Results of extracranial-intracranial arterial bypass for bilateral carotid occlusion

Abstract

The results of superficial temporal to middle cerebral artery bypass surgery for bilateral internal carotid artery occlusion were reviewed in 39 patients. Preoperative symptoms included recurrent transient ischemic attacks (TIA's) in 31 patients (80%) and mild or moderate stroke in 15 (29%). Deficits were unilateral in 23 cases and bilateral in 14. Dementia or personality changes were observed in 19 patients (49%). Operative morbidity occurred in six of 39 cases and was neurological in one; the surgical mortality rate was 8% (three of 39 patients), including two cases of cerebral hemorrhage. The outcome was good or excellent (relief of TIA's and reduction of neurological deficit) in 82% of patients over a follow-up period of 3 to 139 months. Five patients had a late postoperative stroke, which occurred in the unoperated hemisphere in each case; one patient had an ipsilateral TIA 6 years after the bypass procedure. These results suggest that an extracranial-intracranial arterial bypass procedure to augment collateral cerebral blood flow can be performed safely in patients with bilateral internal carotid artery occlusion and may be associated with relief of ischemic symptoms. Future studies may document a role for this procedure in the prevention of stroke.

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

“…The previously reported annual stroke rates in patients with bilateral ICA occlusion range between 0 and 13% [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 , 26 ]. The largest prospective follow-up study on bilateral ICA occlusion with non- or moderately disabling symptoms so far was published more than 20 years ago and consisted of 34 patients, of whom 11 patients suffered a stroke during a mean duration of follow-up of 3.5 years [ 26 ].…”

“…Most other follow-up studies found annual stroke rates between 0 and 6%, which is more in agreement with our findings. However, these included only a small number of patients (between 8 and 21) [ 1 , 18 , 21 , 25 ] or described only patients who underwent an EC/IC bypass operation [ 8 ] or various revascularization operations including EC/IC bypass [ 11 ].…”

“…Information on the management and prognosis of patients with bilateral occlusion of the ICA is limited by the small numbers of patients studied and the short duration of follow-up in the majority of studies [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 – 27 ]. Some studies on outcome of patients with TIA or stroke associated with bilateral ICA occlusion have emphasized a high risk of recurrent ischaemic stroke [ 1 , 8 , 11 ] and therefore have recommended surgical revascularization by means of an extracranial–intracranial (EC/IC) bypass or endarterectomy of an external carotid artery (ECA). In contrast, a meta-analysis of the outcome of patients with transient or moderately disabling signs and symptoms associated with ICA occlusion suggested that patients with a bilateral ICA occlusion may fare as well or even better than patients with unilateral ICA occlusion [ 16 ].…”

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

“…The previously reported annual stroke rates in patients with bilateral ICA occlusion range between 0 and 13% [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 , 26 ]. The largest prospective follow-up study on bilateral ICA occlusion with non- or moderately disabling symptoms so far was published more than 20 years ago and consisted of 34 patients, of whom 11 patients suffered a stroke during a mean duration of follow-up of 3.5 years [ 26 ].…”

“…Most other follow-up studies found annual stroke rates between 0 and 6%, which is more in agreement with our findings. However, these included only a small number of patients (between 8 and 21) [ 1 , 18 , 21 , 25 ] or described only patients who underwent an EC/IC bypass operation [ 8 ] or various revascularization operations including EC/IC bypass [ 11 ].…”

“…Information on the management and prognosis of patients with bilateral occlusion of the ICA is limited by the small numbers of patients studied and the short duration of follow-up in the majority of studies [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 – 27 ]. Some studies on outcome of patients with TIA or stroke associated with bilateral ICA occlusion have emphasized a high risk of recurrent ischaemic stroke [ 1 , 8 , 11 ] and therefore have recommended surgical revascularization by means of an extracranial–intracranial (EC/IC) bypass or endarterectomy of an external carotid artery (ECA). In contrast, a meta-analysis of the outcome of patients with transient or moderately disabling signs and symptoms associated with ICA occlusion suggested that patients with a bilateral ICA occlusion may fare as well or even better than patients with unilateral ICA occlusion [ 16 ].…”

Pial synangiosis for moyamoya syndrome in children with sickle cell anemia: a comprehensive review of reported cases

“…Whereas some evidence 24,25 suggests a significant decrease in cerebral ischemia following direct bypass, other evidence shows that pediatric STA-MCA revascularization is associated with signifi cant complications including symptomatic hyperperfusion, [10][11][12] acceleration of ipsilateral stenosis, 17 and perioper ative ischemic injury due to temporary arterial occlusion. Given the high morbidity and mortality rates 8,24,40 in this procedure and the small arterial diameters of the STA and MCA in children, the STA-MCA bypass is less commonly performed in the treatment of MMS in pediatric patients.…”

Superficial temporal artery to middle cerebral artery bypass: past, present, and future

“…103,120,126,130,137 Subsequently, large studies also demonstrated the feasibility of the STA-MCA bypass and possible neurological improvement in patients with atherosclerotic occlusive cerebrovascular disease, including bilateral disease. 14,24,35,121 By the end of a decade after the introduction of the STA-MCA bypass to the neurosurgical community, the selection of patients and the indications for surgery remained controversial despite attempts to refine the surgical indications based on the concept of hemodynamic insufficiency. 41,107,112 Our knowledge of the natural history of occlusive cerebrovascular disease was rather uncertain, and methods for the identification of hemodynamic cerebrovascular insufficiency were still evolving.…”

