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Eun J, Park IS. Assessing the Adequacy of Superficial Temporal Artery Blood Flow in Korean Patients Undergoing STA-MCA Anastomosis. J Korean Neurosurg Soc 2024; 67:158-165. [PMID: 37678413 PMCID: PMC10924909 DOI: 10.3340/jkns.2023.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is conducted for flow augmentation. In this study, we measured the STA cut flow of a Korean population and evaluated the relationship between STA cut flow and long-term patency of the bypass. METHODS A retrospective study was conducted. Intraoperative measurement of STA flow was conducted using a microvascular flow meter on patients who underwent STA-MCA. After cutting the distal end, the STA flow rate was measured with no resistance and recorded. After finishing anastomosis, STA flow was measured and recorded. The cut flow index was calculated by dividing post anastomosis flow by cut flow in intracranial atherosclerotic stenosis patients. RESULTS The median STA cut flow was 35.0 mL/min and the post anastomosis flow was 24.0 mL/min. The cut flow of STA decreased with aging (p=0.027) and increased with diameter (p=0.004). The cut flow showed no correlation with history of hypertension or diabetes mellitus (p=0.713 and p=0.786), but did correlate a positively with history of hyperlipidemia (p=0.004). There were no statistical differences in cut flow, STA diameter, and post anastomosis flow between the frontal and parietal branches (p=0.081, p=0.853, and p=0.990, respectively). CONCLUSION The median STA cut flow of a Korean population was 35 mL/min. Upon reviewing previous articles, it appears that there are differences in the STA cut flow between Western and Asian patients.
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Affiliation(s)
- Jin Eun
- Department of Neurosurgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ik Seong Park
- Department of Neurosurgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Manjunath N, Dhanakshirur RR, Joshi S, Reddy NG, Raheja A, Devrajan Sebastian LJ, Garg A, Kalra PK, Suri A. Novel method of calculation of MRI perfusion and comparison of single versus double barrel STA-MCA bypass for revascularisation in Moya Moya disease. World Neurosurg 2024; 181:e516-e523. [PMID: 39491233 DOI: 10.1016/j.wneu.2023.10.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/05/2024]
Abstract
INTRODUCTION Moyamoya disease (MMD) is characterised by supraclinoid internal carotid artery (ICA) narrowing causing cerebral parenchyma to starve. Direct and indirect revascularisation techniques are the treatment norm. We provide a clinicoradiological comparison of single and double barrel superficial temporal artery to middle cerebral artery (STA-MCA) bypass for MMD. The perfusion in cerebral hemispheres and vessel density in DSA have been evaluated using novel algorithms. METHODS DSA, ASL MR imaging methods and Suzuki, Matsushima, Angiographic Outcome Score (AOS) scales were used to quantify perfusion parameters; modified Rankin score (mRS) was used for clinical evaluation. A novel image processing algorithm was designed to perform analysis of ASL sequences and compare perfusion. Vessel density was calculated using connected component analysis on thresholded DSA images. RESULTS 54 hemispheres with MMD underwent STA-MCA bypass 42(77.8%) single barrel and 12 (22.2%) double barrel. Clinical outcome - mRS was significant with p<0.001 in single barrel and p=0.001 in double barrel groups. The overall AOS showed improvement post-operatively (p=0.032).Perfusion analysis was performed in 20 hemispheres (13 single barrel; 7 double barrel). MCA territories showed significant improvement in single barrel (2.72%, p=0.0294) and double barrel groups (12.89%, p=0.025). Vessel density calculated in MCA territory, showed an overall post-op improvement (p=1.75 x 10-8). CONCLUSION Double barrel STA-MCA bypass clinically as well as radiologically improves perfusion in the ACA as well as MCA territories in MMD. The novel image processing algorithm is an accurate, objective tool to evaluate perfusion in MR images and vessel density in DSA images of MMD.
