Revascularization of the Posterior Circulation

The primary objective of revascularization procedures in the posterior circulation is the prevention of vertebrobasilar ischemic stroke. Specific anatomical and neurophysiologic characteristics such as posterior communicating artery size affect the susceptibility to ischemia. Current indications for revascularization include symptomatic vertebrobasilar ischemia refractory to medical therapy and ischemia caused by parent vessel occlusion as treatment for complex aneurysms. Treatment options include endovascular angioplasty and stenting, surgical endarterectomy, arterial reimplantation, extracranial-to-intracranial anastomosis, and indirect bypasses. Pretreatment studies including cerebral blood flow measurements with assessment of hemodynamic reserve can affect treatment decisions. Careful blood pressure regulation, neurophysiologic monitoring, and neuroprotective measures such as mild brain hypothermia can help minimize the risks of intervention. Microscope, microinstruments and intraoperative Doppler are routinely used. The superficial temporal artery, occipital artery, and external carotid artery can be used to augment blood flow to the superior cerebellar artery, posterior cerebral artery, posterior inferior cerebellar artery, or anterior inferior cerebellar artery. Interposition venous or arterial grafts can be used to increase length. Several published series report improvement or relief of symptoms in 60 to 100% of patients with a reduction of risk of future stroke and low complication rates.

Vertebrobasilar ischemia - angioplasty - parent vessel occlusion - bypass - revascularization

REFERENCES

• 1 Yasargil M G, Krayenbuhl H A, Jacobson J H. Microneurosurgical arterial reconstruction.  Surgery. 1970;  67 221-233
• 2 Chater N. Neurosurgical extracranial-intracranial bypass for stroke: with 400 cases.  Neurol Res. 1983;  5 1-9
• 3 Collice M, Arean O, Eermino F, Riva M. Surgical and long term results in 100 consecutive patients with ICA occlusion. In: Spetzler RF, Caster LP, Selman WR, Martin N Cerebral Revascularization for Stroke New York, NY; Thieme-Stratton 1985: 445
• 4 Eguchi T, Mayanagi Y, Hanamura T et al.. Treatment of bilateral spontaneous carotid-cavernous fistula by Hamby's method combined with an extracranial-intracranial bypass procedure.  Neurosurgery. 1982;  11 706-711
• 5 Gagliardi R, Benvenuti L, Onesti S. Seven years experience with extracranial-intracranial arterial bypass for cerebral ischemia. In: Spetzler RF, Caster LP, Selman WR, Martin N Cerebral Revascularization for Stroke New York, NY; Thieme-Stratton 1985: 413
• 6 Gratzl O, Roun J. Quality grading of bypass surgery. Operative combined risks less than 4 percentm. In: Spetzler RF, Caster LP, Selman WR, Martin N Cerebral Revascularization for Stroke New York, NY; Thieme-Stratton 1985: 467
• 7 Reale F, Benericettti E, Benvenuti L et al.. Extra-intracranial arterial bypass in typical carotid reversible ischaemic deficits: long-term follow-up in 100 patients.  Neurol Res. 1984;  6 113-114
• 8 Reichman O H. Complications of cerebral revascularization.  Clin Neurosurg. 1976;  23 318-335
• 9 Sundt Jr T M, Whisnant J R, Fode N C, Piepgras D G, Houser O W. Results, complications, and follow-up of 415 bypass operations for occlusive disease of the carotid system.  Mayo Clin Proc. 1985;  60 230-240
