SpringerLink
Log in

Microvascular neurosurgical arterial bypass for cerebral ischemia: A decade of development

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

The microsurgical extracranial-intracranial arterial bypass (EIAB) procedure, usually performed to anastomose the superficial temporal artery to a cortical branch of the middle cerebral artery, offers a therapeutic alternative in treating patients who present with symptoms of cerebral ischemia varying from transient ischemic attack (TIA) to stroke-in-evolution, and who have intracranial or otherwise inaccessible high cervical carotid lesions. Preoperative diagnostic steps include angiography, computer-assisted tomography (CT) scan, and measurements of regional cerebral blood flow (rCBF).

A comparison of our series of 172 patients with series reported in the literature suggests that EIAB is more effective than medical therapy in preventing the development of permanent neurological deficit after a series of TIA and in treating cases of stroke-in-evolution. It also can prevent further deterioration in selected patients after stroke. An analysis of patients who had an unfavorable outcome suggests that bilateral EIAB should be performed in a greater number of patients who have generalized low-perfusion syndrome; that low doses of heparin should be administered intraoperatively and postoperatively in patients who have high-grade siphon stenosis; and that aspirin should be given to patients experiencing TIA after EIAB.

Résumé

Les techniques microchirurgicales de bypass entre vaisseaux extra-et intracrâniens (BEIC) réalisent, en général, une anastomose entre l'artère temporale superficielle et une branche corticale de l'artère cérébrale moyenne. Elles offrent des possibilités thérapeutiques aux malades qui présentent des symptomes d'ischémie cérébrale, allant de l'épisode ischémique transitoire à l'ictus, et qui sont atteints de lésions carotiennes soit intracrâniennes, soit haut situées dans le cou, et inaccessibles par voie cervicale. La mise au point pré-opératoire de ces cas doit comporter une angiographie, une tomographie axiale computérisée et des mesures du débit sanguin cérébral régional.

Une analyse de notre série personnelle de 172 cas et d'autres séries rapportées dans la littérature suggère que le BEIC est plus efficace que le traitement médical pour prévenir les séquelles neurologiques après épisode ischémique transitoire et pour traiter les cas qui évoluent vers l'infarctus cérébral. Le BEIC peut aussi prévenir l'aggravation chez certains malades sélectionnés qui ont fait un ictus. L'analyse des cas qui ont eu une évolution favorable suggère qu'un BEIC bilatéral doit être réalisé chez un plus grand nombre de malades atteints d'un syndrome généralisé de perfusion à faible débit, qu'il faut administrer pendant et après l'opération de l'héparine à faibles doses chez les patients qui ont une sténose serrée du siphon carotidien et qu'il faut prescrire de l'aspirine aux malades qui présentent un épisode ischémique transitoire après BEIC.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Sandok, B.A.: Non-invasive techniques: value in carotid artery disease. Symposium: 3rd Joint Meeting on Stroke and Cerebral Circulation, New Orleans, February 16–18, 1978

  2. Eastcott, H.H.G., Pickering, G.W., Rob, C.G.: Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet2:994, 1954

    Google Scholar 

  3. Hass, W.K., Fields, W.S., North, R.R., Kricheff, I.I., Chase, N.E., Bauer, R.E.: Joint Study of Extracranial Occlusion. II. Arteriography, techniques, sites and complications. J.A.M.A.203:961, 1968

    PubMed  Google Scholar 

  4. Toole, J.R., Janeway, R., Choi, K., Cordell, R., Davis, C., Johnston, F., Miller, H.S.: Transient ischemic attacks due to atherosclerosis. A prospective study in 160 patients. Arch. Neurol.32:5, 1975

    PubMed  Google Scholar 

  5. Fields, W.S., North, R.R., Hass, W.K.: Joint Study of Extracranial Arterial Occlusion as a Cause of Stroke. I. Organization of study and survey of patient population. J.A.M.A.203:955, 1968

    PubMed  Google Scholar 

  6. Bauer, R.B., Meyer, J.S., Fields, W.S., Remington, R., MacDonald, M.C., Callen, P.: Joint Study of Extracranial Arterial Occlusion. III. Progress report of controlled study of long-term survival in patients with and without operation. J.A.M.A.208:509, 1969

    PubMed  Google Scholar 

  7. Blaisdell, W.F., Clauss, R.H., Galbraith, J.G.: Joint Study of Extracranial Arterial Occlusion. IV. A review of surgical considerations. J.A.M.A.209:1889, 1969

