Cerebral revascularization to a main limb of the middle cerebral artery in the Sylvian fissure. An alternative approach to conventional anastomosis

Thirteen patients underwent an anastomosis of the superficial temporal artery (STA) or a saphenous vein graft to one of the secondary trunks of the middle cerebral artery (MCA). They included five patients with giant MCA trifurcation aneurysms, four patients in whom an earlier conventional STA-MCA anastomosis had become occluded, two patients who had stenosis of one of the secondary limbs of the MCA, and one patient who had a carotid-cavernous fistula. One patient had a saphenous vein graft from the common carotid artery to a secondary trunk of the MCA to bypass an occluded internal carotid artery and severely stenosed external carotid artery. The primary advantages of this procedure are that a large-caliber anastomosis to one of the secondary limbs of the MCA immediately restores flow into the MCA tree with a larger amount of vessel filling than with a standard cortical bypass, and large vessels can be used for the anastomosis. The disadvantages are that one of the secondary branches of the MCA must be occluded, the cerebral hemisphere around the Sylvian fissure must be retracted, a lumbar subarachnoid drain is needed, and the anastomosis must be performed deep within the Sylvian fissure. The procedure is a satisfactory alternative in cases in which a conventional STA-MCA anastomosis has either failed or would be less likely to succeed.     

Endarterectomy for persistent primitive hypoglossal artery--case report.

Persistent primitive hypoglossal artery, an anastomosis between the carotid artery and the vertebrobasilar system, is found in about 0.05% of cerebral angiograms. Though usually asymptomatic, it may occasionally cause ischemic disease. A 62-year-old male presented with left hemiparesis. Right carotid angiograms demonstrated a primitive hypoglossal artery originating from the internal carotid artery at the 2nd cervical spine. This artery supplied almost all blood to the basilar artery system. A marked stenosis extended from the origin of the internal carotid artery to the primitive hypoglossal artery. An endarterectomy of the internal carotid and primitive hypoglossal arteries was performed using a special internal shunt 46 days after the onset. Sudden arterial bleeding from the incised part of the internal carotid artery occurred 12 days after the operation. The carotid artery was resutured. The rupture of the carotid artery appeared to be caused by an infection of Pseudomonas aeruginosa, which was detected by culture of the chronic ear discharge. Rupture of the vessel wall due to infection is an important complication after endarterectomy. This is the second reported endarterectomy of the primitive hypoglossal artery.     

First clinical experience with excimer assisted high flow bypass surgery of the brain

Summary A new type of revascularization of the brain is used in patients with brain ischaemia, caused by an occlusion of one or both internal carotid arteries, and in patients in whom the internal carotid artery has been deliberately occluded for the treatment of a giant aneurysm of the internal carotid artery.A so-called high flow extra-intracranial bypass operation is performed. An arterial or venous transplant is interposed between a branch of the external carotid artery or the external carotid artery itself and the intracranial portion of the internal carotid artery. The anastomosis with the intracranial portion of the internal carotid artery is made without temporary occlusion of the recipient artery and with the aid of the newly developed Excimer laser assisted anastomosis technique.The results of animal experiments and of a clinical series of 9 patients are reported.     

Construction of a new posterior communicating artery in a patient with poor posterior fossa circulation: technical case report

OBJECTIVE AND IMPORTANCE: The carotid and the vertebrobasilar circulation were connected, effectively creating a new posterior communicating artery (PComA). The excimer laser-assisted nonocclusive anastomosis technique is a new anastomosis technique whereby formerly untreatable patients may be treated with an intracranial artery-to-intracranial artery bypass procedure. This report is the first one in which an angiographically proved patent internal carotid artery-posterior cerebral artery segment P1 bypass is presented. CLINICAL PRESENTATION: Our patient presented with repeated episodes of vertebrobasilar ischemia because of vertebral artery occlusion and stenosis. INTERVENTION: An internal carotid artery-posterior cerebral artery segment P1 bypass procedure was performed. Because the patient experienced transient ischemia in the left cerebral hemisphere at the end of postoperative angiography procedure, no radiological intervention was performed, and the patient refused to undergo a new radiological intervention at a later stage. TECHNIQUES: Both anastomoses were made using the excimer laser-assisted nonocclusive anastomosis technique. CONCLUSION: Intraoperative flowmetry was performed using an ultrasound flowmeter, which disclosed blood flow of 35 ml/min through the bypass. We hope that this new PComA suffices to protect the patient from infarction in the territory of the vertebrobasilar circulation.     

