Background: While some randomized clinical trials have reduced the indications for
cerebral revascularization in the secondary prevention of ischemic stroke, a distinct subset of patients
with blood pressure augmentation dependent cerebrovascular insufficiency due to large vessel
occlusions remains unaddressed. With the recent paradigm shifts in acute ischemic stroke care,
the role of extracranial to intracranial (EC-IC) bypass must be re-addressed when endovascular intervention
is not a feasible option. We submit a refined classification of cerebrovascular insufficiency
with a category called Pressor-Dependent Cerebrovascular Insufficiency (PD-CVI) for
whom EC-IC bypass may be indicated.
Clinical Presentation: A 61-year-old female former smoker presented with one day of intermittent
left faciobrachial weakness and was found to have middle cerebral artery and cervical internal carotid
artery occlusions. On admission to the intensive care unit, she was found to have PD-CVI
with an intravenous pressor dependent blood pressure threshold over which she had near resolution
of her neurological deficits. With endovascular intervention precluded given the ICA occlusion,
she underwent an urgent right sided EC-IC bypass. The procedure was without complication, with
careful attention to maintaining hypertension perioperatively. She required no pressors postoperatively
and was neurologically intact at three months post-operatively.
Conclusion: With recent advances in acute ischemic stroke care, there remains a need for careful
consideration of cerebral revascularization surgery in patients with evidence of PD-CVI who may
be precluded from or failed endovascular intervention.