Article
Characterisation of arteriosclerotic occlusion patterns in cerebral revascularisation in the post COSS era
Charakterisierung von arteriosklerotischen Verschlussmustern bei zerebraler Revaskularisierung in der post COSS Ära
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Authors
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Lars Wessels
- Charité – Universitätsmedizin Berlin, Neurochirurgie, Berlin, Deutschland
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Nils Hecht
- Charité – Universitätsmedizin Berlin, Neurochirurgie, Berlin, Deutschland
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Peter Vajkoczy
- Charité – Universitätsmedizin Berlin, Neurochirurgie, Berlin, Deutschland
| Published: | June 26, 2020 |
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Outline
Text
Objective: For the prevention of hemodynamic stroke, the COSS trial showed no benefit of STA-MCA bypass surgery compared to medical management. Despite these results, however, patients with arteriosclerotic internal carotid artery occlusion are still presented for evaluation of cerebral revascularization. Against this background, we analyzed the patient cohort that underwent STA-MCA bypass surgery in our Department for treatment of cerebral hemodynamic compromise due to arteriosclerotic cerebrovascular disease (ACVD) following the publication of COSS.
Methods: Between 2011 and 2017, 132 patients underwent 136 STA-MCA bypass procedures for the treatment of cerebral hemodynamic compromise due to ACVD. Surgical eligibility required
- 1.
- unilateral (UVD) or multivessel (MVD) steno-occlusive ACVD,
- 2.
- recurrent TIAs under best medical management, and
- 3.
- impaired cerebrovascular reactivity (CVR).
emographic, clinical and radiographic data were retrospectively analyzed by an independent observer.
Results: Out of 132 STA-MCA bypass surgeries, 118 unilateral and 7 bilateral procedures were performed. Nearly half (48%) of all patients suffered MVD with contralateral steno-occlusive disease in the anterior circulation and/or hemodynamically relevant stenosis in the posterior circulation. Compared to UVD, hemodynamic impairment in MVD was significantly greater due to bilaterally reduced CVR or hemodynamic steal (*p<0.0001). Preoperatively, 57% suffered recurrent TIAs (UVD 55%; MVD 58%), 25% recurrent minor stroke (UVD 23%; MVD 27%) and 2% blood-pressure dependent neurological symptoms (UVD 1%; MVD 3%). Compared to the COSS inclusion criteria, only 16% had a single ischemic event in the last 120 days (UVD 21%; MVD 12%). Bypass patency rate at 1 year was 94%. The perioperative stroke rate at the time-point of discharge was 6% with a 3% risk of disabling stroke. The overall risk of ischemic stroke at 1 year was 7%. The median mRS at admission, discharge and follow-up at 1 year was 1 for both MVD (± 1.5) and UVD (±0.8) and did not differ between groups or time points.
Conclusion: Patients undergoing STA-MCA Bypass for ACVB in the post COSS era suffer more severe clinical symptoms than patients originally considered for COSS and nearly half of these patients suffer MVD with severest hemodynamic impairment. Considering the poor natural history of the disease, we, therefore, believe that STA-MCA bypass surgery remains justified in carefully selected patients.
