title: Clinical significance of STA-MCA double anastomosis for hemodynamic compromise in post-JET/COSS era.
abstract: BACKGROUND
  Even after the recent randomized clinical trials JET and COSS, it is still unclear that impaired cerebrovascular reactivity (CVR) to acetazolamide and oxygen extraction fraction (OEF) can identify the candidates for superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis. This prospective study was aimed to evaluate the benefits of STA-MCA "double" anastomosis on long-term outcome in patients with reduced cerebral blood flow (CBF) and CVR (Type 3 ischemia) and elevated OEF attributable to occlusive carotid diseases.
  
  
  METHODS
  This study included 49 patients with reduced CBF and CVR on SPECT in the ipsilateral MCA area. Using (15)O-gas PET, OEF was also measured in all patients. STA-MCA double anastomosis was recommended to the patients with Type 3 and elevated OEF. Those with Type 3 but normal OEF were medically treated.
  
  
  RESULTS
  Of 36 patients with Type 3 and elevated OEF, 25 consented to surgery. No perioperative morbidity or mortality were noted. The other 11 patients with Type 3 and elevated OEF were medically treated. Annual incidence of ipsilateral stroke was 0.7% and 6.5% in surgically and medically treated patients with Type 3 and elevated OEF, respectively (P = 0.0188). None of patients with Type 3 but normal OEF developed ipsilateral stroke during follow-up periods. STA-MCA "double" anastomosis significantly decreased OEF.
  
  
  CONCLUSIONS
  STA-MCA "double" anastomosis may still have the potential to reduce the risk of recurrent ipsilateral stroke in hemodynamically compromised patients. Further studies would be essential to advance diagnosis, surgical procedures, and perioperative managements to bring out maximal effects of bypass surgery.
authors.affiliation: Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan, skuroda@med.u-toyama.ac.jp.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kuroda
authors.forename: Masahito
authors.initials: M
authors.lastname: Kawabori
authors.forename: Kenji
authors.initials: K
authors.lastname: Hirata
authors.forename: Tohru
authors.initials: T
authors.lastname: Shiga
authors.forename: Daina
authors.initials: D
authors.lastname: Kashiwazaki
authors.forename: Kiyohiro
authors.initials: K
authors.lastname: Houkin
authors.forename: Nagara
authors.initials: N
authors.lastname: Tamaki
mesh_terms: D000086:Acetazolamide / Q000494:pharmacology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D002343:Carotid Artery, Internal / Q000601:surgery*; D016893:Carotid Stenosis / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods; D002560:Cerebrovascular Circulation / Q000187:drug effects / Q000502:physiology; D002986:Clinical Trials as Topic; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery*; D011446:Prospective Studies; D020521:Stroke / Q000188:drug therapy / Q000601:surgery*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods
chemical_list: D000086:Acetazolamide