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Updated: Jun 13, 2026

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
14:58

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Published on: October 20, 2017

Beyond COSS: The Evolution of Hemodynamic Imaging and Revascularization Strategies in Chronic Cerebrovascular

Fareed Jumah1, Hunter Brooks1, Farhan Siddiq1

  • 1Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA.

Missouri Medicine
|June 12, 2026
PubMed

Insights

Chronic carotid occlusion (CCO) increases ischemic stroke risk. While extracranial-intracranial (EC-IC) bypass showed technical success, trials found limited benefit, leading to reduced surgical use. Advances in imaging may refine patient selection for future revascularization strategies.

Area of Science:

  • Neurology
  • Neurosurgery
  • Vascular Surgery

Background:

  • Chronic carotid occlusion (CCO) poses a significant risk for ischemic stroke, especially in patients with compromised cerebrovascular reserve.
  • Extracranial-intracranial (EC-IC) bypass was a common surgical approach for CCO, achieving high technical success rates.
  • Major randomized trials, such as the Carotid Occlusion Surgery Study (COSS), did not demonstrate significant benefits, largely due to perioperative stroke risks and suboptimal patient selection, leading to a decline in surgical revascularization.

Purpose of the Study:

  • To re-evaluate the role of flow augmentation in managing chronic carotid occlusion (CCO).
  • To consider the impact of modern cerebral perfusion imaging advancements on treatment strategies for CCO.
  • To identify patient subsets who may benefit from selective revascularization despite previous trial outcomes.

Main Methods:

  • Review of existing literature on chronic carotid occlusion (CCO) and extracranial-intracranial (EC-IC) bypass.
  • Examination of contemporary cerebral perfusion imaging techniques, including computed tomography (CT) perfusion and magnetic resonance (MR) imaging.
  • Analysis of how advanced imaging can improve patient selection for surgical intervention.

Main Results:

  • Previous large randomized trials (e.g., COSS) failed to show significant benefits for EC-IC bypass in CCO, primarily due to perioperative risks and patient selection issues.
  • Modern imaging modalities (CT perfusion, MR techniques) offer improved capabilities for identifying patients with hemodynamic compromise.
  • These advanced imaging techniques can better pinpoint individuals at high risk of stroke despite medical management.

Conclusions:

  • The role of surgical revascularization for CCO requires re-examination in the context of improved diagnostic tools.
  • Refined patient selection using advanced cerebral perfusion imaging may identify a specific subgroup likely to benefit from EC-IC bypass.
  • Future research should incorporate these advanced imaging criteria to redefine the indications for selective revascularization in CCO.

Keywords:
Carotid occlusioncerebral bypasshypoperfusion

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