Slowly progressive neuronal death associated with postischemic hyperperfusion in cortical laminar necrosis after high-flow bypass for a carotid intracavernous aneurysm.
The authors report a rare case of slowly progressive neuronal death associated with postischemic hyperperfusion in cortical laminar necrosis after radial artery/external carotid artery-middle cerebral artery bypass graft surgery for an intracavernous carotid artery aneurysm. Under barbiturate protection, a 69-year-old man underwent high-flow bypass surgery combined with carotid artery sacrifice for a symptomatic intracavernous aneurysm. The patient became restless postoperatively, and this restlessness peaked on postoperative Day (POD) 7. Diffusion-weighted and FLAIR MR images obtained on PODs 1 and 7 revealed subtle cortical hyperintensity in the temporal cortex subjected to temporary occlusion. On POD 13, (123)I-iomazenil ((123)I-IMZ) SPECT clearly showed increased distribution on the early image and mildly decreased binding on the delayed image with count ratios of the affected-unaffected corresponding regions of interest of 1.23 and 0.84, respectively, suggesting postischemic hyperperfusion. This was consistent with the finding on (123)I-iodoamphetamine SPECT. Of note, neuronal density in the affected cortex on the delayed (123)I-IMZ image further decreased to the affected/unaffected ratio of 0.44 on POD 55 during the subacute stage when characteristic cortical hyperintensity on T1-weighted MR imaging, typical of cortical laminar necrosis, was emerging. The affected cortex showed marked atrophy 8 months after the operation despite complete neurological recovery. This report illustrates, for the first time, dynamic neuroradiological correlations between slowly progressive neuronal death shown by (123)I-IMZ SPECT and cortical laminar necrosis on MR imaging in human stroke.
Iihara
Koji
K
Department of Neurosurgery, National Cardiovascular Center, Osaka, Japan. kiihara@hsp.ncvc.go.jp
Okawa
Masakazu
M
Hishikawa
Tomohito
T
Yamada
Naoaki
N
Fukushima
Kazuhito
K
Iida
Hidehiro
H
Miyamoto
Susumu
S
D000368:Aged; D001284:Atrophy; D001783:Blood Flow Velocity / Q000502:physiology; D001925:Brain Damage, Chronic / Q000473:pathology*; D001929:Brain Edema / Q000473:pathology; D002545:Brain Ischemia / Q000473:pathology*; D002340:Carotid Artery Diseases / Q000473:pathology / Q000601:surgery*; D002426:Cavernous Sinus / Q000601:surgery*; D016923:Cell Death / Q000502:physiology*; D002533:Cerebral Angiography; D002540:Cerebral Cortex / Q000473:pathology*; D002548:Cerebral Revascularization; D038524:Diffusion Magnetic Resonance Imaging; D004292:Dominance, Cerebral / Q000502:physiology; D005500:Follow-Up Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D021621:Imaging, Three-Dimensional; D002532:Intracranial Aneurysm / Q000473:pathology / Q000601:surgery*; D018810:Magnetic Resonance Angiography; D008297:Male; D009410:Nerve Degeneration / Q000473:pathology; D009460:Neurologic Examination; D011183:Postoperative Complications / Q000473:pathology*; D015427:Reperfusion Injury / Q000473:pathology*; D013702:Temporal Lobe / Q000473:pathology; D015899:Tomography, Emission-Computed, Single-Photon