Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients

Abla, Adib A.; McDougall, Cameron M.; Lawton, Michael T.

doi:10.3171/2015.5.jns15368

Cited by 68 publications

(31 citation statements)

References 27 publications

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“…A previous report by Sanai et al illustrated that IC-IC bypasses have patency and complication rates that are similar to those of extracranial-IC bypasses, 26 while Abla et al have argued that PICA aneurysms respond best to PICA-PICA anastomosis. 1 In this series, we performed 11 IC-IC and in situ bypasses with only one major complication, corroborating basic safety and efficacy, but larger studies are needed to demonstrate the complication rates and relative safety of IC-IC and in situ bypasses, which may put at risk normal vascular territories that are used as the "donor" vessels in such cases.…”

Section: Ic-ic and In Situ Bypasssupporting

confidence: 54%

“…4,15,22 Alternatively, these challenging lesions can be managed using parent artery occlusion combined with creative forms of cerebral revascularization to maintain adequate blood flow to the distal vascular territory. [1][2][3][4][5][6][7][8][9] As the indications for endovascular therapy widen, maintaining highly specialized centers that provide a full range of endovascular and surgical approaches, including cerebral revascularization, is necessary to ensure that complex aneurysms can be addressed adequately. This report details our experience with cerebral revascularization procedures in a large series of complex IAs for which traditional clip reconstruction or endovascular repair were felt to carry unacceptably high risks of major complication.…”

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confidence: 99%

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Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience

Nussbaum

Kallmes

Lassig

et al. 2019

Journal of Neurosurgery

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OBJECTIVEBecause simple intracranial aneurysms (IAs) are increasingly treated endovascularly, neurovascular surgery has become focused on complex IAs that may require deconstructive aneurysm therapy with concomitant surgical bypass. The authors describe the decision-making process concerning cerebral revascularization and present outcomes that were achieved in a large case series of complex IAs managed with cerebral revascularization and parent artery occlusion.METHODSThe authors retrospectively reviewed the medical records, including neuroimaging studies, operative reports, and follow-up clinic notes, of all patients who were treated at the National Brain Aneurysm Center between July 1997 and June 2015 using cerebral revascularization as part of the management of an IA. They recorded the location, rupture status, and size of each IA, as well as neurological outcome using the modified Rankin Scale (mRS), aneurysm and bypass status at follow-up, and morbidity and mortality.RESULTSThe authors identified 126 patients who underwent revascularization surgery for 126 complex, atheromatous, calcified, or previously coiled aneurysms. Ninety-seven lesions (77.0%) were unruptured, and 99 (78.6%) were located in the anterior circulation. Aneurysm size was giant (≥ 25 mm) in 101 patients, large (10–24 mm) in 9, and small (≤ 9 mm) in 16 patients. Eighty-four low-flow bypasses were performed in 83 patients (65.9%). High-flow bypass was performed in 32 patients (25.4%). Eleven patients (8.7%) underwent in situ or intracranial-intracranial bypasses. Major morbidity (mRS score 4 or 5) occurred in 2 (2.4%) low-flow cases and 3 (9.1%) high-flow cases. Mortality occurred in 2 (2.4%) low-flow cases and 2 (6.1%) high-flow cases. At the 12-month follow-up, 83 (98.8%) low-flow and 30 (93.8%) high-flow bypasses were patent. Seventy-five patients (90.4%) undergoing low-flow and 28 (84.8%) high-flow bypasses had an mRS score ≤ 2. There were no statistically significant differences in patency rates or complications between low- and high-flow bypasses.CONCLUSIONSWhen treating challenging and complex IAs, incorporating revascularization strategies into the surgical repertoire may contribute to achieving favorable outcomes. In our series, low-flow bypass combined with isolated proximal or distal parent artery occlusion was associated with a low rate of ischemic complications while providing good long-term aneurysm control, potentially supporting its wider utilization in this setting. The authors suggest that consideration should be given to managing complex IAs at high-volume centers that offer a multidisciplinary team approach and the full spectrum of surgical and endovascular treatment options to optimize patient outcomes.

