Acta Neurochirurgica

, Volume 161, Issue 3, pp 601–605 | Cite as

Unexpected immediate postoperative resolution of long-standing neurological deficits following extracranial-intracranial bypass: a report of three cases

  • Eric S. NussbaumEmail author
  • Donald L. Erickson
  • Kevin M. Kallmes
  • Leslie A. Nussbaum
Case Report - Vascular Neurosurgery - Ischemia
Part of the following topical collections:
  1. Vascular Neurosurgery - Ischemia


While intracranial ischemic insults often result in neuronal death and permanent neurological deficits, some patients may develop potentially reversible neurological dysfunction from persistent hypoperfusion, as surviving neurons remain in an “idling” state. We report a unique series of three patients with long-standing neurological deficits who underwent EC-IC bypass for repeated TIAs and demonstrated unexpected, rapid resolution of long-standing pre-existing neurological deficits. We suggest that these individuals harbored regions of underperfused, idling neurons that responded rapidly to restored cerebral reperfusion.


Extracranial-intracranial bypass Leg plegia Perfusion 



We would like to acknowledge Superior Medical Experts for their editing, formatting, and research support.


All authors made substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; drafted the work or revised it critically for important intellectual content; provided final approval of the version to be published; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Sources of support

We received a grant from the United Hospital Foundation to support this work.

Compliance with ethical standards

Conflict of interest

Kevin Kallmes works for and holds equity in Superior Medical Experts. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Patient consent

Consents to the public use of deidentified information were obtained from all patients prior to submission to the journal.


  1. 1.
    Dijkhuizen RM (2013) Imaging neuronal loss and recovery in compromised but viable brain tissue. Brain 136:1689–1691CrossRefPubMedGoogle Scholar
  2. 2.
    Falkowska A, Gutowska I, Goschorska M, Nowacki P, Chlubek D, Baranowska-Bosiacka I (2015) Energy metabolism of the brain, including the cooperation between astrocytes and neurons, especially in the context of glycogen metabolism. Int J Mol Sci 16:25959–25981CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Gazyakan E, Lee CY, Wu CT, Tsao CK, Craft R, Henry SL et al (2015) Indications and outcomes of prophylactic and therapeutic extracranial-to-intracranial arterial bypass for cerebral revascularization. Plast Reconstr Surg Glob Open 3:e372CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Gibbs JM, Wise RJ, Thomas DJ, Mansfield AO, Russell RW (1987) Cerebral haemodynamic changes after extracranial-intracranial bypass surgery. J Neurol Neurosurg Psychiatry 50:140–150CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Greenhalgh RM, Illingworth RD, McFie J, Mills SP, Perkin GD, Rose FC (1980) Extracranial to intracranial microrevascularization for the treatment of completed ischemic stroke. Am Heart J 100:937–938CrossRefPubMedGoogle Scholar
  6. 6.
    Hart RP, Rosner MJ, Muizelaar P (1985) Recovery from aphasia following extracranial-intracranial bypass surgery: case report. J Clin Exp Neuropsychol 7:224–230CrossRefPubMedGoogle Scholar
  7. 7.
    Inoue T, Fujimoto S (2005) Prediction of cerebral blood flow restoration after extracranial-intracranial bypass surgery using superficial temporal artery duplex ultrasonography (STDU). In: Yonekawa Y, Keller E, Sakurai Y, Tsukahara T (eds) New trends of surgery for stroke and its perioperative management. Springer, Vienna, pp 159–163CrossRefGoogle Scholar
  8. 8.
    Jing Z, Shi C, Zhu L, Xiang Y, Chen P, Xiong Z et al (2015) Chronic cerebral hypoperfusion induces vascular plasticity and hemodynamics but also neuronal degeneration and cognitive impairment. J Cereb Blood Flow Metab 35:1249–1259CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Jussen D, Zdunczyk A, Schmidt S, Rosler J, Buchert R, Julkunen P et al (2016) Motor plasticity after extra–intracranial bypass surgery in occlusive cerebrovascular disease. Neurology 87:27–35CrossRefPubMedGoogle Scholar
  10. 10.
    Kalogeris T, Baines CP, Krenz M, Korthuis RJ (2012) Cell biology of ischemia/reperfusion injury. Int Rev Cell Mol Biol 298:229–317CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Nussbaum ES, Erickson DL (2000) Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy. Neurosurgery 46:37–42 discussion 42-33CrossRefPubMedGoogle Scholar
  12. 12.
    Nussbaum ES, Janjua TM, Defillo A, Lowary JL, Nussbaum LA (2010) Emergency extracranial-intracranial bypass surgery for acute ischemic stroke. J Neurosurg 112:666–673CrossRefPubMedGoogle Scholar
  13. 13.
    Payk TR, Wassmann H, Schumacher W, Bollbach R (1986) Psychometric studies of cerebral performance before and following extra-intracranial bypass operations. Nervenarzt 57:244–248PubMedGoogle Scholar
  14. 14.
    Roski R, Spetzler RF, Owen M, Chandar K, Sholl JG, Nulsen FE (1978) Reversal of seven-year old visual field defect with extracranial-intracranial arterial anastomosis. Surg Neurol 10:267–268PubMedGoogle Scholar
  15. 15.
    Rosner MJ, Corales RL, Becker DP (1982) Cerebral revascularization in the management of stroke. Va Med 109:824–835PubMedGoogle Scholar
  16. 16.
    Smith RD (2003) Extracranial-intracranial bypass in cerebral ischemia. Ochsner J 5:31–35PubMedPubMedCentralGoogle Scholar
  17. 17.
    The International Cooperative Study of Extracranial/Intracranial Arterial Anastomosis (EC/IC Bypass Study) (1985) Methodology and entry characteristics. The EC/IC bypass study group. Stroke 16(3):397–406CrossRefGoogle Scholar
  18. 18.
    Vajkoczy P (2009) Revival of extra-intracranial bypass surgery. Curr Opin Neurol 22:90–95CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Eric S. Nussbaum
    • 1
    Email author
  • Donald L. Erickson
    • 1
  • Kevin M. Kallmes
    • 2
  • Leslie A. Nussbaum
    • 1
    • 3
  1. 1.National Brain Aneurysm & Tumor CenterUnited HospitalMinneapolisUSA
  2. 2.Duke University Law SchoolDurhamUSA
  3. 3.J Nasseff Cyberknife CenterSt. PaulUSA

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