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Published on: November 22, 2024
Revascularization of the posterior circulation
Bert A Coert1, Steven D Chang, Michael P Marks
1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94304-5327, USA.
Insights
Revascularization of the posterior circulation prevents vertebrobasilar ischemic stroke. Procedures like bypasses and angioplasty offer symptom relief and reduce stroke risk with low complications.
Area of Science:
- Neurosurgery
- Vascular Neurology
- Cerebrovascular Disease
Background:
- Posterior circulation revascularization aims to prevent vertebrobasilar ischemic stroke.
- Posterior communicating artery size influences ischemia susceptibility.
- Indications include refractory symptomatic ischemia and parent vessel occlusion.
Purpose of the Study:
- To summarize revascularization strategies for posterior circulation ischemia.
- To review treatment options and outcomes.
Main Methods:
- Review of endovascular and surgical revascularization techniques.
- Discussion of pretreatment assessments like cerebral blood flow.
- Emphasis on neuroprotective measures and intraoperative monitoring.
Main Results:
- Various bypass grafts (e.g., superficial temporal artery) can augment posterior circulation.
- Reported symptom improvement in 60-100% of patients.
- Associated with reduced stroke risk and low complication rates.
Conclusions:
- Revascularization is effective in preventing posterior circulation ischemic stroke.
- Multiple surgical and endovascular options exist.
- Careful patient selection and management optimize outcomes.
Abstract:
The primary objective of revascularization procedures in the posterior circulation is the prevention of vertebrobasilar ischemic stroke. Specific anatomical and neurophysiologic characteristics such as posterior communicating artery size affect the susceptibility to ischemia. Current indications for revascularization include symptomatic vertebrobasilar ischemia refractory to medical therapy and ischemia caused by parent vessel occlusion as treatment for complex aneurysms. Treatment options include endovascular angioplasty and stenting, surgical endarterectomy, arterial reimplantation, extracranial-to-intracranial anastomosis, and indirect bypasses. Pretreatment studies including cerebral blood flow measurements with assessment of hemodynamic reserve can affect treatment decisions. Careful blood pressure regulation, neurophysiologic monitoring, and neuroprotective measures such as mild brain hypothermia can help minimize the risks of intervention. Microscope, microinstruments and intraoperative Doppler are routinely used. The superficial temporal artery, occipital artery, and external carotid artery can be used to augment blood flow to the superior cerebellar artery, posterior cerebral artery, posterior inferior cerebellar artery, or anterior inferior cerebellar artery. Interposition venous or arterial grafts can be used to increase length. Several published series report improvement or relief of symptoms in 60 to 100% of patients with a reduction of risk of future stroke and low complication rates.
