title: Indications and results of direct cerebral revascularization in the modern era.
abstract: BACKGROUND
  There has been a progressive decrease in the indications for cerebral revascularization during the past 30 years, particularly with the advance of endovascular techniques. Our objective was to define indications for and evaluate outcomes of patients treated with bypass surgery in the modern endovascular era.
  
  
  METHODS
  We retrospectively reviewed the charts of all patients who underwent direct cerebral revascularization procedures between January 2006 and March 2013.
  
  
  RESULTS
  In total, 121 patients underwent 131 direct microsurgical revascularization procedures. The indications for bypass surgery were moyamoya angiopathy (40 patients, 47 bypasses), complex aneurysms (54 patients, 56 bypasses), and occlusive vascular disease (27 patients, 28 bypasses). Revascularization resulted in improvement of symptoms in 77.5% of patients with moyamoya angiopathy (mean clinical follow-up 18.8 months) and 55.5% of patients with occlusive vascular disease (mean clinical follow-up 10.4 months). Among the aneurysm patients treated with revascularization, 81.5% had a favorable outcome (Glasgow Outcome Scale score 4-5) at long-term follow-up (mean clinical followup 18.5 months).
  
  
  CONCLUSIONS
  Although microvascular cerebral revascularization is no longer performed as commonly as in the past, it remains an essential part of the skill set required to treat select vascular pathologies. Complex aneurysms are the single largest indication for direct bypass procedures. Moyamoya disease is by far the largest indication if indirect bypass procedures are included in the analysis. In experienced hands, the morbidity and mortality of patients undergoing cerebral revascularization procedures are low and long-term outcomes generally excellent.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: M Yashar S
authors.initials: MY
authors.lastname: Kalani
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Rangel-Castilla
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Wyatt
authors.initials: W
authors.lastname: Ramey
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address: Neuropub@dignityhealth.org.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000401:mortality / Q000601:surgery; D002548:Cerebral Revascularization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D002561:Cerebrovascular Disorders / Q000401:mortality / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D007223:Infant; D002532:Intracranial Aneurysm / Q000401:mortality / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009072:Moyamoya Disease / Q000401:mortality / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Aneurysm; Bypass; Cerebral; Dissection; Ischemia; Moyamoya; Revascularization