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Extracranial-Intracranial Bypass for StrokeIs This the End of the Line or a Bump in the Road?

Amin-Hanjani, Sepideh MD; Barker, Fred G. II MD; Charbel, Fady T. MD; Connolly, E. Sander Jr MD; Morcos, Jacques J. MD; Thompson, B. Gregory MD; On behalf of the Cerebrovascular Section of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS)

doi: 10.1227/NEU.0b013e3182621488
Special Article
CNS University of Neurosurgery

The results of the recently published Carotid Occlusion Surgery Study, which failed to show a benefit of extracranial-intracranial (EC-IC) bypass over medical therapy in patients with symptomatic hemodynamically significant carotid occlusion, have been interpreted by some as the end of the line for EC-IC bypass in the management of stroke. Despite being carefully conceived and executed, several aspects of the trial design, study population, and underlying assumptions deserve further examination to determine how best to translate these results into clinical practice. Although a general expansion of EC-IC bypass use in this population would not be supported by the trial results, a select subset of patients with medically refractory hemodynamic symptoms may well benefit from surgery performed with sufficiently low perioperative morbidity. The potential for beneficial functional or cognitive impact of revascularization also remains under investigation. Limited application and further study with an eye to future developments, rather than complete abandonment, is warranted.

ABBREVIATIONS: COSS, Carotid Occlusion Surgery Study

EC-IC, extracranial-intracranial

MCA, middle cerebral artery

OEF, oxygen extraction fraction

PET, positron emission tomographic

STA, superficial temporal artery

Correspondence: Sepideh Amin-Hanjani, MD, Department of Neurosurgery, University of Illinois at Chicago, Neuropsychiatric Institute, Rm 451N, 912 S Wood St, M/C 799, Chicago, IL 60612. E-mail:

Endorsed by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS)

Endorsed by Peter Vajkoczy, Andreas Gruber, Mika Niemelä, François Proust, Luca Regli on behalf of the Section of Vascular Neurosurgery of the European Association of Neurosurgical Societies (EANS)

Received March 30, 2012

Accepted May 16, 2012

Copyright © by the Congress of Neurological Surgeons