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Huang B, Huang C, Alok K, Chen AY. Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Ischemic Stroke With Blood Pressure-Dependent Symptoms. Cureus 2024; 16:e56236. [PMID: 38618338 PMCID: PMC11016294 DOI: 10.7759/cureus.56236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
The efficacy of extracranial-intracranial (EC-IC) bypass in preventing ischemic stroke progression and recurrence is controversial. As per the current hypothesis, EC-IC bypass is most beneficial for patients with persistent hemodynamic insufficiency. Hence, various approaches have been used to evaluate hemodynamic insufficiency, including repeated single photon emission CT (SPECT) imaging or continuous monitoring of cerebral flow with transcranial Doppler ultrasound (TCD). However, both modalities are time- and resource-intensive. In this report, we discuss how EC-IC bypass turned out to be beneficial for a patient presenting with blood pressure-dependent severe aphasia and right hemiparesis due to middle cerebral artery (MCA) occlusion that failed thrombectomy. CT perfusion (CTP) scan at admission demonstrated a persistent volume of delayed perfusion without core infarct. Following the superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, the patient's National Institute of Health Stroke Scale (NIHSS) score improved from 12 to 1. Ischemic penumbra, as seen on CTP imaging, also improved after the STA-MCA bypass. Our case suggests that persistent volume of delayed perfusion and blood pressure-dependent neurological deficits can be used in tandem as selection criteria for EC-IC bypass.
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Affiliation(s)
| | | | - Khaled Alok
- Neurosurgery, Northwell Health, Manhasset, USA
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Guo L, Yang L, Li C, Zeng Y, Xu R, Wang Z, Jiang C. The clinical outcome of emergency superficial temporal artery-to-middle cerebral artery bypass in acute ischemic stroke with large vessel occlusion. Neurosurg Rev 2024; 47:25. [PMID: 38163848 PMCID: PMC10758367 DOI: 10.1007/s10143-023-02257-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
The role of superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass in acute ischemic stroke (AIS) is contentious, with no evidence in patients with AIS and large vessel occlusion (AIS-LVO). We conducted a cohort study to assess emergency STA-MCA outcomes in AIS-LVO and a meta-analysis to evaluate STA-MCA outcomes in early AIS treatment. From January 2018 to March 2021, we consecutively recruited newly diagnosed AIS-LVO patients, dividing them into STA-MCA and non-STA-MCA groups. To evaluate the neurological status and outcomes, we employed the National Institutes of Health Stroke Scale (NIHSS) during the acute phase and the modified Rankin Scale (mRS) during the follow-up period. Additionally, we conducted a meta-analysis encompassing all available clinical studies to assess the impact of STA-MCA on patients with AIS. In the cohort study (56 patients), we observed more significant neurological improvement in the STA-MCA group at two weeks (p = 0.030). However, there was no difference in the clinical outcomes between the two groups. Multivariable logistic regression identified the NIHSS at two weeks (OR: 0.840; 95% CI: 0.754-0.936, p = 0.002) as the most critical predictor of a good outcome. Our meta-analysis of seven studies indicated a 67% rate for achieving a good outcome (mRS < 3) at follow-up points (95% CI: 57%-77%, I2 = 44.1%). In summary, while the meta-analysis suggested the potential role of STA-MCA bypass in mild to moderate AIS, our single-center cohort study indicated that STA-MCA bypass does not seem to improve the prognosis of patients who suffer from AIS-LVO.
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Affiliation(s)
- Lei Guo
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Li Yang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Chunling Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yi Zeng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Zhengyu Wang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Chonggui Jiang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Mizushima M, Sugiyama T, Eguchi K, Tarisawa M, Tokairin K, Ito M, Hashimoto D, Yabe I, Fujimura M. Rescue Extracranial-Intracranial Bypass for Ischemic Stroke Secondary to Progressive Human Immunodeficiency Virus-Associated Vasculopathy. J Neurol Surg A Cent Eur Neurosurg 2024; 85:88-93. [PMID: 35193153 DOI: 10.1055/a-1779-4142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) associated vasculopathy can cause ischemic cerebral stroke; however, there is limited evidence on optimal management. Herein, we report a case of acute ischemic stroke due to progressive internal carotid artery (ICA) stenosis in an HIV-positive patient. Superficial temporal artery to middle cerebral artery (STA-MCA) bypass, in addition to the best medical treatments, prevented stroke progression. CLINICAL DESCRIPTION A 39-year-old man with HIV infection presented with a sudden onset of aphasia and right hemiparesis. Magnetic resonance imaging revealed an ischemic lesion in the left basal ganglia and concentric thickening of the vessel wall in the terminal portion of the bilateral ICAs. Despite maximal medical treatments for HIV-associated vasculopathy and possible opportunistic infections, bilateral ICA stenoses progressed, leading to a second hemodynamic stroke event. Because tissue plasminogen activator treatment failed, we performed STA-MCA bypass. A significant improvement in neurologic symptoms and cerebral blood flow was observed after surgery. No further stroke events occurred during the continuation of medical treatments. CONCLUSION This is the first case of STA-MCA bypass performed in a patient with recurrent ischemic stroke caused by HIV-associated vasculopathy. Although further evidence is needed, such treatment options can shed new light on the management of progressive HIV-associated vasculopathy, which is refractory to maximal medical treatment.
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Affiliation(s)
- Makoto Mizushima
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Katsuki Eguchi
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Monami Tarisawa
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Daigo Hashimoto
- Department of Hematology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ichiro Yabe
- Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Jo H, Lee SU, Jeong HG, Kim YD, Kim T, Sunwoo L, Ban SP, Bang JS, Kwon O, Oh CW. Long-term outcomes and quantitative radiologic analysis of extracranial-intracranial bypass for hemodynamically compromised chronic large artery occlusive disease. Sci Rep 2023; 13:3717. [PMID: 36879127 PMCID: PMC9988922 DOI: 10.1038/s41598-023-30874-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
This study aimed to demonstrate the effectiveness of nonemergent extracranial-to-intracranial bypass (EIB) in symptomatic chronic large artery atherosclerotic stenosis or occlusive disease (LAA) through quantitative analysis of computed tomography perfusion (CTP) parameters using RAPID software. We retrospectively analyzed 86 patients who underwent nonemergent EIB due to symptomatic chronic LAA. CTP data obtained preoperatively, immediately postoperatively (PostOp0), and 6 months postoperatively (PostOp6M) after EIB were quantitatively analyzed through RAPID software, and their association with intraoperative bypass flow (BF) was assessed. The clinical outcomes, including neurologic state, incidence of recurrent infarction and complications, were also analyzed. The time-to-maximum (Tmax) > 8 s, > 6 s and > 4 s volumes decreased significantly at PostOp0 and up through PostOp6M (preoperative, 5, 51, and 223 ml (median), respectively; PostOp0, 0, 20.25, and 143 ml, respectively; PostOp6M, 0, 7.5, and 148.5 ml, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). The postoperative improvement in the Tmax > 6 s and > 4 s volumes was significantly correlated with the BF at PostOp0 and PostOp6M (PostOp0, r = 0.367 (p = 0.001) and r = 0.275 (p = 0.015), respectively; PostOp6M r = 0.511 (p < 0.001) and r = 0.391 (p = 0.001), respectively). The incidence of recurrent cerebral infarction was 4.7%, and there were no major complications that produced permanent neurological impairment. Nonemergent EIB under strict operation indications can be a feasible treatment for symptomatic, hemodynamically compromised LAA patients.
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Affiliation(s)
- Hyunjun Jo
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
| | - Han-Gil Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Young-Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Oki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
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