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Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass
Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass Kampei Shimizu ⇑, Hirotoshi Imamura, Shoichi Tani, Nobuyuki Sakai Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe 650-0047, Japan
a r t i c l e
i n f o
Article history: Received 11 April 2017 Accepted 9 October 2017 Available online xxxx Keywords: Venous-phase delay Carotid artery occlusion Aneurysms Bypass Balloon test occlusion
a b s t r a c t The utility of superficial temporal artery to middle cerebral artery (STA-MCA) bypass before therapeutic internal carotid artery (ICA) occlusion is unclear. A 65-year-old woman with a symptomatic giant left paraclinoid ICA aneurysm underwent endovascular ICA occlusion following STA-MCA double bypass. Preoperative balloon test occlusion (BTO) demonstrated a venous-phase delay of 1.5 s. Only focal improvement in the venous-phase delay was observed immediately after treatment, but three-week postoperative angiography showed remarkable improvement of 0.5 s. To our knowledge, this is the first known case that demonstrates the effect of STA-MCA bypass on postoperative improvement in venousphase delay. Ó 2017 Elsevier Ltd. All rights reserved.
Therapeutic internal carotid artery (ICA) occlusion has often been an effective treatment option for complex ICA aneurysms or skull base tumors. In patients without ischemic tolerance, superficial temporal artery to middle cerebral artery (STA-MCA) bypass is performed prior to therapeutic ICA occlusion [1,2]. However, the nature of the improvements in hemodynamic parameters after STA-MCA bypass during perioperative period remains unclear. Preoperative assessment of venous-phase delay during balloon test occlusion (BTO) is a useful modality of assessing ischemic tolerance to ICA occlusion (i.e., venous-phase delay 1 s) [3]. Herein, we document a perioperative temporal change of venous-phase delay in a case of giant ICA aneurysms treated by therapeutic ICA occlusion with STA-MCA bypass.
venous-phase filling was compared between the occluded hemisphere and the cerebellum on the right vertebral angiogram, which demonstrated a delay of 1.5 s (Fig. 2a–c) [4]. She underwent endovascular ICA occlusion using detachable coils following STA-MCA (M4 portion) double bypass in a hybrid operating room (Fig. 3a). No event was recorded by intraoperative neurophysiological monitoring of somatosensory- and motor-evoked potentials. Postoperatively, she experienced transient motor aphasia, which disappeared within 72 h. Two-day postoperative magnetic resonance imaging (MRI) showed several small watershed infarctions (Fig. 3b–d). Only focal improvement in the venousphase delay was observed immediately after treatment, but three-week postoperative angiography showed a remarkable improvement of 0.5 s (Fig. 2d–i). After discharge, she has been free from ischemic events for 18 months.
2. Case report
3. Discussion
A 65-year-old woman with a symptomatic giant (diameter, 26 mm) left paraclinoid ICA aneurysm was admitted to our hospital (Fig. 1a and b). Venous-phase delay during BTO was calculated to assess ischemic tolerance to ICA occlusion (i.e., venous-phase delay 1 s). Venous-phase delay was defined as a delay in the appearance of the first cortical vein in the territory of the occluded artery. Since, in this case, collateral flow during BTO was mainly supplied via the posterior communicating artery (Fig. 1c and d),
Our case demonstrated the need to consider perioperative temporal change in hemodynamic parameters after STA-MCA bypass. Angiographic results and motor aphasia immediately after treatment suggested that patients require several days to achieve complete ischemic tolerance to ICA occlusion following revascularization by STA-MCA bypass. Motor aphasia during the first 3 days after ICA occlusion was attributable to temporary hemodynamic compromise in Broca’s area, which would be subsequently compensated by flow via the STA-MCA bypass. Indeed, infarctions demonstrated by postoperative MRI were small and occurred in only watershed areas that are irrelevant to neurologic
1. Introduction
⇑ Corresponding author. E-mail address: [email protected] (K. Shimizu). https://doi.org/10.1016/j.jocn.2017.10.031 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031
2
K. Shimizu et al. / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Fig. 1. Preoperative left internal carotid angiograms from anteroposterior (AP) (a) and lateral (LAT) (b) views show a giant paraclinoid internal carotid artery aneurysm. Right vertebral angiograms, AP view (c) and LAT view (d), during balloon test occlusion show collateral flow via the posterior communicating artery to the occluded hemisphere. Flows in the middle cerebral arteries are diffusely supplied but are weak and delayed compared with posterior circulation.
