title: Extracranial-intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience.
abstract: Despite the failure of the international extracranial-intracranial (EC-IC) bypass study in showing the benefit of bypass procedure for prevention of stroke recurrence, it has been regarded to be beneficial in a subgroup of well-selected patients with haemodynamic impairment. This report includes the EC-IC bypass experience of a single centre over a period of 14 years. All consecutive 72 patients with atherosclerotic occlusive cerebrovascular lesions associated with haemodynamic compromise treated by EC-IC bypass surgery were retrospectively reviewed. Pre-operatively, 61% of patients presented with minor stroke and the remaining 39% with recurrent transient ischemic attacks (TIAs) despite maximal medical therapy. Angiography revealed a unilateral internal carotid artery (ICA) stenosis/occlusion in 79%, bilateral ICA stenosis/occlusion in 15%, MCA stenosis/occlusion in 3% and other multiple vessel stenosis/occlusion in 3% of the cases. H(2)(15)O positron emission tomography (PET) or 99mTc-HMPAO SPECT with acetazolamide challenge was performed for haemodynamic evaluation of the cerebral blood flow (CBF). All the patients had impaired haemodynamics pre-operatively in terms of reduced regional cerebrovascular reserve capacity and rCBF. Standard STA-MCA bypass procedure was performed in all patients. A total of 68 patients with 82 bypasses were reviewed with a mean follow-up period of 34 months. Stroke recurrence took place in 10 patients (15%) resulting in an annual stroke risk of 5%. Improved cerebral haemodynamics was documented in 81% of revascularised hemispheres. Patients with unchanged or worse haemodynamic parameters had significantly more post-operative TIAs or strokes when compared to those with improved perfusion reserves (30% vs.5% of patients, p<0.05). In conclusion, EC-IC bypass procedure in selected patients with occlusive cerebrovascular lesions associated with haemodynamic impairment has revealed to be effective for prevention of further cerebral ischemia, when compared with a stroke risk rate of 15% reported to date in patients only under antiplatelet agents or anticoagulant therapy.
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Switzerland. carl.muroi@ksa.ch
authors.forename: Carl
authors.initials: C
authors.lastname: Muroi
authors.forename: Nadia
authors.initials: N
authors.lastname: Khan
authors.forename: David
authors.initials: D
authors.lastname: Bellut
authors.forename: Masayuki
authors.initials: M
authors.lastname: Fujioka
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Yonekawa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal / Q000503:physiopathology / Q000601:surgery*; D002548:Cerebral Revascularization / Q000009:adverse effects / Q000379:methods*; D002561:Cerebrovascular Disorders / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D002537:Intracranial Arteriosclerosis / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D020521:Stroke / Q000517:prevention & control*; D013557:Switzerland; D016896:Treatment Outcome