• Martina Sebök, Giuseppe Esposito, NiftrikChristiaan Hendrik Bas vanCHBV1Departments of Neurosurgery.2Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland., Jorn Fierstra, Tilman Schubert, Susanne Wegener, Jeremia Held, Zsolt Kulcsár, Andreas R Luft, and Luca Regli.
• 1Departments of Neurosurgery.
• J. Neurosurg. 2022 Oct 1; 137 (4): 104710551047-1055.

ObjectiveEndovascular recanalization trials have shown a positive impact on the preservation of ischemic penumbra in patients with acute large vessel occlusion (LVO). The concept of penumbra salvation can be extended to surgical revascularization with bypass in highly selected patients. For selecting these patients, the authors propose a flowchart based on multimodal MRI.MethodsAll patients with acute stroke and persisting internal carotid artery (ICA) or M1 occlusion after intravenous lysis or mechanical thrombectomy undergo advanced neuroimaging in a time window of 72 hours after stroke onset including perfusion MRI, blood oxygenation level-dependent functional MRI to evaluate cerebrovascular reactivity (BOLD-CVR), and noninvasive optimal vessel analysis (NOVA) quantitative MRA to assess collateral circulation.ResultsSymptomatic patients exhibiting persistent hemodynamic impairment and insufficient collateral circulation could benefit from bypass surgery. According to the flowchart, a bypass is considered for patients 1) with low or moderate neurological impairment (National Institutes of Health Stroke Scale score 1-15, modified Rankin Scale score ≤ 3), 2) without large or malignant stroke, 3) without intracranial hemorrhage, 4) with MR perfusion/diffusion mismatch > 120%, 5) with paradoxical BOLD-CVR in the occluded vascular territory, and 6) with insufficient collateral circulation.ConclusionsThe proposed flowchart is based on the patient's clinical condition and multimodal MR neuroimaging and aims to select patients with acute stroke due to LVO and persistent inadequate collateral flow, who could benefit from urgent bypass.

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