| Bypass for the prevention of ischemic stroke. | |
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MedLine Citation:
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PMID: 22182275 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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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. |
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Authors:
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Ana Rodríguez-Hernández; Andrew S Josephson; David Langer; Michael T Lawton |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: World neurosurgery Volume: 76 ISSN: 1878-8750 ISO Abbreviation: World Neurosurg Publication Date: 2011 Dec |
Date Detail:
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Created Date: 2011-12-20 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 101528275 Medline TA: World Neurosurg Country: United States |
Other Details:
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Languages: eng Pagination: S72-9 Citation Subset: IM |
Copyright Information:
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Copyright © 2011 Elsevier Inc. All rights reserved. |
Affiliation:
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Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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