Extracranial-intracranial Bypass Research Articles

Early Post-operative CT-Angiography Imaging After EC-IC Bypass Surgery in Moyamoya Patients.

Objective: To evaluate the clinical value of early post-operative computed tomographic angiography (CTA) after direct extracranial-intracranial (EC-IC) bypass surgery in moyamoya patients.Methods: A retrospective analysis of all adult moyamoya patients treated at our center from 2013 to 2019 with a direct EC-IC bypass was performed. Early post-operative CTA (within 24 h after surgery) was compared with conventional digital subtraction angiography (DSA) 6–12 months after surgery. If available, magnetic resonance time-of-flight angiography (MR-TOF) was evaluated 3 months and 6–12 months post-operatively as well. Imaging results were analyzed and compared with CTA, MR-TOF and DSA, whereat DSA was used as the final and definite modality to decide on bypass patency.Results: A total of 103 direct EC-IC bypasses in 63 moyamoya patients were analyzed. All inclusion criteria were met in 32 patients (53 direct bypasses). In 84.9% the bypass appeared definitively, in 5.7% uncertainly and in 9.4% not patent according to early post-operative CTA. MR-TOF suggested definitive bypass patency in 86.8% 3 months after surgery and in 93.5% 6–12 months after surgery. DSA 6–12 months post-operatively showed a patency in 98.1% of all bypasses. The positive predictive value (to correctly detect an occluded bypass) on post-operative CTA was 12.5%, the negative predictive value (to correctly detect a patent bypass) was 100% with a sensitivity of 100% and a specificity of 86.5%.Conclusion: Early post-operative CTA has a high predictive value to confirm the patency of a bypass. On the other hand, a high false positive rate of (according to CTA) occluded bypasses after direct EC-IC bypass surgery can be seen. This must be considered critically when initiating possible therapeutic measures.

Gross Total Resection of a Recurrent in-and-around Cavernous Sinus Meningioma through a Combined Transcavernous Anterior and Middle Infratemporal Fossa Approach with Extracranial-Intracranial Bypass.

Objectives The study aims to describe surgical management of an invasive cavernous sinus meningioma with a combination of several skull base approaches and bypass surgery. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. Cerebral bypass surgery is an essential adjunct in the armamentarium of skull base surgery when vessel reconstruction is required. In this paper, we describe our experience of successful treatment of an invasive recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 46-year-old woman presented with a 2-year history of gradually worsening left-sided exophthalmos and visual impairment. The patient had previously undergone two craniotomies for resection of the left-sided spheno-orbital meningioma. Pathological diagnosis was chordoid meningioma, which is classified as an intermediate-grade meningioma. The second surgery had been performed for a rapid tumor regrowth 6 months after the first surgery. The patient lost her left-side vision after the second surgery. Aggressive tumor regrowth was confirmed with extension into the left orbit, infratemporal fossa, and cavernous sinus with engulfment of the carotid artery. A balloon occlusion test revealed intolerance of the left internal carotid artery occlusion. Considering the patient's age, tumor behavior, and intolerance of the carotid artery of the lesion side, we scheduled gross total resection of the tumor with vessel reconstruction. Conclusion Although cerebral bypass surgery is a technically challenging procedure, it plays an important role in the surgical management of the complex vessel-engulfing tumor. The link to the video can be found at https://youtu.be/GCmpxK3hW18 .

Combined craniofacial resection of nasopharyngeal malignancies

Nasopharyngeal carcinoma is endemic in south-eastern parts of Asia. Primary treatment modality is definitive radiotherapy ± chemotherapy depending on the stage of disease. Surgery serves as a means of salvage for persistent or recurrent diseases. Maxillary swing operation offers an anterolateral approach for removal of tumors in the nasopharynx ± parapharyngeal space extension including retropharyngeal lymph nodes. Maxillary swing operation may be combined with craniotomy for resection of locally advanced tumors involving the internal carotid artery, temporal bone and temporal dura. Encasement of internal carotid artery warrants prior extracranial intracranial bypass, so that the vessel can be removed en bloc with the tumor to ensure microscopic clearance. Exposed dura, skull base bone and internal carotid artery warrant coverage with well-vascularized muscle flap to facilitate wound healing. Attention to details peri-operation and meticulous tissue handling can help to prevent life threatening complications postoperation.