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Affiliation(s)
- Niveditha Manjunath
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - Rohan Raju Dhanakshirur
- Amarnath and Shashi Khosla School of Information Technology, Indian Institute of Technology, New Delhi
| | - Siddharth Joshi
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - Nikhila Gunna Reddy
- Department of Neuroimaging and Interventional Neuro-radiology, All India Institute of Medical Sciences, New Delhi
| | - Amol Raheja
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | | | - Ajay Garg
- Department of Neuroimaging and Interventional Neuro-radiology, All India Institute of Medical Sciences, New Delhi
| | - Prem Kumar Kalra
- Department of Computer Science Engineering, Indian Institute of Technology, New Delhi
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi.
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3
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Peeters SF, Colby GP, Kim WJ, Bae WI, Sparks H, Reitz K, Tateshima S, Jahan R, Szeder V, Nour M, Duckwiler GR, Vinuela F, Martin NA, Wang AC. Arterial Bypass in the Treatment of Complex Middle Cerebral Artery Aneurysms: Lessons Learned from Forty Patients. World Neurosurg 2024; 181:e261-e272. [PMID: 37832639 DOI: 10.1016/j.wneu.2023.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. METHODS Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. RESULTS The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. CONCLUSIONS Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.
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Affiliation(s)
- Sophie F Peeters
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Whi Inh Bae
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Hiro Sparks
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kara Reitz
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - May Nour
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gary R Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fernando Vinuela
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neil A Martin
- Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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4
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Choi JH, Kim M, Park W, Park JC, Kwun BD, Ahn JS. Superficial temporal artery interposition bypass for the treatment of complex intracranial aneurysms: Flexible and creative options for flow preservation bypass. Clin Neurol Neurosurg 2023; 235:108019. [PMID: 37979563 DOI: 10.1016/j.clineuro.2023.108019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE Flow-preservation bypass is a treatment option for complex intracranial aneurysms (IAs) that cannot be managed with microsurgical clipping or endovascular treatment. Various bypass methods are available, including interposition grafts such as the radial artery or saphenous vein. Size discrepancy, invasiveness, and procedure complexity must be considered when using interposition grafts. We describe our experience of treating complex IAs using a superficial temporal artery (STA) interposition bypass. METHODS We retrospectively reviewed the medical records and operative videos of all patients who were treated for complex IAs at our center from January 2009 to December 2021 using cerebral revascularization. Clinical, radiological, and surgical findings of the cases that underwent STA interposition bypass were investigated. RESULTS Seventy-six bypass procedures were performed of which seven (9.2%) complex IAs were managed using STA interposition bypass. Of these 5 cases were of anterior cerebral artery, 1 of middle cerebral artery, and 1 of posterior inferior cerebellar artery aneurysm. There were no postoperative ischemic complications. Revision surgery for postoperative pseudomeningocele was performed in one case. The long-term bypass patency rate was 85.7% (6 out of 7) and good long-term aneurysm control was achieved in all cases, with a mean follow-up of 64 months. CONCLUSIONS When treating complex IAs, creative revascularization strategies are needed in selective cases for favorable outcomes. STA interposition graft bypass which can reduce the size discrepancy between the donor and recipient may be a less invasive, flexible, and practical option for treating complex IAs.
