Tratamiento neuroquirúrgico de la isquemia cerebral

Abstract

Background: Tissue Plasminogen Activator (t-PA) and mechanical thrombectomy are today the best treatment approach for acute ischemic stroke (AIS). However, the best management for chronic cerebral ischemia (CCI) is still debated. Microsurgical revascularization has been described as alternative treatment for patients with AIS and contraindication for t-PA or endovascular therapy, and for patients with CCI and failure of maximal medical therapy. Aim: To describe the effectiveness of microsurgical embolectomy and cerebral bypass as salvage therapy in AIS, as well as cerebral bypass in CCI. Methods: Five patients were treated by cerebral revascularization between 2013 and 2016. Surgical and functional results were analyzed. Neurological outcomes were assessed by modified Rankin Scale (mRS) at 3, 6 & 12 months. Results: Three patients with AIS from occlusion of middle cerebral artery (MCA) were treated by microsurgical embolectomy, 1 patient with AIS from occlusion of internal carotid artery was treated by external carotid artery - MCA bypass using radial artery graft, and 1 patient with CCI from progressive occlusion of MCA moyamoya-like was treated by combined direct and indirect cerebral bypass (superficial temporal artery [STA]-MCA anastomosis and encephalo-duro-myo-synangiosis [EDMS]). In AIS, total recanalization
was achieved in 2/3 of patients treated by embolectomy. Neurological outcome was mRS =3 at 3 months and mRS = 2 at 12 months for all of these patients. Neurological status for patient with AIS treated by cerebral bypass was mRS = 2 at 3 months and mRS = 0 at 1 year of follow up. The patient with CCI treated by combined bypass improved their neurological condition from mRS = 5 (preoperative) to mRS = 2 (postoperative). Conclusions: Microsurgical embolectomy and cerebral bypass are efective therapeutics options for select patients with IS and CCI.