Quantitative evaluation using single-photon emission computed tomography with acetazolamide is reliable for preoperative evaluation before cardiac surgery in severe carotid intracranial artery stenotic and/or occlusive disease: a case report

• Published in: Journal of cardiothoracic surgery Vol. 14; no. 1; p. 141
• Main Authors: Tayama, Eiki, Mori, Ryusuke, Ueda, Tomohiro, Imasaka, Ken-Ichi, Tomita, Yukihiro, Morita, Shigeki
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 23.07.2019; BioMed Central; BMC
• Subjects: Angina pectoris; Angiography; Arterial stenosis; Arteries; Blood flow; Care and treatment; Carotid and intracranial artery stenotic and/or occlusive disease (CIAD); Case Report; Case studies; CAT scans; Cerebral hemodynamics; Complications and side effects; Coronary artery bypass; Diagnosis; Heart diseases; Ischemia; Medical research; Morbidity; Myocardial ischemia; Off-pump coronary artery bypass grafting (OPCAB); Physiological aspects; Risk assessment; Single photon emission computed tomography; Single-photon emission computed tomography (SPECT); Stenosis; Surgery; Tomography; Japan; Carotid and intracranial artery stenotic and/or occlusive disease (CIAD); Off-pump coronary artery bypass grafting (OPCAB); Cerebral hemodynamics; Single-photon emission computed tomography (SPECT)
• ISSN: 1749-8090; 1749-8090
• DOI: 10.1186/s13019-019-0961-4

Severe carotid and intracranial artery stenosis disease (CIAD) is major risk for perioperative stroke in coronary artery bypass grafting. Then, preoperative risk assessment is quite important. A 58-years old Japanese woman with bilateral carotid stenosis and bilateral middle cerebral artery occlusion was suffered from worsening effort angina due to severe three coronary vessel disease. Magnetic resonance imaging angiography demonstrated severe carotid and intracranial vessel stenosis. Selective carotid/cerebral angiography also showed severe stenosis and delayed filling of the right internal carotid artery and moderate stenosis of the left internal carotid artery, with occlusion of the bilateral middle cerebral arteries. However, quantitative evaluation with brain perfusion, single-photon emission computed tomography (SPECT) with acetazolamide showed depleted cerebral perfusion volume and vascular responses, particularly in the left middle cerebral artery area. However, both sides of MCA reserve cerebral blood flow was maintained at > 34 ml/100 g/min. So, we finally considered that her cerebral perfusion reserve was maintained a certain level and could tolerate open heart surgery. Then, she underwent off-pump coronary artery grafting. Before sternotomy, prophylactic intra-aortic balloon pump support was used to minimize possible perioperative stroke. As a result, hemodynamic status and brain regional oxygen saturation were stable throughout the operation, and recovered uneventfully. Preoperative quantitative evaluation using brain perfusion SPECT with acetazolamide is useful in assessing hemodynamic cerebrovascular risk in patients with severe obstructive CIAD. Off pump coronary artery bypass grafting with intra aortic balloon pump assist is a good option for prevention of cerebrovascular morbidity in ischemic heart disease with severe CIAD.