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World Neurosurg. 2019 Sep 26. pii: S1878-8750(19)32533-1. doi: 10.1016/j.wneu.2019.09.102. [Epub ahead of print]

Rescue cerebral revascularization in patients with progressive steno-occlusive ischemia of the anterior intracranial circulation.

Author information

1
Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA.
2
Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA USA.
3
Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
4
Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA USA. Electronic address: jonathan.russin@med.usc.edu.

Abstract

BACKGROUND:

Despite 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.

OBJECTIVE:

Assess the efficacy and outcomes of bypass surgery for progressive/refractory steno-occlusive cerebrovascular disease.

METHODS:

A 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.

RESULTS:

Seventeen 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.

CONCLUSIONS:

Bypass 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.

KEYWORDS:

cerebral bypass; revascularization; steno-occlusive ischemia; stroke

PMID:
31563694
DOI:
10.1016/j.wneu.2019.09.102

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