Subarachnoid hemorrhage from intracranial dissecting aneurysms of the anterior circulation. Two case reports.

Two rare cases of intracranial dissecting aneurysms of the anterior circulation associated with subarachnoid hemorrhage (SAH) are described. A 56-year-old female presented with a dissecting aneurysm in the proximal segment of the left middle cerebral artery. Proximal occlusion of the affected artery and a superficial temporal artery-middle cerebral artery anastomosis were performed, but the outcome was poor. A 61-year-old male presented with a dissecting aneurysm in the proximal segment of the left anterior cerebral artery. Clipping was enhanced by a piece of fascia lata, allowing patency of the affected artery with a satisfactory outcome. Dissecting aneurysm of the carotid system should be considered in a patient with SAH but no evidence of berry aneurysm.     

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     

Improvement of ischemic symptoms and cerebral blood flow after percutaneous transluminal angioplasty for renovascular hypertension. Report of a case with multiple cerebrovascular occlusive disease]

A 53-year-old male complained of frequent left motor-sensory transient ischemic attack for 4 months. On admission, he demonstrated mild right hemiparesis, dysarthria, and right hemisensory disturbance of all modalities. Cerebral angiography demonstrated complete occlusion of the left internal carotid artery just above the origin of the ophthalmic artery and a stenotic lesion at the horizontal segment of the right middle cerebral artery. Renal angiography showed severe stenosis of the right renal artery. Systolic blood pressure was over 200 mmHg and marked circadian variation of blood pressure was noted. Serum renin was 4.0 ng/ml/hr. Four months after superficial temporal artery-middle cerebral artery anastomosis, left carotid angiography showed good patency of the bypass and the ischemic symptoms completely disappeared. Single photon emission computed tomography (SPECT) showed increased cerebral blood flow (CBF), especially in the left hemisphere after surgery. Six months after the bypass surgery, he complained of mild right hemiparesis again. Shortly after percutaneous transluminal angioplasty (PTA) for renal arterial stenosis, his hemiparesis was improved and the systolic blood pressure stabilized to 150-170 mmHg. SPECT showed the CBF had also recovered in both hemispheres. The improvement in ischemic symptoms and increased CBF after PTA were probably related to stabilization of the systemic blood pressure or inhibition of serum renin-angiotensin.     

Preoperative construction of an extracranial arterial shunt for resection of an aortic arch aneurysm with occluded left carotid artery

A 68-year-old man with aortic arch aneurysm was referred to our department. Preoperative carotid echography and magnetic resonance angiography revealed occlusion of the left internal carotid artery. Single-photon emission computed tomography scanning indicated that cerebral blood flow was decreased and reactivity to acetazolamide was reduced in the left temporal lobe. A successful superficial temporal artery-middle cerebral artery anastomosis was first made by neurosurgeons. A postoperative single-photon emission computed tomography scan showed that cerebral blood flow and reactivity to acetazolamide were remarkably improved. Two months after the anastomosis, the aortic arch aneurysm was successfully repaired.     

Posterior Auricular Artery-Middle Cerebral Artery Bypass: A Rare Superficial Temporal Artery Variant with Well-developed Posterior Auricular Artery—Case Report

The posterior auricular artery (PAA) is one of the branches of the external carotid artery, but is usually too small for use as a donor artery for middle cerebral artery (MCA) territory revascularization. An extremely unusual case of PAA-MCA anastomosis was performed in a patient requiring MCA territory revascularization because the superficial temporal artery (STA) parietal branch was absent and the PAA was large enough. A 65-year-old man developed mild motor weakness in the right extremities caused by multiple small infarctions. Single photon emission computed tomography (CT) revealed deterioration of the vascular reserve capacity in the left MCA area. Cerebral angiography showed severe stenosis in the C2 portion of the left internal carotid artery, absence of the parietal branch of the left STA, and a well-developed PAA extending to the parietal area. The patient underwent STA (frontal branch)-MCA and PAA-MCA double anastomosis, and has suffered no stroke or transient ischemic attack. The STA with no bifurcation is known as a rare variation. The PAA also occurs with size variations but well-developed PAA is thought to be extremely rare. PAA can be used as a donor artery for MCA territory revascularization if the vessel size is suitable. Preoperative evaluation of the anatomy is mandatory for harvesting the arteries.     

Transverse cervical artery bypass pedicle for treatment of common carotid artery occlusion: new adjunct for revascularization of the internal carotid artery domain.

OBJECTIVE: We present two cases of common carotid artery occlusion that were treated by vascular reconstruction using the transverse cervical artery. METHODS: Two patients with common carotid artery occlusion presented with transient ischemic attacks resulting from decreased cerebral blood flow on the affected side. Both patients underwent vascular reconstruction using the transverse cervical artery. The transverse cervical artery was anastomosed to the ipsilateral external carotid artery at its origin, as a pedicle graft. A superficial temporal artery-middle cerebral artery anastomosis was then performed. RESULTS: The postoperative courses were uneventful. The transverse cervical artery bypass grafts were patent, and cerebral blood flow increased to normal levels. CONCLUSION: Transverse cervical artery grafting provides a less tedious alternative to saphenous vein interposition grafting for revascularization of the internal carotid artery domain.     

