Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series

Abstract

BACKGROUND: Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined). OBJECTIVE: To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization. METHODS: This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades. RESULTS: Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade (P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades (P < .05). Tmax >4-second volume inversely predicted indirect bypass patency. CONCLUSION: Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.