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Affiliation(s)
- June Ho Choi
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Minwoo Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byung Duk Kwun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Samarage HM, Kim WJ, Zarrin DA, Goel K, Kim W, Bergsneider M, Wang MB, Suh JD, Lee JT, Colby GP, Johnson JN, Peacock WJ, Wang AC. Endoscope-Assisted Pedicled Maxillary Artery to Middle Cerebral Artery Bypass: An Anatomic Feasibility Study. Oper Neurosurg (Hagerstown) 2023; 24:209-220. [PMID: 36637306 DOI: 10.1227/ons.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Extracranial to intracranial bypass is used to augment and/or replace the intracranial circulation for various pathologies. The superficial temporal artery is the mainstay donor for pedicled bypasses to the anterior circulation but can be limited by its variable size, low native flow rates, and potential scalp complications. Interposition grafts such as the radial artery or greater saphenous vein are alternatives but are sometimes limited by size mismatch, length needed to reach the extracranial circulation, and loss of inherent vascular elasticity. Interposition grafts between the maxillary artery (IMA) and middle cerebral artery (MCA) address these limitations. OBJECTIVE To explore the feasibility of harvesting the IMA through an endoscopic transnasal, transmaxillary approach to perform a direct IMA to MCA bypass. METHODS Combined transcranial and endoscopic endonasal dissections were performed in embalmed human cadavers to harvest the IMAs for intracranial transposition and direct anastomosis to the MCA. Donor and recipient vessel calibers were measured and recorded. RESULTS A total of 8 procedures were performed using the largest and distal-most branches of the IMA (the sphenopalatine branch and the descending palatine branch) as pedicled conduits to second division of middle cerebral artery (M2) recipients. The mean diameter of the IMA donors was 1.89 mm (SD ± 0.42 mm), and the mean diameter of the recipient M2 vessels was 1.90 mm (SD ± 0.46 mm). CONCLUSION Endoscopic harvest of the IMA using a transnasal, transmaxillary approach is a technically feasible option offering an excellent size match to the M2 divisions of the MCA and the advantages of a relatively short, pedicled donor vessel.
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Affiliation(s)
- Hasitha Milan Samarage
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - David A Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Won Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Marvin Bergsneider
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Marilene B Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Jeffrey D Suh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Jivianne T Lee
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Radiology, University of California Los Angeles, Los Angeles, California, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Warwick J Peacock
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Surgery, University of California Los Angeles, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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6
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Moroz V, Harmatina O, Skorokhoda I, Shakhin N, Ghanem R, Maliar U. Surgical revascularization (bypass surgery) in the treatment of complicated cerebral aneurysms. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-55-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The aim of surgical treatment of any cerebral aneurysm is to achieve its total exclusion from the bloodstream. Although the progress in the development and implementation of microsurgical and the latest endovascular technologies, in many cases, the treatment of complex cerebral aneurysms is not an easy task. Unsatisfactory results of the exclusion of complicated cerebral aneurysms are due to many factors, for instance: gigantic size, fusiform or dolichoectatic configuration of the cerebral aneurysm, the presence of atherosclerotic changes, anatomical features of the departure of functionally important arteries directly from the cerebral aneurysm. Such cerebral aneurysms are quite problematic both for microsurgical remodeling clipping and for endovascular exclusion. At the current stage, the introduction and use of the microanastomosis technique provides additional options and expands the possibilities of surgical treatment of complex cerebral aneurysms.Objective ‒ to analyze the possibilities and results of surgical treatment of complicated cerebral aneurysms using the technique of surgical revascularization (bypass surgery).Materials and methods. An analysis of the results of the examination and surgical treatment of 16 patients with complicated cerebral aneurysms for the period from 2016 to 2020, who were treated and operated on in the emergency vascular neurosurgery department with the X-ray operating department Romodanov Institute of Neurosurgery of NAMS of Ukraine. All patients diagnosed with complicated cerebral aneurysms had gigantic sizes. All cases of surgical intervention included placement of extra-intracranial microanastomosis or intra-intracranial anastomosis, sometimes a combination of it, to ensure normal blood supply to the vessel of complicated cerebral aneurysm that were planned to be devascularized. In 14 observations, one-time anastomosis and exclusion of complicated cerebral aneurysms were performed. In 2 observations, the first stage was an anastomosis without exclusion of the complicated cerebral aneurysms due to insufficient vascularization of the distal arterial branch for deconstructive exclusion of aneurysm.Results. Satisfactory results of surgical treatment (grade 1 and 2 of Modified Rankin Scale (MRS)) in the general group of patients were observed in 13 (81 %) patients with complicated cerebral aneurysms. Unsatisfactory results of surgical treatment occurred in 3 (19 %) observations. Profound disability (MRS grade 5) as a result of surgical treatment was recorded in 1 (6 %) patient. Cases that ended fatally occurred in 2 (13 %) observations of the total group of patients. In the group of patients with surgical revascularization and excluded complicated cerebral aneurysms, satisfactory results were observed in 13 (92.9 %) patients. Fatal results of surgical treatment were recorded in 2 patients with a hemorrhagic course of complicated cerebral aneurysms, in which surgical revascularization was performed as first stage and scheduled removal of complicated cerebral aneurysms was planned.Conclusions. The introduction and use of the microanastomosis technique expands the possibilities of surgical treatment of complicated cerebral aneurysms. Revascularization surgical interventions are highly effective in the prevention of ischemic complications when complicated cerebral aneurysms are excluded. Recommendations (indications) for revascularization should be considered in impossibility and high risks of ischemic complications during remodeling clipping or endovascular exclusion of complicated cerebral aneurysms.
