Neuroplastics approach to cerebrovascular bypass surgery: the way forward for centres with small to medium volume caseload

Abstract

Purpose

Cerebral bypasses are technically challenging procedures essential in the neurosurgeon’s armamentarium. Decreasing surgical indications leading to reduced caseload has resulted in less than ideal clinical outcomes, particularly in low to medium volume centres. We describe the neuroplastics approach to cerebral bypasses in the largest retrospective series to date and demonstrate how this approach has been able to smoothen the learning curve and achieve consistent outcomes approximating that of high-volume centres.

Methods

A retrospective study was conducted. All patients who received a bypass were classified into those with bypasses performed using the neuroplastics approach (NP group) and those performed by solo neurosurgeons (Solo group). Technical outcomes and clinical outcomes were compared.

Results

There were 19 patients in the NP group and 50 patients in the Solo group. There were 17 patients in the NP group with double-barrel bypasses and 2 with single-barrel bypasses (total of 36 direct anastomoses) and 45 patients of the Solo group with single-barrel bypasses and 5 patients with conversion to indirect bypasses. Patients in the Solo group were more likely to experience a postoperative stroke in the bypassed territory (Solo, 17.8%; NP, 0%; p = 0.008). Although not statistically significant, there was a difference in the proportion of patients with conversion to indirect bypass (Solo, 10.0%; NP, 0%), postoperative anastomotic bleed (Solo, 8.9%; NP, 0%), and long-term patency (Solo, 93.9%; NP, 100%). Patients in the NP group had a shorter median length of stay (NP, 3 [2 – 7] days; Solo, 6 [5 – 9] days; p = 0.005) and 1-year modified Rankin scale approached significance (NP, 0 [0 – 0]; Solo, 0 [0 – 2]).

Conclusion

Our experience supports the adoption of a neuroplastics approach to the training and execution of cerebrovascular bypasses in small to medium volume centres. This collaboration allowed us to deliver cerebral bypasses to indicated patients with excellent outcomes.