• Jeffrey A Steinberg, Robert C Rennert, Kristine Ravina, Ben A Strickland, and Jonathan J Russin.
• Department of Neurological Surgery, University of California San Diego, San Diego, California, USA.
• World Neurosurg. 2020 Jan 1; 133: e609-e618.

BackgroundDespite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from cerebral revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease.MethodsA retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle cerebral artery over a 4-year period (July 2014-July 2018). Surgical and clinical outcomes were recorded.ResultsSeventeen patients (average age 62 ± 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score ≥4, and 13 (85%) achieved a modified Rankin Scale score ≤2.ConclusionsBypass for steno-occlusive disease of the anterior intracranial circulation is a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms, although the complication rate is significant. Optimal patient selection criteria and timing of surgery remain open questions.Copyright © 2019 Elsevier Inc. All rights reserved.

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