Bypass surgery using a radial artery graft for bilateral extracranial carotid arteries occlusion

A patient presenting with recurrent ischemic attacks was demonstrated to have complete occlusion of the right common and left internal carotid arteries. An external carotid angiogram showed a large left superficial temporal artery (STA) supplying both sides of the scalp. ¹²³I-IMP single photon emission computed tomography (SPECT) revealed hypoperfusion of the both hemispheres, especially the left cerebral hemisphere. An extracranial-intracranial (EC-IC) bypass was performed using a radial artery graft interpositioned between the proximal part of the STA and the M2 segment, thus preserving blood flow to the scalp through the STA. Postoperative angiography after 1 year showed good circulation through the anastomosis, and ¹²³I-IMP SPECT studies demonstrated increased cerebral perfusion. The patient improved clinically. The surgical technique is described below. Received: 2 June 1998 / Accepted: 15 April 1999     

Spontaneous intracranial internal carotid artery dissection treated by intra-arterial thrombolysis and superficial temporal artery-middle cerebral artery anastomosis in the acute stage--case report--

A 22-year-old man presented with sudden onset of right retro-orbital headache followed by left hemiparesis. Right carotid angiography demonstrated almost total occlusion of the intracranial internal carotid artery (ICA) and severe stenosis of the middle cerebral artery (MCA), presumably caused by arterial dissection. Local arterial injection of urokinase was performed 2 hours after onset. The ICA became patent, but the M2 portion of the MCA was still occluded, and the left hemiparesis did not improve. Superficial temporal artery-MCA anastomosis was immediately performed. The left hemiparesis disappeared completely 6 days after this procedure. Angiography 2 weeks after the onset revealed occlusion of the ICA, and maintenance of blood flow to the right cerebral hemisphere via the anastomosis. Magnetic resonance imaging showed small infarcts in the right cerebral cortex. Repeat angiography after 5 months showed recanalization of the right ICA and the right MCA. Combination of thrombolytic therapy and bypass surgery may be a useful treatment option for patients with sudden occlusion of the intracranial artery caused by dissection.     

Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm: association with transsphenoidal surgery and radiation therapy: case report

A 62-year-old woman presented with simultaneous subarachnoid hemorrhage (SAH) and massive epistaxis. The patient had been treated for pituitary prolactinoma by two transsphenoidal surgeries, gamma knife radiosurgery, and conventional radiation therapy since age 43 years. Cerebral angiography showed left petrous internal carotid artery (ICA) aneurysm with slight stenosis on the adjacent left petrous ICA. She underwent superficial temporal artery-middle cerebral artery (STA-MCA) double anastomosis with endovascular internal trapping without complication the day after onset. Postoperative course was uneventful; the patient did not develop symptomatic vasospasm, recurrent epistaxis, or cerebrospinal fluid rhinorrhea. Postoperative angiography demonstrated complete disappearance of the aneurysm with patent STA-MCA anastomosis. The patient was discharged 2 months after surgery without neurological deficit. The present case is extremely rare with simultaneous onset of SAH and epistaxis caused by ruptured petrous ICA aneurysm. The transsphenoidal surgeries and radiation therapies might have been critical in the formation of the petrous ICA aneurysm.     

Two cases of main trunk artery occlusion associated with multiple cerebral aneurysms

We report 2 cases of multiple aneurysms (AN) associated with main trunk artery occlusion. CASE 1: A 52-year-old male was admitted to our hospital with dysarthria and weakness of the right side of the body. Computed tomography (CT) showed cerebral infarction in the left corona radiata. MR angiography and conventional angiography showed occlusion of the left middle cerebral artery (MCA) and saccular aneurysms (ANs) at the origin of the anterior communicating artery (A-com) and bifurcation of the right MCA. Subsequent 123I-IMP-single photon emission tomography (SPECT) revealed marked reduction of cerebral blood flow and disturbed reactivity to acetazolamide in the left cerebral hemisphere. Superficial temporal artery (STA)-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for AN of the A-com and right MCA. At 5 months after the first operation, neck clipping was performed successfully for the non-ruptured A-com AN and right MCA AN. CASE 2: A 65-year-old male was admitted to our hospital. CT revealed subarachnoid hemorrhage (SAH), and 3D-computed tomographic angiography (CTA) and cerebral angiography showed basilar top AN, A-com AN and right MCA AN associated with right internal carotid artery occlusion. Right ACA and MCA territories were visualized from the A-com artery and posterior cerebral artery. STA-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for ANs. In the same operation, successful neck clipping was performed for BA top AN and right MCA AN. In such cases as these, particularly in ischemic cases associated with main trunk artery occlusion, it was important to consider surgery for AN after STA-MCA anastomosis in anticipation of improved cerebral blood flow and reduce hemodynamic stress for AN.     

