Role of the emergency extra-intracranial bypass in acute occlusive arterial disease: evidence in the literature as to the benefit to young patients and an illustrative case of a patient with extra- and intracranial traumatic internal carotid artery occlusion

Abstract

The extra-intracranial bypass has been used in the treatment of patients with chronic cerebrovascular insufficiency. More recent studies have demonstrated the benefit of this technique to patients with arterial occlusion in the acute phase. We relate the case of a 19-year-old patient, victim of cervical trauma, who presented evidence of intra- and extracranial internal carotid artery (ICA) occlusion and progressive intra hospital clinical worsening. He underwent a high-flow bypass surgery with NIHSS at 17, progressing with progressive intra hospital improvement and in the outpatient segment achieved a NIHSS of 2 in 6 months of follow-up. We discuss the role of high- and low-flow bypass in chronic occlusive arterial disease, based on a review of the literature. We conclude that in spite of there being a divergence as to the indication for, and benefits of, these techniques in chronic occlusive arterial disease, in the acute phase, there appears to be a more evident benefit mainly in the young patients, whose etiology is the dissection of the ICA.

Resumo

A anastomose extraintracraniana tem sido utilizada no tratamento de pacientes com insuficiência vascular cerebral crônica. Estudos mais recentes têm demonstrado os benefícios dessa técnica para pacientes com doença arterial oclusiva em sua fase aguda. Relatamos o caso de um jovem de 19 anos, vítima de trauma cervical fechado, que apresentou oclusão da artéria carótida interna (ACI) extra e intracraniana, evoluindo com piora neurológica progressiva. Foi submetido a anastomose de alto fluxo em fase aguda, evoluindo com melhora neurológica, progredindo de um NIHSS de 17 para NIHSS de 2 no seguimento após seis meses. Discutimos, ainda, o papel da anastomose de alto e baixo fluxo na doença arterial oclusiva crônica, com base em revisão da literatura. Concluímos que, embora haja divergência na indicação e nos possíveis benefícios, as técnicas de anastomoses podem proporcionar maior benefício para pacientes jovens, cuja principal etiologia é a dissecção arterial.

Keywords

Brain - cerebral revascularization - stroke - aneurism dissecting

Palavras-chave

Encéfalo - revascularização cerebral - acidente vascular cerebral - aneurisma dissecante

¹Neurosurgeon, Hospital São Camilo (Santana) and Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.

²Neurosurgeon, Hospital São Camilo (Santana) and Hospital dos Servidores Públicos do Estado de São Paulo (HSPE-SP), São Paulo, SP, Brazil.

³Anesthetist, Hospital São Camilo (Santana) and Escola Paulista de Medicina da Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brazil.

⁴Resident in Neurosurgery, Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP, Brazil.

⁵Vascular Surgeon, Hospital São Camilo (Santana) and Unifesp/EPM, São Paulo, SP, Brazil.

⁶Vascular Surgeon, Hospital São Camilo (Santana), São Paulo, SP, Brazil.

⁷Neurosurgeon, Department of Neurosurgery, ISCMSP, São Paulo, SP, Brazil.

⁸Radiologist, Hospital São Camilo (Santana), São Paulo, SP, Brazil.