Cerebral revascularization with superficial temporal – middle cerebral artery anastomosis for complete carotid occlusion: An emerging modality for preventing recurrent stroke
A 60-year-old man presented with recurrent episodes of transient ischemic attacks (TIA) in the form of weakness involving the left side of the face, upper limb and lower limb since 3 months. He had recently been detected to be hypertensive and was on antihypertensive medications. He had no other risk factors for stroke (diabetes, hypercholesterolemia, smoking, alcoholism, hyperhomocystenemia). He continued to have episodes of hemodynamic TIA despite best medical management. These were not related to exertion or valsalva maneuver and were thought to be postural, related to hemodynamic factors. While under evaluation in the hospital, he developed a major stroke involving the left upper and lower limbs from which he recovered only partially (power 3/5).\nRoutine blood investigations were normal. Computed tomography (CT) brain revealed multiple infarcts in the right cerebral hemisphere []. Echocardiogram and electrocardiography were normal. Color Doppler scan of the carotid arteries revealed total occlusion of the right ICA. This was confirmed with CT angiogram (CTA) and MR angiogram (MRA). DSA revealed total occlusion of the right ICA at its origin. There was poor collateral flow to the right hemisphere from the left ICA (across the anterior communicating artery) and from vertebrobasilar system due to an incomplete circle of Willis. There was no evidence of thrombus or embolus in any IC vessel []. This led to an inadequate perfusion of the right cerebral hemisphere resulting in recurrent TIAs. After the major stroke in the hospital, a repeat CT brain revealed a right middle cerebral artery (MCA) territory infarct. Single Photon Emission CT (SPECT) CT of the brain also revealed ischemia of the entire right cerebral hemisphere.\nIt was decided that medical management alone would not be sufficient to improve the cerebral vascularity of the right cerebral hemisphere and prevent further ischemic events. Hence a decision was made to revascularize the right cerebral hemisphere by performing a bypass procedure from superficial temporal artery (STA) to the MCA. Pre-operative trans-cranial Doppler (TCD) could not pick up any flow in the MCA. The STA was localized using Doppler and superficial temporal-MCA (ST-MCA) anastomosis performed in the standard fashion [Figures and ].\nPost-operative recovery was uneventful. Aspirin was continued throughout the peri-operative period to prevent graft thrombosis. Post-operative CT and MRA and DSA confirmed good flow across the graft []. Post-operative TCD was not performed so as not to apply any pressure over the anastomotic area that would lead to thrombosis of the anastomosis. He did not develop any further episodes of TIA and was discharged after 10 days of hospital stay. At 2 months follow-up, he was asymptomatic and was improving from his previous deficits with grade 4/5 power in the left upper and lower limbs and was ambulant. SPECT is planned at the 6 monthly follow-up visit.