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

“…The previously reported annual stroke rates in patients with bilateral ICA occlusion range between 0 and 13% [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 , 26 ]. The largest prospective follow-up study on bilateral ICA occlusion with non- or moderately disabling symptoms so far was published more than 20 years ago and consisted of 34 patients, of whom 11 patients suffered a stroke during a mean duration of follow-up of 3.5 years [ 26 ].…”

“…Most other follow-up studies found annual stroke rates between 0 and 6%, which is more in agreement with our findings. However, these included only a small number of patients (between 8 and 21) [ 1 , 18 , 21 , 25 ] or described only patients who underwent an EC/IC bypass operation [ 8 ] or various revascularization operations including EC/IC bypass [ 11 ].…”

“…Information on the management and prognosis of patients with bilateral occlusion of the ICA is limited by the small numbers of patients studied and the short duration of follow-up in the majority of studies [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 – 27 ]. Some studies on outcome of patients with TIA or stroke associated with bilateral ICA occlusion have emphasized a high risk of recurrent ischaemic stroke [ 1 , 8 , 11 ] and therefore have recommended surgical revascularization by means of an extracranial–intracranial (EC/IC) bypass or endarterectomy of an external carotid artery (ECA). In contrast, a meta-analysis of the outcome of patients with transient or moderately disabling signs and symptoms associated with ICA occlusion suggested that patients with a bilateral ICA occlusion may fare as well or even better than patients with unilateral ICA occlusion [ 16 ].…”

Pial synangiosis for moyamoya syndrome in children with sickle cell anemia: a comprehensive review of reported cases

“…Whereas some evidence 24,25 suggests a significant decrease in cerebral ischemia following direct bypass, other evidence shows that pediatric STA-MCA revascularization is associated with signifi cant complications including symptomatic hyperperfusion, [10][11][12] acceleration of ipsilateral stenosis, 17 and perioper ative ischemic injury due to temporary arterial occlusion. Given the high morbidity and mortality rates 8,24,40 in this procedure and the small arterial diameters of the STA and MCA in children, the STA-MCA bypass is less commonly performed in the treatment of MMS in pediatric patients.…”

Superficial temporal artery to middle cerebral artery bypass: past, present, and future

“…103,120,126,130,137 Subsequently, large studies also demonstrated the feasibility of the STA-MCA bypass and possible neurological improvement in patients with atherosclerotic occlusive cerebrovascular disease, including bilateral disease. 14,24,35,121 By the end of a decade after the introduction of the STA-MCA bypass to the neurosurgical community, the selection of patients and the indications for surgery remained controversial despite attempts to refine the surgical indications based on the concept of hemodynamic insufficiency. 41,107,112 Our knowledge of the natural history of occlusive cerebrovascular disease was rather uncertain, and methods for the identification of hemodynamic cerebrovascular insufficiency were still evolving.…”

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

“…The previously reported annual stroke rates in patients with bilateral ICA occlusion range between 0 and 13% [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 , 26 ]. The largest prospective follow-up study on bilateral ICA occlusion with non- or moderately disabling symptoms so far was published more than 20 years ago and consisted of 34 patients, of whom 11 patients suffered a stroke during a mean duration of follow-up of 3.5 years [ 26 ].…”

“…Most other follow-up studies found annual stroke rates between 0 and 6%, which is more in agreement with our findings. However, these included only a small number of patients (between 8 and 21) [ 1 , 18 , 21 , 25 ] or described only patients who underwent an EC/IC bypass operation [ 8 ] or various revascularization operations including EC/IC bypass [ 11 ].…”

“…Information on the management and prognosis of patients with bilateral occlusion of the ICA is limited by the small numbers of patients studied and the short duration of follow-up in the majority of studies [ 1 , 4 , 8 , 9 , 11 , 18 , 21 , 25 – 27 ]. Some studies on outcome of patients with TIA or stroke associated with bilateral ICA occlusion have emphasized a high risk of recurrent ischaemic stroke [ 1 , 8 , 11 ] and therefore have recommended surgical revascularization by means of an extracranial–intracranial (EC/IC) bypass or endarterectomy of an external carotid artery (ECA). In contrast, a meta-analysis of the outcome of patients with transient or moderately disabling signs and symptoms associated with ICA occlusion suggested that patients with a bilateral ICA occlusion may fare as well or even better than patients with unilateral ICA occlusion [ 16 ].…”

Pial synangiosis for moyamoya syndrome in children with sickle cell anemia: a comprehensive review of reported cases

“…Whereas some evidence 24,25 suggests a significant decrease in cerebral ischemia following direct bypass, other evidence shows that pediatric STA-MCA revascularization is associated with signifi cant complications including symptomatic hyperperfusion, [10][11][12] acceleration of ipsilateral stenosis, 17 and perioper ative ischemic injury due to temporary arterial occlusion. Given the high morbidity and mortality rates 8,24,40 in this procedure and the small arterial diameters of the STA and MCA in children, the STA-MCA bypass is less commonly performed in the treatment of MMS in pediatric patients.…”

Superficial temporal artery to middle cerebral artery bypass: past, present, and future

“…103,120,126,130,137 Subsequently, large studies also demonstrated the feasibility of the STA-MCA bypass and possible neurological improvement in patients with atherosclerotic occlusive cerebrovascular disease, including bilateral disease. 14,24,35,121 By the end of a decade after the introduction of the STA-MCA bypass to the neurosurgical community, the selection of patients and the indications for surgery remained controversial despite attempts to refine the surgical indications based on the concept of hemodynamic insufficiency. 41,107,112 Our knowledge of the natural history of occlusive cerebrovascular disease was rather uncertain, and methods for the identification of hemodynamic cerebrovascular insufficiency were still evolving.…”