Cerebral blood flow and cerebrovascular reserve 5 years after EC-IC bypass

Holzschuh, M.; Brawanski, Alexander; Ullrich, W.; Meixensberger, Jürgen

doi:10.1007/bf00383261

Cited by 15 publications

(13 citation statements)

References 10 publications

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“…Coyle et al [4] could demonstrate a delayed improvement of initially insufficient collateralization after a stroke. Holzschuh et al [6] could even demonstrate a steady decline of CBF after longer follow-up reaching the pre-operative CBF levels. Functioning of our bypasses also got worse over time with the progress of the underlying arteriosclerotic disease, suggesting a role of surgery predominantly in the first year of ischaemic events.…”

Section: Discussionmentioning

confidence: 96%

“…The bypass procedure was shown to affect the vascular reserve capacity in a positive way [1,6]. Yamashita et al [17] demonstrated in 15 patients that the bypass did not increase the resting rCBF but did increase the rCRC.…”

Section: Discussionmentioning

confidence: 98%

“…During the past five years surgical revascularization was re-evaluated and considered as an appropriate treatment for a small subgroup of patients with focal cerebral ischaemia and impaired cerebrovascular reserve capacity [1,6,[7][8][9]14]. Haemodynamics were assessed by TCD, Xenon-CT, SPECT or PET scans after CO2 or Diamox challenge.…”

Section: Introductionmentioning

confidence: 99%

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Long-term evaluation of EC-IC bypass patency

1996

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The EC-IC Bypass Study Group could not detect any benefit from surgery compared to medical management in the prevention of stroke in 1985 [15]. During the past years surgical revascularization was re-evaluated and considered as an appropriate treatment for a small subgroup of patients with recurrent focal cerebral ischaemia and impaired haemodynamics. This retrospective study examines the long-term benefit and patency rate of bypass. We present a follow-up of 5.6 years of 47 patients, all of whom underwent bypass surgery after 1985. Forty patients suffered recurring transient ischaemic attacks due to uni- or bilateral internal carotid artery occlusion. Examination included neurologic status, TCD with CO2 or Diamox challenge, angiography, CT and SPECT scans. Neurological improvement was seen in 23% of patients with better results after early surgery, a worsening in 22% suffering further ischaemic events on a postoperative average of 2.8 years. Patency rate for vein graft material was 50%, for the STA-MCA procedure 91%. Occlusion of the vein graft occurred on an average after 1.4 years, other anastomosis after 2.7 years. We conclude that only few patients derived long-term benefit from EC-IC bypasses. Functioning of the bypass worsens over time, suggesting a role for surgery predominantly in the first year of ischaemic events due to insufficient collateral supply. Actual indications for bypass surgery may be patients with failure of maximal medical therapy and progressive ischaemia and haemodynamic compromise.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 98%

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Long-term evaluation of EC-IC bypass patency

1996

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“…18,21 Although a direct comparison with the current study is difficult due to methodological reasons, the current results indicate a beneficial effect of the bypass procedure for patients with haemodynamic impairment in terms of stroke prevention by improved cerebral haemodynamics in concordance with previous reports. 13,14,[22][23][24][25] One has to consider the racial differences in the distribution of steno-occlusive lesions, which might present with different stroke risk and also different risk-reduction by EC-IC bypass procedure. 26,27 It is noteworthy that in the international EC-IC bypass study a Japanese-Asian subgroup mainly consisting of MCA occlusive lesions showed less incidence of stroke recurrence in the surgical group though of no decisive statistical significance.…”

