World neurosurgery | 2019
Rescue cerebral revascularization in patients with progressive steno-occlusive ischemia of the anterior intracranial circulation.
Abstract
BACKGROUND\nDespite the failure of two randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from cerebral revascularization.\n\n\nOBJECTIVE\nAssess the efficacy and outcomes of bypass surgery for progressive/refractory steno-occlusive cerebrovascular disease.\n\n\nMETHODS\nA retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the ICA or MCA over a four-year period (7/2014-7/2018). Surgical and clinical outcomes were recorded.\n\n\nRESULTS\nSeventeen patients underwent EC-IC bypass for refractory/progressive steno-occlusive disease of the ICA or MCA (average age 62 ± 11 years). 13 of the 17 patients presented with a stroke, three with recurrent TIAs, and one with progressive hemiparesis. All patients had pre-operative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes, and an interposition graft was used in seven patients. There was three ischemic and three hemorrhagic peri-operative strokes (35%), although all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass dependent territories. 16 of 17 patients (78%) achieved a GOS ≥ 4, and 13 of 17 patients (85%) achieved an mRS ≤ 2.\n\n\nCONCLUSIONS\nBypass for steno-occlusive disease of the anterior intracranial circulation can be a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms although there is a significant complication rate. Optimal patient selection criteria and timing of surgery remain open questions.