Creation of a Middle Communicating Artery With External Carotid Artery-Radial Artery Graft-M2 Middle Cerebral Artery Interpositional Bypass and M2 Middle Cerebral Artery-M2 Middle Cerebral Artery Reimplantation for a Recurrent Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 20 (1) ◽  
pp. E44-E45
Author(s):  
Fabio A Frisoli ◽  
Joshua S Catapano ◽  
Dimitri Benner ◽  
Michael T Lawton
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
External Carotid Artery ◽  
External Carotid ◽  
Radial Artery Graft ◽  
Lenticulostriate Arteries ◽  
Artery Graft

Abstract Dolichoectatic aneurysms of the middle cerebral artery (MCA) bifurcation pose unique treatment challenges.1 One treatment consists of an extracranial-intracranial (EC-IC) interpositional bypass and double-reimplantation of the M2 divisions.2-8 We present a variation of this construct in which an M2 MCA-M2 MCA end-to-side reimplantation was performed, creating a middle communicating artery (MCoA). The patient, a 61-yr-old woman, had previously undergone a “picket fence” clip reconstruction of an unruptured, giant left MCA bifurcation aneurysm in 2014.9 After the patient provided informed written consent for treatment, a 5-yr surveillance angiogram revealed substantial aneurysm regrowth opposite the clips.  A pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. Proximal external carotid artery-radial artery graft (ECA-RAG) anastomosis was performed to arterialize the graft. The distal RAG was anastomosed end-to-side to the temporal division of the M2 segment, and the vessel proximal to the bypass inflow was transected from the aneurysm. We repurposed this “dead-end” as an MCoA by end-to-side reimplantation onto a branch of the frontal M2 trunk. The superior trunk was then clip occluded at its origin at the aneurysm. The aneurysm could not be proximally occluded due to lenticulostriate arteries arising from the back of the bifurcation.  Postoperative angiography confirmed patency of the MCoA and its donor bypasses. The aneurysm no longer filled, and the lenticulostriate arteries were preserved. The patient was discharged on postoperative day 3 and made an excellent recovery (3-mo modified Rankin Scale [mRS] = 1). The MCoA is a novel construct that redistributed flow from the interpositional graft into the superior trunk, without the need for additional ischemia time while working with the inferior trunk. Used with permission from Barrow Neurological Institute.

Left External Carotid Artery to the Middle Cerebral Artery Bypass with Radial Artery Graft and Clip Reconstruction of a Large Middle Cerebral Artery Fusiform Aneurysm: 3-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E159-E160 ◽  
Author(s):  
Chun-Yu Cheng ◽  
Zeeshan Qazi ◽  
Laligam N Sekhar
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Temporal Artery ◽  
External Carotid Artery ◽  
External Carotid ◽  
Fusiform Aneurysm ◽  
Radial Artery Graft ◽  
Artery Graft

Abstract This 16-yr-old boy presented with episodes of severe headaches, blurred vision, dizziness, and muffled hearing and was discovered to have a large fusiform aneurysm of the left middle cerebral artery (MCA), M1 segment, 20 × 12 mm in dimension. The lenticulostriate arteries were arising proximal and distal to the aneurysm, but the anterior temporal artery was arising from the aneurysm. The aneurysm culminated in the distal M1 segment, and M1 immediately branched into 3 M2 vessels, the lower one being the larger. Due to origin of the lenticulostriate arteries and the anterior temporal artery and patient's age, a bypass was preferred to a flow diversion stent.  He underwent left frontotemporal craniotomy and orbital osteotomy, left cervical external carotid artery exposure followed by radial artery graft extraction. The Sylvian fissure was opened and intracranial ICA was exposed for proximal control. The distal M2 vessels traced back toward the aneurysm. The aneurysm was not clippable and a bypass to the larger inferior M2 branch was performed followed by aneurysm trapping. The radial artery graft bypass was placed from the left external carotid artery to the M2 segment of left MCA, followed by clip reconstruction and occlusion of the MCA aneurysm with the preservation of the anterior temporal branch and the lenticulostriate vessels. The patient had no postoperative complications. At the follow-up, one month after surgery, he was doing well, and his angiogram demonstrated patency of the bypass.  This video shows the management of a complex fusiform M1 aneurysm with bypass and trapping.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

External Carotid Artery-to-Middle Cerebral Artery Bypass Using a Saphenous Vein Graft With 3-Vessel Anastomosis for the Treatment of a Large, Ruptured Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kristine Ravina ◽  
Joshua Bakhsheshian ◽  
Joseph N Carey ◽  
Jonathan J Russin
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Saphenous Vein ◽  
Saphenous Vein Graft ◽  
Artery Bypass ◽  
Artery Aneurysm ◽  
External Carotid Artery ◽  
External Carotid ◽  
Bifurcation Aneurysm