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7
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Rennert RC, Russin JJ. Rethinking Cerebral Bypass Surgery. Neurosurg Clin N Am 2022; 33:403-417. [DOI: 10.1016/j.nec.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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Complementary Tools in Cerebral Bypass Surgery. World Neurosurg 2022; 163:50-59. [PMID: 35436579 DOI: 10.1016/j.wneu.2022.03.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Cerebral revascularization surgery has been advanced by the refinement of several adjunctive tools. These tools include perioperative blood thinners, intraoperative spasmolytic agents, electrophysiological monitoring, and methods for assessing bypass patency or marking arteriotomies. Despite the array of options, the proper usage and comparative advantages of different complements in cerebral bypass have not been well-cataloged elsewhere. In this literature review, we describe the appropriate usage, benefits, and limitations of various bypass adjuncts. Understanding these adjuncts can help surgeons ensure that they receive reliable intraoperative information about bypass function and minimize the risk of serious complications. Overall, this review provides a succinct reference for neurosurgeons on various cerebrovascular bypass adjuncts.
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9
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Wolfswinkel EM, Ravina K, Rennert RC, Landau M, Strickland BA, Chun A, Wlodarczyk JR, Abedi A, Carey JN, Russin JJ. Cerebral Bypass Using the Descending Branch of the Lateral Circumflex Femoral Artery: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:364-372. [DOI: 10.1227/ons.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
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10
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Kan P, Srinivasan VM, Srivatsan A, Kaufmann AB, Cherian J, Burkhardt JK, Johnson J, Duckworth EAM. Double-barrel STA-MCA bypass for cerebral revascularization: lessons learned from a 10-year experience. J Neurosurg 2021; 135:1385-1393. [PMID: 33740759 DOI: 10.3171/2020.9.jns201976] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In select patients, extracranial-intracranial (EC-IC) bypass remains an important tool for cerebral revascularization. Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed using one limb of the STA only. In an attempt to augment flow and to direct flow to different ischemic areas of the brain, the authors adopted a "double-barrel" technique in which both branches of the STA are used to revascularize distinct MCA territories. METHODS A series of consecutive double-barrel STA-MCA bypasses performed between 2010 and 2020 were reviewed. Each anastomosis was directed to augment flow to a territory most at risk based on preoperative perfusion studies, cerebral angiography, and intraoperative indocyanine green data. CT perfusion and CTA were routinely used to evaluate postoperative augmentation and graft patency. Patient perioperative outcomes, surgical complications, and modified Rankin Scale (mRS) scores at the last follow-up were reported. RESULTS Forty-four patients (16 males, 28 females) successfully underwent double-barrel STA-MCA bypass on 54 cerebral hemispheres: 28 operations were for moyamoya disease, 23 for atherosclerotic disease refractory to medical therapy, 2 for complex cerebral aneurysms, and 1 for carotid occlusion as a sequela of cavernous meningioma growth. Ten patients underwent multiple operations, 9 of whom had moyamoya disease/syndrome, with the subsequent operation on the contralateral hemisphere. The average patient age at surgery was 45.1 years (range 14-73 years), with a mean follow-up time of 22.1 months. Intraoperative graft patency was confirmed in 100% of cases, and 101 (98.1%) of the 103 anastomoses with imaging follow-up were patent. Perfusion to the revascularized hemisphere was improved in 88.2% of cases. Perioperative ischemic and hemorrhagic complications occurred in 8 procedures (2 were asymptomatic), whereas remote ischemic and hemorrhagic events occurred in 7 cases. There was no mortality in the series, and the mean patient mRS scores were 1.72 at presentation and 1.15 at the last follow-up. CONCLUSIONS The high rates of intraoperative and postoperative patency support the feasibility of dual-anastomosis STA-MCA bypass for revascularization. The perioperative complication rate is not significantly different from that of single-anastomosis bypass. The functional outcomes at follow-up and perfusion improvement postoperatively support the efficacy and safety of this method as a treatment strategy.
