Surgical Revascularization Still Matters: Successful Superficial Temporal Artery-Superior Cerebellar Artery Bypass for Acute Vertebrobasilar Occlusion Unamenable to Endovascular Therapy.

The efficacy of extracranial-intracranial bypass in treating acute cerebral infarction due to vertebrobasilar steno-occlusion remains controversial. Although endovascular therapy is often the first-line approach, certain anatomical and clinical situations may warrant surgical revascularization. We report a case involving a 74-year-old woman with progressive neurological deficits despite antiplatelet therapy, secondary to infarction in the left superior cerebellar artery territory caused by vertebrobasilar steno-occlusion. Imaging revealed poor collateral circulation and severe ischemia of the brainstem and cerebellum. Emergency right superficial temporal artery-superior cerebellar artery bypass was performed through a subtemporal transtentorial approach. The procedure was completed without complications, and postoperative imaging confirmed good patency. Although transient brainstem hyperperfusion was observed, the patient recovered gradually, achieving a modified Rankin Scale score of 1 at 4 months postoperatively. This case highlights the potential role of superficial temporal artery-superior cerebellar artery bypass as a rescue therapy in selected cases of acute vertebrobasilar steno-occlusion with poor collateral flow and progressive symptoms. With appropriate patient selection and surgical expertise, extracranial-intracranial bypass may offer a viable alternative to endovascular treatment in anatomically challenging cases.