Introduction: Over 2 decades, advancements in neuroendovascular surgery and the results of the Carotid Occlusion Surgery Study (COSS) trial, have significantly impacted indications for microvascular bypass. Our goal was to explore the impact of endovascular techniques and COSS on trends in cerebral revascularization.

Methods: We retrospectively reviewed our experience with cerebral revascularization between 2006-2014, in a single surgeon’s practice. All patients who had undergone cerebral revascularization were included in the study to evaluate trends in indications for bypass.

Results: 106 patients who underwent bypass were identified and 2 patients were excluded. Of the 104 patients, 58% were female. Overall 48 underwent surgery for giant aneurysm, 31 for arterial occlusion, and 25 for moyamoya disease. In all cases except for Moyamoya disease and syndrome, surgery numbers declined. Marked decrease was noted for treatment of giant aneurysms as well as bypass for occlusion.

Conclusions: This review demonstrates the impact that both scientific evidence and technological advances have had upon a challenging and valuable technique in cerebrovascular surgery. Indications for both flow replacement and augmentative bypass remain. However, the decline in the cerebrovascular treatment for giant aneurysm and occlusion may have an indelible impact upon maintenance of proficiency and training of young neurosurgeons.

Patient Care: There is too much variation in the treatment of aneurysms and occlusions. It is important to a have clear indications and standards for selecting and treating patients using endovascular and open techniques.

Learning Objectives: To investigate trends and indications for cerebral revascularization.

References: Powers, W. J., et al. (2011). "Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial." JAMA 306(18): 1983-1992. P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke, and D. Fiorella The Pipeline Embolization Device for the Intracranial Treatment of Aneurysms Trial AJNR Am. J. Neuroradiol. 2011 32: 34-40.