Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

Abstract

<b><i>Background:</i></b> Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. <b><i>Aims:</i></b> We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. <b><i>Methods:</i></b> Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. <b><i>Results:</i></b> In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. <b><i>Conclusions:</i></b> Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

Early Restoration of Hypoperfusion Confirmed by Perfusion Magnetic Resonance Image after Emergency Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

“…Previous studies by Nussbaum et al 16) in 2010, Lee et al 11) in 2013, and Kim et al 10) in 2021 were similar to our study. Based on the analysis of 13, 20, and 18 cases, respectively, the early bypass results were analyzed, and significantly positive results were achieved compared with the previous analyses.…”

“…The analysis by Nussbaum et al [ 16 ] had several limitations including no record of time between the manifestation of obvious symptoms and surgical treatment. Kim et al [ 10 ] analyzed a prospective study of acute infarction patients with urgent STA-MCA anastomosis that is most similar to the present study; however, the number of enrolled patients was small ( Table 5 ).…”

“…Superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis is one of the alternatives. Although the efficacy of emergent STA-MCA anastomosis has been reported [ 10 , 11 , 16 ], there are concerns about the effectiveness of STA-MCA anastomosis because STA-MCA anastomosis is a lowflow bypass surgery that only restoring a little blood flow. In this study, we analyzed the effectivity of STA-MCA anastomosis for improving perfusion defects after large vessel occlusion by perfusion magnetic resonance imaging (MRI) and which factors were associated with the improvement of the patient’s postoperative outcome.…”

Rescue Extracranial–Intracranial Bypass for Ischemic Stroke Secondary to Progressive Human Immunodeficiency Virus–Associated Vasculopathy

“…13,14 A recent pooled analysis of 117 patients showed that transient complication (including hyperperfusion syndrome), minor complication (including asymptomatic infarction growth and minor hemorrhage), and major complication (including graft occlusion and major hemorrhage) occurred only in five (4.3%), four (3.4%), and three (2.6%) patients, respectively. 15 Although further evidence is needed, extracranial-intracranial bypass can be an effective option if all the following conditions are met: (1) in-progress stroke despite maximal medical treatment, (2) moderate-to-severe neurologic severity, (3) small infarcted core area, and (4) proven low perfusion area.…”

“…13,14 A recent pooled analysis of 117 patients showed that transient complication (including hyperperfusion syndrome), minor complication (including asymptomatic infarction growth and minor hemorrhage), and major complication (including graft occlusion and major hemorrhage) were occurred only in five (4.3%), four (3.4%), and three (2.6%) patients, respectively. 15 Although further evidence is needed, extracranial-…”