Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy

OBJECTIVE: To examine the potential role of cerebral revascularization in t he treatment of patients with symptomatic occlusive cerebrovascular disease refractory to medical therapy. METHODS: Twenty patients with symptomatic occlusive cerebrovascular disease underwent 22 extracranial-intracranial bypass procedures after failing max imal medical therapy. The average follow-up time was 3.5 years, and no pati ent was lost to follow-up. RESULTS: All patients presented with repeated transient ischemic attacks re fractory to medical therapy. Angiographic findings included internal caroti d artery occlusion in 8 patients, middle cerebral artery stenosis or occlus ion in 4, moyamoya disease in 4, internal carotid artery dissection in 2, a nd supraclinoid internal carotid artery stenosis in 2. Outcome was excellen t in 17 patients and good in 3. The only surgical complication occurred in one patient, who experienced postoperative seizures and required anticonvul sant therapy. There were no deaths in this series. CONCLUSION: Although the Cooperative Study on Extracranial-Intracranial Byp ass failed to show a benefit from the bypass procedure, we have continued t o perform the operation in selected cases. Carefully selected individuals w ith occlusive cerebrovascular disease and persistent ischemic symptoms, des pite maximal medical therapy, seem to obtain demonstrable and durable benef it from cerebral revascularization.