Carotid artery aneurysm secondary to cystic medial necrosis

Carotid artery aneurysm secondary to cystic medial necrosis is a rare clinical entity. We report a 59-year-old Chinese male patient who presented with a pulsatile right neck swelling for 2 months. Partial resection of the aneurysm with primary anastomosis of the internal carotid artery was performed. Histopathological examination of the aneurysmal wall demonstrated cystic degeneration of the media with accumulation of glycosaminoglycan material, consistent with the features of cystic medial necrosis. The pathogenesis of carotid artery aneurysm secondary to cystic medial necrosis is discussed.     

Unusual intercarotid anastomosis associated with anterior communicating artery aneurysm. Case report

The case is presented of a 34-year-old man with subarachnoid hemorrhage from rupture of an anterior communicating artery aneurysm. The magnetic resonance imaging and angiographic findings are reported. Angiography showed the aneurysm plus an unusual anastomosis between the intracavernous portions of both internal carotid arteries. The anastomosis crossed posterior to the base of the dorsum sellae and was associated with absence of the right internal carotid artery and the A1 segment of the right anterior cerebral artery. This is the 11th case of such an unusual intercarotid anastomosis reported in the literature.     

Surgical management of carotid artery aneurysm with ball valve thrombus

Operative repair of extracranial carotid artery aneurysms has been infrequently reported. A unique case is presented in which an aneurysm of the cervical internal carotid artery contained a ball valve thrombus. The patient experienced transient ischemic attacks whenever a position was assumed which permitted occlusion of the internal carotid artery by the free floating thrombus. The aneurysm and thrombus were successfully resected and primary anastomosis of the internal carotid artery carried out to the common carotid artery. The patient has remained free of cerebrovascular ischemic symptoms for 18 months following operative repair. The previously reported surgical experience with extracranial carotid artery aneurysms is reviewed.     

Treatment of carotid-cavernous sinus fistula by the balloon technique combined with a by-pass procedure using a vein graft-technical note note

A case with spontaneous carotid-cavernous fistula treated by balloon catheter technique combined with a extra-intracranial by-pass using a saphenous vein graft between the common carotid artery and the middle cerebral artery is reported. A 72-year-old female was admitted with complaints of recurrent symptoms of carotid-cavernous fistula 4 months after spontaneous remission. Angiograms showed the presence left internal carotid-cavernous sinus fistula. Poor cross-filling from the right internal carotid artery to the territory of the left internal carotid artery via the hypoplastic right A1 and left posterior communicating artery was also observed. Symptoms such as chemosis, exophthalmos and visual disturbance gradually progressed during the hospitalization. A common carotid-middle cerebral artery anastomosis was performed with a saphenous vein graft and the carotid cavernous fistula was occluded directly with a balloon catheter. The blood flow via the graft, cortical blood flow, cortical tissue O2 and CO2 were continuously measured during the operation. After the internal carotid artery occlusion, sufficient blood flow via the graft and no significant changes of the cortical blood flow, cortical tissue O2 and CO2 were observed. The postoperative angiogram showed that the by-pass was patent and all branches of the left internal carotid artery were filled via the by-pass. The postoperative course was uneventful and the progressive symptoms improved except for visual disturbance on the left. She is in good condition one year after the operation. The usefulness of this surgical procedure with monitoring of cerebral blood flow and metabolism during operation is also discussed.     

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.     

Internal carotid artery agenesis: correlation by conventional and digital subtraction angiography, and by computed tomography

A case is presented of agenesis of the right internal carotid artery in a fifteen-year-old female with an unrelated seizure disorder. Conventional angiography revealed an absent right internal carotid artery, supply to the right anterior cerebral artery from the left internal carotid artery, and supply to the right middle cerebral artery by anastomosis through the vertebral basilar system. The congenital nature of the anomaly was confirmed by intravenous digital subtraction angiography, which revealed no portion or remnant of the right internal carotid artery to be present, and by computerized tomography of the base of the skull, which demonstrated no bony carotid canal on the right side. This is the first reported case of internal carotid artery agenesis to be elucidated by intravenous digital subtraction angiography. A brief discussion concerning the congenital nature of this anomaly is presented, including the role of angiography and computed tomography in establishing the diagnosis of this condition.     

Persistent hypoglossal artery: An anomaly leading to false-positive carotid duplex sonography

Duplex ultrasonography is becoming increasingly popular as the sole diagnostic test in the evaluation of carotid artery bifurcation disease. We present a patient with a persistent hypoglossal artery, a rare primitive internal carotid-basilar anastomosis, masquerading as an internal carotid artery stenosis on ultrasound. The operative management of this anomaly is reviewed.     

