Extracranial-intracranial (EC-IC) bypass of symptomatic middle cerebral artery (MCA) total occlusion for haemodynamic impairment patients

Abstract

A retrospective, single-centre, non-randomized study in the management of symptomatic middle cerebral artery (MCA) total occlusion disease to evaluate extracranial-intracranial (EC-IC) bypass as an intervention for patients with atherosclerotic MCA total occlusion, ischemic symptoms (transient ischemic attacks [TIAs]) or poor cerebral haemodynamics who had not responded well to maximal medical treatment was reported. Twenty-three patients were included in the study with the criteria of: having ischemic syndrome, for example, TIA; being associated with atherosclerotic MCA total occlusion disease (compatible with radiological assessment); being failed to respond to optimal medical therapy (e.g. antiplatelet therapy), indicating a repeat TIA or ischemic stroke attack was noted during maximal medical therapy; having poor cerebral perfusion on CT imaging; and having regional cerebrovascular reactivity (rCVR) of <20% when acetazolamide challenge was undergone. Patients had acute ischemic stroke or other major medical co-morbidities were excluded. No patient experienced any recurrent ischemic stroke during a mean follow-up period of 26.5 months except one patient suffered of immediate post-operative ischemic stroke because of the temporal vessel being clipped too long and the hypotension caused by anaesthesia. Post-operative follow-up imaging, which included MRI (MR angiography) and four-vessel digital subtraction angiography revealed a 100% patency of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. No significant differences between observation periods (baseline status: 5.46 ± 5.13/85 ± 15; 0.5 month after surgery: 5.18 ± 5.29/85.91 ± 15.46 and 3 months after surgery: 5.09 ± 4.75/85.36 ± 12.27) were found for the neurological evaluations of NIHSS and Barthel Index (both expressed in mean ± SD) in all of the 23 patients. The annual risk of recurrent stroke was 0% after EC-IC bypass. However, studies with a larger scale are warranted to further confirm the effectiveness of EC-IC bypass.