• 10 Yasargil M G, Yonekawa Y. Results of microsurgical extra-intracranial arterial bypass in the treatment of cerebral ischemia.  Neurosurgery. 1977;  1 22-24
• 11 Anson J A, Spetzler R F. Surgery for vertebrobasilar insufficiency: extracranial. In: Carter LP, Spetzler RF, Hamilton MG Neurovascular Surgery New York, NY; McGraw-Hill Inc 1995: 383-404
• 12 Ausman J I, Diaz F G, de los Reyes R A et al.. Posterior circulation revascularization. Superficial temporal artery to superior cerebellar artery anastomosis.  J Neurosurg. 1982;  56 766-776
• 13 Ausman J I, Pak H, Patel S, Boulos R. Superficial temporal to proximal superior cerebellar artery anastomosis for basilar artery stenosis.  Neurosurgery. 1981;  9 56-60
• 14 Ausman J I, Diaz F G, Vacca D F, Sadasivan B. Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency.  J Neurosurg. 1990;  72 554-558
• 15 Berguer R, Feldman A J. Surgical reconstruction of the vertebral artery.  Surgery. 1983;  93 670-675
• 16 Branchereau A, Magnan P E. Results of vertebral artery reconstruction.  J Cardiovasc Surg (Torino). 1990;  31 320-326
• 17 Diaz F G, Ausman J I, de los Reyes R A et al.. Surgical reconstruction of the proximal vertebral artery.  J Neurosurg. 1984;  61 874-881
• 18 Edwards W H, Mulherin J L. The surgical approach to significant stenosis of the vertebral and subclavian arteries.  Surgery. 1980;  87 20-28
• 19 Habozit B. Vertebral artery reconstruction: results in 106 patients.  Ann Vasc Surg. 1991;  5 61-65
• 20 Sundt Jr T M, Piepgras D G. Occipital to posterior inferior cerebellar artery bypass surgery.  J Neurosurg. 1978;  48 916-928
• 21 Sundt Jr T M, Piepgras D G, Fode N C. Techniques, results and complications of occipital and temporal artery bypass pedicles to branches of the vertebral and basilar arteries. In: Meyer FB Sundt's Occlusive Cerebrovascular Disease Philadelphia, PA; WB Saunders Co; Philadelphia:PA 1994: 456-465
• 22 Vishteh A G, Smith K A, McDougall C G, Spetzler R G. Distal posterior cerebral artery revascularization in multimodality management of complex peripheral posterior cerebral artery aneurysms: technical case report.  Neurosurgery. 1998;  43 166-170
• 23 Drake C G, Peerless S J, Ferguson G G. Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation.  J Neurosurg. 1994;  81 656-665
• 24 de Oliveira E, Tedeschi H, Rhoton A, Peace D A. Microsurgical anatomy of the posterior circulation: vertebral and basilar arteries. In: Carter LP, Spetzler RF, Hamilton MG Neurovascular Surgery New York, NY; McGraw-Hill Inc 1995: 25-34
• 25 Lister J R, Rhoton A L. Microsurgical anatomy of the posterior inferior cerebellar artery.  Neurosurgery. 1982;  10 170-199
• 26 Ciceri E F, Kluezmik R P, Grossman R G, Rose G E, Mawad M E. Aneurysms of the posterior cerebral artery: classification and endovascular treatment.  AJNR Am J Neuroradiol. 2001;  22 27-34
• 27 Schomer D F, Marks M P, Steinberg G K et al.. The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction.  N Engl J Med. 1994;  330 1565-1570
• 28 Steinberg G K, Drake C G, Peerless S J. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms: immediate results and long-term outcome in 201 patients.  J Neurosurg. 1993;  79 161-173
• 29 Donnelly D F, Jiang C, Haddad G G. Comparative responses of brain stem and hippocampal neurons to O₂ deprivation: in vitro intracellular studies.  Am J Physiol. 1992;  262 L549-L554
• 30 Cartlidge N EF, Whisnant J P, Evelback L R. Carotid and vertebral basilar transient cerebral ischemic attacks.  Mayo Clin Proc. 1977;  52 117-120