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Affiliation(s)
- Peter Kan
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Aditya Srivatsan
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ascher B Kaufmann
- 2Department of Neurosurgery, College of Human Medicine, Michigan State University, Southfield, Michigan
| | - Jacob Cherian
- 3Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | | | - Jeremiah Johnson
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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11
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Stapleton CJ, Hussein AE, Behbahani M, Alaraj A, Amin-Hanjani S, Charbel FT. Comparative efficacy of autologous versus cadaveric saphenous vein grafts in cerebral revascularization surgery. J Neurosurg 2021; 134:1562-1568. [PMID: 32442978 DOI: 10.3171/2020.3.jns192546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral bypasses are performed for the purpose of either flow augmentation for ischemic cerebrovascular disease or flow replacement for vessel sacrifice during complex aneurysm or tumor surgery. Saphenous vein grafts (SVGs) are commonly used interposition grafts. The authors of this study sought to compare the efficacy of autologous versus cadaveric SVGs in a large series of cerebral bypasses using interposition vein grafts with long-term angiographic follow-up. METHODS All intracranial bypass procedures performed between 2001 and 2018 were reviewed. Demographic, clinical, angiographic, and operative data were recorded and then analyzed according to SVG type. RESULTS A total of 308 consecutive intracranial bypasses were performed during the study period, 53 (17.2%) of which were bypasses with an interposition SVG (38 autologous, 15 cadaveric). At a median follow-up of 2.2 months (IQR 0.2-29.1), 39 (73.6%) bypasses were patent (26 [68.4%] autologous, 13 [86.7%] cadaveric, p = 0.30). Comparing autologous and cadaveric SVG recipients, there were no statistically significant differences in age (p = 0.50), sex (p > 0.99), history of smoking (p = 0.75), hypertension (p > 0.99), diabetes mellitus (p = 0.13), indication for bypass (p = 0.27), or SVG diameter (p = 0.65). While there were higher intraoperative (autologous, 100.0 ml/min, IQR 84.3-147.5; cadaveric, 80.0 ml/min, IQR 47.3-107.8; p = 0.11) and postoperative (autologous, 142.2 ml/min, IQR 76.8-160.8; cadaveric, 92.0 ml/min, IQR 69.2-132.2; p = 0.42) volumetric flow rates in the autologous SVGs compared to those in the cadaveric SVGs, the difference between the two groups did not reach statistical significance. In addition, the blood flow index, or ratio of postoperative to intraoperative blood flow, for each bypass was similar between the groups (autologous, 1.3, IQR 0.9-1.6; cadaveric, 1.5, IQR 1.0-2.3; p = 0.37). Kaplan-Meier estimates showed no difference in bypass patency rates over time between autologous and cadaveric SVGs (p = 0.58). CONCLUSIONS Cadaveric SVGs are a reasonable interposition graft option in cerebral revascularization surgery when autologous grafts are not available.
