60+ year old male for a superficial temporal to middle cerebral artery bypass graft.

Background:

• Left MCA infarct 2017 and recurrent TIAs since, increasing in severity and frequency with a postural component
  • Terrible QoL, fear of episodes, worsening symptoms
• HTN
• PVD
• DM
• Laryngeal cancer – neck dissection, radiotherapy, laser. Residual dysphagia. Likley difficult airway.
• NH resident previously, now cared for by friend.
• CFS 6
• DASI < 4 METS. Wheelchair and walking stick for mobility

Issues

Surgical plans

• Internal carotid occlusive disease so not suitable for vascular surgical intervention
• Reviewed by registrar in the neurosurgical clinic and images/clinical history discussed with the surgeon (not reviewed by the surgeon in person)

Perioperative risks

• Above average for all risks using NSQIP scoring
• Particularly concerning is his risk of discharge to a care location (which the patient says is absolutely unacceptable to him)

Discussion:

Should surgery proceed?

• Concerning that for such a high risk surgery, the patient has not been reviewed by the surgeon directly

Have other causes/solutions to his syncopal events been explored?

• Holter requested by clinic anaesthetist
• Postural BPs and a trial of fludrocortisone could be a low risk investigation/intervention

Could this patient be optimised from a functional perspective?

• Very difficult for him to participate in prehabilitation due to his physical limitations from his hemiparesis.

Plan Patient re-reviewed by the neurosurgeon and deemed not suitable for this high risk procedure. Emphasises the importance of speaking to the surgical teams if you have concerns about the appropriateness of surgery.