ABSTRACT NUMBER: ESOC2026A1562 MICROSURGICAL REVASCULARIZATION AS SALVAGE TREATMENT AFTER FAILED ENDOVASCULAR THERAPY IN ACUTE INTRACRANIAL ARTERIAL OCCLUSION

Abstract Background and aims Endovascular reperfusion, including mechanical thrombectomy and aspiration, is the first-line treatment for acute intracranial arterial occlusion. Despite technical advances, recanalization fails in up to 15% of cases and is associated with poor neurological outcomes. Evidence supporting rescue microsurgical revascularization in this setting remains limited. This study evaluated the feasibility, safety, and short-term outcomes of emergency extracranial–intracranial (EC–IC) bypass after failed endovascular therapy. Methods We retrospectively analyzed eleven consecutive patients with acute intracranial arterial occlusion treated with emergency EC–IC bypass. Indications included acute intracranial stent thrombosis (n=2), persistent occlusion after unsuccessful thrombectomy with or without aspiration and intra-arterial thrombolysis (n=6), acute postoperative occlusion after transnasal endoscopic pituitary surgery (n=1), and coil migration following aneurysm embolization (n=2). All patients underwent superficial temporal artery–to–middle cerebral artery end-to-side anastomosis within 2–6 hours after confirmation of failed endovascular reperfusion. Bypass patency was assessed intraoperatively using indocyanine green angiography and postoperatively by selective cerebral angiography. Functional outcome was evaluated using the modified Rankin Scale (mRS) at discharge. Results All bypasses were patent on postoperative angiography. Seven patients (63.6%) achieved favorable neurological outcomes (mRS 1), two (18.2%) had mild deficits (mRS 2), and two (18.2%) had moderate deficits (mRS 3). No bypass-related complications occurred. Follow-up MRI demonstrated no progression of ischemic infarction. Conclusions Emergency EC–IC bypass is a feasible and safe salvage option in selected patients with failed endovascular reperfusion, supporting its role within comprehensive acute stroke management. Conflict of interest Chingiz Nurimanov: nothing to disclose. Karashash Menlibayeva: nothing to disclose. Iroda Mammadinova: nothing to disclose. Ainur Turzhanova: nothing to disclose. Daultai Batyrkhanov: nothing to disclose. Assel Kabykenova: nothing to disclose. Yerbol Makambetov: nothing to disclose. Assylbek Kaliyev: nothing to disclose. Figure 1 - belongs to Results