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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Indications and results of direct cerebral revascularization in the modern era
M Yashar S Kalani1, Leonardo Rangel-Castilla1, Wyatt Ramey1
1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Insights
Cerebral revascularization via bypass surgery remains crucial for select vascular conditions like complex aneurysms and moyamoya disease, offering excellent long-term outcomes with low risks.
Area of Science:
- Neurosurgery
- Vascular Surgery
- Neurology
Background:
- Cerebral revascularization procedures have seen decreased use due to endovascular advancements.
- This study evaluates bypass surgery in the current endovascular treatment era.
Purpose of the Study:
- To define indications for cerebral revascularization by bypass surgery.
- To assess patient outcomes following these procedures in the modern era.
Main Methods:
- Retrospective review of patients undergoing direct cerebral revascularization.
- Data collected from January 2006 to March 2013.
Main Results:
- 121 patients underwent 131 procedures for moyamoya angiopathy, complex aneurysms, and occlusive vascular disease.
- Symptom improvement observed in 77.5% of moyamoya and 55.5% of occlusive disease patients.
- 81.5% of aneurysm patients achieved favorable long-term outcomes.
Conclusions:
- Microvascular cerebral revascularization is essential for specific pathologies, particularly complex aneurysms and moyamoya disease.
- Bypass surgery in experienced hands demonstrates low morbidity/mortality and excellent long-term results.
Background:
There has been a progressive decrease in the indications for cerebral revascularization during the past 30 years, particularly with the advance of endovascular techniques. Our objective was to define indications for and evaluate outcomes of patients treated with bypass surgery in the modern endovascular era.
Methods:
We retrospectively reviewed the charts of all patients who underwent direct cerebral revascularization procedures between January 2006 and March 2013.
Results:
In total, 121 patients underwent 131 direct microsurgical revascularization procedures. The indications for bypass surgery were moyamoya angiopathy (40 patients, 47 bypasses), complex aneurysms (54 patients, 56 bypasses), and occlusive vascular disease (27 patients, 28 bypasses). Revascularization resulted in improvement of symptoms in 77.5% of patients with moyamoya angiopathy (mean clinical follow-up 18.8 months) and 55.5% of patients with occlusive vascular disease (mean clinical follow-up 10.4 months). Among the aneurysm patients treated with revascularization, 81.5% had a favorable outcome (Glasgow Outcome Scale score 4-5) at long-term follow-up (mean clinical followup 18.5 months).
Conclusions:
Although microvascular cerebral revascularization is no longer performed as commonly as in the past, it remains an essential part of the skill set required to treat select vascular pathologies. Complex aneurysms are the single largest indication for direct bypass procedures. Moyamoya disease is by far the largest indication if indirect bypass procedures are included in the analysis. In experienced hands, the morbidity and mortality of patients undergoing cerebral revascularization procedures are low and long-term outcomes generally excellent.
