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Revascularization of the external carotid artery and hemodynamic stroke - a case report and literature review.
Shirling Tsai1, Mirza S Baig1, Fatima Abrantes-Pais1, R. James Valentine2
1Dallas Veterans Affairs Medical Center, Dallas, TX;2University of Texas Southwestern Medical Center, Dallas, TX

Background: Hemodynamic strokes or TIAs are often associated with episodes of hypoperfusion, such as orthostasis, heart failure, or changes in anti-hypertensive regimen. Herein we describe the management of a patient with TIAs associated with the hemodynamic consequences of coughing.
Methods: The patient is a 65M who presented with right arm and face weakness associated with severe coughing fits. Carotid duplex revealed moderate stenosis of the right internal carotid artery and a total occlusion of the left common and internal carotid arteries. This was confirmed by CT angiogram, which also revealed absent posterior communicating arteries bilaterally. A right carotid and cerebral angiogram demonstrated minimal perfusion of the left cerebral hemisphere through a small anterior communicating artery. A selective angiogram of the left subclavian artery showed reconstitution of the left external carotid artery, which communicated with the intracranial left internal carotid artery through anastomoses between the infraorbital branch of the inferior maxillary artery and the ophthalmic branch of the internal carotid artery (black arrows in figure 1). The patient underwent left subclavian to external carotid artery bypass with reversed saphenous vein.
Results: Immediately post-operatively, the patient had complete resolution of his right sided weakness that occurred during coughing fits. He has not had any recurrent symptoms over 9 months of follow-up.
Conclusions: Cough-induced hemispheric TIA is rarely described. Similar to the physiology underlying cough-syncope, transiently increased intracranial pressure and decreased venous return associated with coughing likely decreases the collateral circulation to the affected hemisphere. Although many patients with hemodynamic TIA or stroke are medically managed with permissive hypertension, revascularization of the external carotid artery is also an important treatment option in select patients.


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