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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 73-74

The quest to revascularize brain in ischemic stroke

Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja National Hospital and MRC, Mumbai, Maharashtra, India

Date of Web Publication12-Jan-2017

Correspondence Address:
Dr. Basant K Misra
Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja National Hospital and MRC, Mahim, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.198183

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How to cite this article:
Misra BK. The quest to revascularize brain in ischemic stroke. Neurol India 2017;65:73-4

How to cite this URL:
Misra BK. The quest to revascularize brain in ischemic stroke. Neurol India [serial online] 2017 [cited 2020 Aug 7];65:73-4. Available from:

The quest to vascularize the brain in an attempt to mitigate the suffering from ischemic stroke has occupied neurosurgeons for decades. It is not uncommon for nature to device ways and means to supply blood to the starved tissue by collaterals. John Hunter was one of the earliest investigators to study collateral flow. After ligating the main artery to the rapidly growing antler of a stag in 1785, he noted no cessation of growth and observed the early appearance of enlarged superficial vessels that carried blood around the obstruction. He called this phenomenon “the blood goes where it is needed.”[1] Unfortunately, this natural collateral protection is unpredictable, and attempts to improve blood supply to the brain in the face of impending ischemia continues. The outstanding work of Alexis Carrel, a French Surgeon and Biologist who was awarded the Nobel Prize in Physiology or Medicine in 1912 for pioneering vascular suturing techniques, was a significant contribution to the progress of vascular surgery. Rapid advances and widespread practice of bypass procedures followed the first successful superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis in 1967 by Yasargil.[2]

The surgery of cerebral revascularization had a major setback with the results of the international randomized trial, the “International co-operative study of extracranial/intracranial anastomoses (EC-IC Bypass Study)” that was initiated to determine whether or not STA–MCA anastomosis could reduce the incidence of stroke and stroke-related deaths among patients with symptomatic occlusion or surgically inaccessible atherosclerotic stenosis of the internal carotid artery (ICA) or MCA. The results demonstrated that STA–MCA bypass did not reduce the rate of subsequent events compared with the best medical therapy in the patients studied.[3] Laboratory training of young neurosurgeons in the art of microvascular anastomosis, a standard practice till then, went out of vogue and generations of young neurosurgeons did not get trained in mastering the procedure. The author was fortunate enough to train in a laboratory dedicated towards microvascular anastomosis, much before the ECIC study was published, thanks to the insistence of his teacher, Prof. Ajit Banerji. We reported the first clinical cerebral revascularization in India in 1988, and continue to practice and train young neurosurgeons in this field.[4],[5],[6],[7]

How relevant is it today for a young neurosurgeon to train to perform a microvascular anastomosis? While the utility of ECIC bypass in the setting of atherosclerotic extracranial and intracranial arterial disease is doubtful, there is no debate about its usefulness in Moya Moya disease and in some very selected clinical settings. Thus, cerebral revascularization for flow augmentation is indicated, though in only a very select group of patients. Less controversial is the cerebral revascularization for flow replacement where a major vessel is interrupted during the management of giant intracranial aneurysms and skull base tumors. In fact, with continuous advances in endovascular treatment of aneurysms, and more and more complex aneurysms coming the microsurgical way, most of them requiring innovative techniques and bypass procedures, young neurosurgeons are best advised to practice microvascular anastomosis in the laboratory. The author started a formal microvascular laboratory training for young neurosurgeons in cooperation with the Ethicon Institution of Surgical Education, Mumbai in July 2005, that still continues today.

Thus, the article by authors Hegazy et al., in the current issue of “Neurology India” is quite relevant and a useful addition to the literature.[8] The authors present their experience with end-to-side microvascular anastomosis in albino Wistar rats. They compare the widely used classic two anchoring stitch technique (the control group) with their study group, where the first suture is placed at the 11 O'clock position instead of at 12 O'clock position (the heel) with no second anchoring suture placed at the toe. They utilize a suturing technique starting from the outside to inside on the recipient vessel and then passing from the inside to outside on the donor vessel. The authors find a significantly better patency rate in their proposed technique in the study group than in the control group. The concept of avoiding heel and toe anchoring sutures at the beginning is not new. However, for the beginner, placing the anchoring sutures helps in keeping the donor and recipient vessels properly aligned and prevents the rotation of the donor on the recipient vessel. The proposed technique of placing the suture first through the recipient vessel in an outside to inside manner and then on the donor vessel in an inside to outside manner does help in visualizing inside the lumen of both the donor and recipient vessels and reduces the risk of transfixing the back wall. A major concern during the starting of the sutures in an outside to inside manner first on the recipient vessels in the clinical setting of STA–MCA anastomosis is the tear of the fragile MCA (M4), especially while putting the first suture. While the authors have found a better patency in their study group compared to the control group, the patency rates in both the groups (87% in the study group and 66% in the control group) are significantly lower than the 95% patency rates in the conventional technique with placement of two anchoring sutures both in the laboratory and clinical settings. Our protocol in STA–MCA anastomosis has been an out-in-out suture placement, starting from the donor vessel, as well as the placement of the classic two sutures, the heel and toe anchoring technique, utilizing interrupted 10 'O' Ethilon sutures with a micropoint needle. One of the critical issues in achieving a high patency rate is to avoid holding the intima of the vessel even with the finest needle holder and only supporting the vessel wall with a jeweler's forceps while passing the needle through the vessel wall. Finally, it suffices to say that there are “9 ways of skinning a cat.” The only way to be perfect is to practice and train in the laboratory. This technique is especially helpful in making one proficient in vessel anastomosis.

  References Top

Fields WS, Lemak NA. History of stroke: Its recognition and treatment. New York, Oxford: Oxford University; 1989.  Back to cited text no. 1
Yasargil MG. Anastomosis between the superficial temporal artery and a branch of the middle cerebral artery. In: Yasargil MG, editor. Microsurgery Applied to Neuro-surgery. Sturrgart: George Thieme Verlag; 1969. pp. 105-15.  Back to cited text no. 2
The EC/IC Bypass Study Group. Failure of extracranial-intracranial bypass to reduce the risk of ischaemic stroke: Results of an international randomized trial. N Engl J Med 1985;313:1191-200.  Back to cited text no. 3
Misra BK, Thorat J, Ashok PP, Udani V. Cerebral revascularization: Our Experience. Prog Clin Neurosci 2005;20:133-52.  Back to cited text no. 4
Misra BK. Treatment of giant intracranial aneurysms: What is the best option? Neurol India 2015;63:138-41.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
Misra BK, Purandare HR. Microsurgery of giant intracranial aneurysms. In: Sekhar LN, Fessler RG 2nd, editors. Atlas of Neurosurgical techniques. New York: Thieme; 2016. pp. 301-21.  Back to cited text no. 6
Misra BK. Experience of combined direct and indirect revascularization for moya moya disease at a tertiary neurosurgical centre. J Cerebrovasc Sci 2016;3:27-32.  Back to cited text no. 7
Hegazy A, Adel MF, Abd-Allah F, Al-Shamy H, Elbassiouny A, Amin SM, et al. The '11 O'clock Heel First' technique for microvascular end-to-side anastomosis. Neurol India 2017;65:69-72.  Back to cited text no. 8
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