Revascularization surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion

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OBJECTIVE

Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust.

METHODS

Consecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter.

RESULTS

From 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%–6.6%).

CONCLUSIONS

Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.

ABBREVIATIONS CI = confidence interval; COSS = Carotid Occlusion Surgery Study; EC-IC = extracranial-to-intracranial; EIBT = EC-IC Bypass Trial; mRS = modified Rankin Scale; OR = odds ratio; RCT = randomized controlled trial; TIA = transient ischemic attack; VIG = venous interposition graft.
Article Information

Contributor Notes

Correspondence Marcus Stoodley: Macquarie University, Sydney, New South Wales, Australia. marcus.stoodley@mq.edu.au.INCLUDE WHEN CITING Published online February 8, 2019; DOI: 10.3171/2018.9.JNS181075.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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