Cerebral revascularization other than carotid endarterectomy

Key points
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By Tarakad S Ramachandran MD and Arun Ramachandran MD

As the superficial temporal artery to middle cerebral artery (STA-MCA) revascularization procedure evolved as a method to treat selected patients with cerebral ischemia, other indirect methods of revascularization have been developed including procedures such as encephalomyosynangiosis, encephaloduroarteriosynangiosis, encephalomyoarteriosynangiosis, and encephaloduroarteriomyosynangiosis. Either alone or in different combinations, these procedures have been used for revascularization of the ischemic regions with varying success. STA-MCA with indirect pial synangiosis remains the treatment of choice for moyamoya disease and is a useful adjunct in aneurysms and tumor cases requiring Hunterian ligation. It is important to keep in mind that everything that recanalizes does not necessarily reperfuse.

Key Points

  • Subsequent cerebral infarction constitutes a common finding in adult and pediatric patients with cerebral ischemia due to various disease entities.
  • Extracranial-intracranial bypass surgery is associated with a low perioperative morbidity rate, while successfully augmenting blood flow in the ischemic territory.
  • Though technically challenging, often posing unexpected problems to the operating surgeon, salvage procedures for revascularization are generally technically successful with good bypass patency, in the postoperative angiography.
  • In moyamoya disease, where intimal and, as recently shown, medial smooth muscle cell proliferation dominates, in addition to superficial temporal artery to middle cerebral artery (STA-MCA) revascularization, indirect pial synangiosis is often considered as an option for therapy.
  • The role of different methods of endovascular revascularization in stroke prevention is still debated, and their efficacy has not been established. But early restoration of flow to perfuse salvageable brain tissue has been shown to significantly reduce the morbidity and mortality of ischemic stroke.