Document Detail


Bypass for the prevention of ischemic stroke.
MedLine Citation:
PMID:  22182275     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: Although most ischemic strokes are thromboembolic in origin and their management is endovascular or medical, some are hemodynamic in origin and their management may be surgical. Extracranial-intracranial bypass with superficial temporal artery-to-middle cerebral artery (MCA) bypass, high-flow interposition grafts, and reconstructive techniques have been developed. Clinical indications and efficacy are controversial, and this review examines current practices.
METHODS: Bypass surgery is indicated for patients with athero-occlusive disease that results in chronic, low cerebral blood flow accompanied by episodes of ischemic symptoms. Specific diagnoses include: (1) internal carotid artery occlusion; (2) MCA occlusion and, rarely, high-grade MCA stenosis; (3) vertebrobasilar atherosclerotic steno-occlusive disease; (4) vasculitis resulting in severe occlusive disease; and (5) moyamoya disease.
RESULTS: Discouraging results from the Extracranial-Intracranial Bypass Trial demonstrated the importance of selecting surgical patients based on objective measures of hemodynamic insufficiency. Two such tests are xenon-enhanced computed tomography with acetazolamide challenge and positron emission tomography with measurement of oxygen extraction fraction. Perfusion computed tomography may be another, more practical test. Surgical series, systematic reviews of the literature, and two new randomized clinical trials that use these diagnostic techniques reveal contradictory results. Although they demonstrate that bypass surgery has a morbidity rate of less than 5% and a patency rate of more than 95%, they have not proven a clear benefit.
CONCLUSIONS: Patients with athero-occlusive disease and symptoms of hemodynamic insufficiency have significant risk of stroke if left untreated or managed medically. On the other hand, surgical intervention lacks supporting evidence. Clinicians must individualize their management recommendations until additional data are published or further consensus develops.
Authors:
Ana Rodríguez-Hernández; S Andrew Josephson; Andrew S Josephson; David Langer; Michael T Lawton
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Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  World neurosurgery     Volume:  76     ISSN:  1878-8750     ISO Abbreviation:  World Neurosurg     Publication Date:  2011 Dec 
Date Detail:
Created Date:  2011-12-20     Completed Date:  2012-02-06     Revised Date:  2012-12-28    
Medline Journal Info:
Nlm Unique ID:  101528275     Medline TA:  World Neurosurg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  S72-9     Citation Subset:  IM    
Copyright Information:
Copyright © 2011 Elsevier Inc. All rights reserved.
Affiliation:
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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MeSH Terms
Descriptor/Qualifier:
Brain Ischemia / etiology,  physiopathology,  prevention & control*,  surgery*
Cerebral Revascularization / methods*,  statistics & numerical data
Endovascular Procedures / methods*
Hemodynamics / physiology
Humans
Stroke / etiology,  physiopathology,  prevention & control*,  surgery*
Comments/Corrections
Erratum In:
World Neurosurg. 2012 Dec;78(6):e1
Note: Josephson, Andrew S [corrected to Josephson, S Andrew]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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