ONS Advance Access: Patient Selection and Clinical Efficacy of Urgent Superficial Temporal Artery-Middle Cerebral Artery Bypass in Acute Ischemic Stroke Using Advanced Magnetic Resonance Imaging Techniques

Extracranial–intracranial (EC-IC) bypass has been generally used for stroke prevention in patients with chronic cerebrovascular insufficiency, including those with Moyamoya disease and athero-occlusive disease.13 The recent Carotid Occlusion Surgery Study (COSS) showed that no additional benefit was provided by EC-IC bypass surgery in patients with symptomatic atherosclerotic internal carotid artery (ICA) occlusion with chronic cerebrovascular insufficiency.4 However, in the COSS, patients underwent surgery during the chronic stage, and it remains unknown whether superficial temporal artery-middle cerebral artery (STA-MCA) bypass can provide any beneficial effects in the acute stage of ischemic stroke. Experience with urgent EC-IC bypass has been extremely limited because it is not generally performed at most centers.

Selected patients with acute ischemic stroke might benefit from urgent STA-MCA bypass, but the indications for this surgery are unknown. Advanced magnetic resonance imaging (MRI) techniques have become helpful for selecting patients before acute stroke therapy, and penumbral imaging can extend the therapeutic time window for treating acute ischemic stroke.5 By using advanced neuroimaging for patient selection, endovascular treatment (EVT) can be feasible beyond 8 h from onset of acute ischemic stroke.68However, aggressive late antegrade recanalization by EVT may increase the risk of reperfusion hemorrhage; 1 study reported a postprocedural hemorrhage rate of 33.3%.8 Low blood flow resulting from STA-MCA bypass would be more advantageous in treatment of acute ischemic patients beyond the standard therapeutic time window than would high-flow antegrade reperfusion by EVT.

In this study, we report our center’s experiences with urgent STA-MCA bypass in patients requiring urgent reperfusion who were ineligible for other reperfusion therapies. In addition, we describe the patient selection for urgent STA-MCA bypass using advanced MRI techniques.

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