Superficial-Temporal-Artery-To-Middle-Cerebral-Artery Bypass in Cerebrovascular Occlusive Disease and Hemodynamic-Related Ischemia: Illustrative Case and Literature Review

AbstractStroke is the third most common cause of death worldwide. About 10% to 15% of strokes related to the territory of the carotid artery are associated with its complete occlusion. There is an important subgroup of patients with cerebrovascular occlusive diseases who might benefit from an external-carotid-to-internal-carotid bypass. In the present study, we report a case of a 53-year-old male patient with stenosis of the M2 branch of the middle cerebral artery (MCA), with a history of ∼ 20 episodes of transient ischemic accidents (TIA)s, in whom an anastomosis of the M4 branch of the superficial temporal artery-MCA was performed. The patient was discharged in three days, and in the two years of follow-up, they were no more TIAs. We also conducted a review of the literature on cerebrovascular occlusive disease and extracranial-intracranial bypass surgery. New methods to evaluate cerebral hemodynamics made it possible to classify a new subgroup of patients with symptomatic cerebrovascular disease and documented cerebrovascular compromise in whom the drug therapy fails, who can benefit from the extracranial-intracranial bypass. Our case report illustrates the advantages of revascularization in these selected patients.

Differentiated method in surgical revascularization of the brain for the treatment of pediatric patients with moyamoya angiopathy

The study objective is to study the results of the differentiated method of surgical revascularization of the brain for the treatment of pediatric patients with moyamoya angiopathy. Materials and methods . Twelve surgical interventions were performed on 12 hemispheres in 8 patients (4 male, 4 female) with moyamoya angiopathy from December 2015 to March 2020. The age of patients ranged from 6 months to 14 years old, the average age is 8 years old. To clarify the clinical course of the disease the Y. Matsushima classification was used: type I (n = 3), type III (n = 2), type IV (n = 2) and type V (n = 1) of Y. Matsushima. Stages of the disease are classified according to J. Suzuki: stage III was revealed in 5 patients, stage IV— in 3. Cerebral angiography, magnetic resonance imaging of the brain and vessels were performed; computed tomography perfusion of the brain was made in every patient. Encephaloduroarteriomyosynangiosis was used in 2 hemispheres. Extra-intracranial bypass and encephaloduro-myosynangiosis in 1; extracranial-intracranial bypass and encephaloduroarteriomyosynangiosis — in 2; extracranial-intracranial bypass and encephaloduromyoperiosteosynangiosis in 5 hemispheres; double-barreled bypass and encephaloduromyosynangiosis — in 1 hemisphere; double-barreled bypass and encephaloduromyoperiosteosynangiosis — in 1 hemisphere. In the follow-up period (6—36 months) neurological status testing, digital subtraction angiography (6 vascular territories), magnetic resonance imaging of the brain and vessels and computed tomography perfusion of the brain were performed. Results . All patients in the follow-up period had no clinically significant ischemic events on the side of surgical intervention; there was an increase in the perfusion of the brain in comparison with preoperational values. In 1 case, transient ischemic attack occurred on the nonoperated hemisphere that did not recur after surgery. There was a regression of symptoms among children with initial neurological deficits. The angiographic result, in accordance with the method suggested by Y. Matsushima, was excellent (A group) and good (B group), except the case of moyamoya syndrome and case after indirect revascularization in zone of brain atrophy. Based on our experience, we have determined the optimal method of suturing the wound with a good cosmetic effect. Conclusion . We can assume, that differentiated method in surgical treatment of pediatric patients with moyamoya angiopathy is highly effective for the prevention of ischemic stroke, and also has good clinic, angiographic and cosmetic result. With suitable arterial sizes, combined revascularization showed better results than indirect, especially in the clinically significant hemisphere.

