Dataset Information

Cerebral hypoperfusion necessitating additional bypass following hunterian ligation of the internal carotid artery despite reassuring intraoperative challenges: Video case report.

ABSTRACT:

Background

Hunterian ligation has been adapted for complex intracranial aneurysm repair when other, more modern techniques are insufficient. Before drastic alteration of cerebral blood flow dynamics, intraoperative challenges and consideration of blood flow dynamics must be completed to ensure adequate perfusion postligation. On satisfaction, ligation may proceed; however, subtle changes related to hypoperfusion may not be immediately observed during intraoperative challenge under general anesthesia and/or before onset of the vasospasm window.

Case description

In this report, we describe a patient who presented with a Hunt-Hess Grade III subarachnoid hemorrhage (SAH), with a right internal carotid artery (ICA) occlusion and a ruptured giant left ICA aneurysm. Endovascular treatment of the aneurysm was aborted because the nominal, 9 mm diameter of the ICA was too large for any intracranial balloon or stent. Three days later, she underwent a left-sided "insurance" extracranial-tointracranial arterial bypass (EIAB) using the superficial temporal artery simultaneously with hunterian ligation of the left ICA following reassuring results on intraoperative occlusion challenge. Over several days, her neurologic condition declined concurrent with the vasospasm window, and a right-sided EIAB was required to augment vascular supply. Following a protracted hospital course, the patient became progressively more independent and is currently residing in an assisted living facility.

Conclusion

We illustrate an ultimately successful microsurgical treatment option in the setting of acute SAH that highlights the importance of cerebrovascular reserve and blood flow replacement in the setting of a compromised circle of Willis, especially during the vasospasm window.

SUBMITTER: Housley SB

PROVIDER: S-EPMC7881615 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ObjectiveWe have shown that almost 50% of patients with asymptomatic carotid stenosis (ACS) will demonstrate cognitive impairment. Recent evidence has suggested that cerebral hypoperfusion is an important cause of cognitive impairment. Carotid stenosis can restrict blood flow to the brain, with consequent cerebral hypoperfusion. In contrast, cross-hemispheric collateral compensation through the Circle of Willis, and cerebrovascular vasodilation can also mitigate the effects of flow restriction. It is, therefore, critical to develop a clinically relevant measure of net brain perfusion in patients with ACS that could help in risk stratification and in determining the appropriate treatment. To determine whether ACS results in cerebral hypoperfusion, we developed a novel approach to quantify interhemispheric cerebral perfusion differences, measured as the time to peak (TTP) and mean transit time (MTT) delays using perfusion-weighted magnetic resonance imaging (PWI) of the whole brain. To evaluate the utility of using clinical duplex ultrasonography (DUS) to infer brain perfusion, we also assessed the relationship between the PWI findings and ultrasound-based peak systolic velocity (PSV).MethodsStructural and PWI of the brain and magnetic resonance angiography of the carotid arteries were performed in 20 patients with ≥70% ACS. DUS provided the PSV, and magnetic resonance angiography provided plaque geometric measures at the stenosis. Volumetric perfusion maps of the entire brain from PWI were analyzed to obtain the mean interhemispheric differences for the TTP and MTT delays. In addition, the proportion of brain volume that demonstrated a delay in TTP and MTT was also measured. These proportions were measured for increasing severity of perfusion delays (0.5, 1.0, and 2.0 seconds). Finally, perfusion asymmetries on PWI were correlated with the PSV and stenosis features on DUS using Pearson's correlation coefficients.ResultsOf the 20 patients, 18 had unilateral stenosis (8 right and 10 left) and 2 had bilateral stenoses. The interhemispheric (left-right) TTP delays measured for the whole brain volume identified impaired perfusion in the hemisphere ipsilateral to the stenosis in 16 of the 18 patients. More than 45% of the patients had had ischemia in at least one half of their brain volume, with a TTP delay >0.5 second. The TTP and MTT delays showed strong correlations with PSV. In contrast, the correlations with the percentage of stenosis were weaker. The correlations for the PSV were strongest with the perfusion deficits (TTP and MTT delays) measured for the whole brain using our proposed algorithm (r = 0.80 and r = 0.74, respectively) rather than when measured on a single magnetic resonance angiography slice as performed in current clinical protocols (r = 0.31 and r = 0.58, respectively).ConclusionsInterhemispheric TTP and MTT delay measured for the whole brain using PWI has provided a new tool for assessing cerebral perfusion deficits in patients with ACS. Carotid stenosis was associated with a detectable reduction in ipsilateral brain perfusion compared with the opposite hemisphere in >80% of patients. The PSV measured at the carotid stenosis using ultrasonography correlated with TTP and MTT delays and might serve as a clinically useful surrogate to brain hypoperfusion in these patients.

Project description:The recent consensus by the Perioperative Quality Initiative (POQI) on intraoperative hypotension (IOH) stated that mean arterial pressure (MAP) below 60-70 mmHg is associated with myocardial infarction (MI), acute kidney injury (AKI), death and also that IOH is a function of not only severity but also of duration. However, most of the data come from large, heterogeneous cohorts of patients who underwent different surgical procedures and types of anaesthesia. We sought to assess how various definitions of IOH can predict clinically significant hypoperfusive outcomes in a homogenous cohort of generally anesthetised patients undergoing abdominal surgery, taking into account thresholds of MAP and their time durations. The data for this study come from a prospective cohort study in which patients who underwent abdominal surgery between 1 October 2018 and 15 July 2019 in the university hospital in Katowice were included in the analysis. We analysed perioperative data to assess how various IOH thresholds can predict hypoperfusive outcomes (defined as myocardial injury, acute kidney injury or stroke). 508 patients were included in the study. The total number of cases of clinically significant hypoperfusion was 38 (7.5%). We found that extending durations of low MAP, i.e., below 55 mmHg, 60 mmHg, 65 mmHg and 70 mmHg, were associated with the development of either AKI, MI or stroke. It was observed that for narrower and lower hypotension thresholds, the time required to induce complications is shorter. Patients who suffered from AKI/MI/Stroke experienced more episodes of any of the IOH definitions applied. Absolute IOH thresholds were superior to the relative definitions. For patients undergoing abdominal surgery, it is vital to prevent the extended durations of intraoperative mean arterial pressure below 70 mmHg. Finally, there appears to be no need to guide intraoperative haemodynamic therapy based on pre-induction values and, consequently, on relative drops of MAP.