Safety of urgent STA-MCA anastomosis after intravenous rt-PA treatment: a report of five cases and literature review

Kanematsu, Ryo; Kimura, Toshikazu; Ichikawa, Yasumitsu; Inoue, Tomohiro

doi:10.1007/s00701-018-3576-y

Cited by 13 publications

(7 citation statements)

References 22 publications

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“…The pooled articles and their relevant information are shown in Table 4. In total, 117 patients from 10 articles (including the present study) were assessed [10, 11, 13-16, 18-20]. Urgent bypass surgeries were performed due to failed IAT ( n = 24), further infarction prevention ( n = 3), and symptom progression ( n = 90).…”

Section: Resultsmentioning

confidence: 99%

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

et al. 2021

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Background: Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. Aims: We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. Methods: Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. Results: In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. Conclusions: Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

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Section: Resultsmentioning

confidence: 99%

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

et al. 2021

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“…Only cases of minimally invasive and rapid surgical embolectomy have been described in non-atherosclerotic artery occlusions,18 similarly to cases of MSE in patients with ELVO for whom MT failed within 8 hours since the onset of symptoms with a favorable clinical outcome after MI 27. Emergent EC–IC bypass with low hemorrhagic complication rates immediately following IVT has been rarely documented 8. A low level of fibrinogen after IVT might be a risk factor for surgery complications.…”

Section: Discussionmentioning

confidence: 99%

“…Microsurgical intervention (MSI) might offer another method for ELVO recanalization in the anterior circulation using two main approaches or their combination: the first, a direct vessel recanalization with microsurgical embolectomy (MSE), and the second using an extracranial–intracranial (EC–IC) bypass 7 8. The advantage of MSE lies in its potential for recanalizing the perforators in cases where they branch from the occluded segment, with the sphenoidal part of the middle cerebral artery (MCA) being an example.…”

Section: Introductionmentioning

confidence: 99%

“…The benefit of the EC–IC bypass in prevention of secondary stroke has not yet been demonstrated 12. The EC–IC bypass is potentially suitable in cases of pronounced intracranial atherosclerosis where MSE failure is expected 8. Thus, the surgeon should be prepared for the eventuality of using both MSE and EC–IC bypass during an urgent surgery.…”

Section: Introductionmentioning

confidence: 99%

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Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study

Fiedler

Roubec

Grubhoffer

et al. 2022

J NeuroIntervent Surg

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BackgroundDespite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome.ObjectiveTo test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy.MethodsA prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial–intracranial bypass was performed in all MSIG patients at center 1.ResultsA total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0–2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2.ConclusionsThis study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.

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“…As the first case occurred in 2011 and the second in 2015, sufficient evidence for the use of MT for acute LVO was lacking at the time both cases were treated. Other nonelderly patients in whom symptoms were also presumed to have been caused by atherosclerosis (Cases 1 and 9) might have met the indications for bypass surgery, but the efficacy of bypass surgery for patients with acute LVO due to intracranial atherosclerosis has not been established [ 17 ]. Consensus remains lacking on the optimal endovascular strategy for such cases [ 18 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of Patency of the Carotid Terminus and Middle Cerebral Artery on Early Clinical Outcomes in Patients with Acute Internal Carotid Artery Occlusion and Mild Symptoms

Itabashi

Saito

Kawabata

et al. 2022

Cerebrovasc Dis Extra

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Introduction: Both collateral flow via the internal carotid artery (ICA) terminus (ICT) and initial mild symptoms might be associated with favorable outcomes in patients with acute ICA occlusion (ICAO). This study aimed to address the association between early clinical outcomes and patency of the ICT and middle cerebral artery (MCA) in patients with acute ICAO with mild symptoms. Methods: Of 1214 consecutive patients with acute ischemic stroke or transient ischemic attack due to large vessel occlusion, patients with ipsilateral ICAO and initial National Institutes of Health Stroke Scale score (NIHSS) ≤ 5 were retrospectively enrolled. We examined the associations between clinical factors including patency of the ICT and MCA and recurrence of stroke or early neurological deterioration (REND). Significant early neurological deterioration was defined as increment in NIHSS score ≥ 1 during hospital stay. Results: Thirteen of the 35 patients who were finally enrolled had REND (37%), and median modified Rankin Scale (mRS) score at discharge was 1 (interquartile range, 0–4). Initial NIHSS score (4 vs. 1, p<0.001) and rates of diabetes mellitus (61.5% vs. 13.6%, p=0.007), intravenous thrombolysis (IVT) (30.9% vs. 0%, p=0.014), and mechanical thrombectomy (MT) (23.1% vs. 0%, p=0.044) were significantly higher in patients with REND rather than in those without. The rate of patent ICT and MCA was comparable between groups. Except for one patient who underwent MT promptly after IVT immediately after REND, 3 patients initially treated with IVT deteriorated after the procedure. One patient without patent ICT and MCA did not meet the indications for MT. In 2 other patients with patent ICT and MCA, MT was not initially performed, but was eventually performed because of REND due to thrombus migration, and both were discharged with an mRS score of 5. Conclusion: The overall clinical outcomes of patients with acute ICAO with mild symptoms were not depending on the patency of the ICT and MCA, but initial treatment with IVT alone might risk unfavorable outcomes due to thrombus migration in patients with patent ICT and MCA.

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Safety of urgent STA-MCA anastomosis after intravenous rt-PA treatment: a report of five cases and literature review

Abstract: In our consecutive cases, urgent STA-MCA anastomosis after at least 5.3 h after intravenous rt-PA was performed safely without hemorrhagic complications.

Cited by 13 publications

References 22 publications

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study

Impact of Patency of the Carotid Terminus and Middle Cerebral Artery on Early Clinical Outcomes in Patients with Acute Internal Carotid Artery Occlusion and Mild Symptoms

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