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Non-Fatal Head Injury Increases Risk of Death Mortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury : A Population-Based Study

Background: Extracranial-intracranial (EC-IC) bypass is an important technique in the management of select complex aneurysms. Intracranial to intracranial (IC-IC) bypass has been reported as an alternative to EC-IC bypass, but large studies on this approach are lacking in the literature. Objective: To evaluate the hypothesis that IC-IC bypass compares favorably to EC-IC and may have advantages in select circumstances. Methods: Between November 1997 and November 2007, 82 aneurysm patients were treated with cerebral revascularization. Data were reviewed retrospectively. Patients had preoperative, early postoperative, and long-term follow-up assessment of their neurological outcome using the Glasgow Outcome Scale (GOS). Aneurysm occlusion and bypass patency were determined with angiography. Results: 57% of patients were treated with EC-IC bypass, and 43% with IC-IC bypass. Choice of procedure depended primarily on aneurysm location and characteristics; 34% of patients underwent staged endovascular aneurysm occlusion on a separate day, whereas in 66% of patients, the aneurysm was occluded at the same time as the bypass. Overall, 97.6% of aneurysms were obliterated, and 91% of bypasses were patent at follow up. Both IC-IC and EC-IC groups had similar aneurysm obliteration and bypass patency rates. Concerning patient outcomes, 3 patients died in the perioperative period, all from the EC-IC bypass group. It should be noted, however, that all 3 patients had undergone an uncomplicated bypass but later succumbed to complications during endovascular treatment. The overall mean follow-up was 41 months. It did not differ significantly between both groups. Four late deaths were noted, 3 in the EC-IC bypass group. Good outcome rates were similar in both groups. Late follow-up GOS scores and postoperative versus preoperative GOS scores showed a trend toward better outcomes in the IC-IC bypass group. Conclusions: Although IC-IC bypass is technically challenging, certain advantages over EC-IC bypass make it a very appealing alternative. IC-IC bypass can replace the conventional EC-IC bypass in the treatment of select aneurysms. Reviewer's Comments: The authors have made an excellent contribution to the literature. They report a number of creative microsurgical solutions to difficult neurovascular pathologies. Clearly, many of the aneurysmal lesions illustrated do not have good endovascular options with existing technology. This type of creative approach represents a transition in the way microvascular surgeons conceptualize neurovascular anatomy. This approach may eliminate the need for cervical dissections for proximal anastomoses in some cases and, in many circumstances, may obviate the need for graft harvest. This article will be a valuable reference to cerebrovascular and cranial base surgeons as they search for creative solutions for complex anatomic problems. (Reviewer-Bernard R. Bendok, MD).