ISCHEMIC STROKE / PREVENTION
Extracranial-intracranial bypass
Created 23/09/2022, last revision 24/12/2022
- ICA occlusion is responsible for ~15-25% of strokes
- ICA occlusion is associated with a 2-year stroke risk of about 10-15%
- the risk is even higher in the presence of impaired VMR [Vernieri, 1999]
- extracranial-intracranial (EC-IC) arterial bypass surgery was developed to prevent stroke by improving hemodynamics distal to the occluded artery
- in patients with symptomatic atherosclerotic ICA occlusion
- in patients who would not tolerate planned ICA ligation (for surgically inaccessible aneurysms, tumors, etc.) according to balloon test occlusion (BTO)
- studies have not demonstrated the effectiveness of EC-IC bypass compared to conservative therapy in secondary stroke prevention in patients with ICA occlusion; even if techniques assessing hemodynamic impairment are used (see the COSS trial from 2011)
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EC-IC bypass in carotid territory
- the theoretical indications are untreatable ICA stenosis/occlusion or MCA occlusion
- the most commonly performed procedures (using a graft from the radial artery or sphenoid):
- bypass between the superficial temporal artery (STA) and one of the cortical MCA branches
- ICA-MCA bypass
- indirect anastomoses
- this bypass is most commonly offered in patients with moyamoya
EC-IC bypass in posterior circulation
- theoretical can be offered in otherwise untreatable stenoses and occlusions of vertebral and basilar arteries
- usually, the connection between the occipital artery and PICA or SCA is established
- it is possible to create a high-flow bypass using a graft from the saphenous vein
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