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12
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Wang G, Zhang X, Gou Y, Wen Y, Zhang G, Li M, Zhang S, Yin Y, Chen S, Qi S, Feng W. A Hybrid Strategy for Patients With Complex Cerebral Aneurysm: STA-MCA Bypass in Combination With Endovascular Embolization. Front Neurol 2021; 11:614601. [PMID: 33519692 PMCID: PMC7844085 DOI: 10.3389/fneur.2020.614601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/27/2020] [Indexed: 12/16/2022] Open
Abstract
Objective: This work aims to present our experience of patients with complex cerebral aneurysm treated with a hybrid approach: superficial temporal artery–middle cerebral artery (STA–MCA) bypass in combination with endovascular exclusion of the aneurysm. Method: Patients with aneurysms deemed unclippable and uncoilable were included. All patients were treated with a hybrid approach. After STA–MCA bypass, the parent artery was temporarily occluded. If the intraoperative motor evoked potential (MEP) and somatosensory evoked potential (SEP) waveforms remain normal and last for 30 min, the aneurysm and te parent artery will be embolized permanently with detachable balloons or coils. Results: A total of 20 patients with 22 aneurysms were included in this study. There were 13 women and 7 men, with an average age of 42.5 years. Intraoperative angiography showed the good patency of all the STA grafts, and neither SEP nor MEP abnormalities were detected. After the parent artery and the aneurysm were occluded, the intraoperative angiography showed an immediately successful exclusion of the aneurysm in 20 aneurysms and immediate contrast stasis in two. All patients recovered uneventfully without ischemic or hemorrhagic complication. Angiography at 6-month follow-up showed the total obliteration in 20 aneurysms. Two aneurysms showed residuals and were recoiled. All STA grafts showed a good patency, and the mean graft flow was 124.2 ml/min. Conclusion: STA–MCA bypass in combination with endovascular exclusion is an appropriate option for patients with complex cerebral aneurysms that are not amenable to direct surgical clipping or endovascular embolization.
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Affiliation(s)
- Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xi'an Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanxia Gou
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyu Wen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guozhong Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingzhou Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shichao Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanyi Yin
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Siyuan Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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13
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Kim YS, Ha MH, Joo SP, Kim TS. Acute Parent Artery Occlusion in Thrombosed Middle Cerebral Artery Aneurysm Presenting with Ischemic Stroke. World Neurosurg 2020; 136:122-127. [PMID: 31953097 DOI: 10.1016/j.wneu.2020.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/05/2020] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thrombosed intracranial aneurysms are complex and unstable lesions that are especially associated with ischemic stroke. Although acute parent artery occlusion manifesting with ischemic stroke is very rare, it can lead to catastrophic consequences. CASE DESCRIPTION This study presents 2 cases of acute parent artery occlusion in thrombosed large and giant middle cerebral artery bifurcation aneurysms manifesting with ischemic stroke. Both patients were successfully treated with emergent double-barrel superficial temporal artery-to-middle cerebral artery bypass followed by aneurysm trapping. CONCLUSIONS Emergent superficial temporal artery-to-middle cerebral artery bypass could be a salvageable treatment option in patients with progressive neurologic deficits and significant mismatch between diffusion- and perfusion-weighted imaging in acute parent artery occlusions associated with large or giant thrombosed aneurysms. Besides diffusion- and perfusion-weighted imaging, preoperative assessment of the collaterals will help in predicting postoperative prognosis.
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Affiliation(s)
- You-Sub Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Myeong-Hun Ha
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
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14
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Zaki Ghali MG, Srinivasan VM, Britz GW. Maxillary Artery to Intracranial Bypass. World Neurosurg 2019; 128:532-540. [DOI: 10.1016/j.wneu.2019.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
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15
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Hu P, Zhang HQ, Li XY, Tong XZ. Double-Barrel Superficial Temporal Artery to Proximal Middle Cerebral Artery Bypass to Treat Complex Intracranial Aneurysms: A Reliable High Blood Flow Bypass. World Neurosurg 2019; 125:e884-e890. [DOI: 10.1016/j.wneu.2019.01.203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
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16
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Ravina K, Strickland BA, Rennert RC, Carey JN, Russin JJ. Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge. Neurosurg Focus 2019; 46:E13. [PMID: 30717063 DOI: 10.3171/2018.11.focus18514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/07/2018] [Indexed: 11/06/2022]
Abstract
Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.
