抄録
Surgical treatment for multiple occlusive lesions of the intracranial and extracranial arteries are still controversial. We report 2 patients treated with successful results by multistaged surgical procedures. Case 1, a 65-year-old man, complained of transient ischemic attacks of aphasia and right hemiparesis with vertebrobasilar insufficiency syndrome. He had a past history of hypertrophic cardiomyopathy. His angiograms revealed multiple intra- and extracranial occlusive lesions (the left subclavian artery occlusion and bilateral internal carotid lesions). A subclavian-subclavian bypass following the right carotid endarterectomy (CEA) was performed using external shunt from the subclavian bypass graft end during CEA. However, transient ischemic attacks continued after the first operation and single photon emission tomography still demonstrated the left hemispheric ischemia. The left STA-MCA anastomosis was then performed 7 months later. Postoperative course was uneventful and recurrent episode of TIAs disappeared.
Case 2, a 56-year-old man, suffered from minor stroke of right hemiparesis and acute myocardial infarction simultaneously. Angiogram showed an unruptured aneurysm of the middle cerebral artery and severe stenosis of the right internal carotid artery with contralateral middle cerebral artery stenosis. The aneurysm was clipped prior to CEA of the ipsilateral internal carotid artery stenosis. As the next procedure, CEA on the right side and the left STA-MCA anastomosis was performed simultaneously.
In the cases of extra- and intracranial tandem occlusive lesions, the proximal severe lesion should be treated surgically initially. During the bypass or CEA procedure, extra care should be taken in these cases to protect the brain from ischemia perioperatively. Such patients may often be suffering from various heart diseases. The selection of surgical procedure should be carefully considered in cooperation with a cardiologist.
