Indications for surgical intervention in middle cerebral artery obstruction

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✓ The clinical, angiographic, and surgical characteristics of 31 patients with high-grade middle cerebral artery (MCA) stenosis or occlusion (jointly termed “MCA obstructions”) referred for cerebral revascularization by extracranial-intracranial (EC-IC) bypass are reviewed. Overall, 12 (66%) of the 18 patients with stenosis and all 13 (100%) of those with complete occlusion experienced clinically evident infarctions. Twenty-five of these patients underwent arteriography at least twice during their clinical course. Eleven (44%) demonstrated significant improvement in flow or complete resolution of obstruction on their second study. Ten of these 11 were patients in whom the initial arteriography was done within 2 weeks of symptom onset. Five other patients with stenosis exhibited obstruction that was worse on serial arteriography without surgical intervention.

The high incidence of resolution of MCA obstructions indicates that surgery should not be contemplated in most instances until delayed arteriography has been performed, at least 6 weeks after the onset of symptoms. Proximal embolic sources, such as the cervical carotid bifurcation, should receive carotid endarterectomy and repeat arteriography in appropriate patients prior to consideration of EC-IC bypass. Persistent high-grade MCA obstructions are thereafter potential candidates for EC-IC bypass, since leptomeningeal collateral vessels are marginal in their protective ability. Overall, of 15 patients who underwent an EC-IC bypass procedure, 14 were either stable or improved postoperatively, and 13 have been free of any further ischemic events without the use of major anticoagulant agents.

Article Information

Address reprint requests to: Arthur L. Day, M.D., Department of Neurological Surgery, J. Hillis Miller Health Center, College of Medicine, University of Florida, P.O. Box J-265, Gainesville, Florida 32610.

© AANS, except where prohibited by US copyright law.

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Figures

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    Angiograms of the left common carotid artery, anteroposterior view, showing resolving stenosis in a 61-year-old man with transient ischemic attacks and mild stroke (Group 3). For a description of groups see text. Left: Study 10 days after symptom onset showing a relatively focal, very high-grade stenosis of the distal M1 segment, with delayed filling into the Sylvian fissure (compare to anterior cerebral artery filling). Right: Study 7 weeks after symptom onset. There is marked resolution of stenosis, with excellent distal filling of the middle cerebral artery. Computerized tomography scanning revealed a lacunar infarct in the left basal ganglia.

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    Angiograms of the left common carotid artery, anteroposterior view, showing progressive middle cerebral artery (MCA) stenosis in a 74-year-old man with multiple transient ischemic attacks (Group 4). For a description of groups see text. Left: Angiogram after 6 months of anticoagulant therapy. There is persistent MCA stenosis with poorer MCA filling, compared to an earlier study. Right: Study 9 days after extracranial-intracranial bypass. There is excellent MCA filling via the bypass, and no further orthograde filling of the MCA beyond the lenticulostriate origins. Three days after surgery, the patient experienced expressive dysphasia which cleared rapidly.

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    Angiograms in a 40-year-old man with acute hemiparesis and no repeat arteriography prior to extracranial-intracranial (EC-IC) bypass (Group 3). For a description of groups see text. Left: Lateral view of the right common carotid artery 1 week after onset of the deficit showing the proximal middle cerebral artery (MCA) occlusion. The patient later received EC-IC bypass without clinical improvement. Right: Lateral view of the right internal carotid artery 9 months after the EC-IC bypass procedure. The MCA trunk occlusion has recanalized. Lower: Lateral view of the right external carotid artery, also at 9 months after bypass. “Successful” EC-IC bypass filling is seen in only one distal cortical branch.

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    Suggested management schema in cases of middle cerebral artery (MCA) obstruction. CT = computerized tomography; TIA's = transient ischemic attacks; EC-IC = extracranial-intracranial.

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