Twenty-Year Follow-up of Flow Reversal and Revascularization for a Giant Serpentine Basilar Artery Aneurysm

Abstract BACKGROUND AND IMPORTANCE: Current microsurgical and endovascular therapies have offered little advancement for the treatment of complex vertebrobasilar aneurysms. The outcome of patients with these rare lesions has remained poor, despite sometimes heroic measures. CLINICAL PRESENTATION: The authors report a case of a 65-year-old man who 20 years earlier had presented with symptoms suggestive of brainstem compression. Imaging at the time revealed a giant, serpentine aneurysm of the basilar artery. The patient was treated with superficial temporal artery to superior cerebellar artery bypass and decompression of the aneurysm contents. Twenty years after this treatment, the patient remains functionally intact with few sequelae from his treatment or the pathology. Follow-up imaging reveals thrombosis of the aneurysm without ischemic damage to the brainstem. CONCLUSION: This case demonstrates that good functional outcomes are possible for select complex posterior circulation aneurysms by using flow reversal and revascularization; however, at this time, we are unable to predict for which patients this strategy will be successful.

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Resolving Occlusive Lesions of the Basilar Artery

Neurosurgery ◽

10.1227/00006123-198511000-00015 ◽

1985 ◽

Vol 17 (5) ◽

pp. 811-814 ◽

Cited By ~ 8

Author(s):

John R. Little ◽

Anthony J. Furlan

Keyword(s):

Basilar Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Posterior Circulation ◽

The Other ◽

Superior Cerebellar Artery ◽

Cerebellar Artery ◽

Basilar Artery Stenosis ◽

Occlusive Lesion

Abstract Progression of severe basilar artery stenosis to occlusion is a well-recognized phenomenon, but regression of a severe basilar artery atherothrombotic lesion has not been described previously. In this report, two patients with a symptomatic severe basilar artery occlusive lesion showed substantial angiographic improvement after 3 months of anticoagulation in one case and 4 months after superficial temporal artery to superior cerebellar artery bypass in the other case. The findings in these cases indicate that clinical improvement in similar cases may reflect recanalization of a basilar artery occlusive lesion. The uncertain natural history and potential for regression of symptomatic basilar artery atherothormbosis make us hesitant to recommend posterior circulation revascularization immediately after such lesions are first demonstrated angiographically.

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Superficial temporal artery-superior cerebellar artery bypass and direct clipping of a large unruptured superior cerebellar artery aneurysm through subtemporal approach: Surgical video

Surgical Neurology International ◽

10.25259/sni_460_2019 ◽

2019 ◽

Vol 10 ◽

pp. 225

Author(s):

Jiangyu Xue ◽

Hugo Andrade-Barazarte ◽

Gangqin Xu ◽

Dongyang Cai ◽

Yang Bowen ◽

...

Keyword(s):

Blood Flow ◽

Surgical Treatment ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Superior Cerebellar Artery ◽

Parent Artery ◽

Subtemporal Approach ◽

Cerebellar Artery

Background: Superior cerebellar artery (SCA) aneurysms are rare. Current treatments include: direct clipping, trapping ± bypass, and endovascular methods (coiling, stenting, or flow diversion). Due to specific characteristics (wide base, location, and shape), a major challenge while dealing with SCA aneurysms is to preserve the flow of the parent artery and perforators. This video demonstrates a revascularization procedure, and clip reconstruction of a large unruptured basilar artery (BA)/SCA aneurysm performed through the subtemporal approach. Case Description: A 60-year-old woman presented with dizziness and headaches. Computed tomography angiography (CTA) and digital subtraction angiography showed a right unruptured large BA/SCA aneurysm. After multidisciplinary discussion, and considering gender, age, risk factors of the patient. Endovascular treatment was considered with a high risk of ischemic complications. Therefore, the patient was consented for a superficial temporal artery (STA)-SCA bypass through subtemporal approach followed by direct clipping/ trapping of the aneurysm. Postoperative CTA showed occlusion of the aneurysm and patency of the parent vessels. Postoperatively, the patient experienced immediate transient left mild monoparesis and right IV nerve palsy, which recovered completely at 6-months follow-up. Results: Surgical treatment of SCA aneurysms is decreasing due to the existence of endovascular therapies such as stents and flow diverters. However, some cases may necessitate surgical treatment and revascularization procedures to maintain the blood flow of the parent artery and to treat the previous lesion. Conclusion: The STA-SCA bypass through the subtemporal approach is a feasible option to maintain the blood flow of the parent artery in cases of SCA requiring surgical treatment and trapping/direct clipping of the aneurysm.