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Affiliation(s)
| | | | - Robert C Rennert
- 4Department of Neurosurgery, University of California, San Diego, California
| | - Joseph N Carey
- 3Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
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17
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Wolfswinkel EM, Landau MJ, Ravina K, Kokot NC, Russin JJ, Carey JN. EC-IC bypass for cerebral revascularization following skull base tumor resection: Current practices and innovations. J Surg Oncol 2018; 118:815-825. [PMID: 30196557 DOI: 10.1002/jso.25178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/05/2018] [Indexed: 11/09/2022]
Abstract
Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic cerebral ischemia, surgical revascularization is required. The purpose of this paper is to review cerebral revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.
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Affiliation(s)
- Erik M Wolfswinkel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark J Landau
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Niels C Kokot
- Department of Otolaryngology- Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan J Russin
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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18
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Cherian J, Srinivasan V, Kan P, Duckworth EAM. Double-Barrel Superficial Temporal Artery-Middle Cerebral Artery Bypass: Can It Be Considered “High-Flow?”. Oper Neurosurg (Hagerstown) 2017; 14:288-294. [DOI: 10.1093/ons/opx119] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/09/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass uses one STA branch. Its augmentation of flow has classically been described as “low flow.” In a double-barrel STA-MCA bypass, however, both branches of the STA are utilized. Here we hypothesize that this should not be considered “low flow.”
OBJECTIVE
To review quantitative flow data from our cases and investigate the impact of double-barrel STA-MCA bypass on total flow augmentation, and to assess whether double-barrel STA-MCA bypass might be useful in situations that traditionally demand more complex bypass strategies.
METHODS
Intraoperative flow probe measurements from STA-MCA bypass cases were retrospectively tabulated and compared. Cut flow and bypass flow measurements were, respectively, taken before and after completion of anastomoses. The higher value was labeled best observed flow (BOF).
RESULTS
We identified 21 STA-MCA bypass cases with available intraoperative flow probe measurements, of which 17 utilized double-barrel technique. Only 1 STA branch was available in 4 cases. Significantly higher average BOF was seen when utilizing 2 STA branches (69 vs 39 cc/min, P < .001). A majority (9/17) of double-barrel bypasses provided BOF ≥ 65 cc/min (120 cc/min maximum). The single branch bypass maximum BOF was 40 cc/min.
CONCLUSION
Double-barrel bypass technique significantly enhances STA-MCA flow capacity and may be useful in situations in which a high-flow bypass is needed. The 2 efferent limbs allow flexibility in distributing flow across separate at-risk territories. The method compares favorably to other descriptions of high-flow bypass without the morbidity of graft harvest or an additional cervical incision.
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Affiliation(s)
- Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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19
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The Valveless Saphenous Vein Graft Technique for EC-IC High-Flow Bypass: Technical Note. World Neurosurg 2016; 87:35-8. [DOI: 10.1016/j.wneu.2015.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 11/15/2022]
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20
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Thines L, Proust F, Marinho P, Durand A, van der Zwan A, Regli L, Lejeune JP. Giant and complex aneurysms treatment with preservation of flow via bypass technique. Neurochirurgie 2015; 62:1-13. [PMID: 26072226 DOI: 10.1016/j.neuchi.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/02/2015] [Accepted: 03/01/2015] [Indexed: 10/23/2022]
Abstract
Due to their anatomical characteristics and the complexity of the procedures required to obtain their complete occlusion, the treatment of giant intracranial aneurysms is a real challenge. Direct reconstructive strategies, whether by interventional neuroradiology (coils, stents) or microsurgical (clipping) means, are not always applicable and, in patients that would not tolerate parent or collateral artery sacrifice, the adjunction of a revascularization procedure using a bypass technique might be necessary. Cerebral arterial bypasses can be classified according to their function (3 types: flow replacement, flow reversal or protective), the branching mode of the graft used (3 types: pedicled, interpositional or in situ), the sites of anastomosis (2 types: extracranial-intracranial or intracranial-intracranial) and the class of flow they are supposed to provide (3 types: low-, intermediate- or high-flow). In this article, the authors review the different aspects in the management of patients with a giant intracranial aneurysm using a bypass: preoperative work-up, types of bypass and indications, surgical techniques and results.
