On September 29, 2006, at Baptist Medical Center Downtown, neurosurgeon Andrew Cannestra, MD, PhD, performed extracranial-to-intracranial bypass surgery on a 30-year-patient with sickle cell anemia whose disease had contributed to a recent stroke.

The cerebrovascular procedure -- which was used to restore blood flow to the patient’s brain and prevent a future, more major stroke -- is the first extracranial-to-intracranial bypass procedure performed in Jacksonville in more than a decade. The surgery was used often in the 1980s, but fell out of favor because it was only useful on a certain subset of stroke patients with limited blood flow in the brain. In recent years, doctors took a wait-and-see approach rather than risk open brain surgery on patients who might not benefit. Neurosurgeon Andrew Cannestra, MD, PhD, attaches a scalp artery to a “recipient” artery in the patient’s brain, restoring blood flow and reducing her risk of stroke.

However, it is once again being used in teaching hospitals and major medical centers now that imaging technology has progressed to the point that surgeons are able to pinpoint which stroke patients will benefit from the procedure. "New imaging techniques, including MRI and CT perfusion scans, can demonstrate where there is at-risk brain tissue so we can reestablish blood flow," explains Cannestra, who was trained in the procedure by world-renowned neurosurgeon Neil A. Martin, MD, professor and chief of the Division of Neurosurgery at University of California-Los Angeles.

"This revascularization procedure is for patients for whom a stent in the brain to redirect blood flow is not possible, due to pathology or anatomy, or is too risky," states Cannestra. "This patient had narrowed vessel deep within her brain over a long distance. In addition, she was in sickle cell crisis. Sickle cells don’t flow as well through a narrowed vessel, which can lead to stroke and death at an early age. This patient experiences a sickle cell crisis every three to five weeks. Two weeks ago, while in a sickle cell crisis, she had a small stroke that had led to weakness on her left side. With every sickle cell crisis, she was at risk for another stroke and the next one could have been fatal."

The extracranial-to-intracranial bypass procedure is performed by putting the patient into a "medication-induced coma" to protect the brain by temporarily shutting down its metabolism. The surgeon takes an artery from the scalp, mobilizes it, opens the skull and sews the scalp artery to an artery on the surface of the brain, called a "recipient artery." The microsurgery is performed using the Zeiss OPMI surgical microscope, along with fine instruments to connect arteries and electrocautery to stem blood loss.

"This creates a new pathway for blood to flow from the scalp into the brain, greatly decreasing the patient’s risk of stroke," says Cannestra.

The patient, who is still in a sickle cell crisis, remains hospitalized at Baptist Downtown, but has recovered from her brain bypass surgery and regained strength in her left arm. "A CT angiogram has demonstrated good blood flow on the right side of her brain, where it had been diminished before surgery," says Cannestra. “We are pleased with her progress. And we are especially pleased to be able to offer this new option to stroke patients in our region, as part of Baptist Health's comprehensive stroke program."