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Deep Bypasses to the Distal Posterior Circulation

Neurosurgery ◽

10.1227/01.neu.0000362034.81037.fc ◽

2010 ◽

Vol 66 (1) ◽

pp. 92-101 ◽

Cited By ~ 33

Author(s):

Zsolt Zador ◽

Daniel C. Lu ◽

Christine M. Arnold ◽

Michael T. Lawton

Keyword(s):

Temporal Lobe ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Posterior Circulation ◽

Superior Cerebellar Artery ◽

Brain Shift ◽

Morphometric Measurements ◽

Subtemporal Approach ◽

Cerebellar Artery

Abstract OBJECTIVE The subtemporal approach for a superficial temporal artery–to–superior cerebellar artery bypass requires significant superior retraction that can injure the temporal lobe, compromise veins, and cause edema postoperatively. In contrast, the pretemporal approach requires posterolateral retraction that seems to be less injurious to the temporal lobe and better tolerated clinically. We hypothesized that the pretemporal approach provides ample exposure, more gentle retraction, and better clinical results than the subtemporal approach. METHODS Standard orbitozygomatic-pterional and subtemporal approaches were performed on both sides of 4 formalin-fixed cadaver heads for morphometric measurements. Temporal lobe retraction was quantified for each approach in terms of brain shift and retraction pressure by using both sides of 3 fresh, unfixed cadaver heads. Similar morphometric measurements were made in 14 patients in whom bypasses to the distal posterior circulation were performed. The effect of temporal lobe retraction was assessed with edema volumes on postoperative computed tomography scans. RESULTS In cadaver heads and in patients, the pretemporal approach optimized exposure of the P2A segment of the posterior cerebral artery (PCA) and the subtemporal approach optimized exposure of the lateral pontomesencephalic segment of the superior cerebellar artery (SCA). Working depths and lengths of exposed artery were similar with these 2 approaches, but the PCA was a larger recipient than the SCA. Brain shift was 42% less with pretemporal than with subtemporal retraction, and retraction pressure was 43% less with pretemporal than with subtemporal retraction. The volume of temporal lobe edema was 56% less in patients with bypasses performed with the pretemporal approach as compared with the subtemporal approach. CONCLUSION Pretemporal exposure of the PCA is equivalent to subtemporal exposure of the SCA, but the pretemporal approach is facilitated by a larger recipient artery. Posterolateral temporal lobe retraction associated with the pretemporal approach is gentler than superior retraction with the subtemporal approach. These results validate our preference for the pretemporal approach over the subtemporal approach when performing deep bypasses to the posterior circulation.

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Disappearance of Ruptured Posterior Cerebral Artery Aneurysm Associated with Internal Carotid Artery Occlusion After Superficial Temporal Artery−to−Middle Cerebral Artery Bypass

World Neurosurgery ◽

10.1016/j.wneu.2018.05.096 ◽

2018 ◽

Vol 116 ◽

pp. 178-181 ◽

Cited By ~ 2

Author(s):

Yabo Huang ◽

Peng Zhou ◽

Zhong Wang ◽

Qingdong Han

Keyword(s):

Cerebral Artery ◽

Internal Carotid ◽

Posterior Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Cerebral Artery Aneurysm

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Pseudoaneurysm complicating superficial temporal artery-superior cerebellar artery bypass

Surgical Neurology ◽

10.1016/0090-3019(86)90162-x ◽

1986 ◽

Vol 26 (3) ◽

pp. 277-281 ◽

Cited By ~ 11

Author(s):

Michael Morgan ◽

Michael Besser ◽

Roger Tuck

Keyword(s):

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Superior Cerebellar Artery ◽

Cerebellar Artery

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Superficial temporal artery–to–middle cerebral artery bypass in combination with indirect revascularization in moyamoya patients ≤ 3 years of age

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.9.peds18224 ◽

2019 ◽

Vol 23 (2) ◽

pp. 198-203 ◽

Cited By ~ 3

Author(s):