Frequent TIA in the territory fed by the anastomosed STA after combined therapeutic ICA occlusion and extracranial-intracranial bypass: Case report

Summary Frequent transient ischaemic attacks (TIAs) in the territory fed by the anastomosed superficial temporal artery (STA) after combined therapeutic internal carotid artery (ICA) occlusion and extra-cranial-intracranial bypass is described in a 52-year-old woman with a giant aneurysm in the supraclinoid portion of the left ICA showing impairment of visual acuity in the left eye and right upper quadrantanopia. After the balloon test occlusion of the left ICA which was tolerated, the left STA-middle cerebral artery anastomosis was performed and occlusion of the left ICA using detachable balloons was carried out a day later. TIAs corresponding to the territory fed by the anastomosed STA occurred nine times two to four days and five times eight to nine days after the ICA occlusion without new infarction on computed tomography (CT) scan. Single-photon emission computed tomography showed no hypoperfusion immediately after the initial TIA. CT scan revealed thrombosis of half of the aneurysm a day after the ICA occlusion. The patient developed the same TIA as previously by compression of the left anastomosed STA at the time of follow-up angiography which was carried out eight days after the occlusion. Although heparin was continuously administered after the ICA occlusion for two days, the initial TIA occurred during heparinization.Anticoagulation seemed to be inadequate judging from activated coagulation time and incomplete thrombosis of the aneurysm occurred during heparinization. It is likely that the TIAs are caused by embolism via the STA, which is a rare ischaemic complication.     

STA-MCA anastomosis in patients with skull base tumours involving the internal carotid artery—Haemodynamic assessment by ultrasonic Doppler flowmeter

Summary The role of superficial temporal artery -middle cerebral artery (STA-MCA) anastomosis was investigated with an ultrasonic Doppler flowmeter in 3 patients with sphenoid ridge meningiomas and one with a parasellar malignant teratoma, all of which involved the intracranial internal carotid artery. The intraoperative Doppler flow study revealed a remarkable increase in flow volume of the STA after trial occlusion of the middle cerebral artery in one case and permanent occlusion in two cases. These results substantiate the effectiveness of STA-MCA anastomosis. We also discuss surgical and other contrivances for obtaining sufficient blood supply from this bypass to prevent cerebral ischaemia in the acute phase after elective or accidental occlusion of a major cerebral artery. This is the first report of STA-MCA anastomosis in cases with brain tumour.     

Superficial temporal artery to proximal middle cerebral artery anastomosis: clinical and angiographic long term results

Anastomosis of the superficial temporal artery (STA) with a proximal segment of the middle cerebral artery (MCA) has been proposed as a new cerebral revascularization technique alternative to the conventional bypass on the cortical surface. We introduced this procedure in our surgical practice in 1982 for patients with internal carotid artery (ICA) aneurysms not suitable for direct repair in whom occlusion of the ICA is considered necessary. One patient died because a conventional STA-MCA bypass did not prevent a major stroke caused by a therapeutic ICA occlusion. We are reporting our surgical technique and the immediate and long term clinical and angiographic results in five cases operated on during the period June 19, 1982, through January 19, 1983. The early and late patency rates were good. No neurological complications were observed after the bypass procedure or during a 3-year follow-up period. In our opinion, the use of proximal segments of the MCA as recipient arteries for supratentorial revascularization is a good alternative to the use of cortical surface arteries and, in selected cases, could be the first choice technique.     