Fig. 2. (a–c) Preoperative right vertebral angiograms (VAGs) in the anteroposterior (AP) view during balloon test occlusion from 0.5 to 1.5 s after the appearance of the first cerebellar vein showed a venous-phase delay of 1.5 s (black arrow). (d–f) Right VAGs in the AP view at the same phase as a–c just after treatment showed only focal improvement in venous-phase delay (white arrowheads). (g–i) Right VAGs in the AP views at the same phase as a–c three weeks postoperatively show remarkable improvement in the venous-phase delay of 0.5 s (black arrowhead). The frame rate is 2 frames/s.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031
K. Shimizu et al. / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 3. (a) Left common carotid angiograms at 3-week postoperatively showing occlusion of the ICA and the patency of the STA-MCA double bypass. (b–d) Diffusion-weighted images 2-day postoperatively showing small watershed infarctions.
symptoms. Therefore, postoperative improvements in venousphase delay after STA-MCA bypass could be beneficial for patients. Recent studies have shown that a venous-phase delay of 1 s was a robust criterion for ischemic tolerance to therapeutic ICA occlusion [3], whereas a delay of 1–2 s was associated with perioperative ischemic events [1]. Our angiographic results were consistent with previous data, suggesting that STA-MCA bypass prior to therapeutic ICA occlusion in patients with venous-phase delay of 1–2 s was effective for preventing perioperative major or delayed (31 days postoperatively) ischemic events, although it could not prevent perioperative minor events [1]. To our knowledge, this is the first known case that presents the effect of STA-MCA bypass on the postoperative improvement of venous-phase delay in the context of therapeutic ICA occlusion. Disclosures None.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Shimizu K, Imamura H, Mineharu Y, Adachi H, Sakai C, Tani S, et al. Endovascular parent-artery occlusion of large or giant unruptured internal carotid artery aneurysms: a long-term single-center experience. J Clin Neurosci 2017;37:73–8. https://doi.org/10.1016/j.jocn.2016.11.009. [2] Hara T, Arai S, Goto Y, Takizawa T, Uchida T. Bypass surgeries in the treatment of cerebral aneurysms. Acta Neurochir Suppl 2016;123:57–64. https://doi.org/ 10.1007/978-3-319-29887-0_8. [3] Bechan RS, Majoie CB, Sprengers ME, Peluso JP, Sluzewski M, van Rooij WJ. Therapeutic internal carotid artery occlusion for large and giant aneurysms: a single center cohort of 146 patients. AJNR Am J Neuroradiol 2016;37:125–9. https://doi.org/10.3174/ajnr.A4487. [4] Abud DG, Spelle L, Piotin M, Mounayer C, Vanzin JR, Moret J. Venous phase timing during balloon test occlusion as a criterion for permanent internal carotid artery sacrifice. AJNR Am J Neuroradiol 2005;26:2602–9.
Patient consent The patient provided consent for the publication of this case report.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass Kampei Shimizu ⇑, Hirotoshi Imamura, Shoichi Tani, Nobuyuki Sakai Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe 650-0047, Japan
a r t i c l e
i n f o
Article history: Received 11 April 2017 Accepted 9 October 2017 Available online xxxx Keywords: Venous-phase delay Carotid artery occlusion Aneurysms Bypass Balloon test occlusion
a b s t r a c t The utility of superficial temporal artery to middle cerebral artery (STA-MCA) bypass before therapeutic internal carotid artery (ICA) occlusion is unclear. A 65-year-old woman with a symptomatic giant left paraclinoid ICA aneurysm underwent endovascular ICA occlusion following STA-MCA double bypass. Preoperative balloon test occlusion (BTO) demonstrated a venous-phase delay of 1.5 s. Only focal improvement in the venous-phase delay was observed immediately after treatment, but three-week postoperative angiography showed remarkable improvement of 0.5 s. To our knowledge, this is the first known case that demonstrates the effect of STA-MCA bypass on postoperative improvement in venousphase delay. Ó 2017 Elsevier Ltd. All rights reserved.
Therapeutic internal carotid artery (ICA) occlusion has often been an effective treatment option for complex ICA aneurysms or skull base tumors. In patients without ischemic tolerance, superficial temporal artery to middle cerebral artery (STA-MCA) bypass is performed prior to therapeutic ICA occlusion [1,2]. However, the nature of the improvements in hemodynamic parameters after STA-MCA bypass during perioperative period remains unclear. Preoperative assessment of venous-phase delay during balloon test occlusion (BTO) is a useful modality of assessing ischemic tolerance to ICA occlusion (i.e., venous-phase delay 1 s) [3]. Herein, we document a perioperative temporal change of venous-phase delay in a case of giant ICA aneurysms treated by therapeutic ICA occlusion with STA-MCA bypass.
venous-phase filling was compared between the occluded hemisphere and the cerebellum on the right vertebral angiogram, which demonstrated a delay of 1.5 s (Fig. 2a–c) [4]. She underwent endovascular ICA occlusion using detachable coils following STA-MCA (M4 portion) double bypass in a hybrid operating room (Fig. 3a). No event was recorded by intraoperative neurophysiological monitoring of somatosensory- and motor-evoked potentials. Postoperatively, she experienced transient motor aphasia, which disappeared within 72 h. Two-day postoperative magnetic resonance imaging (MRI) showed several small watershed infarctions (Fig. 3b–d). Only focal improvement in the venousphase delay was observed immediately after treatment, but three-week postoperative angiography showed a remarkable improvement of 0.5 s (Fig. 2d–i). After discharge, she has been free from ischemic events for 18 months.
