Cerebral revascularization: direct versus indirect bypass. Case presentation and review

Abstract

Abstract Since 1985 when the EC-IC bypass study results were published and less procedures were performed for cerebral ischemia, the EC-IC bypass even high or low flow and the IC-IC bypass as flow replacement procedures gain acceptance for many neurosurgical pathologies, from extrinsic and intrinsic tumors requiring large vessels sacrifice to large giant and fusiform aneurysms. In recent years, after the results of Carotid Occlusion Surgery Study (COSS) and the Japanese EC-IC trial published their results the indications for extracranial-intracranial (EC-IC) by-pass expanded, including both extracranial carotid artery occlusive disease and intracranial atherosclerotic disease. The authors make a literature review of the indications for cerebral revascularization, with focus on the direct STA-MCA and indirect (EDAMS) revascularization techniques as a treatment for ischemic stroke. They present two cases of Moyamoya disease one treated with combined approaches and one with indirect approach and discuss the technical skills the surgeon should acquire in order to perform an anastomosis, focusing on the details of STA-MCA bypass, concluding that a combined approach gives better neurological results visible shortly after the surgery.