Superficial temporal artery-middle cerebral artery anastomosis patency correlates with cerebrovascular reserve in adult moyamoya syndrome patients

ObjectivesTo evaluate the effectiveness of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in improving cerebrovascular reserve (CVR) in Moyamoya syndrome.Patients and methodsThis prospective study included 10 consecutive patients treated for Moyamoya syndrome by STA-MCA bypass in our institution between June 2016 and January 2018. Perfusion MRI, transcranial Doppler and 99 m Tc-HMPAO SPECT with acetazolamide challenge were performed before and after treatment to evaluate perfusion and cerebrovascular reserve. STA-MCA bypass was indicated for patients with history of ischemic or hemorrhagic stroke and when CVR was diminished on both transcranial Doppler and 99 m Tc-HMPAO SPECT with acetazolamide challenge or brain perfusion was deteriorated on MRI.ResultsBypass anastomosis was patent in all patients at end of surgery. One patient presented partial postoperative sensorimotor deficit related to an ischemic lesion in the frontal cortical area. One patient presented regressive chronic subdural hematoma without neurological deficit. Three months after treatment, CVR was significantly improved in 8 patients and unchanged in 2, probably related to low flow. Further follow-up found CVR deterioration in 1 patient, with anastomosis occlusion at 1 year.ConclusionOur data suggest that improvement in cerebral perfusion and CVR depends on flow in the STA-MCA anastomosis in patients with Moyamoya syndrome. Systematic long-term follow-up of anastomosis flow, brain perfusion and CVR improves quantification of the benefit of STA-MCA anastomosis in terms of disease progression.     

Intracerebral hemorrhage from a ruptured aneurysm at the site of anastomosis 27 years after superficial temporal artery-middle cerebral artery bypass

A 77-year-old female presented with a very rare case of intracerebral hemorrhage (ICH) from a ruptured aneurysm at the site of the anastomosis 27 years after superficial temporal artery-middle cerebral artery (STA-MCA) bypass manifesting as sudden onset of unconsciousness and right hemiparesis. Computed tomography (CT) on admission demonstrated massive ICH in the left frontoparietal region. Magnetic resonance angiography showed good patency of the anastomosis and no obvious aneurysm, but three-dimensional CT (3D-CT) angiography revealed a small aneurysm at the site of the left STA-MCA anastomosis. Emergency evacuation of the hematoma was performed, and the aneurysm was trapped and resected after ligation. After the operation, she continued to exhibit deep consciousness disturbance. Unfortunately, her general condition grew steadily worse and she died 3 months later. Patients who undergo STA-MCA anastomosis should be carefully followed up by periodical imaging examinations. 3D-CT angiography is very useful to detect aneurysm formation at the anastomosis site.     

Temporal change of 3-T magnetic resonance imaging/angiography during symptomatic cerebral hyperperfusion following superficial temporal artery–middle cerebral artery anastomosis in a patient with adult-onset moyamoya disease

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a safe and effective treatment for moyamoya disease, although recent evidence suggests its substantial risk for symptomatic cerebral hyperperfusion. The diagnostic value of single-photon emission computed tomography (SPECT) for postoperative hyperperfusion in moyamoya patients is well established, but that of magnetic resonance (MR) imaging/angiography is undetermined. A 22-year-old woman with hemorrhagic-onset moyamoya disease underwent STA-MCA anastomosis on the right hemisphere, but she suffered from transient left hemiparesis and facial paresis owing to cerebral hyperperfusion from 3 to 11 days after surgery as delineated by SPECT. The time-sequential 3-T MR angiography revealed intense high signal of donor STA and dilated branches of MCA around the site of the anastomosis. These findings were most prominent at 8 days after surgery, when her neurologic signs were most apparent. Intensive blood pressure control relieved her symptom and she was discharged without neurologic deficit. MR findings normalized 3 months later. The characteristic findings of 3-T MR angiography, which was not evident by 1.5-T MR angiography in the previous studies, may reflect intrinsic pathology of postoperative cerebral hyperperfusion. It could be a useful diagnostic tool after revascularization surgery for moyamoya disease.     