• 31 Stoodley M A, Thompson R C, Mitchell R S, Marks M P, Steinberg G K. Neurosurgical and neuroendovascular management of Takayasu's arteritis.  Neurosurgery. 2000;  46 841-852
• 32 Golby A J, Marks M P, Thompson R C, Steinberg G K. Direct and combined revascularization in pediatric moyamoya disease.  Neurosurgery. 1999;  45 50-60
• 33 Kawaguchi S, Okuno S, Sakaki T. Effect of direct arterial bypass on the prevention of future stroke in patients with the hemorrhagic variety of moyamoya disease.  J Neurosurg. 2000;  93 397-401
• 34 Carlson D H, Thomson D. Spontaneous thrombosis of a giant cerebral aneurysm in five days. Report of a case.  Neurology. 1976;  26 334-336
• 35 Scott R M, Ballantine Jr H T. Spontaneous thrombosis in a giant middle cerebral artery aneurysm. Case report.  J Neurosurg. 1972;  37 361-363
• 36 Bull J. Massive aneurysms at the base of the brain.  Brain. 1969;  92 535-570
• 37 Duvoisin R C, Yahr M D. Posterior fossa aneurysms.  Neurology. 1965;  15 231-241
• 38 Michael W F. Posterior fossa aneurysms simulating tumours.  J Neurol Neurosurg Psychiatry. 1974;  37 218-223
• 39 Morley T P, Barr H W. Giant intracranial aneurysms: diagnosis, course, and management.  Clin Neurosurg. 1969;  16 73-94
• 40 Ojemann R G, Ogilvy C S, Crowell R M, Heros R C. Surgical Management of Cerebrovascular Disease. 3rd ed. Baltimore; William and Wilkins 1995
• 41 Drake C G. Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms.  J Neurosurg. 1975;  43 255-274
• 42 Eckard D A, O'Boynick P L, McPherson C M et al.. Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms.  AJNR Am J Neuroradiol. 2000;  21 137-142
• 43 Graves V B, Perl II J, Strother C M, Wallace R C, Kesava P P, Masaryk T J. Endovascular occlusion of the carotid or vertebral artery with temporary proximal flow arrest and microcoils: clinical results.  AJNR Am J Neuroradiol. 1997;  18 1201-1206
• 44 Aymard A, Gobin Y P, Hodes J E et al.. Endovascular occlusion of vertebral arteries in the treatment of unclippable vertebrobasilar aneurysms.  J Neurosurg. 1991;  74 393-398
• 45 Hopkins L N, Bundy J L, Castellani D. Extracranial-intracranial arterial bypass and basilar artery ligation in the treatment of giant basilar artery aneurysms.  Neurosurgery. 1983;  13 189-194
• 46 Rozario R A, Stein B M. Ligation of the basilar artery as the definitive treatment for a giant aneurysm of the basilar artery apex: case report.  Neurosurgery. 1980;  6 87-91
• 47 Shintani A, Zervas N T. Consequence of ligation of the vertebral artery.  J Neurosurg. 1972;  36 447-450
• 48 Spetzler R F, Carter L P. Revascularization and aneurysm surgery: current status.  Neurosurgery. 1985;  16 111-116
• 49 Yamada K, Hayakawa T, Ushio Y et al.. Therapeutic occlusion of the vertebral artery for unclippable vertebral aneurysm: relationship between site of occlusion and clinical outcome.  Neurosurgery. 1984;  15 834-838
• 50 Chang S D, Lopez J R, Steinberg G K. The usefulness of electrophysiologic monitoring during resection of central nervous system vascular malformations.  J Stroke Cerebrovas Dis. 1999;  8 411-422
• 51 Grosso S, Mostardini R, Venturi C et al.. Recurrent torticollis caused by dissecting vertebral artery aneurysm in a pediatric patient: results of endovascular treatment by use of coil embolization: case report.  Neurosurgery. 2002;  50 204-207 , discussion 207-208