    PubMed  Google Scholar 

  8. Fields, W.S., Maslenikow, V., Meyer, J.S., Hass, W.K., Remington, R.D., MacDonald, M.: Joint Study of Extracranial Arterial Occlusion. V. Progress report following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions. J.A.M.A.211:1993, 1970

    PubMed  Google Scholar 

  9. Heyman, A., Fields, W.S., Keating, R.D.: Joint Study on Extracranial Arterial Occlusion. VI. Racial differences in hospitalized patients with ischemic stroke. J.A.M.A.222:285, 1972

    PubMed  Google Scholar 

  10. Gomensoro, J.B., Maslenikow, V., Azambuja, N., Fields, W.S., Lemak, N.A.: Joint Study of Extracranial Arterial Occlusion. VIII. Clinical-radiographic correlation of carotid bifurcation lesions in 177 patients with transient cerebral ischemic attacks. J.A.M.A.224:985, 1973

    PubMed  Google Scholar 

  11. Fields, W.S., Lemak, N.A.: Joint Study of Extracranial Arterial Occlusion. IX. Transient ischemic attacks in the carotid territory. J.A.M.A.235:2608, 1976

    PubMed  Google Scholar 

  12. Fields, W.S., Lemak, N.A.: Joint Study of Extracranial Arterial Occlusion. X. Internal carotid occlusion. J.A.M.A.235:2734, 1976

    PubMed  Google Scholar 

  13. Chater, N.L., Weinstein, P.R., Spetzler, R.: Microvascular bypass for cerebral ischemia—an overview, 1966–1976, In Microsurgery for Stroke, Schmiedek, P., editor. New York-Berlin-Heidelberg, Springer-Verlag, 1977, pp. 79–88

    Google Scholar 

  14. Henschen, C.: Operative Revascularisation des zirkulatorisch geschaedigten Gehirns durch Auflage gestielter Muskellappen (Encephalo-myo-synangiose). Langenbecks. Arch. Klin. Chir.264:392, 1950

    PubMed  Google Scholar 

  15. Fisher, C.M.: Occlusion of the internal carotid artery. Arch. Neurol. Psychiat.65:346, 1951

    Google Scholar 

  16. Romanus, F.C.A., Abramowicz, A.: Changes of brain and pial vessels in arterial border zones. Arch. Neurol.11:40, 1964

    PubMed  Google Scholar 

  17. Hossman, R.A., Sato, K.: Recovery of neuronal function after prolonged cerebral ischemia. Science168:375, 1970

    PubMed  Google Scholar 

  18. Branston, N., Simon, L., Crockart, H.: Recovery of the cortical evoked response following temporary middle cerebral artery occlusion in baboons. Stroke7:151, 1976

    PubMed  Google Scholar 

  19. Yasargil, M.G.: Experimental small vessel surgery in the dog including patching and grafting of cerebral vessels and the formation of functional extra-intracranial shunts. In Microvascular Surgery, Donaghy, R.M.P., Yasargil, M.G., editors. St. Louis, C.V. Mosby, 1967, pp. 87–126

    Google Scholar 

  20. Yasargil, M.G.: Microsurgery Applied to Neurosurgery. New York, Academic Press, 1969, pp. 95–119

    Google Scholar 

  21. Yasargil, M.G., Krayenbuhl, H.A., Jacobsen, J.H.: Microneurosurgical arterial reconstruction. Surgery67:221, 1970

    PubMed  Google Scholar 

  22. Donaghy, R.M.P., Yasargil, M.G.: Extra-intracranial blood flow diversion. Presentation before the American Association of Neurological Surgeons, Chicago Ill., April 11, 1968 (abstr. 52)

  23. Austin, G.M., editor: Microneurosurgical Anastomoses for Cerebral Ischemia. Proceedings of International Symposium, Loma Linda, California, June 1973. Springfield, Ill., Charles C. Thomas, 1976

    Google Scholar 

  24. Schmiedek, P., editor: Microneurosurgery for Stroke. New York-Heidelberg-Berlin, Springer-Verlag, 1977

    Google Scholar 

  25. Chater, N.L., Mani, J., Tonnemacher, K.: Superficial temporal artery bypass in occlusive vascular cerebral disease. Calif. Med.119:9, 1973

    PubMed  Google Scholar 

  26. Thompson, J.R., Simmons, C.R., Tsao, E.: Angiography of brain ischemia and the superficial temporal artery-middle cerebral artery anastomosis candidate. In Microneurosurgical Anastomoses for Cerebral Ischemia, Austin, G.M., editor. Proceedings of International Symposium, Loma Linda, California, June 1973. Springfield, Ill., Charles C. Thomas, 1976, pp. 157–175

