Surgical Neurology International

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1 Surgicl Neurology Interntionl SNI: Unique Cse Oservtions, supplement to Surgicl Neurology Interntionl OPEN ACCESS For entire Editoril Bord visit : Editor: Jmes I. Ausmn, MD, PhD University of Cliforni, Los Angeles, CA, USA Superficil temporl rtery to middle cererl rtery nstomosis for neovsculr glucom due to common crotid rtery occlusion Shusuke Ymmoto, Din Kshiwzki, Noki Akiok, Noy Kuwym, Stoshi Kurod Deprtment of Neurosurgery, Grdute School of Medicine nd Phrmcologicl Science, University of Toym, 2630 Sugitni, Toym , Jpn E mil: *Shusuke Ymmoto - s.ymmoto1007@gmil.com; Din Kshiwzki - gktqx702@yhoo.co.jp; Noki Akiok - kiok@med.u-toym.c.jp; Noy Kuwym - kuwym@med.u-toym.c.jp; Stoshi Kurod - skurod@med.u-toym.c.jp *Corresponding uthor Received: 28 Jnury 15 Accepted: 09 My 15 Pulished: 25 June 15 This rticle my e cited s: Ymmoto S, Kshiwzki D, Akiok N, Kuwym N, Kurod S. Superficil temporl rtery to middle cererl rtery nstomosis for neovsculr glucom due to common crotid rtery occlusion. Surg Neurol Int 2015;6:S Aville FREE in open ccess from: Copyright: 2015 Ymmoto S. This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution License, which permits unrestricted use, distriution, nd reproduction in ny medium, provided the originl uthor nd source re credited. Astrct Bckground: Common crotid rtery (CCA) occlusion sometimes requires surgicl revsculriztion to resolve persistent cererl/oculr ischemi. High flow ypss is often indicted in these cses, using the interposed grft such s sphenous vein nd rdil rtery. However, high flow ypss surgery is invsive nd my provide excessive lood flow to ischemic rin. In this report, we present cse tht developed neovsculr glucom due to CCA occlusion nd ws successfully treted with superficil temporl rtery to middle cererl rtery (STA MCA) nstomosis. Cse Description: A 61 yer old mle complined of left visul disturnce nd ws dmitted to our hospitl. He underwent crotid endrterectomy for left internl crotid rtery stenosis in previous hospitl 1 yer efore, ut he experienced left visul disturnce fter surgery. Postopertive exmintions reveled tht the CCA ws occluded. His visul disturnce grdully progressed, nd he ws dignosed s neovsculr glucom. None of ophthlmologicl therpy could improve his symptoms. Blood flow mesurement showed n impired rectivity to cetzolmide in the left cererl hemisphere. Cererl ngiogrphy demonstrted tht the left STA ws opcified through the musculr rnches from the left deep cervicl rtery. Therefore, he successfully underwent left STA MCA doule nstomosis. His visul cuity improved nd new lood vessels round the iris mrkedly decresed 3 months fter surgery. Conclusions: Precise rdiologicl exmintion my enle stndrd STA MCA nstomosis even in ptients with CCA occlusion. Access this rticle online Wesite: DOI: / Quick Response Code: Key Words: Common crotid rtery occlusion, neovsculr glucom, superficil temporl rtery to middle cererl rtery nstomosis INTRODUCTION Common crotid rtery (CCA) occlusion is rre, ut sometimes requires surgicl revsculriztion to resolve persistent cererl ischemi. In ptients with CCA occlusion, however, high flow ypss surgery is often indicted, ecuse the superficil temporl rtery (STA), one of the terminl rnches of the externl crotid S304

2 SNI: Unique Cse Oservtions 2015, Vol 6: Suppl 9 - A Supplement to Surgicl Neurology Interntionl rtery (ECA), is not ville s the donor grft. Usully, sphenous vein grft is used s n interposed grft in high flow ypss for CCA occlusion. [1,24] However, high flow ypss is invsive nd excessive lood flow through ypss grft my sometimes provoke postopertive hyperperfusion. [4] In this report, we present cse tht developed neovsculr glucom due to the ipsilterl CCA occlusion. By mximlly utilizing the collterl circultion in the externl crotid system, stndrd STA to middle cererl rtery (STA MCA) doule nstomosis could successfully e performed nd drmticlly improved glucom relted symptoms. Less invsive STA MCA nstomosis my e indicted in certin sugroup of ptients with CCA occlusion, when the STA still keeps enough collterl circultion. CASE REPORT A 61 yer old mle complined of left visul disturnce nd ws dmitted to our hospitl. He underwent crotid endrterectomy for left internl crotid rtery (ICA) stenosis in previous hospitl 1 yer efore, ut he experienced left visul disturnce fter surgery. Postopertive exmintions reveled tht the operted CCA ws completely occluded. Additionl surgery ws not performed. His visul disturnce grdully progressed, nd he ws dignosed s neovsculr glucom. None of ophthlmologicl therpy could improve his symptoms. Neurologicl exmintion on dmission reveled nisocori. The size of pupils ws 3.5 mm nd 5.5 mm in the right nd left side, respectively. Light reflex ws sent in the left side. Left visul disturnce ws severe (20/400 vision). Introculr pressure ws elevted up to 38 mmhg in the left side. No prenchyml lesion ws oserved on rin mgnetic resonnce (MR) imging. However, MR ngiogrphy demonstrted tht the left CCA nd left verterl rtery were completely occluded. 123 I IMP single photon emission computed tomogrphy (SPECT) showed n impired rectivity to cetzolmide in the territory of the left ICA [Figure 1]. On cererl ngiogrphy, the left CCA ws occluded t the origin. Left nterior cererl rtery nd MCA were opcified vi the nterior communicting rtery on right crotid ngiogrm. Left suclvin ngiogrm showed the development of collterl circultion to the left ICA through the left ECA. Thus, the deep cervicl rtery extensively supplied collterl lood flow to the distl prt of the left occipitl rtery. The lood flowed to the proximl prt of the left ECA with retrogrde fshion, nd then to the left ICA vi the left ophthlmic rtery [Figure 2]. At the sme time, the left STA ws opcified without significnt dely [Figure 2]. Ultrsound exmintion lso reveled the reversed lood flow in the left ophthlmic rtery. The pek systolic flow velocity ws 40 cm/s, suggesting tht oculr ischemi ws closely relted to severe neovsculr glucom in this cse [Figure 3]. [7] Bsed on these findings, he underwent left STA MCA doule nstomosis to resolve the reversed lood flow in the left ophthlmic rtery nd improve his glucom relted symptoms. The frontl nd prietl rnches of the STA were crefully dissected under surgicl microscope. We could confirm tht the lood flow from the distl end of the ipsilterl STA hd enough high pressure during surgery. The rnches of STA were nstomosed to the frontl nd temporl rnches of the MCA with n end to side fshion, respectively. The ptency ws confirmed during surgery, using indocynine green videongiogrphy. Postopertive course ws uneventful. Postopertive SPECT study performed 2 weeks fter surgery demonstrted tht the rectivity to cetzolmide completely recovered in the territory of the left MCA [Figure 4]. Postopertive cererl ngiogrphy demonstrted tht STA MCA nstomosis supplied enough lood flow to the operted hemisphere [Figure 5]. Follow up ultrsound exmintion lso reveled tht the reversed lood flow in the left ophthlmic rtery improved from 40 cm/s to 20 cm/s t 6 dys fter surgery [Figure 3]. His visul disturnce did not deteriorte for these 21 months fter surgery. Anorml lood vessels round the iris grdully decresed nd disppered. Introculr pressure decresed from 38 to 16 mmhg. DISCUSSION Figure 1: Preopertive single photon emission computed tomogrphy findings of cererl lood flow efore () nd fter intrvenous injection of cetzolmide. () Cererl lood flow ws kept within norml, ut the rectivity to cetzolmide ws impired in the left middle cererl rtery territory (rrows) Common crotid rtery occlusion is rrely recognized in 0.5 5% of totl popultion, which is much less frequent thn ICA occlusion. [3,5,12,13,18] Becuse collterl circultion S305

3 SNI: Unique Cse Oservtions 2015, Vol 6: Suppl 9 - A Supplement to Surgicl Neurology Interntionl Figure 2: Preopertive cererl ngiogrphy. () Erly rteril phse of left suclvin ngiogrm. Lterl view: The occipitl rtery (OA) ws opcified through the deep cervicl rtery. Then the retrogrde lood flow of the OA opcified the min trunk of the externl crotid rtery nd then superficil temporl rtery. () Lte rteril phse of left suclvin ngiogrm. Lterl view: Note tht the internl crotid rtery ws opcified through the retrogrde lood flow of the ophthlmic rtery (OphA, rrow) Figure 3: Ultrsound findings of left ophthlmic rtery efore () nd fter () superficil temporl rtery to middle cererl rtery (STA-MCA) nstomosis. Note the decrese in systolic velocity of retrogrde lood flow in the ophthlmic rtery (rrows) Figure 4: Postopertive single photon emission