebral artery infarctions after Hunterian ligation and trapping of a ruptured right cavernous aneurysm, despite a high-flow extracranial-intracranial bypass. This is a rare complication, and it highlights the need for further refinements in our understanding of the hemodynamic insufficiency created by major vessel sacrifice.CLINICAL PRESENTATION:The patient was a 59-year-old woman who experienced multiple episodes of massive epistaxis before undergoing angiography, which revealed left internal carotid artery occlusion and an irregular right cavernous aneurysm. The patient was then transferred to our center for treatment. The patient was neurologically intact at presentation, and her epistaxis was controlled by nasal packing.INTERVENTION:The patient underwent an extracranial-intracranial bypass from the external carotid artery to the M2 segment of the right middle cerebral artery, followed by trapping of the aneurysm. Despite evidence of graft patency, the patient experienced bilateral middle cerebral artery distribution infarctions after surgery.CONCLUSION:Although extracranial-intracranial bypasses protect the majority of patients who undergo carotid artery ligation from ischemic complications, this case demonstrates that hemodynamic insufficiency can occur even with a high-flow saphenous vein graft. Better ways to quantitate the hemodynamic needs of the brain after major vessel sacrifice may facilitate matching of the revascularization strategy to the specific needs of each patient, thus further reducing the likelihood of ischemic complications.

Journal

NeurosurgeryOxford University Press

Published: Aug 1, 1999

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