Hemodynamically significant stenosis of the internal carotid artery treated with endarterectomy. Case report

Repeated cerebral blood flow (CBF) measurements with xenon-133 inhalation and single photon emission tomography were performed in a patient suffering a minor stroke with subsequent orthostatic-provoked transient ischemic attacks (TIA's). Angiography revealed a thread-like internal carotid artery and an occluded external carotid artery on the side of the ischemic neurological symptoms. Computerized tomography and technetium-99m-pertechnetate brain scintigraphy 2 weeks after stroke were both normal. Before reconstructive vascular surgery, resting CBF showed a hypoperfused area corresponding to the clinical symptoms. Diamox (acetazolamide, 1 gm) increased CBF by 24% in the unaffected hemisphere, whereas even a slight decrease in flow ("steal") was seen in the maximally affected region. In contrast, theophylline (220 mg) reduced CBF in the unaffected hemisphere and caused a slight increase in the previously maximally hypoperfused area ("inverse steal"). After surgery, the flow pattern practically normalized and the TIA's disappeared. The CBF measurements before surgery and also after the injection of the vasoactive drugs indicated that focal hemodynamic insufficiency elicited the TIA's, and pointed at a low mean arterial blood pressure of about 35 mm Hg in the affected hemisphere. The perioperative finding of a mean blood pressure in the internal carotid artery of 31 mm Hg on the symptomatic side confirmed that the brain tissue had a severely reduced perfusion pressure. On clamping the artery, a stump pressure of 22 mm Hg and electroencephalogram flattening was noted, so a temporary internal shunt was inserted. The findings demonstrate that preoperative CBF measurements, including studies of the regional vasoreactivity, may identify patients with hemodynamic TIA's. These patients are at particular risk of developing cerebral ischemia during carotid endarterectomy, as any further compromise of the inflow may precipitate frank ischemia.