2. Case report
3. Discussion
A 65-year-old woman with a symptomatic giant (diameter, 26 mm) left paraclinoid ICA aneurysm was admitted to our hospital (Fig. 1a and b). Venous-phase delay during BTO was calculated to assess ischemic tolerance to ICA occlusion (i.e., venous-phase delay 1 s). Venous-phase delay was defined as a delay in the appearance of the first cortical vein in the territory of the occluded artery. Since, in this case, collateral flow during BTO was mainly supplied via the posterior communicating artery (Fig. 1c and d),
Our case demonstrated the need to consider perioperative temporal change in hemodynamic parameters after STA-MCA bypass. Angiographic results and motor aphasia immediately after treatment suggested that patients require several days to achieve complete ischemic tolerance to ICA occlusion following revascularization by STA-MCA bypass. Motor aphasia during the first 3 days after ICA occlusion was attributable to temporary hemodynamic compromise in Broca’s area, which would be subsequently compensated by flow via the STA-MCA bypass. Indeed, infarctions demonstrated by postoperative MRI were small and occurred in only watershed areas that are irrelevant to neurologic
1. Introduction
⇑ Corresponding author. E-mail address: [email protected] (K. Shimizu). https://doi.org/10.1016/j.jocn.2017.10.031 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031
2
K. Shimizu et al. / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Fig. 1. Preoperative left internal carotid angiograms from anteroposterior (AP) (a) and lateral (LAT) (b) views show a giant paraclinoid internal carotid artery aneurysm. Right vertebral angiograms, AP view (c) and LAT view (d), during balloon test occlusion show collateral flow via the posterior communicating artery to the occluded hemisphere. Flows in the middle cerebral arteries are diffusely supplied but are weak and delayed compared with posterior circulation.
Fig. 2. (a–c) Preoperative right vertebral angiograms (VAGs) in the anteroposterior (AP) view during balloon test occlusion from 0.5 to 1.5 s after the appearance of the first cerebellar vein showed a venous-phase delay of 1.5 s (black arrow). (d–f) Right VAGs in the AP view at the same phase as a–c just after treatment showed only focal improvement in venous-phase delay (white arrowheads). (g–i) Right VAGs in the AP views at the same phase as a–c three weeks postoperatively show remarkable improvement in the venous-phase delay of 0.5 s (black arrowhead). The frame rate is 2 frames/s.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031
K. Shimizu et al. / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 3. (a) Left common carotid angiograms at 3-week postoperatively showing occlusion of the ICA and the patency of the STA-MCA double bypass. (b–d) Diffusion-weighted images 2-day postoperatively showing small watershed infarctions.
symptoms. Therefore, postoperative improvements in venousphase delay after STA-MCA bypass could be beneficial for patients. Recent studies have shown that a venous-phase delay of 1 s was a robust criterion for ischemic tolerance to therapeutic ICA occlusion [3], whereas a delay of 1–2 s was associated with perioperative ischemic events [1]. Our angiographic results were consistent with previous data, suggesting that STA-MCA bypass prior to therapeutic ICA occlusion in patients with venous-phase delay of 1–2 s was effective for preventing perioperative major or delayed (31 days postoperatively) ischemic events, although it could not prevent perioperative minor events [1]. To our knowledge, this is the first known case that presents the effect of STA-MCA bypass on the postoperative improvement of venous-phase delay in the context of therapeutic ICA occlusion. Disclosures None.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Shimizu K, Imamura H, Mineharu Y, Adachi H, Sakai C, Tani S, et al. Endovascular parent-artery occlusion of large or giant unruptured internal carotid artery aneurysms: a long-term single-center experience. J Clin Neurosci 2017;37:73–8. https://doi.org/10.1016/j.jocn.2016.11.009. [2] Hara T, Arai S, Goto Y, Takizawa T, Uchida T. Bypass surgeries in the treatment of cerebral aneurysms. Acta Neurochir Suppl 2016;123:57–64. https://doi.org/ 10.1007/978-3-319-29887-0_8. [3] Bechan RS, Majoie CB, Sprengers ME, Peluso JP, Sluzewski M, van Rooij WJ. Therapeutic internal carotid artery occlusion for large and giant aneurysms: a single center cohort of 146 patients. AJNR Am J Neuroradiol 2016;37:125–9. https://doi.org/10.3174/ajnr.A4487. [4] Abud DG, Spelle L, Piotin M, Mounayer C, Vanzin JR, Moret J. Venous phase timing during balloon test occlusion as a criterion for permanent internal carotid artery sacrifice. AJNR Am J Neuroradiol 2005;26:2602–9.
Patient consent The patient provided consent for the publication of this case report.
Please cite this article in press as: Shimizu K et al. Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.031