Indirect revascularization for nonmoyamoya intracranial arterial stenoses: clinical and angiographic outcomes

Clinical article

Joshua R. Dusick Departments of Neurosurgery,

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 M.D.
,
David S. Liebeskind Neurology, and
UCLA Stroke Center, Los Angeles, California

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 M.D.
,
Jeffrey L. Saver Neurology, and
UCLA Stroke Center, Los Angeles, California

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 M.D.
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Neil A. Martin Departments of Neurosurgery,

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 M.D.
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Nestor R. Gonzalez Departments of Neurosurgery,
Radiology, David Geffen School of Medicine at UCLA; and

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 M.D.
Page Range:
94–102
Volume/Issue:
Volume 117: Issue 1
DOI link:
https://doi.org/10.3171/2012.4.JNS111103
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Object

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.

Abbreviations used in this paper:

COSS = Carotid Occlusion Surgery Study; ECA = external carotid artery; EC-IC = extracranial-intracranial; EDAS = encephaloduroarteriosynangiosis; MCA = middle cerebral artery; MMA = middle meningeal artery; SAMMPRIS = Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; STA = superficial temporal artery; TIA = transient ischemic attack; WASID = Warfarin-Aspirin Symptomatic Intracranial Disease.
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Contributor Notes

Address correspondence to: Nestor R. Gonzalez, M.D., Department of Neurosurgery, David Geffen School of Medicine at UCLA, 10833 LeConte Avenue, Room 18-251 Semel, Los Angeles, California 90095-7039. email: ngonzalez@mednet.ucla.edu.

Please include this information when citing this paper: published online May 4, 2012; DOI: 10.3171/2012.4.JNS111103.

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