Higher magnification microsurgical repair of donor artery dissection in superficial temporal artery to middle cerebral artery anastomosis--technical note

Donor artery dissection is a known cause of technical failure in microvascular anastomosis. A method for detection and direct repair of donor artery dissection before superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis is described using a high magnification operating microscope (maximum 50.4× magnification). Before STA-MCA anastomosis, the stump of the STA is stained using methylrosaniline chloride (pyoctaninum blue) and is observed under higher magnifications. Microsurgical suturing of the arterial dissection is performed before the anastomosis procedure under the high magnification microscope. This method was used in two patients with symptomatic hemodynamic cerebrovascular occlusive disease. Postoperative angiography revealed good patency and no complications occurred. This method may be useful for detection and direct repair of arterial dissection in small vessel walls before STA-MCA anastomosis.     

Intracerebral hemorrhage from a ruptured pseudoaneurysm after STA-MCA anastomosis--case report

A 43-year-old hypertensive male developed a pseudoaneurysm at the site of a superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis, causing massive intracerebral hemorrhage 5 years after the operation. He first experienced repeated transient ischemic attacks, and cerebral angiography disclosed complete occlusion in the cervical portion of the left internal carotid artery. STA-MCA anastomosis was performed, and the ischemic attacks stopped. Postoperative angiography confirmed patency of the anastomosis and good filling of the cortical branches of the left MCA. Five years after surgery, the patient suffered sudden onset of generalized convulsions and consciousness disturbance. Computed tomography disclosed a massive intracerebral hemorrhage in the left frontoparietal region, and angiography revealed an aneurysmal dilatation at the site of the anastomosis that was not seen before. Emergency evacuation of the hematoma and clipping of the aneurysmal dilatation were performed. The patient recovered well and became ambulatory. Histological examination of the surgical specimen showed collagen tissue, indicating a pseudoaneurysm. Patients who undergo STA-MCA anastomosis, especially hypertensive patients, should be followed up by repeated magnetic resonance angiography to confirm the patency of the anastomosis and cerebral perfusion, and to detect the formation of pseudoaneurysms at the anastomosis site, which can cause fatal bleeding.     

Temporal change of 3-T magnetic resonance imaging/angiography during symptomatic cerebral hyperperfusion following superficial temporal artery-middle cerebral artery anastomosis in a patient with adult-onset moyamoya disease

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a safe and effective treatment for moyamoya disease, although recent evidence suggests its substantial risk for symptomatic cerebral hyperperfusion. The diagnostic value of single-photon emission computed tomography (SPECT) for postoperative hyperperfusion in moyamoya patients is well established, but that of magnetic resonance (MR) imaging/angiography is undetermined. A 22-year-old woman with hemorrhagic-onset moyamoya disease underwent STA-MCA anastomosis on the right hemisphere, but she suffered from transient left hemiparesis and facial paresis owing to cerebral hyperperfusion from 3 to 11 days after surgery as delineated by SPECT. The time-sequential 3-T MR angiography revealed intense high signal of donor STA and dilated branches of MCA around the site of the anastomosis. These findings were most prominent at 8 days after surgery, when her neurologic signs were most apparent. Intensive blood pressure control relieved her symptom and she was discharged without neurologic deficit. MR findings normalized 3 months later. The characteristic findings of 3-T MR angiography, which was not evident by 1.5-T MR angiography in the previous studies, may reflect intrinsic pathology of postoperative cerebral hyperperfusion. It could be a useful diagnostic tool after revascularization surgery for moyamoya disease.     

Microsurgical neurovascular anastomosis: The example of superficial temporal artery to middle cerebral artery bypass. Technical principles

The superficial temporal artery to the middle cerebral artery (STA-MCA) bypass is a good example of cerebrovascular anastomosis. In this article, we describe the different stages of the procedure: patient installation, superficial temporal artery harvesting, recipient artery exposure, microsurgical anastomosis, and closure of the craniotomy. When meticulously performed, with the observance of important details at each stage, this technique offers a high rate of technical success (patency > 90%) with a very low morbi-mortality (respectively 3% and 1%). Some anesthetic parameters have to be considered to insure perioperative technical and clinical success. STA-MCA bypass is a very useful technique for the management of complex or giant aneurysms where surgical treatment sometimes requires the sacrifice and revascularization of a main arterial trunk. It is also a valuable option for the treatment of chronic and symptomatic hemispheric hypoperfusion (Moyamoya disease, carotid or middle cerebral artery occlusion).     