Section: Discussionmentioning

confidence: 99%

Extracranial–intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience

Muroi¹,

Khan²,

Bellut³

et al. 2011

British Journal of Neurosurgery

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Despite the failure of the international extracranial-intracranial (EC-IC) bypass study in showing the benefit of bypass procedure for prevention of stroke recurrence, it has been regarded to be beneficial in a subgroup of well-selected patients with haemodynamic impairment. This report includes the EC-IC bypass experience of a single centre over a period of 14 years. All consecutive 72 patients with atherosclerotic occlusive cerebrovascular lesions associated with haemodynamic compromise treated by EC-IC bypass surgery were retrospectively reviewed. Pre-operatively, 61% of patients presented with minor stroke and the remaining 39% with recurrent transient ischemic attacks (TIAs) despite maximal medical therapy. Angiography revealed a unilateral internal carotid artery (ICA) stenosis/occlusion in 79%, bilateral ICA stenosis/occlusion in 15%, MCA stenosis/occlusion in 3% and other multiple vessel stenosis/occlusion in 3% of the cases. H(2)(15)O positron emission tomography (PET) or 99mTc-HMPAO SPECT with acetazolamide challenge was performed for haemodynamic evaluation of the cerebral blood flow (CBF). All the patients had impaired haemodynamics pre-operatively in terms of reduced regional cerebrovascular reserve capacity and rCBF. Standard STA-MCA bypass procedure was performed in all patients. A total of 68 patients with 82 bypasses were reviewed with a mean follow-up period of 34 months. Stroke recurrence took place in 10 patients (15%) resulting in an annual stroke risk of 5%. Improved cerebral haemodynamics was documented in 81% of revascularised hemispheres. Patients with unchanged or worse haemodynamic parameters had significantly more post-operative TIAs or strokes when compared to those with improved perfusion reserves (30% vs.5% of patients, p<0.05). In conclusion, EC-IC bypass procedure in selected patients with occlusive cerebrovascular lesions associated with haemodynamic impairment has revealed to be effective for prevention of further cerebral ischemia, when compared with a stroke risk rate of 15% reported to date in patients only under antiplatelet agents or anticoagulant therapy. Extracranial-intracranial Bypass in Atherosclerotic Cerebrovascular AbstractDespite the negative results of the international EC-IC bypass study, well-selected patients with haemodynamic impairment might benefit from the bypass procedure in terms of stroke prevention. This report is about a single centre experience in EC-IC bypass procedure. All patients with atherosclerotic occlusive cerebrovascular diseases treated by EC-IC bypass surgery were retrospectively reviewed.Preoperatively, 61% of patients presented with minor stroke and the remaining 39%

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“…All 8 the studies in which postsurgical reactivity was reported noted a significant increase in reactivity for a combined rate of 80% (68/86). 17,19,20,[23][24][25]39 However, the original authors of the 1985 trial raised 3 objections to these case series. First, in the majority of these studies surrogate markers were used (such as blood flow and dilation response) instead of stroke and mortality rates.…”

Section: Literature Reviewmentioning

confidence: 99%

The Extracranial–Intracranial Bypass Trial: implications for future investigations

Garrett

Komotar

Merkow

et al. 2008

FOC

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✓The 1985 International Extracranial–Intracranial (EC-IC) Bypass Trial failed to show a surgical benefit of EC-IC bypass in patients with varying degrees of angiographic stenosis. This study was limited by the technology available at the time it was conducted. In the 20 years since, there has been considerable progress in imaging techniques that now enable the identification of a subset of stroke patients with hemodynamic ischemia. In the present study, the authors review the relevant literature and propose a reevaluation of the benefits of the EC-IC bypass procedure using these new imaging techniques. The authors reviewed the admission criteria for the EC-IC Bypass Trial in the light of more recently discovered neurovascular physiology and showed that the imaging criteria used in that trial are not physiologically adequate. A MED-LINE (1985–2007) database search for EC-IC case studies was conducted, and additional studies were identified manually by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files.

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Cerebral blood flow and cerebrovascular reserve 5 years after EC-IC bypass

Cited by 15 publications

References 10 publications

Long-term evaluation of EC-IC bypass patency

Long-term evaluation of EC-IC bypass patency

Extracranial–intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience

The Extracranial–Intracranial Bypass Trial: implications for future investigations

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