Emergency extracranial-intracranial bypass surgery for acute ischemic stroke.

OBJECT:The purpose of this study was to evaluate the safety and efficacy of urgent extracranial-intracranial (ECIC) bypass in the management of intracranial cerebrovascular disease and acute cerebral ischemic injury in carefully selected patients. METHODS:The authors reviewed the medical records and neuroimaging studies in 13 consecutive patients who underwent urgent surgical cerebral revascularization to treat acute cerebral ischemia. None were thought to be appropriate candidates for endovascular therapy. The patients' ages ranged from 21 to 65 years (mean 41.2 years). The mean follow-up review was 3.5 years, and no patient was lost to follow-up. RESULTS:Preoperative angiographic evaluation identified critical narrowing of the supraclinoid internal carotid artery (ICA) in 8 patients, the M(1) segment of the middle cerebral artery (MCA) in 3, and the cervical/petrous ICA in 2. All patients had progressive, refractory symptoms associated with enlarging areas of infarction on diffusion weighted MR imaging, despite maximal medical therapy, which included anticoagulation and antiplatelet agents, blood pressure elevation, and fluid resuscitation. All patients underwent superficial temporal artery-MCA anastomosis on an urgent basis. In every case, the bypass prevented further stroke progression. In 2 cases, revascularization was followed by rapid, dramatic improvement of preoperative neurological deficits. CONCLUSIONS:In the authors' experience, emergency EC-IC bypass in patients with acute ischemic injury was both safe and effective. This population was characterized by relatively young patients with severely limited collateral circulation. In this series of 13 carefully selected patients, bypass was successful in arresting progression of stroke, and in some cases resulted in rapid neurological improvement.