computed tomogrphy findings of cererl lood flow efore () nd fter intrvenous injection of cetzolmide. () Note tht the rectivity to cetzolmide completely recovered in the left middle cererl rtery territory extensively develops in most cses, it is further rre to require surgicl revsculriztion for CCA occlusion. However, ypss surgery is necessry in ptients who develop ischemic ttcks due to hemodynmic compromise. [6] The most common technique performed for CCA occlusion is suclvin rtery to crotid rtery ypss, using n interposed grft from the sphenous vein. [9] Riles et l. (1984) clssified CCA occlusion into four types from surgicl viewpoints. [18] They defined CCA occlusion with the ptent externl nd/or internl crotid rteries s Type 1. In Type 1A ptients, oth the externl nd internl crotid rteries were ptent. In Type 1B ptients, only the ECA ws ptent. In Type 1C ptients, only the ICA ws ptent. On the other hnds, they defined CCA occlusion with the occluded externl nd Figure 5: Postopertive ngiogrphy. Erly () nd lte rteril phse of left suclvin ngiogrm () reveled tht superficil temporl rtery to middle cererl rtery doule nstomosis supplied enough collterl lood flow to the operted hemisphere internl crotid rteries s Type 2. Their clssifiction is quite importnt to decide the surgicl strtegy for CCA occlusion. According to their clssifiction, the present cse cn e clssified into Type 1B. In previous reports, mjority of ptients with symptomtic CCA occlusion hve een clssified into Types 1A or 1B. [14,18] The ptients with Type 1A CCA occlusion re potentilly t high risk for oth rtery to rtery emolism nd hemodynmic stroke, which lrgely depends on S306

4 SNI: Unique Cse Oservtions 2015, Vol 6: Suppl 9 - A Supplement to Surgicl Neurology Interntionl the development of collterl circultion in ech cse. [18,24] Previously, surgicl options for them include ortic rch to ICA ypss, suclvin rtery to MCA ypss, xillry rtery to ICA ypss, hlf collr ypss, trnsverse cervicl rtery to ECA ypss, nd verterl rtery to ICA. [1,9,16,21] In ptients with Type 1B CCA occlusion, persistent reduction of perfusion pressure my induce ischemic ttcks due to inppropritely developed collterl circultion. [24] Previously, STA MCA nstomosis comined with suclvin, trnsverse cervicl, or thyrocervicl rtery to ECA ypss hs een indicted for them. Alterntively, contrlterl STA MCA ypss (Bonnet ypss) is lso reported. [15,22] Of course, ll of these procedures re rther invsive. However, the nturl course of CCA occlusion nd enefits of ypss surgery re uncler. [17,18] Therefore, surgicl tretment should e limited to selected ptients t high risk of future ischemic events, nd the procedure should e s noninvsive s possile. In this cse, preopertive cererl ngiogrphy reveled tht the extensive formtion of collterl circultion mintined the nterogrde lood flow of the ipsilterl STA. In ddition, we could confirm tht the lood flow from the distl end of the ipsilterl STA hd enough high pressure during surgery. Considering these rdiologicl nd intropertive findings, we determined to employ the left STA s donor. In fct, STA MCA nstomosis could e performed without ny prolem sfely nd less invsively, nd provided enough collterl lood flow to the operted hemisphere, improving neovsculr glucom. In this cse, we did not mesure the lood pressure of the operted STA during surgery. However, Aso et l. previously proposed tht the STA is suitle for use s donor rtery when the rtio of STA pressure to systemic lood pressure exceeds 90%. [2] Therefore, it would e etter to monitor the lood pressure in the nstomosed STA during surgery to yield enough ypss flow through STA MCA nstomosis. Common crotid rtery occlusion does not lwys cuse visul disturnce. However, the symptom is the only clinicl sign in some ptients with CCA occlusion. [11] Beneficil effects of revsculriztion on visul disturnce is still uncler in ptients with crotid occlusion. There re few reports tht demonstrte significnt improvement of visul cuity fter STA MCA nstomosis for ICA stenosis or occlusion. [7,10,19,20,23,25] However, STA-MCA nstomosis my e useful to inhiit the progression of visul disturnce y improving retinl circultion. [7,8,10,19,20,23] In fct, surgicl revsculriztion ttenuted retrogrde lood flow in the ophthlmic rtery nd could improve the signs of neovsculr glucom