Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review

Abstract

Background: Carotid occlusive disease is a type of progressive disease resulting in ischemic stroke. Extracranialintracranial bypass surgery represents a valid therapeutic option when medical treatment does not make effects. The appearance of cerebral edema following bypass is common during acute stage. Additionally, there are many causes of mild cerebral edema, such as hemodynamic changes, venous congestion and others. However, severe edema involving large brain tissue, which presents as reversible aphasia and hemiplegia, remains to be elucidated. Case presentation: A 55-year-old man was admitted to the neurosurgery department for repeated dizziness for over a year and sudden onset of syncope 1 month prior, and he was diagnosed with carotid occlusive disease. After surgical contraindications were excluded, dual bypass and encephalo-duro-myo-synangiosis were performed. Although blood pressure and fluid management were strictly under control promptly after surgery, massive cerebral edema involving the left anterior cerebral artery and middle cerebral artery territories occurred from the 6th day after surgery. Additionally, no discernible cerebral infarction or hemorrhage occurred. Moreover, the cerebral blood flow of the middle cerebral artery displayed an early decrease followed by delayed elevation on the left side. Without restricting the spreading of cerebral edema, life-threatening cerebral herniation could develop at any time. Mannitol and furosemide were administered for impending cerebral herniation. The amelioration of symptoms was noticed on the 16th day after surgery. The patient felt relief on the 21st day after surgery. Digital subtraction angiography performed on the 180th day after surgery demonstrated the patency of dual anastomosed vessels, and the patient recovered without any permanent neurological deficit. Conclusion: Based on changes in cerebral blood flow and reversible symptoms, the "watershed shift" phenomenon could explain such a severe deficit. However, this deficit was not the same as the classical presentation of the "watershed shift", which involves a moderate amount of brain tissue and presents significant increases in cerebral blood flow. In addition to the "watershed shift", a swollen temporal muscle may also participate in the progression of focal edema.

Clinical effects and safety of edaravone in treatment of acute ischaemic stroke: A meta‐analysis of randomized controlled trials

“…The progress of the acute ischaemic stroke would trigger local blood flow disorder, tissue ischaemia, hypoxia, and eventually, nerve cell necrosis. At this time, patients tend to present with various clinical symptoms such as hemiplegia and aphasia, indicating clinically gradual deterioration 26 . Penumbra was proposed for the first time on the basis of a research conducted by Abstrup 27 .…”

“…At this time, patients tend to present with various clinical symptoms such as hemiplegia and aphasia, indicating clinically gradual deterioration. 26 Penumbra was proposed for the first time on the basis of a research conducted by Abstrup. 27 In the early stage of ischaemia, cells in the ischaemic penumbra region will incur irreversible damage if blood flow cannot be recovered in time.…”

Bibliometric and visual analysis of cerebral revascularization from 1999 to 2022

“…In recent years, with the continuous in-depth study of imaging technology and clinical understanding of carotid artery occlusion, an increasing number of clinical researchers have gradually realized that hemodynamic disorders play a crucial role in cerebral ischemia caused by carotid artery occlusion ( Tsukada et al, 2022 ). The study revealed that among patients with carotid artery occlusion receiving drug treatment ( Li et al, 2020 , 2022 ), the annual incidence of ipsilateral ischemic stroke was 3%, but the annual incidence of stroke increased to 10–20% in patients with severe cerebral hemodynamic disorders. The enhancement of brain hemodynamics has therefore received considerable attention from researchers.…”