Surgical treatment and radiological consideration of supergiant cerebral aneurysms

We have collected four cases of supergiant cerebral aneurysm, each greater than 6.0 cm in diameter. Two of these cases were saccular aneurysms of the anterior communicating artery and middle cerebral artery, of which the necks were clipped with resection of the aneurysms. Another patient had a fusiform aneurysm of the middle cerebral artery, which was resected accompanied by a reconstructive procedure of cerebral blood flow. The last patient had a fusiform aneurysm of the internal carotid artery. Following internal carotid artery occlusion surgery with superficial temporal artery-middle cerebral artery anastomosis, the aneurysm completely disappeared radiologically within several months.     

Pseudoaneurysm complicating superficial temporal artery--middle cerebral artery bypass

A patient with transient ischemic attacks from occlusion of a left common carotid artery was treated with common carotid endarterectomy immediately followed by superficial temporal artery-middle cerebral artery bypass. Subsequent angiography demonstrated a pseudoaneurysm formation at the anastomotic site. To our knowledge, this is the first report of this complication occurring in a human being.     

上颌动脉-大脑中动脉血管搭桥的解剖学研究

【摘要】〓目的〓探讨上颌动脉与大脑中动脉第二段近端之间进行血管搭桥的可行性。方法 解剖观察10具尸头标本(20侧)的颞浅动脉、上颌动脉及颞深动脉、大脑中动脉分叉部、颈总动脉分叉部及颈外、颈内动脉起始部,分别测量其外径,颈外、颈内动脉起始部及上颌动脉至大脑中动脉分叉部移植血管的走行距离。多普勒超声检查10例健康成人(20侧)的上颌动脉、颈总、颈外、颈内动脉及颞浅动脉主干、额支、顶支的内径和相关血流动力学参数。 结果〓尸头解剖上颌动脉外径为(2.60±0.20) mm,大于颞浅动脉分叉部外径(1.70±0.30) mm,两者差异具有统计学意义(P<0.05);上颌动脉至大脑中动脉分叉部移植血管的行程为(61.70±1.50) mm,而颈外、颈内动脉至大脑中动脉分叉部移植血管的行程分别为(162.40±2.60) mm、(171.00±2.70) mm。超声多普勒检查上颌动脉第二段血流量为(62.70±13.30) mL/min,而颞浅动脉额支、顶支血流量仅(15.90±3.70) mL/min、(17.70±4.10) mL/min,均具有统计学差异(P<0.05)。结论〓上颌动脉与大脑中动脉第二段近端进行血管搭桥是切实可行的,具有血流量大、移植血管短、路径直等优点,是一种有效的颅内外血管搭桥方法。     

Temporal profile of de novo development of moyamoya vasculopathy in an adult: case report

A 46-year-old woman developed transient ischemic attack (TIA) caused by progressive moyamoya vasculopathy in the right hemisphere. She had presented with minor cerebellar infarction due to left vertebral artery dissection 7 years prior to the onset of TIA. Initial carotid angiography at the onset of vertebral artery dissection demonstrated absence of steno-occlusive changes in the anterior circulation. During the next 7 years, she had been strictly followed up with magnetic resonance angiography every 6 months, which demonstrated the asymptomatic development of steno-occlusive change in the proximal right middle cerebral artery, finally involving the terminal internal carotid artery. Carotid angiography at the onset of TIA showed terminal internal carotid artery stenosis with abnormal vascular network at the right base of the brain, indicating a definitive diagnosis of moyamoya vasculopathy with unilateral involvement. She underwent right superficial temporal artery-middle cerebral artery anastomosis without complication one month later. TIA completely disappeared after surgery, and no cerebrovascular events occurred during the follow-up period of 6 months. De novo formation of moyamoya vasculopathy is extremely rare in adulthood. The present case demonstrated the entire temporal profile of the development of this rare entity in adulthood. The previous presentation of vertebral artery dissection before the development of moyamoya vasculopathy as well as the initiation of steno-occlusive change at the middle cerebral artery is apparently unique.     

Extracranial-intracranial arterial bypass in the management of symptomatic vasospasm

Delayed neurologic deterioration from vasospasm remains the greatest cause of morbidity and mortality following subarachnoid hemorrhage. The authors performed superficial temporal artery-middle cerebral artery bypass in three patients with symptomatic vasospasm and studied its effects on cerebral hemodynamics. All three patients responded neurologically to the bypass procedure within 24 hours. The average cerebral blood flow in the region supplied by the spastic middle cerebral artery increased from 40 ml/100 g/min to 49 ml/100 g/min after bypass. Angiography disclosed dilatation of donor vessels during the peak of spasm, followed by their decrease in caliber coincident with alleviation of vasospasm. The authors conclude that superficial temporal artery-middle cerebral artery anastomosis for the management of symptomatic vasospasm can increase blood flow in the ischemic region supplied by the spastic artery. This management strategy may lower the incidence of death and disability from vasospasm after subarachnoid hemorrhage.     

