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Future of extracranial-intracranial bypass
Murali Guthikonda1, Lisa L Guyot, Fernando G Diaz
1Department of Neurological Surgery, Wayne State University, Detroit, MI 48201, USA. Mguthikonda@neurosurgery.wayne.edu
Insights
Patients with total internal carotid artery occlusion may face delayed stroke risk. A new trial will assess if extracranial-intracranial bypass reduces stroke rates in these high-risk individuals.
Area of Science:
- Vascular Surgery
- Neurology
- Neurosurgery
Background:
- Progressive occlusive vascular disease can lead to total internal carotid artery occlusion.
- A subset of patients develop symptomatic cerebral ischemia due to hypoperfusion.
- Previous trials on bypass for carotid occlusion have yielded inconclusive or questioned results.
Purpose of the Study:
- To evaluate the efficacy of extracranial-intracranial bypass in reducing future stroke rates in patients with total carotid occlusion.
- To identify patients at risk of stroke from carotid occlusion and peri-operative events.
- To assess the role of new imaging technologies in managing these at-risk patients.
Main Methods:
- Initiation of The Carotid Occlusion Surgery Study, a new trial employing current technology.
- Focus on patients with total internal carotid artery occlusion.
- Inclusion of a subset of patients undergoing carotid sacrifice for skull base pathology.
Main Results:
- The Carotid Occlusion Surgery Study aims to determine if bypass decreases stroke rate by at least 40%.
- Pre-operative testing will identify patients at risk of peri-operative and delayed stroke.
- New imaging technologies will guide management and bypass decisions.
Conclusions:
- Extracranial-intracranial bypass may be a crucial prophylactic treatment for select patients with total carotid occlusion.
- Early identification and intervention are key to preventing catastrophic stroke events.
- Advanced imaging will play a vital role in patient selection and management for bypass procedures.
Abstract:
Total occlusion of internal carotid artery in the cervical region is an end result of progressive occlusive vascular disease. A small proportion of these patients will have symptoms of cerebral ischemia due to cerebral hypoperfusion in a delayed fashion. Identification of those individuals who are at risk of developing symptoms and prophylactically treating with a revascularization procedure will prevent such catastrophic events. With the co-operative study for bypass not supporting the bypass procedure and trial being questioned for its design and conclusions, a new trial of extracranial-intracranial bypass, The Carotid Occlusion Surgery Study, using the currently available technology will be undertaken to verify that the bypass will decrease the future stroke rate by at least 40% in patients with total carotid occlusion. A subset of patients with skull base pathology including tumors and aneurysms who may have to undergo carotid sacrifice as part of the surgical procedure are at risk of peri-operative and delayed stroke. Identification of these patients at risk by pre-operative tests may allow performance of extracranial-intracranial bypass prior to undertaking complex skull base procedures. The new imaging technology will guide management of these patients at risk and help identify patients who may need a bypass procedure.
