Extra-Cranial to Intra-Cranial By-Pass Anastomosis: An Initial Report on Preliminary Experience at a Low Volume Center

Material and Methods: 18 patients suffering either from hemodynamic ischemia or from complex aneurysms or skull base tumors were operated at Cairo university hospitals in the period between May 2009 and January 2013. All patients operated by a low flow by-pass were operated through a superficial temporal artery to middle cerebral artery anastomosis. All patients chosen for a high flow by-pass were operated using a radial artery graft interposed between the middle cerebral artery distally and the common or the external carotid artery proximally. Patency was confirmed at the end of surgery using clinical examination on table and confirmed after surgery by Trans cranialcolor coded duplex or C.T Angiography whenever possible. All patient data were prospectively collected and retrospectively analyzed at the end of surgery. Results: 13 patients (72.2%) were operated upon for flow augmentation and 5 patients (27.7%) were operated upon for flow replacement. A total of 24 anastomoses were performed. All except one were patent which gives a patency rate of 95.9%. There was one death in the present series resulting from a hyper perfusion syndrome. 79.6% of patients with hemodynamic ischemia stopped having symptoms after sur-gery. All patients operated for hemodynamic ischemia showed a considerable cognitive improvement after surgery. None of the patients operated upon for flow replacement showed improvement of occulomotor nerve function in spite of adequate intraoperative decompression. All patients treated for flow replacement showed absence of recurrence on follow up. Conclusion: Our initial results for both low and high flow by-pass procedures in our low volume center indicate that such complex surgical procedures are possible with results comparable to those obtained in other larger referral centers throughout the world. This procedure not only represents a more definitive treatment when compared to other endovascular or radiation treatments but is also much less costly when compared to other treatment modalities.