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Emergency EC-IC bypass for symptomatic atherosclerotic ischemic stroke

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Abstract

Previous studies have shown that extracranial–intracranial (EC-IC) bypass surgery has no preventive effect on subsequent ipsilateral ischemic stroke in patients with symptomatic atherosclerotic internal carotid occlusion and hemodynamic cerebral ischemia. A few studies have assessed whether an urgent EC-IC bypass surgery is an effective treatment for main trunk stenosis or occlusion in acute stage. The authors retrospectively reviewed 58 consecutive patients who underwent urgent EC-IC bypass for symptomatic internal carotid artery or the middle cerebral artery stenosis or occlusion between January 2003 and December 2011. Clinical characteristics and neuroimagings were evaluated and analyzed. Based on preoperative angiogram, responsible lesions were the internal carotid artery in 19 (32.8 %) patients and the middle cerebral artery in 39 (67.2 %). No hemorrhagic complication occurred. Sixty-nine percent of patients showed improvement of neurological function after surgery, and 74.1 % of patients had favorable outcome. Unfavorable outcome was associated with insufficient collateral flow and new infarction after bypass surgery.

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Authors and Affiliations

  1. Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan

    Tetsuyoshi Horiuchi, Junpei Nitta, Shigetoshi Ishizaka, Kohei Kanaya, Takao Yanagawa & Kazuhiro Hongo

Authors
  1. Tetsuyoshi Horiuchi
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  2. Junpei Nitta
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  3. Shigetoshi Ishizaka
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  4. Kohei Kanaya
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  5. Takao Yanagawa
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  6. Kazuhiro Hongo
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Correspondence to Tetsuyoshi Horiuchi.

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Comments

Akitsugu Kawashima, Tokyo, Japan

This article describes excellent results with emergency EC-IC bypass in a big cohort of acute ischemic stroke cases, induced by atherosclerotic stenosis or occlusion of the ICA or MCA. The authors concluded that 69 % of the patients improved and only 8.6 % worsened by this procedure. Emergency EC-IC bypass for acute ischemia has been traditionally considered a contraindication, due to the potential reperfusion ischemic injury1. However, the authors reported few surgical complications, especially no hemorrhagic complications, despite the large number of cases. Recently, some papers stated similar findings2,3. These data may become also valuable for management by surgical acute flow replacement in general.

Particular attention deserves the described 74.1 % favorable outcome (good recovery, 50 % and moderate disability, 24.1 % as Glasgow Outcome Scale) in patients treated with this procedure, which was superior to endovascular therapies (intravenous tissue plasminogen activator application or intraarterial thrombolysis).4

As authors also indicate, this study has some limitations due to the lack of CBF evaluation and for not being a randomized control study. However these data may encourage the interest of neurosurgeons to treat atherosclerotic stroke and reconfirm these findings.

References

1. Gratzl O, Schmiedek P, Spetzler R, Steinhoff H, Marguth F. Clinical experience with extra-intracranial arterial anastomosis in 65 cases. Journal of neurosurgery. 1976;44:313–324

2. Diaz FG, Ausman JI, Mehta B, Dujovny M, de los Reyes RA, Pearce J, et al. Acute cerebral revascularization. Journal of neurosurgery. 1985;63:200–209

3. Nussbaum ES, Janjua TM, Defillo A, Lowary JL, Nussbaum LA. Emergency extracranial-intracranial bypass surgery for acute ischemic stroke. Journal of neurosurgery. 2010;112:666–673

4. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. The New England journal of medicine. 2013;368:904–913