    Google Scholar 

  27. Reichman, O.H.: Discussion: Indication for EIAB. In Cerebrovascular Diseases. 10th Princeton Conference, Scheinberg, P., editor. New York, Raven Press, 1976, pp. 336–337

    Google Scholar 

  28. Chater, N., Spetzler, R., Tonnemacher, K., Wilson, C.B.: Microvascular bypass surgery. Part I. Anatomical studies. J. Neurosurg.44:712, 1976

    PubMed  Google Scholar 

  29. Chater, N., Spetzler, R., Tonnemacher, K.: Anatomical localization of optimal middle cerebral branch for anastomosis. In Microneurosurgical Anastomoses for Cerebral Ischemia, Austin, G.M., editor. Proceedings of International Symposium, Loma Linda, California, June 1973. Springfield, Ill., Charles C. Thomas, 1976, pp. 39–51

    Google Scholar 

  30. Merei, T.F., Bodosi, M.: Microsurgical anastomosis for cerebral ischemia in ninety patients. In: Microsurgery for Stroke, Schmiedek, P., editor. New York-Heidelberg-Berlin, Springer-Verlag, 1977, pp. 264–270

    Google Scholar 

  31. Peerless, S.J.: Techniques of cerebral revascularization. Clin. Neurosurg.23:258, 1976

    PubMed  Google Scholar 

  32. Spetzler, R., Chater, N.: Occipital artery-middle cerebral artery anastomosis for cerebral artery occlusive disease. Surg. Neurol.2:235, 1974

    PubMed  Google Scholar 

  33. Khodadad, G.: Transient postoperative occlusion of the superficial temporal-middle cerebral artery branch anastomosis. Surg. Neurol.3:341, 1975

    PubMed  Google Scholar 

  34. Piepgras, D.G.: Factors influencing postoperative vascular patency. Clin. Neurosurg.23:310, 1976

    PubMed  Google Scholar 

  35. Reichman, O.H.: Neurosurgical microsurgical anastomosis for cerebral ischemia: five years' experience. In Cerebrovascular Diseases. 10th Princeton Conference, Scheinberg, P., editor. New York, Raven Press, 1976, pp. 311–329

    Google Scholar 

  36. Spetzler, R., Chater, N.: Microvascular bypass surgery. Part 2. Physiological studies. J. Neurosurg.45:508, 1976

    PubMed  Google Scholar 

  37. Barnett, H.J.M.: Canadian Cooperative Platelet-Inhibiting Drug Trial in Threatened Stroke. Presented at 3rd Joint Meeting on Stroke and Cerebral Circulation, New Orleans, February 16–18, 1978

  38. Cooperative Study of Extracranial/Intracranial Arterial Anastomosis. Protocol 1978

  39. Ostfeld, A.M., Shekelle, R.B., Klawans, H.L.: Transient ischemic attacks and risk of stroke in an elderly poor population. Stroke4:980, 1973

    PubMed  Google Scholar 

  40. Abu-Zeid, H.A.H., Choi, N.W., Maini, K.K., Hsu, P.H., Nelson, N.A.: Relative role of factors associated with cerebral infarction and cerebral hemorrhage. Stroke8:106, 1977

    PubMed  Google Scholar 

  41. Nefzger, M.D., Kuller, L.H., Lilienfeld, A.M., Diamond, E.L., Miller, G.D., Stolley, P.D., Tonascia, S.: Three area epidemiological study of geographic differences in stroke mortality. I. Background and methods. Stroke8:546, 1977

    PubMed  Google Scholar 

  42. Stolley, P.D., Kuller, L.H., Nefzger, M.D., Tonascia, S., Lilienfeld, A.M., Miller, G.D., Diamond, E.L.: Three area epidemiological study of geographic differences in stroke mortality. II. Results. Stroke8:551, 1977

    PubMed  Google Scholar 

  43. Marshall, J.: The natural history of transient ischemic cerebrovascular attacks. Q. J. Med.33:309, 1964

    PubMed  Google Scholar 

  44. Friedman, G.D., Wilson, W.S., Mosier, J.M., Colandrea, M.A., Nichaman, M.Z.: Transient ischemic attacks in a community. J.A.M.A.210:1428, 1969

