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Revascularization and Aneurysm Surgery: Techniques, Indications, and Outcomes in the Endovascular Era

Kalani, M. Yashar S. MD, PhD; Ramey, Wyatt MD; Albuquerque, Felipe C. MD; McDougall, Cameron G. MD; Nakaji, Peter MD; Zabramski, Joseph M. MD; Spetzler, Robert F. MD

doi: 10.1227/NEU.0000000000000312
Research-Human-Clinical Studies

BACKGROUND: Given advances in endovascular technique, the indications for revascularization in aneurysm surgery have declined.

OBJECTIVE: We sought to define indications, outline technical strategies, and evaluate the outcomes of patients treated with bypass in the endovascular era.

METHODS: We retrospectively reviewed all aneurysms treated between September 2006 and February 2013.

RESULTS: We identified 54 consecutive patients (16 males and 39 females) with 56 aneurysms. Aneurysms were located along the cervical internal carotid artery (ICA) (n = 1), petrous/cavernous ICA (n = 1), cavernous ICA (n = 16), supraclinoid ICA (n = 7), posterior communicating artery (n = 2), anterior cerebral artery (n = 4), middle cerebral artery (MCA) (n = 13), posterior cerebral artery (PCA) (n = 3), posterior inferior cerebellar artery (n = 4), and vertebrobasilar arteries (n = 5). Revascularization was performed with superficial temporal artery (STA) to MCA bypass (n = 25), STA to superior cerebellar artery (SCA) (n = 3), STA to PCA (n = 1), STA-SCA/STA-PCA (n = 1), occipital artery (OA) to PCA (n = 2), external carotid artery/ICA to MCA (n = 15), OA to MCA (n = 1), OA to posterior inferior cerebellar artery (n = 1), and in situ bypasses (n = 8). At a mean clinical follow-up of 18.5 months, 45 patients (81.8%) had a good outcome (Glasgow Outcome Scale 4 or 5). There were 7 cases of mortality (12.7%) and an additional 9 cases of morbidity (15.8%). At a mean angiographic follow-up of 17.8 months, 14 bypasses were occluded. Excluding the 7 cases of mortality, the majority of aneurysms (n = 42) were obliterated. We identified 7 cases of residual aneurysm and recurrence in 6 patients at follow-up.

CONCLUSION: Given current limitations with existing treatments, cerebral revascularization remains an essential technique for aneurysm surgery.

ABBREVIATIONS: ACA, anterior cerebral artery

aSAH, aneurysmal subarachnoid hemorrhage

BTO, balloon test occlusion

GOS, Glasgow Outcome Scale

ICA, internal carotid artery

MCA, middle cerebral artery

OA, occipital artery

PCA, posterior cerebral artery

PComm, posterior communicating artery

PICA, posterior inferior cerebellar artery

SCA, superior cerebellar artery

STA, superficial temporal artery

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona

Correspondence: Joseph M. Zabramski, MD, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85013. E-mail: Neuropub@dignityhealth.org

Received September 06, 2013

Accepted January 28, 2014

Copyright © by the Congress of Neurological Surgeons