Frequent TIA in the territory fed by the anastomosed STA after combined therapeutic ICA occlusion and extracranial-intracranial bypass: Case report

Summary

Frequent transient ischaemic attacks (TIAs) in the territory fed by the anastomosed superficial temporal artery (STA) after combined therapeutic internal carotid artery (ICA) occlusion and extra-cranial-intracranial bypass is described in a 52-year-old woman with a giant aneurysm in the supraclinoid portion of the left ICA showing impairment of visual acuity in the left eye and right upper quadrantanopia. After the balloon test occlusion of the left ICA which was tolerated, the left STA-middle cerebral artery anastomosis was performed and occlusion of the left ICA using detachable balloons was carried out a day later. TIAs corresponding to the territory fed by the anastomosed STA occurred nine times two to four days and five times eight to nine days after the ICA occlusion without new infarction on computed tomography (CT) scan. Single-photon emission computed tomography showed no hypoperfusion immediately after the initial TIA. CT scan revealed thrombosis of half of the aneurysm a day after the ICA occlusion. The patient developed the same TIA as previously by compression of the left anastomosed STA at the time of follow-up angiography which was carried out eight days after the occlusion. Although heparin was continuously administered after the ICA occlusion for two days, the initial TIA occurred during heparinization.

Anticoagulation seemed to be inadequate judging from activated coagulation time and incomplete thrombosis of the aneurysm occurred during heparinization. It is likely that the TIAs are caused by embolism via the STA, which is a rare ischaemic complication.