Surgical treatment of smog disease Five vascular bypasses were performed on four people in one day On September 2, 2014, our department successfully performed comprehensive cerebrovascular reconstruction surgery, i.e. direct vascular bypass, meningeal and muscular with cerebral surface patching, on three patients with smog disease and one patient with middle cerebral artery occlusion, under the guidance of experts from Shanghai Huashan Hospital and with the cooperation of anesthesia department and operating room, in which one patient with middle cerebral artery occlusion underwent two vascular bypasses. The patient recovered well after the surgery and will be discharged recently. For a long time, smog disease has been a problem for neurosurgeons, the disease has no obvious cause and trigger, early detection is not easy, the emergence of cerebral infarction and cerebral hemorrhage is dangerous, drug treatment effect is poor, often life-threatening, survivors often recur within a short time. Since 2012, under the leadership of Director Ma Jinxian, a cerebrovascular reconstruction treatment team led by Chief Physician Zhou Guoping has been established in our department to actively carry out treatment of cerebral ischemic diseases mainly due to smog. After extensive screening of patients and collective discussions in the department, specific treatment plans are determined according to different vascular conditions. Over the past two years, 37 cases of direct and indirect cerebrovascular reconstructive surgery have been performed, with postoperative follow-up from 6 months to 2 years. The patients’ clinical symptoms have significantly improved, more than 85% of them have resumed self-care, 77% of them have resumed normal labor force, and 17 patients have undergone cerebrovascular DSA, MRA and CTA more than half a year after surgery, showing that the bypass vessels are smooth and the patching vessels have spontaneous anastomosis with the blood vessels in the brain, which fully demonstrates This fully demonstrates the great role of cerebral revascularization surgery in the treatment of smog. The success of this surgery marks a new step in the treatment of ischemic cerebrovascular diseases and enriches our hospital as a national stroke screening base. Etiology: The exact cause of smog disease is still unknown. Those who know the cause, such as some atherosclerosis and intracranial vascular disease caused by leptospirosis, can also cause smoke-like changes in blood vessels on angiographic images, and this kind of known cause is called smog syndrome. Why can it cause both cerebral ischemia and cerebral hemorrhage: Smog is a chronic progressive cerebrovascular occlusive disease of unknown cause. To use an analogy, the neurons in our brain that are in charge of various functions are like crops planted in the ground, the neuroglial tissue is like the soil, and the cerebral blood vessels are like irrigation channels. Under normal circumstances, the brain is well irrigated and the crops grow lushly. If the irrigation channels gradually blocked, then it will cause drought, the brain on the “drought”, the crops will be dehydrated, gradually withered yellow (ischemia), and even in severe cases directly withered (infarction), this is the process of smog caused by cerebral ischemia and cerebral infarction. But our brain is very “smart”, the main channel is blocked, will automatically open some small “secondary channels” to relieve the “drought” downstream as much as possible, these secondary channels are in the angiogram we see inside the These are the “smoky vessels” we see in angiography. However, these smoky vessels are not original, and their walls are very thin, so they can easily rupture and bleed. Once they rupture and bleed, they can cause “flooding” in the brain, which can drown crops and affect neurological function. Therefore, smog can cause both cerebral ischemia (drought) and cerebral hemorrhage (flooding). The principle of surgery: Surgery is to connect blood vessels outside the cerebral cortex to the brain. Bridging is to connect the superficial temporal artery or occipital artery outside the skull directly to the cortical vessels inside the skull. It is like drawing water from the Yangtze River to the Yellow River to relieve the drought in the Yellow River basin. Bridging can directly improve the blood supply to the brain. Indirect surgery involves attaching muscle and meningeal tissues rich in extra-cortical blood supply to the surface of the cerebral cortex, from which the brain automatically draws blood vessels to form spontaneous anastomoses with the cortical vessels. This process usually takes about 4 months to 6 months. After the blood supply to the brain improves, the need for smoldering blood vessels will gradually diminish and, therefore, indirectly reduce the probability of cerebral hemorrhage. For those crops that have withered, they can usually be restored to life by improving irrigation. Crops that have already died will not help even if irrigation is restored. However, improved irrigation can reduce the risk of other crops dying again. Smoker’s disease often involves the blood supply to the cerebral hemispheres bilaterally, and it is best to perform bilateral surgery. Our surgical approach: Our department refers to the recommended surgical approach in recent years of domestic and international guidelines for smog disease, and combined with the actual situation in our region, we mostly use indirect reconstruction in pediatric patients, i.e. superficial temporal artery and muscle with cerebral surface patching, and in adults, depending on the ischemia, we use indirect reconstruction or a comprehensive surgical approach including direct bypass, i.e. superficial temporal-middle cerebral artery direct bypass plus cerebral-dural-muscular vascular fusion (STA-MCA bypass plus EDMS procedure).