• Robert C Rennert, Jeffrey A Steinberg, Ben A Strickland, Kristine Ravina, Joshua Bakhsheshian, Vance Fredrickson, J Scott Pannell, Alexander A Khalessi, and Jonathan J Russin.
• Department of Neurological Surgery, University of California San Diego, San Diego, California, USA.
• World Neurosurg. 2019 Jun 1; 126: 552-559.

BackgroundVertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset.MethodsA multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded.ResultsFive patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter.ConclusionsRefractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.Copyright © 2019 Elsevier Inc. All rights reserved.

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