William J. Powers, Chapel Hill, USA

Dr. Horiuchi and colleagues have documented their experience with 58 patients treated by urgent EC-IC bypass for acute ischemic stroke based on retrospective medical records review. These patients’ diffusion-weighted images revealed no abnormal findings or minimum early signs and medical therapy with heparin infusion and oral antiplatelet drugs failed to provide sufficient recanalization and halt progression of ischemic symptoms. Presumed atherosclerotic stenosis or occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA) was confirmed by angiography. Thirty-four (58.6 %) were operated the day of onset and most were operated within 2 days. Postoperative MR angiography and/or angiogram showed a patent bypass in 37 of 38 in whom it was performed. No patient received intravenous tPA, though it is not stated how many would have met eligibility criteria. New infarction developed in 23 (40 %), and major complications occurred in 4 including one death due to myocardial infarction. Forty-three (74 %) patients had favorable (Glasgow outcome score 4–5) and 15 (26 %) patients had unfavorable (Glasgow outcome score, 1–3) outcome.

How do these data help us in treating patients with acute stroke with stenosis or occlusion of the MCA or ICA? They do not. In the absence of a randomized control group, it is impossible to determine if the EC-IC bypass surgery helped or hurt these patients. The 74 % rate of favorable outcome is likely due to the careful selection of patients to exclude those with a large diffusion lesion, a major determinant of poor outcome after stroke [1]. A patent bypass is not evidence of clinical efficacy; reperfusion will only ameliorate the effects of acute ischemic stroke if performed very rapidly, probably within <4.5 h and even then not in all cases [2–4]. Recent data from trials of intra-arterial intervention have shown that reperfusion >6 h in those with persistent ICA or MCA occlusion provides no benefit [5] and even delays of one hour render the better recanalization achieved by intra-arterial approaches no better than intravenous tPA [6]. Thus, revascularization by EC-IC bypass as reported here is highly unlikely to prove to be of benefit even if tested in a randomized, controlled trial. The treatment of choice for those with acute ischemic stroke with MCA or ICA occlusion who met NINDS or ECASS III criteria is intravenous tPA and for those who do not, it is anti-platelet therapy [2,3,7,8].

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2. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1588

3. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, Von Kummer R, Wahlgren N, Toni D, For the ECASS Investigators (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329

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6. Ciccone A, M.D., Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, Boccardi E, for the SYNTHESIS Expansion Investigators (2013) . Endovascular treatment for acute ischemic stroke. N Engl J Med 368:904–13.

7. Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, Xie JX, Warlow C, Peto R on behalf of the CAST and IST collaborative groups.(2000) Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40 000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial. Stroke.31:1240–9

8. Wang Y, Johnston SC, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, for the CHANCE investigators. Clopidogrel and aspirin versus aspirin alone for the treatment of high-risk patients with acute non-disabling cerebrovascular event (CHANCE): a randomized, double-blind, placebo-controlled multicenter trial. Presented at the International Stroke Conference, Honolulu, HI February 8, 2013

Rod Samuelson, Phoenix, USA

The authors present and important series of 58 patients with emergent EC-IC bypass for symptomatic atherosclerotic ischemic stroke. The included patients presented with acutely symptomatic stenosis or occlusion of the cervical/intracranial internal carotid artery or M1 / M2 middle cerebral artery. This group of patients was not evaluated in the larger (negative) trials for EC-IC bypass. Patient selection was by a careful process including severe symptoms, favorable neuroimaging, and lack of response to basic medical interventions. Endovascular interventions were used on an unspecified number of patients as well.

In general, the patients had favorable outcomes, and 69 % had improved neurologic function postoperatively. However, 40 % of the patients went on to have strokes in the affected vascular territory.

This is an important series of patients for study and consideration, although the algorithm for stroke treatment in these patients is somewhat different than that advocated by the American Heart Association/American Stroke Association. My main reservation with this paper is that some of the included patients may have benefited from IV tPA or additional endovascular treatments. Intracranial atherosclerosis is not a contraindication for IV tPA that I am familiar with. Nevertheless, when patients are treated with emergent EC-IC bypass, they appear to have a similar potential for favorable outcome as those treated with IV tPA or intra-arterial interventions.

For future study, comparison with patients who receive “standard” therapies is in order. Intracranial balloon angioplasty and stenting is also an attractive alternative.

