The Carotid and Middle Cerebral Artery Occlusion Surgery Study

Patients with symptoms of cerebral or retinal ischemia associated with ipsilateral internal carotid artery (ICA) occlusion have an annual risk of 5-8% of recurrent ischemic stroke. While in China, the incidence of middle cerebral artery (MCA) occlusion is higher than in western countries. The annual risk of recurrent ischemic stroke in patients with symptomatic ICA or MCA occlusion has not improved over the years. The proportion of recurrence that was minor disabling was rather high.

Inclusion criteria

• Age ranging between 18 and 65 years;
• Digital subtraction angiography imaging studies demonstrating occlusion of unilateral ICA or MCA;
• Digital subtraction angiography imaging studies demonstrating less than 50% stenosis of any other vessels especially contralateral ICA and MCA;
• Modified Rankin Scales (mRS) 0-2;
• Qualifying TIA or ischemic stroke in the territory of the occluded ICA or MCA must have occurred within the past 12 months;
• The most recent stoke attacked more than 3 weeks ago;
• The neurological deficit must be stable for more than 1 month;
• No massive cerebral infarction (>50% of the MCA territory) in CT or MRI study;
• CT Perfusion demonstrates "misery perfusion" ;
• Competent to give informed consent;
• Legally an adult;
• Geographically accessible and reliable for follow-up;

Exclusion criteria

• Other neurovascular disease (such as cerebral aneurysm or arteriovenous malformation) conditions likely to cause focal cerebral ischemia;
• Known unstable angina or myocardial infarction within recent 6 months;
• Pregnant or perinatal stage women;
• Blood coagulation dysfunction;
• Any diseases likely to death within 2 years;
• Past history of EC-IC bypass surgery;
• Any contraindications or allergy to aspirin or clopidogrel;
• Any heart disease likely to cause cerebral ischemia including prosthetic valves, infective endocarditis, atrial fibrillation, sick sinus syndrome, myxoma and cardiomyopathy with ejection fraction less than 25%;
• Allergy to iodine or radiographic contrast media;
• Serum creatinine > 3mg/dl;
• Uncontrolled diabetes mellitus (fasting blood glucose >16.7mmol/l);
• Uncontrolled hypertension (systolic BP >180 mmHg, diastolic BP>110 mmHg);
• Severe liver dysfunction [alanine transaminase (ALT) and/or aspartate aminotransferase (AST) > 3 times of normal level];
• Concurrent participation in any other experimental treatment trial;
• Any condition that in the surgeon's judgment suggests the patient an unsuitable surgical candidate;