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Affiliation(s)
- L Thines
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France.
| | - F Proust
- Service de neurochirurgie, Hôpital Charles-Nicolle, CHU de Rouen, 76038 Rouen, France
| | - P Marinho
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France
| | - A Durand
- Clinique du Tonkin, 69626 Villeurbanne cedex, France
| | - A van der Zwan
- Department of Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - J-P Lejeune
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France
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21
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Thines L, Durand A, Penchet G, Proust F, Lenci H, Debailleul A, Lejeune JP, Pelissou-Guyotat I. Microsurgical neurovascular anastomosis: The example of superficial temporal artery to middle cerebral artery bypass. Technical principles. Neurochirurgie 2014; 60:158-64. [DOI: 10.1016/j.neuchi.2014.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 03/22/2014] [Accepted: 03/25/2014] [Indexed: 11/26/2022]
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22
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Universal extracranial-intracranial graft bypass for large or giant internal carotid aneurysms: techniques and results in 38 consecutive patients. World Neurosurg 2013; 82:130-9. [PMID: 23454690 DOI: 10.1016/j.wneu.2013.02.063] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 02/06/2013] [Accepted: 02/13/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To present indications, surgical techniques, and outcomes of extracranial-intracranial (EC-IC) graft bypass. METHODS Between January 1996 and June 2011, 38 patients with large or giant internal carotid artery (ICA) aneurysms were treated using graft bypass, employing the radial artery (RA) or the saphenous vein (SV) as a graft. Preoperative balloon test occlusions were not performed in any of the cases. In 17 patients, the external carotid artery (ECA)-RA-M2 segment of the middle cerebral artery bypass was used for treatment, and ECA-SV-M2 bypass was used in 21 patients. RESULTS All aneurysms were completely trapped, and there were no subarachnoid hemorrhages or recanalizations of aneurysms during the follow-up period (8-170 months). Of the 38 bypasses, 36 (94.7%) remained patent, and there were no permanent neurologic deficits. Hyperperfusion syndrome was not experienced in this series. There were 2 temporary neurologic deficits. In 1 case using the RA, graft vasospasm occurred, and kinking occurred in 1 case using the SV. Another patient with a SV graft had to undergo an emergent revision of the graft 8 hours after the initial operation. One patient with a SV graft underwent a second operation to control an epidural abscess. CONCLUSIONS Universal EC-IC graft bypass is a safe and effective method for treating large or giant ICA aneurysms.
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23
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Mery FJ, Amin-Hanjani S, Charbel FT. Cerebral revascularization using cadaveric vein grafts. ACTA ACUST UNITED AC 2009; 72:362-8; discussion 368. [DOI: 10.1016/j.surneu.2009.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 04/05/2009] [Indexed: 11/26/2022]
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24
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Bisson EF, Visioni AJ, Tranmer B, Horgan MA. External carotid artery to middle cerebral artery bypass with the saphenous vein graft. Neurosurgery 2008; 62:134-8; discussion 138-9. [PMID: 18424977 DOI: 10.1227/01.neu.0000317383.53314.3c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Patients with occlusive cerebrovascular disease who have failed maximal medical therapy, which consists of antiplatelet agents as well as maximizing modifiable risk factors such as blood pressure, cholesterol, smoking cessation, and obesity, and whose lesions are not amenable or have not responded to the more common vascular procedures (i.e., carotid endarterectomy or stenting) are considered candidates for an extracranial-intracranial bypass. Additionally, for a patient to be a candidate, he/she must have an adequate graft vessel. Typically, this vessel is the superficial temporal artery. However, oftentimes, the superficial temporal artery is an inadequate vessel or the patient requires a high-flow conduit. It is in these patients that use of the saphenous vein should be considered. In this report, we detail the technical aspects of performing an extracranial-intracranial bypass by using a saphenous vein graft.
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Affiliation(s)
- Erica F Bisson
- Division of Neurosurgery, Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
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