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Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review.
BMC Neurol. 2020 Sep 05; 20(1):335.BN

Abstract

BACKGROUND

Carotid occlusive disease is a type of progressive disease resulting in ischemic stroke. Extracranial-intracranial 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.

Authors+Show Affiliations

Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China.Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China.Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China.Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China.Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China.Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, 310009, China. dr_wang@zju.edu.cn.

Pub Type(s)

Case Reports
Journal Article
Review

Language

eng

PubMed ID

32891141

Citation

Li, Yin, et al. "Severe Cerebral Edema Induced By Watershed Shift After Bypass in a Patient With Chronic Steno-occlusive Disease: a Case Report and Short Literature Review." BMC Neurology, vol. 20, no. 1, 2020, p. 335.
Li Y, Wei YY, Cao Y, et al. Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review. BMC Neurol. 2020;20(1):335.
Li, Y., Wei, Y. Y., Cao, Y., Lu, X. Y., Yao, Y., & Wang, L. (2020). Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review. BMC Neurology, 20(1), 335. https://doi.org/10.1186/s12883-020-01912-z
Li Y, et al. Severe Cerebral Edema Induced By Watershed Shift After Bypass in a Patient With Chronic Steno-occlusive Disease: a Case Report and Short Literature Review. BMC Neurol. 2020 Sep 5;20(1):335. PubMed PMID: 32891141.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review. AU - Li,Yin, AU - Wei,Yu-Yu, AU - Cao,Yang, AU - Lu,Xiao-Yang, AU - Yao,Yuan, AU - Wang,Lin, Y1 - 2020/09/05/ PY - 2019/09/07/received PY - 2020/08/27/accepted PY - 2020/9/6/entrez PY - 2020/9/7/pubmed PY - 2020/9/7/medline KW - Bypass KW - Cerebral edema KW - Magnetic resonance imaging 3D–arterial spin labeling (MRI 3D-ASL) KW - Swollen temporal muscle KW - Watershed shift SP - 335 EP - 335 JF - BMC neurology JO - BMC Neurol VL - 20 IS - 1 N2 - BACKGROUND: Carotid occlusive disease is a type of progressive disease resulting in ischemic stroke. Extracranial-intracranial 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. SN - 1471-2377 UR - https://www.unboundmedicine.com/medline/citation/32891141/Severe_cerebral_edema_induced_by_watershed_shift_after_bypass_in_a_patient_with_chronic_steno-occlusive_disease:_a_case_report_and_short_literature_review. L2 - https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-020-01912-z DB - PRIME DP - Unbound Medicine ER -