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Carotid Bypass / Aneurysm Factor VIII Deficiency

Presented by Clara Raquel Epstein, M.D., Fellow

Presentation

A 61-year-old Peruvian male with a history of hypertension, type II diabetes, hypothyroidism, and a recent 30-pound weight loss, investigated with upper and lower endoscopies which were negative, presented to St. Joseph's Hospital in New Jersey with complaints of headache, nausea, and vomiting, and diplopia with upward gaze. The patient was also found to have upon further investigation a Factor VIII deficiency reflected by an elevated PTT. In July, 1999, an MRI was obtained that demonstrated a giant L ICA cerebral aneurysm.

Hospital Course

The patient was transferred to The Mount Sinai Hospital NSICU for surgical correction.

On admission the patient presented with a left third nerve palsy, decreased sensory in the V2 and V3 distribution, diplopia with upward gaze, and was otherwise neurologically intact. Recombinant Factor VIII was administered with a goal of raising the Factor VIII from 15 percent to 60 percent.

Surgical Procedure

On the second hospital day, a left ICA occlusion with an ECA-MCA saphenous vein bypass was performed by Joshua Bederson, M.D.

Postoperative Course

The patient tolerated the surgical procedure well. Postoperative recovery included close hematologic monitoring and continued therapy, including FFP, Vitamin K, and PRBC replacement, as well as continued recombinant Factor VIII replacement throughout the remainder of the hospital course. The patient did not have postoperative bleeding problems.

Postoperative angiography confirmed patency of the graft.

The patient was discharged to home in excellent condition, and has returned to his baseline activities.