in our cse, lthough visul cuity did not improve proly ecuse of long term ischemi of retin. [11] Therefore, erly pproprite dignosis nd tretment would e essentil to improve the visul cuity in ptients with crotid occlusive diseses. CONCLUSION The uthors present cse with neovsculr glucom due to CCA occlusion. Extensive formtion of collterl circultion enled us to perform stndrd STA MCA nstomosis sfely nd less invsively. Enough lood flow through ypss grft cesed the deteriortion of visul cuity nd resolve norml lood vessels round the iris. Less invsive STA MCA nstomosis should e considered s one of the surgicl options for the certin ptients with CCA occlusion. REFERENCES 1. Archie JP Jr. Axillry to crotid rtery ypss grfting for symptomtic severe common crotid rtery occlusive disese. J Vsc Surg 1999;30: Aso K, Ogswr K, Koyshi M, Yoshid K. Arteril ypss surgery using spontneously formed onnet superficil temporl rtery in ptient with symptomtic common crotid rtery occlusion: Cse report. Neurosurgery 2010;67:onsE Collice M, D Angelo V, Aren O. Surgicl tretment of common crotid rtery occlusion. Neurosurgery 1983;12: Crocker M, Wlsh D, Epliynge P, Tolis CM. Excimer lser ssisted non occlusive cererl vsculr nstomosis (ELANA): Review of the first UK experience. Br J Neurosurg 2010;24: Cull DL, Hnsen JC, Tylor SM, Lngn EM 3 rd, Snyder BA, Coffey CB. Internl crotid rtery ptency following common crotid rtery occlusion: Mngement of the symptomtic ptient. Ann Vsc Surg 1999;13: Hshimoto Y, Kin S, Hrguchi K, Niw J. Two symptomtic cses of common crotid rtery occlusion. Jpn J Neurosurg 2005;14: Kwguchi S, Skki T, Kmd K, Iwng H, Nishikw N. Effects of superficil temporl to middle cererl rtery ypss for ischemic retinopthy due to internl crotid rtery occlusion/stenosis. Act Neurochir (Wien) 1994;129: Kwguchi S, Skki T, Urnishi R, Id Y. Effect of crotid endrterectomy on the ophthlmic rtery. Act Neurochir (Wien) 2002;144: Kzumt K, Asok K, Yokoym Y, Sugiym T, Kneko S, Itmoto K. Isolted crotid ifurction nd verterl crotid rtery ypss for common crotid rtery occlusion. Neurol Med Chir (Tokyo) 2013;53: Kerns TP, Siekert RG, Sundt TM Jr. The oculr spects of ypss surgery of the crotid rtery. Myo Clin Proc 1979;54: Koyshi T, Houkin K, Kurod S, Sito H, Iwski Y. Internl crotid rtery occlusive disese presected with visul disturnce: A retrospective study. Surg Cere Stroke (JPN) 2002;30: Levine SR, Welch KM. Common crotid rtery occlusion. Neurology 1989;39: Mrtin RS 3 rd, Edwrds WH, Mulherin JL Jr, Edwrds WH Jr. Surgicl tretment of common crotid rtery occlusion. Am J Surg 1993;165: McGuiness CL, Short DH, Kerstein MD. Suclvin externl crotid ypss for symptomtic severe cererl ischemi from common nd internl crotid rtery occlusion. Am J Surg 1988;155: Melgr MA, Weinnd ME. Thyrocervicl trunk externl crotid rtery ypss for positionl cererl ischemi due to common crotid rtery occlusion. Report of three cses. Neurosurg Focus 2003;14:e Ngsw S, Tnk H, Kwnishi M, Oht T. Contrlterl externl crotid to externl crotid rtery (hlf collr) sphenous vein grft for common crotid rtery occlusion. Surg Neurol 1996;45: Podore PC, Ro CG, DeWeese JA, Green RM. Chronic common crotid occlusion. Stroke 1981;12: Riles TS, Imprto AM, Posner MP, Eikeloom BC. Common crotid occlusion. Assessment of the distl vessels. Ann Surg 1984;199: Shiuy M, Suzuki Y, Tkysu M, Sugit K. Effects of STA MCA nstomosis for ischemic oculopthy due to occlusion of the internl crotid rtery. Act Neurochir (Wien) 1990;103: Sivlingm A, Brown GC, Mgrgl LE. The oculr ischemic syndrome. III. S307

5 SNI: Unique Cse Oservtions 2015, Vol 6: Suppl 9 - A Supplement to Surgicl Neurology Interntionl Visul prognosis nd the effect of tretment. Int Ophthlmol 1991;15: Spetzler RF, Rhodes RS, Roski RA, Likvec MJ. Suclvin to middle cererl rtery sphenous vein ypss grft. J Neurosurg 1980;53: Spetzler RF, Roski RA, Rhodes RS, Modic MT. The onnet ypss. Cse report. J Neurosurg 1980;53: Stndefer M, Little JR, Tomsk R, Furln AJ, Zegrr H, Willims G. Improvement in the retinl circultion fter superficil temporl to middle cererl rtery ypss. Neurosurgery 1985;16: Sullivn TM. Suclvin crotid ypss to n isolted crotid ifurction: A retrospective nlysis. Ann Vsc Surg 1996;10: Young LH, Appen RE. Ischemic oculopthy. A mnifesttion of crotid rtery disese. Arch Neurol 1981;38: S308