Cerebral Hypoperfusion Caused by Brachiocephalic Artery Stenosis.

Introduction: Extracranial cerebrovascular disease can cause cerebral ischaemia through embolism or hypoperfusion. Managing cerebral ischaemia in patients with hypoperfusion and multivessel cerebrovascular disease can pose challenges owing to the risks of embolisation and haemodynamic instability, especially when normal embolisation protection techniques and cross clamping are hazardous. Report: This article presents the case of a 74 year old woman who experienced a peri-operative cardiac arrest during femoropopliteal bypass surgery, secondary to undiagnosed severe left ventricular hypertrophy with dynamic outflow obstruction. Following recovery, she developed recurrent right hemispheric transient ischaemic attacks including left hemiplegia. Imaging revealed mild to moderate bilateral carotid bulb, carotid siphon, and vertebral stenoses, but the most significant lesion was a severe, calcified stenosis of brachiocephalic artery. Given the recent cardiac arrest and multiple levels of the disease, the initial plan was for conservative management. Despite medical management with permissive hypertension, the patient continued to experience transient ischaemic attacks as soon as the systolic pressure dropped below 160 mmHg. This scenario led to a multidisciplinary decision to proceed with brachiocephalic artery stenting. The neurointerventional team recommended avoidance of cross clamping if possible given the severe lesions and lack of intact circle of Willis. The procedure was done under general anaesthesia via open, retrograde right axillary access without carotid cross clamping. The post-operative course was uneventful. Discussion: This case underscores the importance of procedural planning and a multidisciplinary approach in managing complex cerebrovascular conditions, and that unusual pathologies may need unusual treatment.