Background: Patients with atherosclerotic intracranial occlusion are at high risk of recurrent hemodynamic stroke despite best medical management. Extracranial-Intracranial (EC-IC) bypass may benefit selected patients.
Case-report: A 47-yr old man with no risk factors except for hyperlipidemia (LDL 3.64 mmol/L) presented with sudden onset of left sided weakness. Neurologic examination revealed left hemiparesis.
MRI brain showed acute infarcts in a watershed distribution involving the right corona radiata, centrum semiovale and basal ganglia. CT angiogram revealed diffuse narrowing with reduced opacification of the right internal carotid artery (ICA) in the neck with non-opacification of the horizontal and vertical segments of the intracranial right ICA with multiple foci of atherosclerotic calcific plaques. There was diffuse narrowing of the right middle cerebral artery with markedly reduced arborization.
Young stroke workup was normal. He was treated with aspirin, clopidrogel, and statins. Two months later he developed recurrent hemodynamic stroke with giddiness.
MRI brain showed new acute infarcts in the right peritrigonal region and right corona radiata. Cerebral angiogram revealed diffuse small calibre right ICA secondary to distal chronic occlusion of the right supraclinoid-terminal ICA segment. LDL was 0.83 mmol/L.
In view of recurrent hemodynamic stroke with interim development of new infarcts despite best medical treatment, right superficial temporal artery-middle cerebral artery bypass was performed. Post procedure ICG showed patent bypass and good antegrade flow.
Conclusion: EC-IC bypass can be considered in patients with recurrent hemodynamic stroke due to symptomatic intracranial atherosclerosis despite best medical management.