Preventive Effect of Bypass Surgery on Rebleeding in Patients with Hemorrhagic Twiglike Middle Cerebral Artery

Aplastic or twiglike middle cerebral artery (Ap/T-MCA) is a rare cerebrovascular anomaly correlated to stroke. The most common characteristic of the disease is intracerebral hemorrhage. However, treatment measures that can prevent rebleeding have not yet been established. We sought to validate whether extracranial-intracranial (EC-IC) bypass is effective in preventing recurrent intracerebral hemorrhage in patients with Ap/T-MCA. Ap/T-MCA was defined on the basis of the following criteria: 1) M1 occlusion with plexiform vessels, 2) unilateral MCA involvement without progression to the contralateral side, 3) no significant stenosis in the M2 segment, and 4) no stenoocclusive lesions in other intracranial major arteries. The clinical features, surgical procedures, radiologic changes, and treatment outcomes of patients with Ap/T-MCA who presented with ipsilateral intracerebral hemorrhage at our institution from April 2004 to December 2019 were retrospectively reviewed. Seven patients fulfilled the criteria for hemorrhagic Ap/T-MCA. Female preponderance was observed, and the mean age at the time of onset was 38 (range: 28-47) years. Three patients presented with pure intraventricular hemorrhage and 4 with intraparenchymal hemorrhage. Of the 4 patients, 2 had intraventricular extension. All patients underwent EC-IC bypass and did not present with stroke during the follow-up period (median: 36 [range: 5-140] months). Follow-up magnetic resonance imaging revealed regression of the twiglike vessels or periventricular choroidal anastomosis within 1 year after surgery in all patients. EC-IC bypass may be a treatment option that can prevent rebleeding in patients with hemorrhagic Ap/T-MCA.

Retinal Vasculature Changes after Bypass Surgery for Moyamoya Disease

A 48-year-old woman with slurred speech was diagnosed with Moyamoya disease. Digital subtraction angiography disclosed left ophthalmic artery originating from the internal carotid artery (Fig A, arrow), and supplied by orbital branches of the middle meningeal and facial artery (Fig A, arrowhead). Preoperative examinations showed normal superficial vascular complex (SVC) in the left eye (OS) on OCT angiography (Fig B). She underwent left extracranial-intracranial bypass from the superficial temporal artery to the middle cerebral artery.

Flow-augmentation bypass in the treatment of acute ischemic stroke.

Results of two randomized trials did not show benefit of revascularization with extracranial-intracranial (EC-IC) flow augmentation bypass in patients with symptomatic occlusion of internal carotid artery (ICA). However, patients with acute stroke were not included in these studies. Herein, we systematically analyze and discuss the literature about flow augmentation bypass for treatment of acute ischemic stroke. This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. MEDLINE, Web of Science and EMBASE were independently searched by two reviewers for published series to identify literature relating to EC-IC bypass in the surgical management of acute ischemic stroke up to June 2020. Studies were categorized according to their level of evidence. Nineteen studies met the inclusion criteria for the systematic literature review, including 16 level IV studies (ten case series and six6 case reports) and three level III studies (retrospective cohort case-control studies). Occurrence of fatal or non-fatal ischemic or hemorrhagic postoperative stroke, as well as clinical functional outcome at follow-up were considered as primary and secondary endpoints, respectively. The literature about flow augmentation bypass for treatment of acute ischemic stroke is scarce and heterogenous, with only 19 studies. The results of the present systematic review encourage further study to explore and validate the use of EC-IC bypass in the treatment of anterior circulation acute ischemic stroke in highly selected patients (symptomatic and with persistent penumbra despite best medical/endovascular treatment).

Safety, Feasibility and Patient-rated Outcome of Sonolucent Cranioplasty in Extracranial-Intracranial (EC-IC) Bypass Surgery to Allow for Trans-cranioplasty Ultrasound Assessment.

