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1、Is the age of the Cerebral Bypass Gone?Jonathan White, M.D.Associate Professor of NeurosurgeryUT Southwestern Medical CenterDallas, TexasHistorical Indications For Historical Indications For Bypass:Bypass:nVascular replacement:uComplex aneurysmsuTumorsnIschemiauMoya Moya diseaseuAtherosclerosisHisto
2、rical use of bypass?Historical use of bypass?nFukushima 1986-2006n100 patients, Saphenous veinnAneurysm, Menigioma, carotid body, glomus, othernThree types of bypassuPetrous to paraclinoiduCervical external to petrousuCervical external to M2Things ChangeThings ChangeTraditional ways no longer needed
3、:Traditional ways no longer needed:Better Technology?Better Technology?Tumors:Tumors:nBetter microsurgerynMicroscopenUltrasonic aspiratorTumors: Gamma KnifeTumors: Gamma KnifeAneurysms?Aneurysms?nBetter microscopenBetter clipsnIntra-operative angiographynAnesthesianBetter surgeons?nBetter surgical t
4、rainingAneurysms: Coils and StentsAneurysms: Coils and StentsWhat about Ischemia?What about Ischemia?Results of Bypass Studies:Results of Bypass Studies:Bypass does not workBypass does not worknN Engl J Med. 313 (19):1191-2000, 1985, Nov 7.n714 Medical and 663 STA-MCA bypass patientsnFollowed 56 mon
5、thsnNo difference overall between groupsnSome surgical subgroup did worse:uMCA stenosis, carotid occlusion with TIAAngioplasty and StentAngioplasty and StentDoes new technology and Does new technology and information eliminate the need information eliminate the need for traditional techniques?for tr
6、aditional techniques?Gamma Knife?Gamma Knife?Gamma knife resultsGamma knife resultsnPoor control with large volume tumorsnRisk of vascular injury Aneurysm Coiling?Aneurysm Coiling?UT Southwestern 2002-200695 aneurysms greater then 2.0 CM17 were treated by primary endovascularOnly 9 (53%) completely
7、occluded12 (71%) required re-treatment Ischemic disease:Ischemic disease:Flaws of previous bypass trialsFlaws of previous bypass trialsnPre operative strokes considered surgical failurenSelection bias good surgical candidates not randomizednMedical failure cases did not crossnNot enough power to ide
8、ntify subgroups which may benefit from bypassIschemia: Need to measure at Ischemia: Need to measure at risk tissuerisk tissuenYonas, J NSG 1993uXe CT; compared 5% vs 50% drop in flow with diamoxu68 patients for 24 monthsu4.4% vs 36% stroke risk in low flow PtsnGrubb, JAMA 1998uPET evidence of high o
9、xygen extraction, 31 monthu11/39 (28%) vs 2/42 (5%) ipislateral stroke riskSTA-MCA bypass for ischemia:STA-MCA bypass for ischemia:STA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA BypassSTA-MCA BypassSTA-MCA resultsSTA-MCA resultsnJapanese EC-IC Bypass tria
10、l (JET)u1st 206 patients, surgery group has significantly fewer strokesnStanford study of Moya Moya patientsuDecreased future risk of strokeuRegression of Moya Moya collateralsnCoss trialuHigh risk group randomizedTraditional techniques still have Traditional techniques still have role.role.nCarotid
11、 replacementuComplex aneurysmuSkull based tumornIschemic diseaseuMeasure blood flow to find at risk tissueuSelect proper patientsConcluding Case:Concluding Case:Combined TechniquesCombined techniquesCombined techniquesCombined TechniquesCombined TechniquesCombine past and futureCombine past and future
