CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2023; 42(01): e24-e39
DOI: 10.1055/s-0042-1742708
Original Article

EC-IC Bypass: “Learning Curve” Experiences of Initial 100 Bypasses in Bangladesh

Bypass EC-CI: Experiências de “curva de aprendizado” de desvios iniciais em Bangladesh
1   National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
,
2   Dhaka Medical College Hospital, Dhaka, Bangladesh
,
Jalaluddin Muhammad Rumi
1   National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
,
1   National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
,
Mohammod Shamsul Arifin
2   Dhaka Medical College Hospital, Dhaka, Bangladesh
,
Moajjem Hossain Talukder
1   National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
,
Atul Goel
3   Department of Neurosurgery, Seth G S medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
,
Mainul Haque Sarker
2   Dhaka Medical College Hospital, Dhaka, Bangladesh
› Institutsangaben

Abstract

Objectives Extracranial to intracranial (EC-IC) bypass is an important part of the armamentarium of a neurosurgeon in managing different vascular and neoplastic pathologies. Here, we report our initial experiences of EC-IC bypasses as experiences in the ‘learning curve’, including preparation and training of the surgeon, getting cases, patient selection, imaging, operative skills and microtechniques, complications, follow-up, and outcome. Lessons learned from the ‘learning curve experiences’ can be very useful for young vascular neurosurgeons who are going to start EC-IC bypass or have already started to perform and find themselves in the learning curve.

Methods From July 2009 to September 2018, 100 EC-IC bypasses were performed. We looked back to these cases of EC-IC bypass as our initial or ‘learning curve’ experiences. The recorded data of patient management (EC-IC bypass patient) were reviewed retrogradely. Our preparation for EC-IC bypass was described briefly. Case selection, indications, preparation of the patient for operation, techniques and technical experiences, preoperative difficulties and challenges, postoperative follow-up, complications, patency status of the bypass, and ultimate results were reviewed and studied.

Result A total of 100 bypasses were performed in 83 patients, of which 43 were male and 40 were female. The age range was from 04 to 72 years old (average 32 years old). Eleven patients were lost to follow-up postoperatively after 3 months and they were not even available for telephone follow-up. The follow-up period ranged from 3 to 120 months (average of18.4 months). Eight bypasses were high flow bypasses, whereas the number of low flow STA-MCA bypasses was 92. Indication of bypass were (in 83 cases):1. Arterial stenosis/occlusion/dissection causing cerebral ischemia (middle cerebral artery [MCA] stenosis/occlusion-05, MCA dissection-04, internal carotid artery [ICA] occlusion-19); 2. Intracranial aneurysm-30; 3. Moya-Moya disease-21; and 4. Direct carotid cavernous fistula [CCF]-04. Common clinical presentation was hemiparesis & dysphasia in ischemic group with history of transient ischemic attack (H/O TIA) (including Moya Moya disease). Features of subarachnoid hemorrhage (SAH) were the presenting symptoms in intracranial aneurysm group. The average ischemic time, due to clamping of recipient artery, was 28 minutes (range: 20–60 minutes). There was no clamp-related infarction. Two anastomoses were found thrombosed intraoperatively.

One preoperatively ambulant patient deteriorated neurologically in the postoperative period. She developed hemiplegia but improved later. Here, the cause seemed to be hyperperfusion. Headache resolved in all cases. TIA and seizures were also gone postoperatively. Ophthalmoplegia recovered in all cases in which it was present, except in one CCF, in which abducent nerve palsy persisted. Complete unilateral total blindness developed in one patient postoperatively (due to ophthalmic artery occlusion), where high flow bypass with ICA occlusion were performed. Red eye and proptosis were cured in CCF cases. Motor and sensory dysphasia improved in all cases in which it was present, except for one case in which preoperative global aphasia converted to sensory aphasia in the postoperative period. Three patients died in the postoperative period. The rest of the patients improved postoperatively. All patients were ambulant with static neurostatus and without new stroke/TIA until the last follow-up. All bypasses were patent until the last follow-up.

Conclusion The initial experiences of 100 cases of EC-IC bypass revealed even in inexperienced hand mortality and morbidity in properly indicated cases were low and result were impressive according to the pathological group and aim of bypass. Lessons learned from these experiences can be very helpful for new and beginner bypass neurosurgeons