Albert van der Zwan, Utrecht, The Netherlands

The study of Dr Horiuchi and colleagues clearly demonstrates that early bypass surgery in a broad cohort of symptomatic internal carotid artery or the middle cerebral artery stenosis of occlusion can be done safely performed within 2 days after the first ictus. Although previous publications describe hyperperfusion rates between 0.6 and 15 %, the results of this study are splendid with no hyperperfusion complications having occurred.1,2,3

Yet, it is still unclear what the reason is for this. The explanation of this by suggesting that more proximal diseases like in this study could be the reason for this is not very strong as MCA stenosis is not only proximally located per se.

Yet, the absence of hemorrhagic conditions cannot be the final goal of a study to determine a role for EC-IC bypass surgery in ischemic cerebral conditions. As the authors already denoted, this is a retrospective study on bypass surgeries performed on a broad scale of patients groups (stenosis or occlusion of the precommunicating ICA and postcommunicating ICA and MCA), still without DWI image infarcts, using one or two EC-IC bypasses without determining added blood flows.

This diversity of patients and therapy in this study is the reason that this study will not help us in deciding whether bypass surgery will be beneficial for a selected group of patients.

Stenosis or occlusion of any artery and the existence of sufficient collaterals play an important role in the final outcome. In addition, it is unclear whether in this cohort of patients pure hemodynamic or additional embolic factors play a role in the neurological outcome. The existence of a stenosis does not tell us whether any infarction is originated in embolus or hemodynamics. In addition, the assessment of the Glasgow Coma (Outcome) Scale in inclusion and follow-up could miss essential factors in patient assessment 4. The therapeutical window in this study varied between 0 and 2 days. In addition, this relatively broad time frame could disturb the results. Moreover, the use of one or two bypasses based on ICG does not give any information about flows that are added to the specific patients. ICG is, until now, no flow measurement technique. In the best, it can give information about flow velocities and direction. Therefore, to our experience, added flows in this study may vary between 10 and 90 ml/min which is again a broad spectrum.

Finally, the described 74.1 % of patients having favorable outcome does not tell us what the additional value of the bypass was in these patients. In the COSS study, the functional outcome of the nonsurgical patients was much better than in previous studies (follow up, 2 years), and it is difficult to compare the results of the present study (follow up at discharge) with the COSS study.4

In conclusion, this study is helpful in the discussion on the risk of hemorrhagic complications of acute bypass surgery, but does not help us in the search for selected patients that could benefit from this type of surgery. For that, we need more specific pathology inclusion, more defined functional investigations (MRI, MRF, and MRS), and more quantitative data on the added flows than has been used in this (or COSS) study.

Therefore, it is important that more studies like this encourage neurosurgeons in close cooperation with neurologists to perform more specific research on selected patient groups that could benefit from EC-IC bypass surgery.

References

1. The EC-IC Bypass Study. N Engl J Med. 1987;317:1030–1032

2. Sundt TM jr, Whisnant JP, Fode NC, Piepgras DG, Houser OW. Results. Complications, and follow-up of 415 bypass-operations for occlusive disease of the carotid system. Mayo Clin Proc. 1985;60(4):230–240

3. Van Doormaal PC, Klijn CJM, van Doormaal PTC, Kapelle LJ, Regli L, Tulleken CAF, van der Zwan A. High-flow extracranial-to-intracranial excimer laser-assisted nonocclusive anastomosis bypass for symptomatic carotid artery occlusion. Neurosurgery. 2011;68(4):1687–1693

4. Powers JP, Clarke WR, Grubb Jr RL, Videen TO, Adams jr HP, Derdeyn CP. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia. JAMA. 2011; 206(8):1983–1992

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Horiuchi, T., Nitta, J., Ishizaka, S. et al. Emergency EC-IC bypass for symptomatic atherosclerotic ischemic stroke. Neurosurg Rev 36, 559–565 (2013). https://doi.org/10.1007/s10143-013-0487-5

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