• 52 Fox A J, Vineula F, Pelz D M et al.. Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms.  J Neurosurg. 1987;  66 40-46
• 53 Halsey Jr J H, Morawetz R B, Blauenstein U W. The hemodynamic effect of STA-MCA bypass.  Stroke. 1982;  13 163-167
• 54 Holzschuh M, Brawenski A, Ullrich W, Meixensgerger J. Cerebral blood flow and cerebrovascular reserve 5 years after EC-IC bypass.  Neurosurg Rev. 1991;  14 275-278
• 55 Schmiedek P, Piepgras A, Leinsinger G, Kirsch C M, Einhupl K. Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in patients with ICA occlusion and hemodynamic cerebral ischemia.  J Neurosurg. 1994;  81 236-244
• 56 Yamashita T, Kashigawa S, Nakano S et al.. The effect of EC-IC bypass surgery on resting cerebral blood flow and cerebrovascular reserve capacity studied with stable Xe-CT and acetazolamide test.  Neuroradiology. 1991;  33 217-222
• 57 Klijn C JM, Kappelle L J, Tulleken C A, van Gijn J. Symptomatic carotid artery occlusion: a reappraisal of hemodynamic factors.  Stroke. 1997;  28 2084-2093
• 58 Higashida R T, Tsai F Y, Halback V V. Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries.  J Neurosurg. 1993;  78 192-198
• 59 [No authors listed] . Prognosis of patients with symptomatic vertebral or basilar artery stenosis. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study Group.  Stroke. 1998;  29 1389-1392
• 60 Marks M P, Marcellus M, Norbash A M, Steinberg G K, Tong D, Albers G W. Outcome of angioplasty for atherosclerotic intracranial stenosis.  Stroke. 1999;  30 1065-1069
• 61 Levy E I, Horowitz M B, Koebbe C K et al.. Transluminal stent-assisted angiplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results.  Neurosurgery. 2001;  48 1215-1221 , discussion 1221-1223
• 62 Kellogg J X, Nesbit G M, Clark W M, Barnwell S L. The role of angioplasty in the treatment of cerebrovascular disease.  Neurosurgery. 1998;  43 549-555 , discussion 555-556
• 63 Mori T, Fukuoka M, Kazita K, Mori K. Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty.  AJNR Am J Neuroradiol. 1998;  19 1525-1533
• 64 Fischman D L, Leon M B, Baim D S et al.. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. Stent Restenosis Study Investigators.  N Engl J Med. 1994;  331 496-501
• 65 Ko Y G, Park S, Kim J Y et al.. Percutaneous interventional treatment of extracranial vertebral artery stenosis with coronary stents.  Yonsei Med J. 2004;  45 629-634
• 66 Levy E I, Hanel R A, Bendak B R et al.. Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis.  J Neurosurg. 2002;  97 1294-1301
• 67 Lopez J R, Chang S D, Steinberg G K. The utility of electrophysiologic monitoring during microsurgery of cerebral aneurysms.  J Neurol Neurosurg Psychiatry. 1999;  66 189-196
• 68 Chang S D, Steinberg G K. Other treatment for stroke prevention. In: Bogousslavsky J, Ginsberg M Cerebrovascular Disease. London, England; Blackwell Scientific Publications 1998: 1945-1963
• 69 Liu A Y, Lopez J R, Do H M, Steinberg G K, Cockroft K, Marks M P. Neurophysiological monitoring in the endovascular therapy of aneurysms.  AJNR Am J Neuroradiol. 2003;  24 1520-1527
• 70 Steinberg G K, Grant G, Yoon E J. Deliberate hypothermia. In: Andrews RJ Intraoperative Neuroprotection. Baltimore, MD; Williams & Wilkins 1996: 65-84
• 71 Ogilvy C S, Carter B S, Kaplan S, Rich C, Crowell R M. Temporary vessel occlusion for aneurysm surgery: risk factors for stroke in patients protected by induced hypothermia and hypertension and intravenous mannitol administration.  J Neurosurg. 1996;  84 785-791