Giant aneurysm at the junction of the left internal carotid and persistent primitive trigeminal arteries--case report.

A 67-year-old female presented with an unruptured giant aneurysm at the junction of the left internal carotid artery (ICA) and the persistent primitive trigeminal artery (PTA), manifesting as progressive left abducens nerve paresis. The PTA was clipped by the left suboccipital approach. The aneurysm was then successfully thrombosed by ligation of the left ICA at the cervical portion following left superficial temporal artery-middle cerebral artery anastomosis. The left abducens nerve paresis improved postoperatively. Magnetic resonance imaging was of considerable value in the pre- and postoperative evaluation of the giant aneurysm.     

Fatal complication of the "bonnet bypass": case report

A patient with transient ischemic attacks and an occluded right common carotid artery underwent a left superficial temporal artery to right middle cerebral artery vein graft (bonnet bypass). One week after operation, minor trauma to the scalp caused avulsion of the anastomosis and a massive fatal acute subdural hematoma. The mechanism of the vascular avulsion and precautions to be taken to avoid such problems in other patients undergoing this procedure are discussed.     

Treatment of bilateral mycotic intracavernous carotid aneurysms. Case report

A case of bilateral mycotic intracavernous carotid aneurysms is reported. Because of progressive bilateral ophthalmoplegia, the internal carotid artery (ICA) was ligated on both sides, combined with bilateral extracranial-intracranial arterial bypass. A superficial temporal artery-middle cerebral artery anastomosis was performed first on the right side followed by ligation of the right ICA at the neck. After an interval of 20 days, a bypass and ICA ligation was carried out on the left side. The patient developed mild hemiparesis and dysphasia during and immediately after the second operation, but these neurological deficits disappeared after elevation of systemic blood pressure.     

Hyperbaric oxygen as an adjunct to acute revascularization of the brain

Two recent cases suggest that hyperbaric oxygen may be an important adjunct to the surgical treatment of occlusion of major cerebral arteries within the first few hours after onset of neurological deficit. In both patients, one with an embolus to the right middle cerebral artery and one with a surgical occlusion of the left internal carotid artery, circulation to the ischemic area was restored more than eight hours after occlusion. In the patient with the middle cerebral artery embolus, hemiplegia cleared after a six-minute exposure to hyperbaric oxygen. The patient with occlusion of the internal carotid artery was revascularized by anastomosis of a superficial temporal artery less than 1 mm in diameter to a branch of the middle cerebral artery. Her hemiplegia and aphasia cleared rapidly and concomitantly with intermittent exposure to hyperbaric oxygen during the first nine postoperative days. Postoperative angiograms demonstrated patency in both cases. The implications of these observations are discussed.     

Moyamoya disease with persistent primitive hypoglossal artery. Case report

A 44-year-old female developed aphasia and visual disturbance of the left eye. Four-vessel angiography showed occlusion of the extra- and intracranial portions of the right internal carotid artery, severe stenosis of the left internal carotid fork, bilateral moyamoya vessels, and a persistent primitive hypoglossal artery on the left side. Measurement of cerebral blood flow by 133xe inhalation revealed decreased flow and no response to acetazolamide loading in the left cerebral hemisphere. The patient underwent superficial temporal artery-middle cerebral artery anastomosis, first on the left and then on the right side. There have been no other reported cases of moyamoya disease associated with a persistent primitive hypoglossal artery. Although the cause of moyamoya disease remains to be established, it is generally believed that stenotic changes of the carotid fork cause the development of moyamoya vessels as collateral pathways. According to this theory, there is no significant etiological relationship between moyamoya disease and persistent primitive hypoglossal artery. However, persistent primitive hypoglossal artery is compatible with moyamoya disease in terms of providing a collateral pathway via the vertebrobasilar system.     

Giant pediatric aneurysm treated with ligation of the middle cerebral artery with the Drake tourniquet and extracranial-intracranial bypass

Saccular intracranial aneurysms occur infrequently in children, and the incidence of pediatric giant aneurysms is statistically in the same proportion as in adults. The management of these giant aneurysms can be treacherous. This paper presents a case of a 9-year-old boy with a giant aneurysm of the right middle cerebral artery that was successfully managed by ligation of the middle cerebral artery using a Drake tourniquet with the patient awake and by augmentation of the middle cerebral artery circulation with superficial temporal artery-middle cerebral artery anastomosis without excision of the lesion.     

Traumatic stenosis of the internal carotid artery in children

Two cases of stenosis of the internal carotid artery after blunt craniocervical trauma in children are described. Their neurological symptoms developed a few hours after the injury. A superficial temporal artery-middle cerebral artery anastomosis was performed in one, and the other was conservatively treated because of the spontaneous resolution of the stenosis. The pathophysiology and treatment of this clinical entity, especially in children, are discussed.     

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.