Pre- and Postoperative Cerebral Haemodynamic Assessments and Multidisciplinary Team Management for Patients Undergoing Cerebral Revascularization Procedures: 2 Case Reports

Abstract

Background: Cerebrovascular bypasses are complex neurosurgical procedures with specific indications. Surgical risks and outcome are associated with the type of bypass intended and patient’s underlying conditions. A multidisciplinary team approach is therefore pivotal in the management of these bypass patients. Objective: The aim of this study is to provide an overview of the perioperative haemodynamic assessments and management of patients undergoing cerebral revasculaization with 2 illustrative cases. Case Report: Case 1: A 40-year-old male with cerebrovascular occlusive condition and recurrent transient ischaemic attacks (TIA’s) affecting his left side. Preoperative computed tomography (CT) brain perfusion and carbon dioxide (CO2) inhalation technique revealed poor cerebrovascular reserve (CVR) in the right middle cerebral artery (MCA) territory. The patient underwent a right superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. Case 2: A 56-year-old female with a left giant cavernous sinus aneurysm presented with left-sided intractable facial pain. Preoperative cerebral digital subtraction angiography (DSA) with carotid compression test revealed inadequate collateral circulation. She underwent a high flow, common carotid-middle cerebral artery bypass with saphenous vein graft and trapping of the giant aneurysm. Results: Case 1: Postoperative computed tomography angiography (CTA) brain scan on day 1 confirmed graft patency. The patient improved rapidly in strength of the left arm and right leg. CT brain perfusion scan at 3 months showed improved brain perfusion and CVR. Case 2: Postoperative CTA brain on day 1 confirmed graft patency. On day 3 post-operatively, she developed self-limiting left-sided ophthalmoplegia, which completely resolved by 6 weeks. CTA brain at 5 months showed patency of the bypass graft. There was no further facial pain or ophthalmoplegia at the last follow-up. Conclusion: Although many new surgical techniques had been developed, the outcome for patients undergoing bypass surgery remains highly dependent on multidisciplinary teamwork, detailed preoperative haemodynamic assessment, patient selection and perioperative care. Keywords: Cerebrovascular bypass; EC-IC bypass; STA-MCA bypass; Cerebral ischaemia; Cerebrovacular reserve; Balloon occlusion test