ISCHEMIC STROKE / PREVENTION

Extracranial-intracranial bypass

Created 23/09/2022, last revision 23/09/2022

  • ICA occlusion is responsible for ~15-25% of strokes
  • ICA occlusion is associated with a 2-year stroke risk of about 10-15%
  • 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)

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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