Flores, Alex; Srinivasan, Visish; Seeley, Jill; Huggins, Charity; Kan, Peter MD, MPH; Burkhardt, Jan-Karl Author Information

Anatomical variations in the origins of the lateral circumflex femoral arteries in a South African sample: A cadaver study

BackgroundClinically, the lateral circumflex femoral artery (LCFA) is used in a variety of procedures, these include anterolateral thigh flaps, aortopopliteal bypass, coronary artery bypass grafting and extracranial-intracranial bypass surgeries. Variations in the anatomy of the LCFA, profunda femoris artery (PFA) and their branches have been noted in several studies. There are numerous clinical implications related to the inadequate anatomical knowledge of this region. MethodsThe study sample consisted of 55 cadavers of different ages, ancestry groups and varying body mass index. A total of 90 legs were dissected. The anterior thigh compartment was dissected and the common femoral artery (CFA), superficial femoral artery (SFA), PFA and LCFA further exposed. The course and variations were noted and results documented for further analysis. ResultsThe LCFA was present in all the legs dissected. The origin of the LCFA was found to be the PFA in 75.6% of the left legs and 82.2% of the right legs dissected.In two cases, a male and female limb, the branching of the PFA from the CFA was observed directly from the external iliac artery, deep to the inguinal ligament.A variation was noted in a female cadaver, where the branches of the LCFA on the left limb had different points of origin. Another variation was noted on a male cadaver, the left limb had two different points of branching for the ascending and descending branches of the LCFA, a common trunk was absent. ConclusionThis study indicates that the most common site of origin for the LCFA was the PFA. The branching of the PFA from the CFA was found to be variable in 2.2% of the cases, where the PFA was a direct branch of the external iliac artery. The study also noted variations relating to the origin of the transverse branch of the LCFA, this branch was absent in 4.4% of the limbs dissected.Knowledge of the variations related to the origin of the PFA, LCFA and their branches is important in reducing the chances of intra-operative bleeding, during different surgical procedures.

Continuous Interrupted Double Throw Suturing Method: A Novel Suturing Technique for Extracranial-Intracranial Bypass

Despite failure of the EC/IC Bypass Study Group to demonstrate effectiveness in minimizing future stroke events, superior temporal artery-medial cerebral artery (STA-MCA) bypass remains an essential treatment for complex giant intracranial aneurysms, tumors, moyamoya disease with ischemia, and atherosclerotic steno-occlusive disease with hemodynamic cerebrovascular insufficiency. The objective of this report is to describe a novel suturing technique for STA-MCA bypass that helps reduce donor-recipient anastomosis time, allowing for a well-organized systematic workflow. Step 1 involves passing the needle of a 9-0 polypropylene suture from out-to-in on the donor vessel followed by in-to-out on the recipient vessel. Step 2: Before cutting and tying a knot as per the established method of suturing, repeat step 1 and leave the needle "parked", creating a loop that is then cut at its proximal end. Step 3: Tie knots using the jeweler's forceps. Repeat previous steps until there are enough throws to seal the bypass adequately. The STA-MCA bypass serves as a principal method for flow augmentation. The technique described here allows for more efficient and organized microsurgical movements reducing vessel tissue manipulation and clamp time. We describe a novel technique for interrupted STA-MCA bypass suturing that adds efficiency, safety, organization, and operative ease compared with the conventional method of interrupted vessel suturing.

Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes.

Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms. The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes. In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction). Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.

Hemoglobin Concentration May Influence the Incidence of Postoperative Transient Neurological Events in Patients With Moyamoya After Extracranial-intracranial Arterial Bypass: A Retrospective Single Center Experience.