Abstract Cerebral revascularization is the treatment of choice for select complex intracranial aneurysms unamenable to traditional approaches.1 Complex middle cerebral artery (MCA) bifurcation aneurysms can include the origins of 1 or both M2 branches and may benefit from a revascularization strategy.2,3 A novel 3-vessel anastomosis technique combining side-to-side and end-to-side anastomoses, allowing for bihemispheric anterior cerebral artery revascularization, was recently reported.4  This 2-dimensional operative video presents the case of a 73-yr-old woman who presented as a Hunt-Hess grade 4 subarachnoid hemorrhage due to the rupture of a large right MCA bifurcation aneurysm. The aneurysm incorporated the origins of the frontal and temporal M2 branches and was deemed unfavorable for endovascular treatment. A strategy using a high-flow bypass from the external carotid artery to the MCA with a saphenous vein (SV) graft was planned to revascularize both M2 branches simultaneously, followed by clip-trapping of the aneurysm. Intraoperatively, the back walls of both M2 segments distal to the aneurysm were connected with a standard running suture, and the SV graft was then attached to the side-to-side construct in an end-to-side fashion. Catheter angiograms on postoperative days 1 and 6 demonstrated sustained patency of the anastomosis and good filling through the bypass. The patient's clinical course was complicated by vasospasm-related right MCA territory strokes, resulting in left-sided weakness, which significantly improved upon 3-mo follow-up with no new ischemia.  The patient consented for inclusion in a prospective Institutional Review Board (IRB)-approved database from which this IRB-approved retrospective report was created.

Treatment of a Giant Thrombotic M1 Segment Middle Cerebral Artery Aneurysm With Radial Artery Bypass and Distal Occlusion to Create a “Blind Sac” Following Endovascular Failure: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Sheila R Eshraghi ◽  
Daniel L Barrow
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Cerebral Angiogram ◽  
Lenticulostriate Arteries ◽  
Thrombosed Aneurysm

Abstract The case is of a 36-yr-old male with a previously coiled aneurysm arising from the proximal M1 segment of the middle cerebral artery (MCA) just beyond the internal carotid artery (ICA) bifurcation who presented to our institution with subjective left hemiparesis, headache, and vomiting. Physical exam revealed a left facial droop, but neurological exam was otherwise normal, including full motor strength. Neuroimaging showed a large partially thrombosed aneurysm recurrence, measuring 5.2 cm, with obstructive hydrocephalus. Cerebral angiogram showed filling within a small portion of the aneurysm and marked stenosis of the MCA beyond the neck. A ventriculostomy was placed, and he underwent a pterional craniotomy for high-flow radial artery bypass from the common carotid artery to an M2 branch of the MCA and clip placement. This case demonstrates the creation of a blind sac by placing a clip on the MCA distal to the aneurysm and proximal to the lenticulostriate arteries for the treatment of a giant proximal M1 segment aneurysm. Postoperative digital subtraction angiography shows the MCA distribution, including the lenticulostriate arteries, filling through the radial artery bypass, and anterograde flow through the ICA, which perfuses up to and including the anterior choroidal artery. There is no residual filling of the aneurysm. The patient remained at his neurological baseline postoperatively and required ventriculoperitoneal shunt placement for hydrocephalus. At outpatient follow-up, computed tomography imaging showed decreased size of the thrombosed aneurysm, measuring 4.5 cm, and he had no neurological deficits. The patient gave informed consent for surgery and deidentified video recording of this case.

Radial Artery Graft for Bypass of the Maxillary to Proximal Middle Cerebral Artery: An Anatomic and Technical Study

Neurosurgery ◽  
2004 ◽  
Vol 54 (3) ◽  
pp. 667-671 ◽  
Author(s):  
Mehmet Erkan Üstün ◽  
Mustafa Büyükmumcu ◽  
Cagatay Han Ulku ◽  
Aynur Emine Cicekcibasi ◽  
Hamdi Arbag
Keyword(s):  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Radial Artery Graft ◽  
Artery Graft ◽  
Proximal Middle Cerebral Artery ◽  
The Mean ◽  
Artery Branch

Abstract OBJECTIVE In this study, we aimed to investigate the use of a radial artery graft for bypass of the maxillary artery (MA) to the proximal middle cerebral artery (MCA) as an alternative to superficial temporal artery-to-MCA anastomosis or extracranial carotid-to-MCA bypass using long grafts. METHODS Five adult cadavers were used bilaterally. After a frontotemporal craniotomy and a zygomatic arch osteotomy, the MA was found easily 1 to 2 cm inferior to the infratemporal crest. A hole was created with a 4-mm-tip drill in the sphenoid bone 2 to 3 mm lateral to the foramen rotundum extradurally, and the dura over the hole was opened. After the carotid and sylvian cisterns had been opened, the M2 segment of the MCA was exposed. The graft was passed through the hole to reach the M2 segment. Then, the MA was freed from the surrounding tissue and was transected before the infraorbital artery branch. The radial artery graft was anastomosed end-to-end to the MA proximally and end-to-side to the M2 segment of the MCA distally. RESULTS The mean thickness of the MA before the infraorbital artery branch was 2.6 ± 0.3 mm. The mean thickness of the largest trunk of the MCA was 2.3 ± 0.3 mm. The average length of the graft was 36 ± 5.5 mm. CONCLUSION MA-to-MCA bypass is as feasible as proximal MCA revascularization using long vein grafts. The thickness of the MA provides sufficient flow; the length of the graft is short, and it has a straight course. MA-to-proximal MCA bypass may be an alternative to superficial temporal artery-to-MCA as well as extracranial carotid-to-MCA bypasses.

Sign in / Sign up

Export Citation Format

Share Document