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.     

Vertebral artery-posterior inferior cerebellar artery bypass with a superficial temporal artery graft to treat aneurysms involving the posterior inferior cerebellar artery

OBJECT: In patients with aneurysms that require occlusion of the posterior inferior cerebellar artery (PICA), revascularization of this artery should be performed. A novel surgical method for revascularization of the PICA is presented. METHODS: After a segment of the superficial temporal artery (STA) was harvested, the aneurysm was treated by trapping, followed by placement of a vertebral artery (VA)-PICA bypass in which the STA segment was used as a graft. When the length of the proximal PICA was inadequate, the distal end of the STA was anastomosed to the proximal PICA in an end-to-side fashion. When the length of the proximal PICA was adequate, the STA was anastomosed to the proximal PICA in an end-to-end fashion. In either case, the proximal end of the STA was anastomosed to the VA in an end-to-side fashion. This procedure was used in nine patients whose aneurysms involved the PICA. Although partial lateral medullary syndrome developed in one of them, follow-up evaluation revealed graft patency in all patients. There were no instances of recurrent hemorrhage or ischemia. CONCLUSIONS: Although this procedure requires harvesting of an STA graft and two anastomoses, it facilitates anterograde flow to the PICA territory. It also involves minimal mobilization of brainstem perforating vessels and the proximal PICA.     

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).     

Training of A3-A3 side-to-side anastomosis in a deep corridor using a box with 6.5-cm depth: technical note

BACKGROUND: Cerebral revascularization in the deep surgical field is technically challenging. Especially, side-to-side anastomosis like A3-A3 could be technically more difficult compared with end-to-side anastomosis. To improve surgeon's dexterity and maneuverability in the deep surgical field, the authors developed an easily accessible and well-simulating training system using prosthetic tubes and a box. METHODS: Two prosthetic tubes (silicon tube, 1.2 mm in diameter) are mounted in parallel on the bottom of 6.5-cm-deep emptied 'tissue paper box.' The orifice of the box is restricted to 2 x 2 cm to simulate a deep and narrow surgical corridor. Using bayonet-shaped micro needle holder and forceps, the side-to-side anastomosis of the tubes is performed with 10-0 nylon under operative microscope. RESULTS: Prosthetic tubes well simulated real A3-A3 anastomosis. From the standpoint of technical difficulty, this training system needed slightly higher level of dexterity compared with real A3-A3 anastomosis because of narrower and deeper surgical corridor, and the wall of prosthetic tube was slightly thicker and more inflexible. After this training, the surgical technique in real A3-A3 anastomosis was improved. CONCLUSIONS: This training system worked well to ease the transition from anastomosis in shallow surgical field to deep and narrow surgical field. The prosthetic tube we used approximates real A3 relatively well, and the ease in setting up this system enabled repeated practice, which resulted in steep learning curve of the technique.     

Proximal superficial temporal artery to proximal middle cerebral artery bypass using a radial artery graft: an anatomic approach

We present the use of radial artery graft for bypass of the proximal superficial temporal artery to the proximal middle cerebral artery. Six adult cadaver sites were used bilaterally. After apterional incision, 2×2-cm minicraniectomy was performed which began 2 cm behind the zygomatic process of the frontal bone. The superficial temporal artery was transsected before exposing the zygomatico-orbital artery branch. The proximal side of the radial artery graft was anastomosed end-to-end to the proximal superficial temporal artery and the distal side end-to-side to the proximal middle cerebral artery. The mean calibers of the proximal superficial temporal artery and largest trunk of the middle cerebral artery were 2.25±0.35 mm and 2.3±0.3 mm, respectively. The average graft length was 85±5.5 mm. We conclude that such bypasses are simpler than proximal middle cerebral artery revascularization using long vein grafts. This method proves that the caliber of the proximal superficial temporal artery is more suited to providing sufficient flow than the distal superficial temporal artery, and the graft is short. Such bypasses to the middle cerebral artery may be an alternative to those from the distal superficial temporal artery or extracranial carotid artery.     

A modified technique to treat chronic and subacute subdural hematoma: technical note

BACKGROUND: We present a patient on warfarin in whom a drainage port system was attached to the skull, successfully draining a subacute subdural hematoma. CASE DESCRIPTION: An elderly male presented to our institution with right hemiparesis a week following a motor vehicle accident. He was on warfarin for recurrent pulmonary emboli and suffered from severe coronary artery disease. Physical examination demonstrated a grade 3/5 hemiparesis and a computerized tomography (CT) scan confirmed the diagnosis of subacute subdural hematoma. He underwent twist drill craniostomy and attachment of the subdural evacuating port system. Recovery in this patient was dramatic. CONCLUSION: The subdural evacuating port system (SEPS) permits the neurosurgeon to drain subacute or chronic hematomas by a method that is minimally invasive, simple, and safe. The SEPS appears to promote brain expansion without the potential biohazards of other standard techniques.     

Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow

PURPOSE: Use of inflow sources distal to the common femoral artery (CFA) for bypass to infrapopliteal arteries is a compromise measure when the length of the vein is not adequate. The purpose of this study was to compare the clinical outcome of vein infrapopliteal bypass arising from the CFA and from the distal superficial femoral or popliteal and tibial arteries in patients with limb-threatening ischemia. METHODS: Over 13 years, 160 vein infrapopliteal vein bypass procedures (160 patients) were randomized into 2 groups, 80 with inflow arising from the CFA (group 1) and 80 with inflow from below the CFA (group 2). Patency and limb salvage rates were assessed with the Kaplan-Meier method. All patients underwent graft surveillance at discharge and at 30 days and 6 months after surgery, then every 6 months thereafter. Follow-up ranged from 30 days to 127 months (mean, 49 months). RESULTS: Groups were similar with regard to age, sex, and most atherosclerotic risk factors. Gangrene as an indication for surgery was statistically more frequent in group 1 (73.7% vs 48.7%; P = .002), whereas nonhealing ulcer and rest pain were statistically more frequent in group 2 (respectively, 51.2% vs 25%; P = .001 and 46.2% vs 28.7%; P = .03). No patients died during the perioperative (30 days) period. At 1, 3, and 5 years patency and limb salvage rates were comparable between groups, tending toward significance for the 5-year primary patency rate (73% vs 57%; P = .08). CONCLUSIONS: In the absence of significant proximal disease, infrapopliteal revascularization arising distal to the CFA can ensure patency and limb salvage rates statistically similar to those with use of the CFA. Moreover, procedures arising distal to the CFA required fewer graft revisions to maintain patency of failing grafts.     

A case of simultaneous operation of coronary artery bypass and ascending aorta to bifemoral bypass for ischemic heart disease combined with bilateral leg ischemia]

A 58-year-old man was admitted to our hospital because of angina pectoris with severe intermittent claudication. Angiography showed triple-vessel disease of the coronary artery and complete obstruction of the bilateral common iliac arteries from their origins. Both femoral arteries were patent by collateral supplies. Combined revascularization of coronary and femoral arteries was performed. Coronary arteries were bypassed with in situ left internal thoracic artery, gastroepiploic artery and saphenous vein graft. Bilateral femoral arteries were bypassed with externally supported Dacron graft from ascending aorta through the preperitoneal space. The patient recovered well and postoperative angiography revealed all bypass grafts patent.     

Presentation and surgical management of a superficial temporal artery pseudoaneurysm: A case report

Introduction and ImportanceA Superficial Temporal Artery Pseudoaneurysm is an uncommon, but important, differential diagnosis for masses in the head and neck region.This work has been reported in line with SCARE 2020 criteria [1].Case PresentationAn 81-year-old male presented to the Oral and Maxillofacial Department with a facial swelling that had been present for a duration of three weeks. A provisional diagnosis of a haematoma was made and an ultrasound carried out to confirm diagnosis. Ultrasonography and CT Angiography confirmed a pseudoaneurysm arising from the left superficial temporal artery.Clinical DiscussionAlthough this is a relatively uncommon diagnosis it is important to be aware of the key diagnostic tools used to identify a pseudoaneurysm. Specifically, their potential to exclude a pseudoaneurysm prior to diagnosing a simple post-traumatic haematoma. This is important as the treatment strategies for the two pathologies differ considerably. Useful learning points from this case include diagnostic aids such as the unique pulsatile nature of the mass and the role of ultrasonography and CT Angiography in confirming diagnosis and guiding surgical management.ConclusionPseudoaneurysms are an important consideration as a differential diagnosis of masses in the head and neck region. This case report may impact upon management of future similar cases by highlighting significant aspects of their clinical diagnosis and surgical management, enabling early identification and appropriate management.     

Simultaneous superficial temporal artery to middle cerebral or anterior cerebral artery bypass with pan-synangiosis for Moyamoya disease covering both anterior and middle cerebral artery territories

Some patients with moyamoya disease treated by conventional surgical procedures may develop postoperative refractory ischemia and perioperative cerebral infarction in the anterior cerebral artery (ACA) territory. We present a novel operative procedure for moyamoya disease to avoid the risk of ischemia in the ACA territory, which consists of simultaneous superficial temporal artery (STA) to middle cerebral artery (MCA) or ACA bypass with pan-synangiosis, encephalo-duro-arterio-myo-synangiosis for the lateral frontal and temporal areas, and encephalo-galeo-arterio-synangiosis for the medial frontal area. This procedure can establish direct bypass to the ACA territory at the first intervention. Simultaneous STA-MCA and STA-ACA bypasses with pan-synangiosis is suitable for patients with moyamoya disease associated with severely impaired perfusion of the ACA territory requiring direct bypass surgery.     

