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  • Updated 07.21.2021
  • Released 12.05.2001
  • Expires For CME 07.21.2024

Cerebral revascularization: surgical and endovascular approaches

Introduction

Overview

Cerebral vascular insufficiency, typically caused by extra- or intracranial steno-occlusive disease, is the leading cause of ischemic stroke. Surgical treatment options for cerebral vascular insufficiency due to extracranial steno-occlusive disease include endarterectomy, and endovascular treatment options include angioplasty with or without stent placement. Surgical treatment options for cerebral vascular insufficiency due to intracranial steno-occlusive disease include cerebral revascularization procedures, such as extracranial to intracranial bypass (EC-IC bypass); endovascular treatment options include angioplasty with or without stent placement as well as mechanical thrombectomy. In this updated article, etiologies of cerebral vascular insufficiency are reviewed, and revascularization techniques are discussed.

Key points

• Cerebral vascular insufficiency with or without stroke is a prevalent cause of neurologic morbidity and mortality worldwide.

• Many steno-occlusive lesions, particularly when refractory to medical management, can be managed by endovascular or surgical revascularization.

• Mechanical thrombectomy has become the standard of care for selected patients with acute large cerebral artery occlusion.

• Further research is required to better define the indications and the limitations of cerebral revascularization techniques.

Historical note and terminology

Descriptions of early attempts of surgical embolectomy for the treatment of brain ischemia appeared in the literature in the 1950s (109; 24). Microsurgical reconstruction of brain arteries, ie, cerebral bypass surgery, became available following introduction of the operating microscope in the 1960s (113). Indications for intracranial revascularization procedures have subsequently been refined, and surgical techniques have considerably evolved over the following decades.

The association between extracranial carotid pathology and ipsilateral ischemic stroke was recognized in the early 1900s (54; 60), and carotid endarterectomy for stroke prevention was introduced only in the second half of the 20th century (35; 43). There has been an exponential growth in the application of carotid endarterectomy for the treatment of carotid atherosclerotic disease, with over 30,000 carotid endarterectomies being carried out annually in the United States by the 1980s.

Endovascular cerebral revascularization began with the introduction of percutaneous dilating angioplasty in the 1960s (38). A decade later, percutaneous transluminal angioplasty was adopted (51). Carotid artery stenting became available mid-1990s (37). Stents have since been used in nearly every segment of the cerebral circulation and for various indications.

Intraarterial installation of thrombolytic drugs directly into the occluding thrombus for the urgent revascularization of patients suffering from cerebral artery occlusions became available in the 1980s (116; 117). However, intra-arterial thrombolysis remained limited by its comparatively low ability to re-establish flow, which contributed to the development of endovascular mechanical thrombectomy. Initially, the occluding particle was retrieved using various types of snares. However, snares were technically challenging to use and were, therefore, progressively replaced by more trackable and more efficient devices, so-called stent retrievers (aka "stentrievers") (44). Although first-generation stent retrievers allowed an increase in recanalization rates, their ability to improve functional outcomes in patients suffering from large cerebral artery occlusions remains unproven (102; 11; 12). The turning point for mechanical thrombectomy occurred in 2015 when 5 multicenter, open-label randomized controlled trials (MR CLEAN, ECAPE, SWIFT PRIME, EXTED-IA, and REVASCAT) unequivocally demonstrated that mechanical thrombectomy with second-generation stent retriever devices was superior to standard treatment with intravenous thrombolysis alone (09; 16; 47; 64; 97). Since then, indications for mechanical thrombectomy continue to expand, and clot retrieval techniques continue to be refined.

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