    PubMed  Google Scholar 

  45. Whisnant, J.P., Goldner, J.C., Taylor, W.F.: Natural history of transient ischemic attacks. In Cerebrovascular Diseases. 7th Princeton Conference, Moossy, J., Janeway, R., editors. New York, Grune and Stratton, 1970, pp. 161–165

    Google Scholar 

  46. Whisnant, J.P., Siekert, R.C.G., Millikan, C.H.: Ischemic cerebrovascular disease (focal cerebral ischemia). In Allen-Barker-Hines Peripheral Vascular Disease, 4th edition, Fairbairn, J.F., II, Jueggens, J.L., Spittell, J.A., editors. Philadelphia, W.B. Saunders, 1972, pp. 241–253

    Google Scholar 

  47. Marshall, J., Wilkinson, I.M.S.: The prognosis of carotid transient ischemic attacks in patients with normal angiograms. Brain94:395, 1971

    PubMed  Google Scholar 

  48. Karp, H.R., Heyman, A., Heyden, S., Bartel, A.G., Tyroler, H.A., Haymes, C.G.: Transient cerebral ischemia. Prevalence and prognosis in a biracial rural community. J.A.M.A.225:125, 1973

    PubMed  Google Scholar 

  49. Dyken, M.L., Kolar, O.J., Jones, F.H.: Differences in the occurrence of carotid transient ischemic attacks associated with antiplatelet aggregation therapy. Stroke4:732, 1973

    PubMed  Google Scholar 

  50. Whisnant, J.P., Matsumoto, N., Elveback, L.R.: The effect of anticoagulant therapy on the prognosis of patients with transient cerebral ischemic attacks in a community. Rochester, Minnesota, 1955 through 1969. Mayo Clin. Proc.48:844, 1973

    PubMed  Google Scholar 

  51. Toole, J.F., Grindal, A.B.: Natural history of untreated transient ischemic attacks. In Current Controversies in Neurosurgery, Morley, T.P., editor. Philadelphia, W.B. Saunders, 1976, pp. 289–293

    Google Scholar 

  52. Cartlidge, N.E.F., Whisnant, J.P., Elveback, L.R.: Carotid and vertebral-basilar transient cerebral ischemic attacks. A community study, Rochester, Minnesota. Mayo Clin. Proc.52:117, 1977

    PubMed  Google Scholar 

  53. Acheson, J., Hutchinson, E.C.: The natural history of focal cerebral vascular disease. Q. J. Med.40:157, 1971

    Google Scholar 

  54. Toole, J.F.: Management of transient ischemic attacks. In Cerebrovascular Diseases. 10th Princeton Conference, Scheinberg, P., editor. New York, Raven Press, 1976, pp. 23–30

    Google Scholar 

  55. Matsumoto, N., Whisnant, J.P., Kurland, L.T., Okazaki, H.: Natural history of stroke in Rochester, Minnesota, 1955–1969. An extension of a previous study, 1945–1954. Stroke4:20, 1973

    PubMed  Google Scholar 

  56. Hutchinson, E.C., Acheson, E.J.: Strokes. Natural History, Pathology and Treatment. Philadelphia, W.B. Saunders, 1975

    Google Scholar 

  57. Genton, E., Barnett, H.J.M., Fields, W.S., Gent, M., Hoak, J.C.: XIV. Cerebral Ischemia. The role of thrombosis and of antithrombotic therapy. Study Group on Antithrombotic Therapy. Stroke8:150, 1977

    PubMed  Google Scholar 

  58. Fisher, C.M.: The use of anticoagulants in cerebral thrombosis. Neurology8:311, 1958

    PubMed  Google Scholar 

  59. Baker, R.N.: An evaluation of anticoagulant therapy in the treatment of cerebrovascular disease: Report of the Veterans Administration. Neurology11:132, 1961

    Google Scholar 

  60. Baker, R.N., Broward, J.A., Fang, H.C.: Anticoagulant therapy in cerebral infarction. Report on a cooperative study. Neurology12:823, 1962

    PubMed  Google Scholar 

  61. Pearce, J.M.S., Gubbay, S.S., Walton, J.N.: Longterm anticoagulant therapy in transient cerebral ischemia attacks. Lancet1:6, 1965

    Google Scholar 

  62. Baker, R.N., Schwartz, W.S., Rose, A.S.: Transient ischemic strokes. A report of a study of anticoagulant therapy. Neurology16:841, 1966

    Google Scholar 

  63. Beever, D.G., Hamilton, M., Fairman, M.J., Harpur, J.E.: Antihypertensive treatment and the course of established cerebral vascular disease. Lancet2:1407, 1973