Moyamoya is a rare condition characterized by cerebral angiographic findings of intracranial carotid artery stenosis with abnormal net-like vessels in the brain, and often presents as transient ischemic attacks or intracranial hemorrhage. Revascularization in the form of extracranial-intracranial (EC-IC) artery bypass has demonstrated efficacy in preventing ischemic attacks and intracranial hemorrhage, although it is associated with a relatively high rate of perioperative ischemic and hemorrhagic stroke. This retrospective analysis aims to evaluate the possible association between postoperative hemoglobin (Hgb) concentration and early postoperative transient neurological events (TNEs) experienced at our center. Consecutive patients undergoing EC-IC bypass between January 1, 2017 and August 31, 2019 were identified, resulting in a study population of 24 patients with 34 individual cases for different cerebral hemispheres. Postoperative Hgb level was evaluated upon arrival to the intensive care unit (ICU) and the primary outcome was the occurrence of TNEs within 24-hours after surgery. The incidence of TNEs within 24 hours postoperatively was 12% (n=4). Statistically significant differences were demonstrated between patients who did and did not experience TNEs in the postoperative period: total Hgb value (mean 9.4 vs. 11.3 g/dL, respectively; P=0.012) and percentage of patients with Hgb <10 g/dL (75% vs. 20%, respectively; P=0.048). Patients with a postoperative Hgb value <10 g/dL upon arrival to the ICU were significantly more likely to experience TNEs (odds ratio, 12; 95% confidence interval, 1.053-136.794; P=0.045). This study reports a possible association between postoperative Hgb level and the occurrence of TNEs within the first 24 hours after surgery in patients undergoing EC-IC for moyamoya.

Letter to the Editor Regarding “Large Craniotomy Increases the Risk of Minor Perioperative Complications in Revascularization Surgery for Moyamoya Disease”

Cerebral aneurysms are rare in the pediatric population, making a definitive treatment algorithm difficult. Microsurgical clipping is the first choice for treatment but is not always feasible, while high recurrence rates and radiation exposure make endovascular options less favorable. Extracranial-intracranial (EC-IC) bypass, though not commonly performed in the pediatric aneurysm population, has been reported in a small number of studies to be both safe and effective for the management of cerebral aneurysms. The authors present the case of a child with a distal middle cerebral artery (MCA) aneurysm in eloquent territory, successfully treated with a superficial temporal artery (STA) to MCA bypass and trapping. A review of the current literature on pediatric EC-IC bypass in the treatment of intracranial aneurysms is presented.

Trends in hospitalizations and epidemiological characteristics of adults Moyamoya disorder in the United States

Background and purposeThere has been an increasing prevalence of Moyamoya disorder (MMD) reported from recent US literature. There is a paucity of data available regarding trends of prevalence and epidemiological factors in the United States. To goal of this study was to test the hypotheses that racial-, sex-specific MMD hospitalizations and epidemiological factors have been increasing in the United States over the last decade. MethodsIn this retrospective observational study, using the National Inpatient Sample (NIS) database from 2005 to 2016, MMD-related hospitalizations in patients aged ≥18 years were identified. Trends of epidemiological factors were analyzed over time using the linear regression model with the significance of differences in trend over time assessed using the Wald test. Sex- and race-specific burden of MMD were calculated using the annual US Census data. Joinpoint regression model was used to evaluate trends of hospitalizations over time. ResultsA total of 24,484 adult hospitalizations were identified from January 2005 to September 2015 after excluding <18 years. Among them, approximately ~90% were aged ≤60 years, and 73.5% were females. The most common vascular and non-vascular presentations were ischemic stroke (17.3%) and seizures (21%), respectively. The trend of antithrombotic therapy has increased, while extracranial-intracranial bypass has remained stagnant. The actual average hospitalizations of MMD was 10.4 cases/ million population/year (range 4.1–17.9) and varied significantly by sex (females 14.7 [range 6.2–23.6] and males 5.9 [range 1.8–11.9]) over the 2005 to 2016 study period. The burden of hospitalizations also differed by race (African Americans 40.6 [range 32.8–63.7], Asians 24.8 [15.4–34.8], Non-Hispanic Whites 8.1 [range 6.4–11.5], and Hispanics 8.4 [2.8–12.8]) over the 2010 to 2016 study period. Joinpoint regression analysis showed an increasing overall MMD trend across the study period (+11.7%; P < 0.001), which was higher in males (+14.5% vs. +10.7%; P < 0.001). The Hispanic group had significantly increased hospitalizations over the years (+20.2%; P < 0.001). ConclusionAlthough overall more prevalent in females, MMD-related hospitalizations are increasing more rapidly in males. Among the racial subpopulations, African Americans had the highest MMD-related hospitalizations, even higher than Asian Americans. MMD-related hospitalizations have increased quicker in Hispanics than in any other racial group.