Treatment strategy for giant aneurysms in the cavernous portion of the internal carotid artery

BACKGROUND: As direct surgery to treat giant aneurysms of the ICA is difficult, ICA occlusion is the conventional treatment in patients with BTO tolerance. To determine whether bypass surgery should be performed after carotid occlusion by trapping or proximal occlusion, we developed a treatment strategy that includes BTO and SPECT. METHODS: We report 19 patients with symptomatic giant aneurysms in the cavernous portion of ICA. The appropriate type of bypass surgery was determined by the results of BTO and SPECT. The type of ICA occlusion selected was based on the evaluation of retrograde filling of the aneurysm during BTO. RESULTS: In all 19 patients, the ICA was sacrificed; 10 patients also underwent bypass surgery (low-flow bypass with STA-MCA anastomosis, n = 7; medium-flow bypass with radial artery graft, n = 2; high-flow bypass with vein graft, n = 1). Coil trapping was performed in 11 patients; proximal occlusion in 8. In 18 patients, there were no ischemic complications after treatment; 1 patient who had been treated by proximal ICA occlusion developed transient ischemia due to an intra-aneurysmal thrombus. Cranial nerve palsies were improved in 16 patients. CONCLUSIONS: Based on our experience, we recommend that patients with giant aneurysms in the cavernous portion of the ICA be evaluated by BTO and SPECT. In conjunction with bypass surgery, ICA trapping or proximal occlusion constitutes an effective treatment strategy.     

Superficial temporal artery to middle cerebral artery double bypass via a small craniotomy: technical note

Frontotemporal craniotomy is usually necessary to perform superficial temporal artery (STA)-middle cerebral artery (MCA) double bypass for cerebrovascular occlusive disease. This report describes a less invasive technique of double bypass through a small craniotomy with minimum skin incision. Thirty-four consecutive patients underwent an elective STA-MCA double bypass via a small craniotomy from January 2006 to October 2009. The parietal and frontal branches of the STA were divided through a minimum linear or y-shaped skin incision, and these branches were anastomosed to the supra- and infrasylvian portions of the MCA. No periprocedural complication such as subdural hematoma or cutaneous necrosis occurred. Postoperative cerebral angiography within 6 months showed that the bypasses were patent in all 34 patients. Double STA-MCA bypass via a small craniotomy might be less invasive, especially for patients at high risk for postoperative hemorrhagic complication or cutaneous necrosis.     

Radiation-induced cerebrovasculopathy of the distal middle cerebral artery and distal posterior cerebral artery--case report

A 15-year-old girl underwent partial removal of a pituitary adenoma followed by local irradiation of the brain with a total of 70 Gy through two lateral opposing ports. Twenty years later, she experienced frequent transient ischemic attacks with left sensory disturbance. Cerebral angiography revealed stenoses of the right distal middle cerebral artery (MCA) and the right distal posterior cerebral artery without net-like vessels. There was a severe decrease of vasoreactivity in the right hemisphere. Right superficial temporal artery (STA)-MCA anastomosis was performed. Her neurological deficits were resolved and perfusion reserve capacity had markedly improved 6 months later. We recommend STA-MCA anastomosis in such cases.     

Anastomosis of the superficial temporal artery to the middle cerebral artery for occlusive disease of the bilateral internal carotid arteries with dementia

