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Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance

  • Clinical Article - Vascular
  • Published:
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Abstract

Background

The mechanisms underlying post-extracranial to intracranial (EC-IC) bypass neurocognitive changes are poorly understood.

Methods

Data from 55 patients who underwent a unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised (WMS-R) before and 6 months after EC-IC bypass. Results of NPEs were converted into Z-scores from which preoperative cognitive composite scores (CSpre) and postoperative cognitive composite scores (CSpost) were obtained. The association between the change of composite score between pre- and postoperative NPEs (CSpost-pre = CS post – CS pre) and various variables were assessed. These latter variables included occluded artery (ICA or MCA), preexisting ischemic lesion as verified in preoperative T2WI, robust bypass patency as verified by MRA performed approximately 6 months postoperatively, and postoperative transient neurological symptoms and/or postoperative chronic subdural hematoma (CSDH), both of which were dichotomized as postoperative events.

Results

Postoperative MRI follow-up (median, 6 months; interquartile range, 5–8 months) confirmed successful bypasses in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypasses in all patients. A nearly statistically significant CS post-pre decrease was observed in patients with postoperative events when compared with those without postoperative events (−0.158 vs. 0.039; p = 0.069). A multiple regression model predicting CSpost-pre was performed. After controlling for occluded arteries, postoperative events were identified as an independent predictor of a decline in CSpost-pre (p = 0.044). In the group rate analysis, three of four postoperative NPE scores (Performance IQ, WMS-memory, WMS-attention) were significantly improved relative to preoperative NPE scores.

Conclusions

Postoperative transient neurological symptoms and/or CSDH might play a significant role in the subtle decline in cognition following an EC-IC bypass. However, this detrimental effect was small, and based on the group rate analysis, we concluded that a successful unilateral EC-IC bypass does not adversely affect postoperative cognitive function.

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Abbreviations

CBF:

cerebral blood flow

CSDH:

chronic subdural hematoma

DSA:

digital subtraction angiography

DWI:

diffusion-weighted imaging

EC-IC:

extracranial to intracranial

ICA:

internal carotid artery

MCA:

middle cerebral artery

MRA:

magnetic resonance angiography

NPE:

neuropsychological examination

OA:

occipital artery

PIQ:

performance IQ

SPECT:

single-photon emission computed tomography

STA:

superficial temporal artery

T2WI:

T2-weighted image

VIQ:

verbal IQ

WAIS-III:

Wechsler Adult Intelligence Scale-Third Edition

WMS-attention:

attention/concentration score in WMS-R

WMS-memory:

composite memory score in WMS-R

WMS-R:

Wechsler Memory Scale-Revised

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Authors and Affiliations

  1. Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan

    Tomohiro Inoue, Akira Tamura & Isamu Saito

  2. Health Management Center, JCHO Tokyo Shinjuku Medical Center, Tokyo, Japan

    Kazuhiro Ohwaki

  3. Department of Neurosurgery, Showa General Hospital, Tokyo, Japan

    Kazuo Tsutsumi

  4. Department of Neurosurgery, University of Tokyo, Tokyo, Japan

    Nobuhito Saito

Authors
  1. Tomohiro Inoue
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  2. Kazuhiro Ohwaki
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  3. Akira Tamura
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  4. Kazuo Tsutsumi
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  5. Isamu Saito
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  6. Nobuhito Saito
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Corresponding author

Correspondence to Tomohiro Inoue.

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Video 1

Intraoperative video showing left STA-MCA double anastomosis for a 53-year-old female with left MCA occlusion. (MP4 32651 kb)

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Inoue, T., Ohwaki, K., Tamura, A. et al. Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance. Acta Neurochir 158, 207–216 (2016). https://doi.org/10.1007/s00701-015-2620-4

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  • DOI: https://doi.org/10.1007/s00701-015-2620-4

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