Extracranial–Intracranial High-Flow Bypass for Giant Ruptured Paraclinoid Aneurysm with Concomitant Bilateral Internal Carotid Artery Stenotic Dissection

Alternative Bypass Technique Using Radial Artery Graft between V3 Segment of Vertebral Artery and Middle Cerebral Artery: Technical Note

BACKGROUND

 There are some cases where a radial artery (RA) graft is needed for a high-flow extracranial to intracranial (EC-IC) bypass as the external carotid artery (ECA) cannot be utilized as a donor artery. In this report, we describe two cases of extracranial vertebral artery (VA) to middle cerebral artery (MCA) high-flow bypass using an RA graft with an artificial vessel as an alternative bypass technique.

METHODS

 The patient was placed supine with a head rotation of 80 degrees. After frontotemporal craniotomy, another C: -shaped skin incision was made at the retroauricular region and the V3 portion of the VA was exposed at the suboccipital triangle. Prior to attempting the high-flow bypass, the superficial temporal artery (STA) was anastomosed to the M4 portion of the MCA as an insurance bypass. The RA graft was anastomosed to the V3 portion of the VA that traveled under the periosteum at the supra-auricular region through an artificial vessel. After RA-M2 anastomosis, an alternative EC-IC bypass, the V3-RA-M2 bypass, was achieved.

RESULTS

 Postoperative angiography demonstrated successful graft patency and no perioperative complications were observed in both cases.

CONCLUSIONS

 In the cases where a high-flow bypass is required, the V3 portion of the VA is a suitable alternative proximal anastomosis site when the ECA is not a candidate donor. Furthermore, an artificial vessel shows satisfactory protection against graft complications.

[Surgical treatment of a patient with saccular arterial aneurysm of the cavernous-ophthalmic segment]

Presented in the article are the results of surgical management of a patient with an extremely rare pathology - a saccular arterial aneurysm of the cavernous-ophthalmic segment of the left internal carotid artery. We performed multistage open surgical intervention in the following scope: osteoplastic pterional craniotomy on the left, creation of a wide-lumen anastomosis between the left external carotid artery and M2 segment of the left middle cerebral artery with the use of the radial artery, ligation of the cervical portion of the left internal carotid artery and clipping of its supraclinoid portion. The chosen surgical policy made it possible to create sufficient volumetric blood flow through the shunt, comparable to the blood flow through the internal carotid artery, which helped avoid ischaemic stroke after exclusion of the aneurysm from circulation. A conclusion was drawn on efficacy of this method of treatment.