• 72 Maier CM, Steinberg GK Hypothermia and Cerebral Ischemia: Mechanisms and Clinical Application. Totowa, NJ; Humana Press 2003
• 73 Steinberg G K, Ogilvy C S, Shuer L M et al.. Comparison of endovascular and surface cooling during unruptured cerebral aneurysm repair.  Neurosurgery. 2004;  55 307-314 , discussion 314-315
• 74 Lenhardt R, Marker E, Goll V et al.. Mild intraoperative hypothermia prolongs postanesthetic recovery.  Anesthesiology. 1997;  87 1318-1323
• 75 Schmied H, Kurz A, Sessler D I, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty.  Lancet. 1996;  347 289-292
• 76 Kurz A, Sessler D I, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.  N Engl J Med. 1996;  334 1209-1215
• 77 Chang S D, Steinberg G K. Surgical management of moyamoya disease. In: Tindall GT Contemporary Neurosurgery. Baltimore, MD; Lippicott, Williams & Wilkins 2000
• 78 Stoodley M A, Mitchell R S, Steinberg G K. Extracranial brachiocephalic reconstruction and grafts.  Techniques in Neurosurgery. 2000;  6 152-163
• 78a Chang S D, Steinberg G K. Superficial temporal artery to middle cerebral artery anastomosis.  Techniques in Neurosurgery. 2000;  6 86-100
• 79 Sekhar L N, Bucur S D, Bank W O, Wright D C. Venous and arterial bypass grafts for difficult tumors, aneurysms, and occlusive vascular lesions: evolution of operative management and improved results.  Neurosurgery. 1999;  44 1207-1224
• 80 Drake C G. Giant posterior cerebral artery aneurysms: 66 patients. In: Drake PSJ, Hernesniemi CC, JA Surgery of Vertebrobasilar Aneurysms: London Ontario Experience on 1767 Patients New York, NY; Thieme-Stratton 1985: 548-554
• 80a Diaz F G et al.. Surgical correction of lesions affecting the second portion of the vertebral artery.  Neurosurgery. 1986;  19 93-100
• 80b El-Fiki M, Chater N L, Weinstein P R. Extracranial-intracranial arterial bypass for vertebrobasilar insufficiency. In: Spetzler RF Cerebral Revascularization for Stroke. New York, NY; Thieme Stratton 1985: 483-489
• 81 Hopkins L N, Bundy J L. Complications of intracranial bypass for vertebrobasilar insufficiency.  J Neurosurg. 1989;  70 207-211
• 82 Allen G S, Cohen R J, Preziosi T J. Microsurgical endarterectomy of the intracranial vertebral artery for vertebrobasilar transient ischemic attacks.  Neurosurgery. 1981;  8 56-59
• 83 Ausman J I, Diaz F G, Sadasian B. Intracranial endarterectomy.  Neurosurgery. 1990;  26 465-471
• 84 Hardin C A, Williamson W P, Steegmann A T. Vertebral artery insufficiency produced by cervical osteoarthritic spurs.  Neurology. 1960;  10 855-858
• 85 Nagashima C. Surgical treatment of vertebral artery insufficiency caused by cervical spondylosis.  J Neurosurg. 1970;  32 512-521
• 86 Ausman J I, Diaz F G, Dujovny M. Posterior circulation revascularization.  Clin Neurosurg. 1986;  33 331-343
• 87 Sundt T M et al.. Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation.  J Neurosurg. 1982;  56 205-215
• 88 Regli L, Piepgras D G, Hansen K K. Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation.  J Neurosurg. 1995;  83 806-811
• 89 Sundt T M, Piepgras D G. Extracranial to intracranial bypass grafting: posterior circulation. In: Wilkins RH, Rengachary SS Neurosurgery. New York, NY; McGraw-Hill 1985: 1281-1292
• 90 Roski R A, Spetzler R F, Hopkins L N. Occipital artery to posterior inferior cerebellar artery bypass for vertebrobasilar ischemia.  Neurosurgery. 1982;  10 44-49