title: Indirect revascularization for nonmoyamoya intracranial arterial stenoses: clinical and angiographic outcomes.
abstract: OBJECTIVE
  Symptomatic intracranial arterial stenoses have a high rate of recurrent stroke despite medical and endovascular treatments. The authors present clinical and angiographic quantitative outcomes of indirect revascularization for patients with symptomatic intracranial stenosis.
  
  
  METHODS
  Patients treated for symptomatic intracranial arterial stenosis by indirect revascularization were included. The patient population comprised those in whom medical management had failed and for whom endovascular therapy was unsuitable or had failed. Patients underwent encephaloduroarteriosynangiosis (EDAS) with or without bur holes. Preoperative and postoperative angiograms were evaluated for change in caliber of extracranial blood vessels (superficial temporal artery [STA] and middle meningeal artery [MMA]) and for evidence of neovascularization.
  
  
  RESULTS
  Thirteen patients underwent EDAS. Ischemic symptoms ceased within the follow-up period in all patients, returning in a delayed fashion in only 2. No other patients had recurrent TIAs or strokes after the initial postoperative period. Donor blood vessels increased in size relative to preoperative sizes in all but 1 case (average increase of 52% for proximal STA [p=0.01], 74% for midpoint of STA [p=0.01], and 84% for the MMA [p=0.02]). In addition, 8 of 11 patients demonstrated direct spontaneous anastomoses from extracranial to middle cerebral artery branches, and all patients demonstrated angiographic evidence of vascular blush and/or new branches from the STA and/or MMA.
  
  
  CONCLUSIONS
  Indirect revascularization appears to be a safe and effective method to improve blood flow to ischemic brain due to intracranial arterial stenosis. Neovascularization and enlargement of the branches of the ECA were observed in all patients and correlated with improvement in ischemic symptoms. Indirect revascularization is an option for patients in whom medical therapy has failed and who are not suitable for endovascular treatment.
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at UCLA, UCLA Stroke Center, Los Angeles, CA 90095-7039, USA.
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Dusick
authors.forename: David S
authors.initials: DS
authors.lastname: Liebeskind
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.forename: Neil A
authors.initials: NA
authors.lastname: Martin
authors.forename: Nestor R
authors.initials: NR
authors.lastname: Gonzalez
mesh_terms: D000328:Adult; D000758:Anesthesia; D002545:Brain Ischemia / Q000209:etiology; D002533:Cerebral Angiography; D002539:Cerebral Arterial Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods*; D002560:Cerebrovascular Circulation / Q000502:physiology; D003251:Constriction, Pathologic; D023381:Endpoint Determination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002546:Ischemic Attack, Transient / Q000000981:diagnostic imaging / Q000601:surgery; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D019635:Neurosurgical Procedures / Q000379:methods*; D011300:Preoperative Care; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome