What is the role of vertebral artery bypass in the treatment of posterior cerebral artery (PCA) stroke?

Answer

In unusual circumstances, vertebral artery bypass may be considered; however, this surgical procedure remains an unproven therapy. Extracranial (EC)-to-intracranial (IC) vertebral artery bypass may be undertaken by connection of the occipital artery to the vertebral, superior cerebellar, anterior internal carotid artery (ICA), or posterior ICA. The superficial temporal artery has also been used as a donor artery. Shunting to the posterior cerebral artery (PCA) may be accomplished by using veins or synthetic grafts. In general, EC-to-IC circulation shunting has been relegated to use in extenuating circumstances since the publication of the negative EC-IC bypass trial.^[21]

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Media Gallery

Unenhanced head computed tomography (CT) scan demonstrating a subacute L posterior cerebral artery (PCA) infarct.
Unenhanced head computed tomography (CT) scan demonstrating hemorrhagic conversion of an ischemic stroke, approximately 72 hours after symptom onset.
Brain magnetic resonance imaging (MRI) scan demonstrating acute stroke. Diffusion restriction is seen on diffusion-weighted imaging.
Magnetic resonance (MR) angiogram demonstrating bilateral fetal posterior cerebral artery (PCA) variants (black arrows) with the basilar artery terminating in bilateral superior cerebellar arteries (blue arrows).
Digital subtraction angiogram demonstrating an acute L posterior cerebral artery (PCA) occlusion (red arrow) following balloon-assisted coiling of a basilar tip aneurysm.
Digital subtraction angiogram demonstrating revascularization of acute L posterior cerebral artery (PCA) occlusion (red arrow) during a balloon-assisted basilar tip aneurysm revascularization with use of balloon angioplasty.
Computed tomography (CT) scan of the brain showing hypodense areas in the right occipital lobe consistent with a recent posterior cerebral artery (PCA) ischemic infarct.

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Author

Erek K Helseth, MD Fellow, Vascular and Interventional Neurology, Oregon Health and Science University School of Medicine

Erek K Helseth, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Executive Committee for the NINDS-funded DEFUSE3 Trial; Physician Advisory Board for Coherex Medical.

Acknowledgements

Alastair M Buchan, DSc, MBBCh Professor, Head of Medical Sciences Division, University of Oxford, UK