Publikationsverlauf

Eingereicht: 04. Oktober 2019

Angenommen: 11. Dezember 2019

Artikel online veröffentlicht:
04. Oktober 2022

© 2022. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 
  • References

  • 1 Hayden MG, Lee M, Guzman R, Steinberg GK. The evolution of cerebral revascularization surgery. Neurosurg Focus 2009; 26 (05) E17
  • 2 Soldozy S, Costello JS, Norat P. et al. Extracranial-intracranial bypass approach to cerebral revascularization: a historical perspective. Neurosurg Focus 2019; 46 (02) E2 DOI: 10.3171/2018.11.FOCUS18527.
  • 3 Bollman J. The animal with an Eck fistula. Physiol Rev 1961; 41: 607
  • 4 Carrel A. Nobel Prize in Physiology or Medicine 1912. Amsterdam: Elsevier Publishing Company; 1967
  • 5 Kredel FE. Collateral cerebral circulation by muscle graft: technique of operation with report of 3 cases. South Surg 1942; 10: 235-244
  • 6 Beck CS, McKHANN CF, Belnap WD. Revascularization of the brain through establishment of a cervical arteriovenous fistula; effects in children with mental retardation and convulsive disorders. J Pediatr 1949; 35 (03) 317-329
  • 7 Jacobson II JHII, Wallman LJ, Schumacher GA, Flanagan M, Suarez EL, Donaghy RM. Microsurgery as an aid to middle cerebral artery endarterectomy. J Neurosurg 1962; 19: 108-115
  • 8 Jacobson JHII, Suarez EL. c. Surg Forum 1960; 11: 243-245
  • 9 Kurze T. Microtechniques in neurological surgery. Clin Neurosurg 1964; 11: 128-137
  • 10 Thanapal S, Duvuru S, Sae-Ngow T, Kato Y, Takizawa K. Direct Cerebral Revascularization: Extracranial-intracranial Bypass. Asian J Neurosurg 2018; 13 (01) 9-17 DOI: 10.4103/ajns.AJNS_76_17.
  • 11 Pool DP, Potts DG. Aneurysms and Arteriovenous Anomalies of the Brain: Diagnosis and Treatment. New York: Harper & Row;; 1965
  • 12 Woringer E, Kunlin J. Anastomosis between the common carotid and the intracranial carotid or the sylvian artery by a graft, using the suspended suture technic. Neurochirurgie 1963; 9: 181-188
  • 13 Biswas A, Samadoni AE, Elbassiouny A, Sobh K, Hegazy A. Extracranial to intracranial by-pass anastomosis: Review of our preliminary experience from a low volume center in Egypt. Asian J Neurosurg 2015; 10 (04) 303-309 DOI: 10.4103/1793-5482.162711.
  • 14 Fiedler J, Přibáň V, Skoda O, Schenk I, Schenková V, Poláková S. Cognitive outcome after EC-IC bypass surgery in hemodynamic cerebral ischemia. Acta Neurochir (Wien) 2011; 153 (06) 1303-1311 , discussion 1311–1312
  • 15 Yaşargil MG. Microsurgery Applied to Neurosurgery. Stuttgart: Georg Thieme Verlag, Academic Press; Diagnosis and indications for operations in cerebrovascular occlusive disease; 95-118 1969
  • 16 Kalani MY, Zabramski JM, Hu YC, Spetzler RF. Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery 2013; 72 (03) 428-435 , discussion 435–436
  • 17 Sundt Jr TM, Whisnant JP, Piepgras DG, Campbell JK, Holman CB. Intracranial bypass grafts for vertebral-basilar ischemia. Mayo Clin Proc 1978; 53 (01) 12-18
  • 18 Anonymous. The International Cooperative Study of Extracranial/Intracranial Arterial Anastomosis (EC/IC Bypass Study): methodology and entry characteristics. The EC/IC Bypass Study group. Stroke 1985; 16 (03) 397-406
  • 19 EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 1985; 313 (19) 1191-1200
  • 20 Day AL, Rhoton Jr AL, Little JR. The extracranial-intracranial bypass study. Surg Neurol 1986; 26 (03) 222-226
  • 21 Kawaguchi S, Noguchi H, Sakaki T. et al. Evaluating the effect of superficial temporal artery to middle cerebral artery bypass on pure motor function using motor activation single photon emission computed tomography. Neurosurgery 1997; 41 (05) 1065-1071 , discussion 1071–1072
  • 22 Nussbaum ES, Erickson DL. Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy. Neurosurgery 2000; 46 (01) 37-42 , discussion 42–43
  • 23 Sundt Jr TM, Fode NC, Jack Jr CR. The past, present, and future of extracranial to intracranial bypass surgery. Clin Neurosurg 1988; 34: 134-153
  • 24 Derdeyn CP, Videen TO, Simmons NR. et al. Count-based PET method for predicting ischemic stroke in patients with symptomatic carotid arterial occlusion. Radiology 1999; 212 (02) 499-506
  • 25 Grubb Jr RL, Derdeyn CP, Fritsch SM. et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 1998; 280 (12) 1055-1060
  • 26 Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J. Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors. Stroke 1997; 28 (10) 2084-2093
  • 27 Yamauchi H, Fukuyama H, Nagahama Y. et al. Significance of increased oxygen extraction fraction in five-year prognosis of major cerebral arterial occlusive diseases. J Nucl Med 1999; 40 (12) 1992-1998
  • 28 Vishteh AG, Marciano FF, David CA, Schievink WI, Zabramski JM, Spetzler RF. Long-term graft patency rates and clinical outcomes after revascularization for symptomatic traumatic internal carotid artery dissection. Neurosurgery 1998; 43 (04) 761-767 , discussion 767–768
  • 29 Schmiedek P, Gratzl O, Spetzler R. et al. Selection of patients for extra-intracranial arterial bypass surgery based on rCBF measurements. J Neurosurg 1976; 44 (03) 303-312
  • 30 Liu JK, Kan P, Karwande SV, Couldwell WT. Conduits for cerebrovascular bypass and lessons learned from the cardiovascular experience. Neurosurg Focus 2003; 14 (03) e3
  • 31 Tachibana E, Suzuki Y, Harada T, Saito K, Gupta SK, Yoshida J. Bypass surgery using a radial artery graft for bilateral extracranial carotid arteries occlusion. Neurosurg Rev 2000; 23 (01) 52-55
  • 32 Friedman JA, Piepgras DG. Current neurosurgical indications for saphenous vein graft bypass. Neurosurg Focus 2003; 14 (03) e1
  • 33 Sekhar LN, Kalavakonda C. Cerebral revascularization for aneurysms and tumors. Neurosurgery 2002; 50 (02) 321-331
  • 34 Liu JK, Couldwell WT. Interpositional carotid artery bypass strategies in the surgical management of aneurysms and tumors of the skull base. Neurosurg Focus 2003; 14 (03) e2
  • 35 Sekhar LN, Duff JM, Kalavakonda C, Olding M. Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery 2001; 49 (03) 646-658 , discussion 658–659