Risk of subsequent stroke, with or without extracranial-intracranial bypass surgery: a nationwide, retrospective, population-based study

XianXiu Chen; Cheng-Li Lin; Yuan-Chih Su; Kuan-Fei Chen; Shih-Wei Lai; Sung-Tai Wei; Ching-Tien Peng; Cheng-Di Chiu; Shwn-Huey Shieh; Chun-Chung Chen

doi:10.3171/2017.12.JNS172178

Risk of subsequent stroke, with or without extracranial-intracranial bypass surgery: a nationwide, retrospective, population-based study

J Neurosurg. 2018 Jun 1:1-8. doi: 10.3171/2017.12.JNS172178. Online ahead of print.

Authors

XianXiu Chen^{1

2}, Cheng-Li Lin^{3

4}, Yuan-Chih Su^{3

4}, Kuan-Fei Chen⁵, Shih-Wei Lai^{3

6}, Sung-Tai Wei⁷, Ching-Tien Peng^{8

9}, Cheng-Di Chiu^{2

7

10}, Shwn-Huey Shieh¹¹, Chun-Chung Chen^{2

3

7}

Affiliations

¹ 1Department of Public Health, China Medical University.
² 2Stroke Center, China Medical University Hospital.
³ 3College of Medicine, China Medical University.
⁴ 4Management Office for Health Data, China Medical University Hospital.
⁵ 5Department of Neurology, China Medical University Hospital.
⁶ 6Department of Family Medicine, China Medical University Hospital.
⁷ 7Department of Neurosurgery, China Medical University Hospital.
⁸ 8Department of Hemato-oncology, Children's Hospital, China Medical University.
⁹ 9Department of Biotechnology, Asia University.
¹⁰ 10Graduate Institute of Basic Medical Science, China Medical University; and.
¹¹ 11Department of Health Services Administration, China Medical University, Taichung, Taiwan.

PMID: 29999468
DOI: 10.3171/2017.12.JNS172178

Abstract

OBJECTIVEAlthough no benefits of extracranial-intracranial (EC-IC) bypass surgery in preventing secondary stroke have been identified previously, the outcomes of initial symptomatic ischemic stroke and stenosis and/or occlusion among the Asian population in patients with or without bypass intervention have yet to be discussed. The authors aimed to evaluate the subsequent risk of secondary vascular disease and cardiac events in patients with and without a history of this intervention.METHODSThis retrospective nationwide population-based Taiwanese registry study included 205,991 patients with initial symptomatic ischemic stroke and stenosis and/or occlusion, with imaging data obtained between 2001 and 2010. Patients who underwent EC-IC bypass (bypass group) were compared with those who had not undergone EC-IC bypass, carotid artery stenting, or carotid artery endarterectomy (nonbypass group). Patients with any previous diagnosis of ischemic or hemorrhagic stroke, moyamoya disease, cancer, or trauma were all excluded.RESULTSThe risk of subsequent ischemic stroke events decreased by 41% in the bypass group (adjusted hazard ratio [HR] 0.59, 95% CI 0.46-0.76, p < 0.001) compared with the nonbypass group. The risk of subsequent hemorrhagic stroke events increased in the bypass group (adjusted HR 2.47, 95% CI 1.67-3.64, p < 0.001) compared with the nonbypass group.CONCLUSIONSBypass surgery does play an important role in revascularization of the ischemic brain, while also increasing the risk of hemorrhage in the early postoperative period. This study highlights the fact that the high risk of bypass surgery obscures the true benefit of revascularization of the ischemic brain and also emphasizes the importance of developing improved surgical technique to treat these high-risk patients.

Keywords: AMI = acute myocardial infarction; CHF = congestive heart failure; EC-IC = extracranial-intracranial; EC-IC bypass; HR = hazard ratio; ICA = internal carotid artery; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; MCA = middle cerebral artery; NHIRD = National Health Insurance Research Database; STA = superficial temporal artery; cerebrovascular procedures; extracranial-intracranial bypass; ischemic stroke; revascularization; secondary prevention; vascular disorders.