Carotid endarterectomy with active extracorporeal perfusion for bilateral ocular ischemic syndrome in a patient with a preoperatively defined critical single-vessel cerebral supply on four-dimensional flow magnetic resonance imaging

Ocular ischemic syndrome is a rare manifestation of severe carotid artery occlusive disease with risk of vision loss. We report a patient with bilateral ocular ischemic syndrome secondary to advanced atherosclerosis, including brachiocephalic and subclavian artery occlusions and high-grade bilateral carotid stenosis. Four-dimensional flow magnetic resonance imaging demonstrated near-exclusive cerebral perfusion derived from the left carotid system. Carotid endarterectomy was performed using extracorporeal veno-arterial antegrade selective cerebral perfusion for neuroprotection, as standard shunting was deemed inadequate. This case highlights the utility of four-dimensional flow magnetic resonance imaging in identifying hypoperfusion risk and the utility of extracorporeal cerebral perfusion in complex carotid revascularization.