Potential roles for early revascularization in patients with acute cerebral ischemia

The risk of carotid endarterectomy in acute cerebral ischemic situations is well documented. By using the superficial temporal or occipital artery, it is possible to provide relatively low flow revascularization conduits, potentially avoiding the risk of postoperative hemorrhage. Eighteen patients at The University of Texas Health Science Center at Dallas, Texas, have been treated recently with extracranial to intracranial bypass in the setting of acute neurological deficit, stroke in evolution, or recent completed infarction. Angiographic causes of these deficits included cervical carotid occlusion in 5 patients, carotid siphon disease in 2 patients, middle cerebral stenosis or occlusion in 3 patients, and delayed cerebral ischemia following subarachnoid hemorrhage in 8 patients. Neurological improvement was demonstrated within 24 hours following revascularization in 15 cases (83%); 3 patients were unchanged following bypass, and no patient's condition was worsened. The only case of postoperative intracerebral hemorrhage occurred 1 week following a long saphenous vein graft from the subclavian to the middle cerebral artery. After an average follow-up of 19 months, 7 patients are neurologically normal, 8 patients have mild to moderate deficits, and 3 patients have died. Low flow revascularization procedures appear to be safe in the setting of acute cerebral ischemia and may in selected patients boost regional cerebral blood flow from levels of symptomatic ischemia into a range compatible with normal neuronal function.