Gyang Markus Bot ◽

Jan-Karl Burkhardt ◽

Nalin Gupta ◽

Michael T. Lawton

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Scale Scores ◽

Indirect Revascularization ◽

Direct Bypass ◽

Dependent Patient

OBJECTIVERevascularization is indicated in the management of moyamoya disease (MMD), with options that include direct and indirect techniques. Indirect bypass is popular in young children because the diminutive caliber of donors and recipients makes direct bypass difficult. The authors reviewed a series of patients treated with direct superficial temporal artery (STA)–to–middle cerebral artery (MCA) bypass in combination with encephalomyosynangiosis (EMS) in children 3 years or younger to demonstrate feasibility and safety.METHODSA retrospective review of all surgeries for MMD over a 19-year period identified 11 procedures in 6 patients. Surgical results, angiographic outcomes, and clinical outcomes were analyzed.RESULTSPatients had a mean age of 22.4 months. The symptomatic hemisphere was revascularized first, and the contralateral hemisphere was revascularized on average 2.8 months later in 5 patients. All direct bypasses were patent postoperatively and remained patent at late follow-up (mean 4.1 years), with both STA and MCA diameters increasing significantly (n = 5, p < 0.03). At last follow-up (mean follow-up duration, 5.0 years), favorable outcomes (modified Rankin Scale scores 0–2) were observed in 5 of the 6 patients (83%), with 1 dependent patient remaining unchanged postoperatively.CONCLUSIONSDirect STA-MCA bypass in combination with EMS for MMD is feasible and safe in patients 3 years or younger, based on favorable clinical and radiological outcomes in this patient cohort. Direct bypass should be considered when immediate revascularization is needed, without the biological delay associated with indirect bypass.

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Excision of a Large Complex Left Middle Cerebral Artery Aneurysm With a Middle Cerebral Artery—Middle Cerebral Artery and Superficial Temporal Artery—Middle Cerebral Artery Bypass: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa107 ◽

2020 ◽

Vol 19 (2) ◽

pp. E147-E148

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Video Recording ◽

Artery Aneurysm ◽

Temporal Artery ◽

Left Middle Cerebral Artery ◽

Bifurcation Aneurysm ◽

Orbitozygomatic Approach

Abstract Revascularization techniques for microsurgical manage-ment of middle cerebral artery (MCA) bifurcation aneurysms are often necessary for treatment of fusiform or giant aneurysms. Augmentation of the standard pterional approach to include an extended orbitozygomatic or modified orbitozygomatic approach provides a wider and more favorable approach to the MCA when attempting revascularization. Direct excision of a giant aneurysm (aneurysmectomy) with mobilization and reanastomosis of the MCA afterward has been reported. This patient had a giant MCA bifurcation aneurysm for which aneurysmectomy and distal reanastomosis were performed between the M1 and two M2 branches via a modified orbitozygomatic craniotomy. A second bypass between a third M2 branch at the ipsilateral superficial temporal artery was performed. Postoperative angiography confirmed patency of the bypasses. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Revascularization of the Anterior Cerebral Artery with an A3–A3 Anastomosis and a Superficial Temporal Artery Bypass Using an A3-Radial Artery Graft to Trap a Giant Anterior Communicating Artery Aneurysm: Technical Case Report

Operative Neurosurgery ◽

10.1227/01.neu.0000163682.31075.28 ◽

2005 ◽

Vol 57 (suppl_1) ◽

pp. E207-E207 ◽

Cited By ~ 11

Author(s):

Tomohiro Inoue ◽

Kazuo Tsutsumi ◽

Hiroyasu Ohno ◽

Munehisa Shinozaki

Keyword(s):

Radial Artery ◽

Anterior Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Anterior Communicating Artery ◽

Radial Artery Graft ◽

Anterior Communicating Artery Aneurysm ◽

Artery Graft

Abstract OBJECTIVE AND IMPORTANCE: How to manage the distal anterior cerebral artery (ACA) circulation in the treatment of a giant anterior communicating artery aneurysm or a giant azygous A2 aneurysm is still controversial. CLINICAL PRESENTATION: We are reporting the case of a 70-year-old man who presented with an evolving giant thrombosed anterior communicating artery aneurysm. INTERVENTION: He was successfully treated by trapping the aneurysm in conjunction with an A3–A3 side-to-side anastomosis and a superficial temporal artery bypass using an A3-radial artery graft. The postoperative angiography showed an excellent filling of all the bilateral distal ACA area through the bypass. CONCLUSION: In cases in which direct clipping to preserve distal ACA flow is quite difficult, the bilateral ACA revascularization described here should be considered as another possibility.

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