A pilot study of cerebral tissue oxygenation and postoperative cognitive dysfunction among patients undergoing coronary artery bypass grafting randomised to surgery with or without cardiopulmonary bypass*

Coronary artery bypass surgery, performed with or without cardiopulmonary bypass, is frequently followed by postoperative cognitive decline. Near‐infrared spectroscopy is commonly used to assess cerebral tissue oxygenation, especially during cardiac surgery. Recent studies have suggested an association between cerebral desaturation and postoperative cognitive dysfunction. We therefore studied cerebral oxygen desaturation, defined as area under the cerebral oxygenation curve < 40% of > 10 min.%, with respect to cognitive performance at 4 days (early) and 3 months (late) postoperatively, compared with baseline, using a computerised cognitive test battery. We included 60 patients, of mean (SD) age 62.8 (9.4) years, scheduled for elective coronary artery bypass grafting, who were randomly allocated to surgery with or without cardiopulmonary bypass. Cerebral desaturation occurred in only three patients and there was no difference in cerebral oxygenation between the two groups at any time. Among patients who received cardiopulmonary bypass, 18 (62%) had early cognitive decline, compared with 16 (53%) in the group without cardiopulmonary bypass (p = 0.50). Three months after surgery, 11 patients (39%) in the cardiopulmonary bypass group displayed cognitive dysfunction, compared with four (14%) in the non‐cardiopulmonary bypass group (p = 0.03). The use of cardiopulmonary bypass was identified as an independent risk factor for the development of late cognitive dysfunction (OR 6.4 (95% CI 1.2–33.0) p = 0.027. In conclusion, although cerebral oxygen desaturation was rare in our population, postoperative cognitive decline was common in both groups, suggesting that factors other than hypoxic neuronal injury are responsible.     

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.     

Clipping and superficial temporal artery-M2 bypass for unruptured anterior communicating artery aneurysm associated with atherosclerotic internal carotid artery occlusion: report of 2 cases

BACKGROUND: The management of the unruptured AcomA aneurysm associated with atherosclerotic occlusion of the unilateral internal carotid artery (ICA) raises several strategic dilemmas. METHODS: Two such patients with unruptured aneurysm on the AcomA, which supply cross-flow toward the hemisphere with ICA occlusion, are presented. RESULTS: Both patients were treated with STA-M2 bypass followed by clipping of the unruptured AcomA aneurysm in 1 stage through the transsylvian route. Both patients were doing well without neurological deficit nor cognitive impairment at 1 year follow-up. CONCLUSIONS: In the surgical treatment of unruptured AcomA aneurysm with atherosclerotic ICA occlusion, preceding bypass would be ideal in case of intraoperative rupture as well as to reduce perioperative ischemia if the bypass procedure itself could be performed with minimal risk. Enough and atraumatic exposure of the sylvian fissure contributed to reduce brain retraction during the clipping of AcomA aneurysm and, in addition, to ease the STA-M2 bypass.     

Correction to: Efficacy of superficial temporal artery-middle cerebral artery double bypass in patients with hemorrhagic moyamoya disease: surgical effects for operated hemispheric sides

Neurosurgical Review - Table 2 of the original version of this article contained an added data. Correct Table 2 is presented here.     

Unexpected hemodynamic deterioration and mitral regurgitation due to a tissue stabilizer during left anterior descending coronary anastomosis in off-pump coronary artery bypass graft surgery.

We have experienced three rare cases of hemodynamic deterioration and transient mitral regurgitation (MR) induced by a suction-type tissue stabilizer during the left internal thoracic artery (LITA)-to-LAD (left anterior descending) coronary artery anastomosis. Transesophageal echocardiogram (TEE) showed new or worsening MR during the placement of a tissue stabilizer. In all three cases, the positioning of the stabilizer was difficult to secure a good surgical field, because the LAD coronary artery migrated deep into the myocardium. This anatomical variation seemed to require a stronger fixation of the stabilizer to the heart. We concluded that compression of the left ventricular (LV) wall may have possibly caused morphologic changes of the LV and the distortion of the annulus of the mitral valve. These changes are thought to have caused decreased LV filling and the MR, which led to an unexpected hemodynamic deterioration.