Elsevier

World Neurosurgery

Volume 115, July 2018, Pages 143-146
World Neurosurgery

Case Report
Hyperperfusion syndrome after trapping with high-flow bypass for a giant paraclinoid internal carotid artery aneurysm

https://doi.org/10.1016/j.wneu.2018.04.081Get rights and content

Highlights

  • A giant internal carotid artery aneurysm may have decreased cerebral blood flow on the side of the aneurysm.

  • Hyperperfusion syndrome may occur after high-flow bypass surgery for cerebral aneurysm.

  • Postoperative single photon emission computed tomography and arterial spin-labeling magnetic resonance perfusion imaging may be useful in identifying potential cases of hyperperfusion syndrome.

Background

Hyperperfusion syndrome associated with aneurysm surgery is rare. The occurrence of the syndrome after trapping with high-flow bypass has not been described previously. Herein, we present a case of the syndrome that occurred after trapping with high-flow bypass of an unruptured giant paraclinoid internal carotid artery (ICA) aneurysm.

Case Description

The patient was a 68-year-old woman with progressive loss of vision in her left eye. After a diagnosis of left giant ICA aneurysm, she underwent successful trapping with high-flow bypass. No new neurologic deficits were observed after surgery. Computed tomography on the same day and magnetic resonance imaging on the next day revealed no hemorrhage or infarction. The patient had a headache and transit motor aphasia on postoperative day (POD) 8. Arterial spin-labeling magnetic resonance perfusion imaging on the same day and single photon emission CT on POD 10 demonstrated hyperperfusion in the left cerebral cortex. The symptoms gradually improved over a week, and she had no new neurologic deficits when discharged from hospital.

Conclusions

This report suggests that hyperperfusion syndrome after trapping with high-flow bypass, although rare, should be considered in patients with giant aneurysm if they present with headache and neurologic deficits after a delay.

Introduction

Hyperperfusion syndrome is known to occur after carotid endarterectomy, carotid artery stenting, and extracranial-intracranial bypass surgery. The syndrome has also been reported after aneurysmal surgery for a giant aneurysm after neck clipping and for a large aneurysm after flow diversion.1, 2, 3, 4, 5 However, to our knowledge, hyperperfusion syndrome has never been reported after trapping with high-flow bypass. We present a case of hyperperfusion syndrome after trapping with high-flow bypass of an unruptured giant paraclinoid internal carotid artery (ICA) aneurysm.

Section snippets

History

The patient, a 68-year-old right-handed woman, had symptoms of progressive loss of vision in her left eye and temporal visual field defect in her right eye. She had a history of hypertension and a family history of subarachnoid hemorrhage.

Examination

Magnetic resonance imaging (MRI) revealed a nonthrombotic left paraclinoid ICA giant aneurysm and local compression of the optic chiasma (Figure 1A). A three-dimensional time of flight magnetic resonance angiography also revealed attenuation in her ipsilateral

Discussion

Giant aneurysm has a dismal natural history and often results in hemorrhage, cerebral compression, and thromboembolism. Giant aneurysms of the intracranial ICA frequently involve the parent artery and critical neighboring branches, and direct surgical clip reconstruction is difficult in many cases. Trapping with high-flow bypass can completely exclude giant ICA aneurysms from the flow stream, promptly inducing thrombosis inside the aneurysm. Ischemia resulting from the bypass graft occlusion

Conclusion

When a giant ICA aneurysm, wherein blood flow is reduced on the side of the aneurysm, is trapped with high-flow bypass, the increase in blood flow through the bypass may lead to hyperperfusion syndrome. Postoperative SPECT and ASL-MRI may be useful in identifying potential cases of hyperperfusion syndrome.

Acknowledgment

The authors thank Editage (www.editage.jp) for English language editing.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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