Systemic multiple aneurysms of the extracranial internal carotid artery, intracranial vertebral artery, and visceral arteries: case report.

A rare case of systemic multiple aneurysms located in the extracranial internal carotid artery, intracranial vertebral artery, and intraperitonial arteries is described. A 56-year-old woman was referred to our hospital with suspected rupture of an aneurysm of the right extracranial internal carotid artery. Digital subtraction angiography demonstrated a giant aneurysm in the right extracranial internal carotid artery and an aneurysm of fusiform type of the left intracranial vertebral artery. The extracranial carotid artery aneurysm was successfully resected, with end-to-end anastomosis of the internal carotid artery, preserving the cranial nerves. Five days later, an aneurysm of the left hepatic artery ruptured unexpectedly and was treated with emergency surgery. Other aneurysms in the liver and spleen were identified on postoperative celiac angiography. The patient subsequently underwent an operation for a left intracranial vertebral artery aneurysm by proximal clipping.     

Improvement of cerebral blood flow and/or CO2 reactivity after superficial temporal artery-middle cerebral artery bypass in patients with transient ischemic attacks and watershed-zone infarctions

The effect of extracranial-intracranial bypass anastomosis on cerebral blood flow and CO₂ reactivity during hypocapnia was investigated in ten patients with transient ischemic attacks or watershed infarctions due to carotid occlusive diseases. Six patients had occlusion and four had stenosis (>50%) of the internal carotid artery. Those with infarctions had increased cerebral blood flow and CO₂ reactivity postoperatively, and improved clinically. Those with transient ischemic attacks due to stenosis (>50%) of the internal carotid artery had increased CO₂ reactivity postoperatively but constant normal regional blood flow. Cerebral blood flow improved in those with poorer flow, CO₂ reactivity increased in those with better reactivity, and better CO₂ reactivity preoperatively brought about a greater flow increase. The pre- and postoperative evaluation of cerebral blood flow and CO₂ reactivity is believed to be useful in evaluating the effectiveness of bypass anastomosis. Preoperative evaluation might be informative in selecting candidates for bypass.     

External carotid-basilar anastomosis: case report (author's transl)]

The occipital-vertebral anastomosis is one of the anastomotic channels between the external carotid system and the intracranial vessels. In this paper, we have reported a large, left external carotid-basilar anastomosis which was incidentally revealed in a patient with left hemiparesis due to arteriosclerotic occlusion of the right internal carotid artery. A 55-year-old man suddenly developed left hemiparesis without headache, unconsciousness or vomiting on the morning of January 15, 1973. When he was referred to our service on April 11, the noticeable neurological findings were left hemiparesis and left homonymous hemianopsia. The right carotid angiogram revealed occlusion of the internal carotid artery associated with collateral channels from the external carotid artery. Also a segment of the vertebral artery was visualized via the muscular branch of the occipital artery. In the left carotid angiogram, the posterior circulation was markedly visualized throught the left vertebral artery originating from the external carotid artery trunk. This anastomotic vessel had a large branch with constant caliber leading to the occipital fossa. But the posterior cerebral artery was directly visualized from the internal carotid artery without connection to the basilar artery. Repeated bilateral brachial angiograms revealed hypoplasis of the vertebral arteries. It was suggested that the persistent external carotid-basilar anastomosis might be constantly associated with hypoplasia or aplasia of the bilateral vertebral arteries.     

The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.     

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.     

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.     

New surgical procedures for the management of carotid kinking

Three new operative techniques for the management of the kinking of the internal carotid artery are reviewed. Method 1: Resection of the internal carotid artery, end-to-end anastomosis with patch-graft angioplasty. Method 2: In situ reimplantation of the internal carotid artery by grafting. Method 3: Shortening of the internal carotid artery by suturing and its dilatation by patch-grafting. The advantages and the conditions of application of these methods are reported. Their application is also recommended to others.     

Complete imaging study of internal carotid artery agenesis with intercavernous anastomosis

We report a complete imaging study of an exceptional developmental anomaly of the internal carotid artery in a 42-year-old man presenting with a few days history of left visual blurring. MRI and conventional angiography demonstrated unilateral cervical and petrous agenesis of the left internal carotid artery, with an intercavernous anastomosis. CT-scan revealed total absence of the bony carotid canal. We briefly review the embryological hypotheses and discuss clues to correct diagnosis.