Slowly progressive neuronal death associated with postischemic hyperperfusion in cortical laminar necrosis after high-flow bypass for a carotid intracavernous aneurysm

Case report

Restricted access

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, 123I-iomazenil (123I-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 123I-iodoamphetamine SPECT. Of note, neuronal density in the affected cortex on the delayed 123I-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 123I-IMZ SPECT and cortical laminar necrosis on MR imaging in human stroke.

Abbreviations used in this paper: CA = carotid artery; EC-IC = extracranial-intracranial; ECA = external carotid artery; 123I-IMP = 123I-iodoamphetamine; 123I-IMZ = 123I-iomazenil; MCA = middle cerebral artery; POD = postoperative day; RA = radial artery.
Article Information

Contributor Notes

Address correspondence to: Koji Iihara, M.D., Ph.D., Department of Neurosurgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan. email: kiihara@hsp.ncvc.go.jp.Please include this information when citing this paper: published online October 30, 2009; DOI: 10.3171/2009.9.JNS09345.
Headings
References
  • 1

    Garcia JHLiu KFYe ZRGutierrez JA: Incomplete infarct and delayed neuronal death after transient middle cerebral artery occlusion in rats. Stroke 28:230323101997

    • Search Google Scholar
    • Export Citation
  • 2

    Hantraye PKaijima MPrenant CGuibert BSastre JCrouzel M: Central type benzodiazepine binding sites: a positron emission tomography study in the baboon's brain. Neurosci Lett 48:1151201984

    • Search Google Scholar
    • Export Citation
  • 3

    Heiss WDGrond MThiel AGhaemi MSobesky JRudolf J: Permanent cortical damage detected by flumazenil positron emission tomography in acute stroke. Stroke 29:4544611998

    • Search Google Scholar
    • Export Citation
  • 4

    Heiss WDSobesky JSmekal UKracht LWLehnhardt FGThiel A: Probability of cortical infarction predicted by flumazenil binding and diffusion-weighted imaging signal intensity: a comparative positron emission tomography/magnetic resonance imaging study in early ischemic stroke. Stroke 35:189218982004

    • Search Google Scholar
    • Export Citation
  • 5

    Hongo KHoriuchi TNitta JTanaka YTada TKobayashi S: Double-insurance bypass for internal carotid artery aneurysm surgery. Neurosurgery 52:5976022003

    • Search Google Scholar
    • Export Citation
  • 6

    Jafar JJRussell SMWoo HH: Treatment of giant intracranial aneurysms with saphenous vein extracranial-to-intracranial bypass grafting: indications, operative technique, and results in 29 patients. Neurosurgery 51:1381462002

    • Search Google Scholar
    • Export Citation
  • 7

    Komiyama MNakajima HNishikawa MYasui T: Serial MR observation of cortical laminar necrosis caused by brain infarction. Neuroradiology 40:7717771998

    • Search Google Scholar
    • Export Citation
  • 8

    Lavine SDMasri LSLevy MLGiannotta SL: Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection. J Neurosurg 87:8178241997

    • Search Google Scholar
    • Export Citation
  • 9

    Lawton MTHamilton MGMorcos JJSpetzler RF: Revascularization and aneurysm surgery: current techniques, indications, and outcome. Neurosurgery 38:83841996

    • Search Google Scholar
    • Export Citation
  • 10

    Marchal GYoung ARBaron JC: Early postischemic hyperperfusion: pathophysiologic insights from positron emission tomography. J Cereb Blood Flow Metab 19:4674821999

    • Search Google Scholar
    • Export Citation
  • 11

    McKinney AMTeksam MFelice RCasey SOCranford RTruwit CL: Diffusion-weighted imaging in the setting of diffuse cortical laminar necrosis and hypoxic-ischemic encephalopathy. AJNR Am J Neuroradiol 25:165916652004

    • Search Google Scholar
    • Export Citation
  • 12

    Mohit AASekhar LNNatarajan SKBritz GWGhodke B: High-flow bypass grafts in the management of complex intracranial aneurysms. Neurosurgery 60:2 Suppl 1ONS105ONS1232007

    • Search Google Scholar
    • Export Citation
  • 13

    Nakagawara JSperling BLassen NA: Incomplete brain infarction of reperfused cortex may be quantitated with iomazenil. Stroke 28:1241321997

    • Search Google Scholar
    • Export Citation
  • 14

    Ogilvy CSCarter BSKaplan SRich CCrowell RM: Temporary vessel occlusion for aneurysm surgery: risk factors for stroke in patients protected by induced hypothermia and hypertension and intravenous mannitol administration. J Neurosurg 84:7857911996

    • Search Google Scholar
    • Export Citation
  • 15

    Rojas SMartin AJusticia CFalcon CBargallo NChamorro A: Modest MRI signal intensity changes precede delayed cortical necrosis after transient focal ischemia in the rat. Stroke 37:152515322006

    • Search Google Scholar
    • Export Citation
  • 16

    Sette GBaron JCYoung ARMiyazawa HTillet IBarre L: In vivo mapping of brain benzodiazepine receptor changes by positron emission tomography after focal ischemia in the anesthetized baboon. Stroke 24:204620481993

    • Search Google Scholar
    • Export Citation
  • 17

    Siskas NLefkopoulos AIoannidis ICharitandi ADimitriadis AS: Cortical laminar necrosis in brain infarcts: serial MRI. Neuroradiology 45:2832882003

    • Search Google Scholar
    • Export Citation
  • 18

    Streefkerk HJBremmer JPTulleken CA: The ELANA technique: high flow revascularization of the brain. Acta Neurochir Suppl 94:1431482005

    • Search Google Scholar
    • Export Citation
  • 19

    Takahashi SHigano SIshii KMatsumoto KSakamoto KIwasaki Y: Hypoxic brain damage: cortical laminar necrosis and delayed changes in white matter at sequential MR imaging. Radiology 189:4494561993

    • Search Google Scholar
    • Export Citation
  • 20

    Weiller CWillmes KReiche WThron AIsensee CBuell U: The case of aphasia or neglect after striatocapsular infarction. Brain 116:150915251993

    • Search Google Scholar
    • Export Citation
  • 21

    Westermaier TZausinger SBaethmann ASteiger HJSchmid-Elsaesser R: No additional neuroprotection provided by barbiturate-induced burst suppression under mild hypothermic conditions in rats subjected to reversible focal ischemia. J Neurosurg 93:8358442000

    • Search Google Scholar
    • Export Citation
  • 22

    Yamauchi HKudoh TKishibe YIwasaki JKagawa S: Selective neuronal damage and borderzone infarction in carotid artery occlusive disease: a 11C-flumazenil PET study. J Nucl Med 46:197319792005

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 239 180 17
Full Text Views 145 40 1
PDF Downloads 131 25 0
EPUB Downloads 0 0 0
PubMed
Google Scholar