Pterygo-Maxillary Fissure as a Landmark for Localization of Internal Maxillary Artery for Use in Extracranial-Intracranial Bypass.

Internal maxillary artery (IMax) is a relatively new donor vessel used in the extracranial-intracranial bypass surgery. However, unfamiliarity and relatively elaborate techniques of its harvest precluded its widespread use. To present a simplified technique of IMax harvest based on constant anatomical landmarks without the need of extensive skull-base drilling while providing adequate space for proximal anastomosis. Cadaveric dissection on 4 cadaveric heads (8 sides) was performed. Zygomatic osteotomy was performed and temporal muscle was dissected off the zygomatic process of the frontal bone and the frontal process of the zygomatic bone and reflected inferiorly into the bony gap created by the zygomatic osteotomy. Posterior wall of the maxilla (PWoM) was palpated. Following PWoM inferiorly leads to pterygo-maxillary fissure (PMF), which is a constant landmark IMax passes through. IMax was localized following this technique before its entrance into PMF in every specimen. Proximal dissection was carried on to the exposed adequate length of the vessel. Depending on the relationship with the lateral pterygoid muscle, this might need to be incised to allow for identification of the IMax. After its transection, proximal stump is mobilized superiorly into the surgical field. Clinical application of this technique was demonstrated on an aneurysm case. Using the palpation of the PWoM as a landmark for localization of PMF facilitates harvesting of IMax without need for extensive skull-base drilling and shortens the time of the surgery.

Extracranial-Intracranial Bypass as Primary Treatment for Internal Carotid Artery Blood Blister-Like Aneurysms, Not Just a Last Resort

Extracranial-Intracranial Bypass as Primary Treatment for Internal Carotid Artery Blood Blister-Like Aneurysms, Not Just a Last Resort

Tactics of surgical treatment of acute brain ischemia caused by atherosclerotic damage of the brachiocephalic arteries

The study objective is to test tactics of surgical treatment of patients with brachiocephalic artery pathology in the acute stage of ischemic stroke.Materials and methods. In the period between 01.07.2014 and 31.12.2017 at the Neurosurgery Division of the N.V. Sklifosovsky Research Institute of Emergency Medicine and the Neurosurgery Division of the N.A. Semashko Republican Clinical Hospital (Simferopol), 125 surgeries were performed in patients with occlusion and stenosis of the precerebral arteries in the acute stage of ischemic stroke. Carotid endarterectomy was performed in 69 cases, among them 54 were performed by eversion technique, 15 traditionally, in 4 cases sympathectomy of the internal carotid artery (ICA) was performed, in 4 – endarterectomy from the external carotid artery, in 3 – redirection of the ICA, in 2 – ICA prosthesis, in 9 – thrombointimectomy. Extracranial-intracranial bypass anastomosis was performed in patients with acute ICA thrombosis (n = 16) and symptomatic ICA occlusion (n = 22).Results. Good and moderate results (4–5 points per the Glasgow Outcome Scale) were achieved in 119 (95.2 %) observations. Level of consciousness impairment, evaluations per the NIHSS, Rankin, Rivermead scales, brain ischemia volume, presence of brain hypoperfusion prior to surgery, timetable of surgical intervention, postoperative characteristics of the volumetric blood flow and brain reperfusion characteristics significantly affected treatment results. Total rate of complications and deaths was 4.8 %. In 3 cases, death was caused by myocardial infarction, malignant hyperperfusion with hemorrhagic transformation of the ischemic lesion and repeat stroke.Conclusion. Surgical treatment of patients with transient ischemic attacks, acute small or completed stroke should be performed as soon as possible: this tactic decreases the risk of repeat ischemic attacks and improves functional outcomes of treatment. In case of crescendo of a transient ischemic attack or progressing stroke, surgical treatment should be postponed and performed 24 hours after stabilization of the patient’s neurological status.

