Abstract TP365: Bypass Beyond Medical Therapy: Outcomes in Chronic Carotid/MCA Occlusion with Misery Perfusion, A Single Center Experience

Background: Patients with chronic carotid or middle cerebral artery (MCA) occlusions who fail maximal medical therapy and demonstrate impaired cerebrovascular reserve (CVR) are at high risk for recurrent ischemic events. Direct extracranial–intracranial bypass surgery for carotid steno-occlusive disease remains controversial however may offer benefit in carefully selected cases undergoing specialized imaging techniques and interdisciplinary approach. Methods: We retrospectively reviewed patients who underwent superficial temporal artery–MCA (STA–MCA) bypass at our hospital between September 2023 and July 2024. All cases were selected after appropriate testing and were presented at an interdisciplinary conference for discussion of patient symptoms and diagnostic results, involving Neurosurgery, Neurology, and Neurocognitive teams.This was used for consensus determination of management (ongoing medical or surgical). Inclusion criteria were: chronic carotid/MCA occlusion, failure of maximal medical management defined by use of Dual Antiplatelet therapy (DAPT) and Statin, and evidence of misery perfusion or impaired CVR on CT perfusion (CTP) Diamox challenge. Demographics, perioperative outcomes, bypass patency, and stroke incidence at 1 year were analyzed. Results: A total of 21 patients were reviewed. 8 were male and 13 female. Mean Age of these patients was 65 years. All patients had a baseline modified Rankin Scale (mRS) of ≤2. At 1-year follow-up, two patients (9.5%) experienced symptomatic ischemic strokes confirmed by MRI. One patient died of a non-stroke cause. Angiographic follow-up demonstrated bypass patency in 20 patients (excluding the deceased). All patients remained on dual antiplatelet therapy postoperatively. Conclusion: In this single-center series, STA–MCA bypass in carefully selected patients with chronic carotid/MCA occlusion and impaired CVR achieved high long-term patency and low stroke recurrence rates. These findings support the role of bypass as a potential treatment option in select medically refractory patients, using specific imaging criteria and comprehensive interdisciplinary approach, warranting a further large scale prospective evaluation.