Extracranial-Intracranial Bypass for Ischemic Cerebrovascular Disease Refractory to Maximal Medical Therapy

OBJECTIVE: To examine the potential role of cerebral revascularization in the treatment of patients with symptomatic occlusive cerebrovascular disease refractory to medical therapy. METHODS: Twenty patients with symptomatic occlusive cerebrovascular disease underwent 22 extracranial-intracranial bypass procedures after failing maximal medical therapy. The average follow-up time was 3.5 years, and no patient was lost to follow-up. RESULTS: All patients presented with repeated transient ischemic attacks refractory to medical therapy. Angiographic findings included internal carotid artery occlusion in 8 patients, middle cerebral artery stenosis or occlusion in 4, moyamoya disease in 4, internal carotid artery dissection in 2, and supraclinoid internal carotid artery stenosis in 2. Outcome was excellent in 17 patients and good in 3. The only surgical complication occurred in one patient, who experienced postoperative seizures and required anticonvulsant therapy. There were no deaths in this series. CONCLUSION: Although the Cooperative Study on Extracranial-Intracranial Bypass failed to show a benefit from the bypass procedure, we have continued to perform the operation in selected cases. Carefully selected individuals with occlusive cerebrovascular disease and persistent ischemic symptoms, despite maximal medical therapy, seem to obtain demonstrable and durable benefit from cerebral revascularization.