    Google Scholar 

  64. Hypertension-Stroke Cooperative Study Group: Effect of antihypertensive treatment on stroke recurrence. J.A.M.A.229:409, 1974

    Google Scholar 

  65. Hass, E.W.K.: Aspirin for the lim** brain (Editorial). Stroke3:299, 1977

    Google Scholar 

  66. Fields, W.S., Lemak, N.A., Frankowski, R.F., Hardy, R.J.: Controlled trial of aspirin in cerebral ischemia. Stroke83:801, 1977

    Google Scholar 

  67. Meyer, J.S., Gilroy, J., Barnhart, M.E.: Therapeutic thrombolysis in cerebral thromboembolism: double-blind evaluation of intravenous plasmin therapy in carotid and middle cerebral arterial occlusion. Neurology13:927, 1963

    PubMed  Google Scholar 

  68. Meyer, J.S., Gilroy, J., Barnhart, M.E.: Therapeutic thrombolysis in cerebral thromboembolism: randomized evaluation of intravenous streptokinase. In Cerebrovascular Diseases. 4th Princeton Conference, Siekert, R.G., Whisnant, J.P., editors. New York, Grune and Stratton, 1965, pp. 200–213

    Google Scholar 

  69. Fletcher, A.P., Alkjaersig, N., Lewis, M.: A pilot study of urokinase therapy in cerebral infarction. Stroke7:135, 1976

    PubMed  Google Scholar 

  70. Hanaway, J., Torack, R., Fletcher, A.P.: Intracranial bleeding associated with urokinase therapy for acute ischemic hemispheral stroke. Stroke7:143, 1976

    PubMed  Google Scholar 

  71. Svien, H.J., Hollenhorst, R.W.: Pressure in retinal arteries after ligation or occlusion of the carotid artery. Proc. Staff Meet. Mayo Clin.31:684, 1956

    Google Scholar 

  72. Kartchner, M.M., McRae, L.P., Morrison, F.D.: Noninvasive detection and evaluation of carotid occlusive disease. Arch. Surg.106:528, 1973

    PubMed  Google Scholar 

  73. Machleder, H.I.: Evaluation of patients with cerebrovascular disease using the Doppler ophthalmic test. Angiology24:374, 1973

    PubMed  Google Scholar 

  74. Thomas, G.I., Spencer, M.P., Jones, T.W., Edmarck, K.W., Stavney, L.S.: Noninvasive carotid bifurcation map**. Its relation to carotid surgery. Am. J. Surg.128:168, 1974

    PubMed  Google Scholar 

  75. Moore, W.S., Hall, A.D.: Importance of emboli from carotid bifurcation in pathogenesis of cerebral ischemic attacks. Arch. Surg.101:708, 1970

    PubMed  Google Scholar 

  76. Baker, R.N.: Prospective study of transient ischemic attacks. In 7th Princeton Conference on Cerebrovascular Disease, Moossy, J., Janeway, R., editors. New York, Grune and Stratton, 1970, pp. 166–169

    Google Scholar 

  77. Acheson, E.J.: Factors affecting the natural history of “focal cerebral vascular disease.” Q. J. Med.40:25, 1971

    PubMed  Google Scholar 

  78. Piepgras, D.G., Sundt, T.M., Jr.: Bypass surgery for vascular disease of the carotid and vertebral artery system. In Microsurgery for Stroke, Schmiedek, P., editor. New York-Heidelberg-Berlin, Springer-Verlag, 1977, pp. 281–285

    Google Scholar 

  79. Khodadad, G.: Occipital artery-posterior inferior cerebellar artery anastomosis. Surg. Neurol.5:225, 1976

    PubMed  Google Scholar 

  80. Khodadad, G., Singh, R.S., Olinger, C.P.: Possible prevention of brain stem stroke by microvascular anastomosis in the vertebro-basilar system. Stroke8:316, 1977

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Editorial Office, University of California School of Medicine, 350 Parnassus, Suite 807, 94143, San Francisco, California, USA

    H. Maximilian Mehdorn M.D., William F. Hoffman M.D. & Norman L. Chater M.D.

Authors
  1. H. Maximilian Mehdorn M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. William F. Hoffman M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Norman L. Chater M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mehdorn, H.M., Hoffman, W.F. & Chater, N.L. Microvascular neurosurgical arterial bypass for cerebral ischemia: A decade of development. World J. Surg. 3, 197–206 (1979). https://doi.org/10.1007/BF01561274

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01561274

Keywords

Search

Navigation