Severe cerebral edema induced by watershed shift after bypass in a patient with chronic steno-occlusive disease: a case report and short literature review

BackgroundCarotid occlusive disease is a type of progressive disease resulting in ischemic stroke. Extracranial-intracranial bypass surgery represents a valid therapeutic option when medical treatment does not make effects. The appearance of cerebral edema following bypass is common during acute stage. Additionally, there are many causes of mild cerebral edema, such as hemodynamic changes, venous congestion and others. However, severe edema involving large brain tissue, which presents as reversible aphasia and hemiplegia, remains to be elucidated.Case presentationA 55-year-old man was admitted to the neurosurgery department for repeated dizziness for over a year and sudden onset of syncope 1 month prior, and he was diagnosed with carotid occlusive disease. After surgical contraindications were excluded, dual bypass and encephalo-duro-myo-synangiosis were performed. Although blood pressure and fluid management were strictly under control promptly after surgery, massive cerebral edema involving the left anterior cerebral artery and middle cerebral artery territories occurred from the 6th day after surgery. Additionally, no discernible cerebral infarction or hemorrhage occurred. Moreover, the cerebral blood flow of the middle cerebral artery displayed an early decrease followed by delayed elevation on the left side. Without restricting the spreading of cerebral edema, life-threatening cerebral herniation could develop at any time. Mannitol and furosemide were administered for impending cerebral herniation. The amelioration of symptoms was noticed on the 16th day after surgery. The patient felt relief on the 21st day after surgery. Digital subtraction angiography performed on the 180th day after surgery demonstrated the patency of dual anastomosed vessels, and the patient recovered without any permanent neurological deficit.ConclusionBased on changes in cerebral blood flow and reversible symptoms, the “watershed shift” phenomenon could explain such a severe deficit. However, this deficit was not the same as the classical presentation of the “watershed shift”, which involves a moderate amount of brain tissue and presents significant increases in cerebral blood flow. In addition to the “watershed shift”, a swollen temporal muscle may also participate in the progression of focal edema.

Dural Substitutes Differentially Interfere with Imaging Quality of Sonolucent Transcranioplasty Ultrasound Assessment in Benchtop Model

Sonolucent cranioplasty implants were recently introduced into clinical practice and tested for use with transcranioplasty ultrasound (TCUS). In situations where dural substitutes (DSs) are needed during closure, such as in extracranial-intracranial bypass, it is unclear if the DS influences the imaging quality of TCUS. The aim of this study was to assess the influence of DSs on imaging quality during TCUS assessment with sonolucent cranioplasty. A tofu vascular brain model was constructed with a ClearFit implant in between 2 layers of tofu. Injection of saline solution through a 6-F Envoy DA XB endovascular catheter (6-F Envoy DA XB) inserted into the deeper tofu layer mimicked an intracranial vessel. TCUS image quality, including Doppler, with 4 different DSs (DuraGen, Durepair, DuraMatrix-Onlay, DuraMatrix Suturable) placed under the cranioplasty was compared against a control by 2 examiners. A literature search of MEDLINE and EMBASE was conducted to find previous reports of acoustic properties of DSs. TCUS assessment including Doppler was feasible with the model in longitudinal and axial planes, and the pulsatile particle injection was visualized in real time. DuraGen and Durepair showed Doppler quality and picture detail comparable to the control, while the DuraMatrix-Onlay and DuraMatrix Suturable were inferior to the control. The literature search yielded only 1 previous report on acoustic properties of DSs. DSs interfere differentially with imaging quality during TCUS assessment. However, these results are based on a benchtop model and need to be further assessed in the clinical setting.