Two cases are reported of occlusive disease of the bilateral internal carotid arteries with dementia in which the anastomosis of the superficial temporal artery to the middle cerebral artery (STA-MCA bypass) resulted in marked improvement in clinical aspects. One patient was a 29-year-old male who complained of transient weakness of the extremities and memory impairment. Computerized tomography (CT) scans showed multiple small infarctions, while cerebral angiography demonstrated findings of Moya-like disease. The cognitive function tests were subnormal and the study of cerebral blood flow (CBF study) showed diffuse low flow in both hemispheres. Based on his clinical symptoms and CBF study, the STA-MCA bypass was performed on both sides in two stages without complications. Postoperatively, his clinical symptoms and cognitive function improved gradually, in accordance with increased CBF in both hemispheres. Six months after the operation, cognitive function tests were within normal limits. Another patient was a 61-year-old hypertensive male who complained of motor weakness, impairment of memory and urinary incontinence. CT scans showed multiple small infarctions, while cerebral angiography revealed occlusion of both internal carotid arteries at the cervical portion. The cognitive function was at the pre-dementia level, and CBF study revealed diffuse low flow in both hemispheres. Based on the clinical symptoms and CBF study, the STA-MCA bypass was performed on both sides in two stages. Postoperatively, clinical symptoms and cognitive function markedly improved. From our results, the diagnosis of vascular dementia, and indications for the use of STA-MCA bypass in this category of patients are discussed.     

Intraoperative Measurement of Arterial Blood Flow Using a Transit Time Flowmeter: Monitoring of Hemodynamic Changes During Cerebrovascular Surgery

Summary  Background. The purpose of this study was to examine the utility and reliability of arterial flow measurements made with a transit time ultrasonic flowmeter for monitoring blood flow changes during intracranial and carotid surgery.  Method. A total of 25 patients underwent intra-operative arterial blood flow measurements. The pulsatile flow curve and mean flow values were obtained using 1- to 6-mm transit time probes with a dual channel flowmeter. Four cases underwent aneurysm clipping, 11 cases superficial temporal artery (STA) – middle cerebral artery (MCA) bypass, 2 cases external carotid artery (ECA) – radial artery – MCA bypass for aneurysm trapping, and 8 cases carotid endarterectomy. In aneurysm clipping, blood flow in the branches distal to the aneurysm was measured before and after clipping. Blood flow in the STA was measured before and after STA-MCA anastomosis, and blood flow in the internal carotid artery (ICA) cervical portion was measured during carotid endarterectomy. Blood flow in the MCA and STA was monitored during radial artery grafting.  Findings. Blood flow in the STA was elevated after STA-MCA anastomosis. However, post-operative hyperperfusion syndrome was found in some cases whose flow elevation was over 50 ml/min. Also in one case of carotid stenosis, of which blood flow of ICA was elevated to 400 ml/min after carotid endarterectomy, hyperperfusion syndrome was found after surgery. In the cases of MCA aneurysm clipping, decreasing of M2 flow was detected when clipping caused bifurcation stenosis.  Interpretation. We found transit time flow measurement useful for management of cerebrovascular surgery: the technique was simple to use and provided stable, reliable results. The method was able to reveal distal branch flow diminution in aneurysm clipping, or residual flow during temporary clipping in aneurysm surgery, and has the potential to predict post-operative complications such as hyperperfusion by signalling over-elevation of donor artery flow in bypass surgery or ICA flow in carotid surgery.     

A 10-year follow-up of extracranial–intracranial bypass for the treatment of bilateral giant internal carotid artery aneurysms in a patient with fibromuscular dysplasia: case report

Cervicocephalic fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory and non-atherosclerotic arteriopathy which usually affects small- and medium-sized cervical arteries distributed at the atlas and axis interspace. Few cervicocephalic FMD patients are associated with multiple intracranial aneurysms which may rupture or develop. So the authors describe a cervicocephalic FMD patient with a history of right oculomotor palsy in 2000. Angiography revealed bilateral internal carotid artery (ICA) aneurysms and a fusiform aneurysm in right vertebral artery. Typical “string-of-beads” phenomenon was observed in V2 segment of left vertebral artery. The right ICA giant aneurysm was treated by right ICA occlusion and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass at that time. Five years later, the patient presented with paroxysmal weakness in right limbs. The subsequent angiography showed the enlargement of left ICA aneurysm. It was treated satisfactorily with left external carotid artery-saphenous vein-MCA bypass and left ICA ligation. During the long-term follow-up, the patient kept no neurological deficit and the angiography showed good patency of bilateral grafts and the lesions in bilateral vertebral arteries remained unchanged.