Pediatric bypasses for aneurysms and skull base tumors: short- and long-term outcomes

Clinical article

Louis J. Kim M.D., Farzana Tariq M.D., and Laligam N. Sekhar M.D.
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  • Department of Neurological Surgery, University of Washington, Seattle, Washington
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Object

Cerebral bypass is a useful microsurgical technique for the treatment of unclippable aneurysms and invasive skull base tumors. The authors present the largest reported series of cerebrovascular bypasses in the pediatric population. They describe the short- and long-term clinical and radiographic outcomes of extracranial-intracranial and local bypasses performed for complex cerebral aneurysms and recurrent, invasive, and malignant skull base tumors in pediatric patients.

Methods

A consecutive series of 17 pediatric patients who underwent revascularization were analyzed retrospectively for indications, graft patency, and neurological outcomes.

Results

The mean age was 12 years (median 11 years, range 4–17 years), and there were 7 boys (41%) and 10 girls (59%). A total of 18 bypasses were performed in 17 patients and included 10 aneurysm cases (55.5%) and 8 tumor cases (45%). Of these 18 bypasses, there were 11 (61.1%) extracranial-intracranial bypasses (10 saphenous vein grafts [90%] and 1 radial artery graft [10%]), 1 side-to-side anastomosis (5.5%), 2 intracranial reimplants (11.1%), and 4 interposition bypass grafts (22.2%; 2 radial artery grafts, 1 saphenous vein graft, and 1 lingual artery graft). The mean clinical follow-up was 40.5 months (median 24 months, range 3–197 months). The mean radiographic follow-up was 40 months (median 15 months, range 9–197 months). Eighty-two percent of patients (14 of 17) achieved a modified Rankin Scale score between 0 and 2; however, 2 patients died of disease progression during long-term follow-up. The short-term (0- to 3-month) graft patency rate was 100%. Two patients had graft stenosis (11.7%) and underwent graft revisions. Two patients (11.1%) with giant middle cerebral artery aneurysms (> 25 mm) had strokes postoperatively but recovered without a persistent neurological deficit. One patient observed for 197 months showed a stable dysplastic change at the end of the graft. The long-term graft patency was 100% with a mean follow-up of 40 months. There were 2 deaths in the cohort during follow-up; both patients died of malignant tumors (osteogenic sarcoma and chondrosarcoma).

Conclusions

The authors conclude that in properly selected cases, bypasses can be safely performed in patients with aneurysms and skull base tumors. The bypasses remained patent over long periods of time despite the growth of the patients.

Abbreviations used in this paper:

ACoA = anterior communicating artery; BA = basilar artery; CTA = CT angiography; DSA = digital subtraction angiography; EC-IC = extracranial-intracranial; ICA = internal carotid artery; MCA = middle cerebral artery; mRS = modified Rankin Scale; NF = neurofibromatosis; PCA = posterior cerebral artery; RAG = radial artery graft; STA = superficial temporal artery; SVG = saphenous vein graft.

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