BACKGROUND: Intracranial stenoses carry increased risk for cerebral ischemia. We perform external carotid-internal carotid (EC-IC) artery bypass in our patients with severe stenosis of the intracranial internal carotid (ICA) or middle cerebral artery (MCA) with impaired cerebral vasodilatory reserve (CVR).
OBJECTIVE: To evaluate cerebral hemodynamics and cerebral hyperperfusion syndrome (HPS) in patients who develop focal neurological deficits after EC-IC bypass surgery.
METHODS: Patients with severe intracranial ICA or MCA stenosis and impaired CVR on transcranial Doppler (TCD) derived breath-holding index (BHI) were evaluated with acetazolamide-challenged technetium-99m hexamethylpropyleneamineoxime–single-photon emission computed tomography (SPECT). EC-IC bypass surgery was offered to patients with impaired CVR on SPECT. Close monitoring was performed in patients developing focal neurological deficits within 7 days of surgery.
RESULTS: Of 112 patients with severe intracranial ICA/MCA stenosis, 77 (69%) showed impaired CVR and 46 (41%) underwent EC-IC bypass. Transient neurological deficits within 7 days of surgery developed in 8 (17%). HPS was confirmed by CT perfusion and/or SPECT in 7 cases. A strong correlation was observed between HPS and preoperative TCD-BHI values (0%, 6.3%, and 41% in patients with BHI 0.3-0.69, 0-0.3 and <0, respectively; P = .012). HPS patients showed more than a 50% increase in MCA flow velocity on TCD (compared with preoperative values) on the operated side (63.3% vs 3.3% on control side, P < .001). Meticulous control of blood pressure and hydration led to rapid and complete resolution of neurological deficits in all cases.
CONCLUSION: Symptomatic cerebral HPS is common in the early postoperative period after EC-IC bypass surgery. Early diagnosis and appropriate management might prevent the complications of this syndrome.
ABBREVIATIONS: BHI, breath-holding index
CVR, cerebral vasodilatory reserve
99Tc HMPAO, technetium-99m hexamethylpropyleneamineoxime
HPS, hyperperfusion syndrome
ICA, intracranial internal carotid
MCA, middle cerebral artery
SPECT, single-photon emission computed tomography
STA, superficial temporal artery
TCD, transcranial Doppler
*Division of Neurosurgery, National University Hospital, Singapore;
‡Division of Neurology, National University Hospital, Singapore;
§Department of Diagnostic Imaging, National University Hospital, Singapore;
‖Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Correspondence: Vijay K Sharma, MD, Division of Neurology, Department of Medicine National University Hospital Level 10, Tower Block1E Kent Ridge Rd, Singapore 119228. E-mail: firstname.lastname@example.org
Received September 09, 2012
Accepted January 29, 2013