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Section: Ic-ic and In Situ Bypasssupporting

confidence: 54%

mentioning

confidence: 99%

Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience

Nussbaum

Kallmes

Lassig

et al. 2019

Journal of Neurosurgery

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“…This may reflect a consolidation of referral patterns toward high-volume academic centers of excellence. 1,2,17,33,39 Our analysis has shown that the bypass is predominantly performed in individuals with an Elixhauser comorbidity index of 2 or greater (77%) and is virtually never performed in individuals with a score of 0. This suggests that certain comorbidities may play a role in the progression of aneurysms to the complex lesions requiring bypass.…”

Section: Discussionmentioning

confidence: 87%

National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015

Sharma¹,

Ugiliweneza²,

Fortuny³

et al. 2019

Neurosurgical Focus

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OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.

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“…23 Even with the continued evolution of technology, bypass remains uniquely suited for complex and/or fusiform aneurysms in certain regions of the cerebral circulation including the middle cerebral artery, posterior inferior cerebellar arteries, or more distal cerebral arterial branches. 1,2,14,15,28 Cerebral aneurysms remain a leading indication for bypass at some centers, 14,15 and bypass will likely remain an important treatment option for aneurysms not amenable to endovascular therapy or open surgical clipping. However, our data suggest that cerebral bypass for aneurysms is associated with a comparatively higher rate of complications, including iatrogenic stroke and death.…”

Section: Discussionmentioning

confidence: 99%

National trends in cerebral bypass surgery in the United States, 2002–2014

Winkler

Yue

Deng

et al. 2019

Neurosurgical Focus

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OBJECTIVECerebral bypass procedures are microsurgical techniques to augment or restore cerebral blood flow when treating a number of brain vascular diseases including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. With advances in endovascular therapy and evolving evidence-based guidelines, it has been suggested that cerebral bypass procedures are in a state of decline. Here, the authors characterize the national trends in cerebral bypass surgery in the United States from 2002 to 2014.METHODSUsing the National (Nationwide) Inpatient Sample, the authors extracted for analysis the data on all adult patients who had undergone cerebral bypass as indicated by ICD-9-CM procedure code 34.28. Indications for bypass procedures, patient demographics, healthcare costs, and regional variations are described. Results were stratified by indication for cerebral bypass including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. Predictors of inpatient complications and death were evaluated using multivariable logistic regression analysis.RESULTSFrom 2002 to 2014, there was an increase in the annual number of cerebral bypass surgeries performed in the United States. This increase reflected a growth in the number of cerebral bypass procedures performed for adult moyamoya disease, whereas cases performed for occlusive vascular disease or cerebral aneurysms declined. Inpatient complication rates for cerebral bypass performed for moyamoya disease, vascular occlusive disease, and cerebral aneurysm were 13.2%, 25.1%, and 56.3%, respectively. Rates of iatrogenic stroke ranged from 3.8% to 20.4%, and mortality rates were 0.3%, 1.4%, and 7.8% for moyamoya disease, occlusive vascular disease, and cerebral aneurysms, respectively. Multivariate logistic regression confirmed that cerebral bypass for vascular occlusive disease or cerebral aneurysm is a statistically significant predictor of inpatient complications and death. Mean healthcare costs of cerebral bypass remained unchanged from 2002 to 20014 and varied with treatment indication: moyamoya disease $38,406 ± $483, vascular occlusive disease $46,618 ± $774, and aneurysm $111,753 ± $2381.CONCLUSIONSThe number of cerebral bypass surgeries performed for adult revascularization has increased in the United States from 2002 to 2014. Rising rates of surgical bypass reflect a greater proportion of surgeries performed for moyamoya disease, whereas bypasses performed for vascular occlusive disease and aneurysms are decreasing. Despite evolving indications, cerebral bypass remains an important surgical tool in the modern endovascular era and may be increasing in use. Stagnant complication rates highlight the need for continued interest in advancing available bypass techniques or technologies to improve patient outcomes.

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Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients

Cited by 68 publications

References 27 publications

Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience

Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience

National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015

National trends in cerebral bypass surgery in the United States, 2002–2014

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