1Faculty of Medicine, University of New South Wales.
2Department of Clinical Medicine, Macquarie University; and.
J Neurosurg. 2019 Feb 8;132(2):415-420. doi: 10.3171/2018.9.JNS181075. Print 2020 Feb 1.
Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust.
Consecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter.
From 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%-6.6%).
Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.
先前的试验否定了颅外-颅内旁路手术治疗症状性动脉粥样硬化疾病的作用。然而，如果旁路手术能够以较低的发病率进行，并且通畅性良好，那么血流动力学不足仍然是手术的一个合理依据。
回顾性地确定了 1992 年至 2017 年间因症状性非烟雾病颅内动脉狭窄或闭塞而行旁路手术的连续患者。在 6 周、6 个月和此后每年评估队列的临床过程和手术结果。
112 例患者共行 127 例旁路手术。80%的血管造影异常为动脉闭塞，20%为狭窄。手术目的是预防未来的中风（76%）和中风逆转（24%），80%采用动脉蒂移植物进行血运重建，20%采用静脉间置移植物（VIG）。8.9%的患者出现不良结局（旁路闭塞、新发中风、新发神经功能缺损或神经功能缺损恶化），动脉蒂移植物（优势比 [OR]0.15）、预防未来中风的旁路手术（OR0.11）或前循环旁路手术（OR0.17）被认为是保护因素。在手术后的头 8 年中，66 例同时具有这三种特征的患者发生不良结局的风险极小（95%置信区间 0%-6.6%）。
对于前循环缺血，预防性动脉蒂旁路手术与高移植物通畅率以及低中风和手术并发症发生率相关。急性手术（通常为后循环病变，需要 VIG）风险较高。有血流动力学不足和缺血症状的精心挑选的亚组患者可能受益于脑血运重建手术。
