Extracranial-Intracranial Bypass and Vessel Occlusion for the Treatment of Unclippable Giant Middle Cerebral Artery Aneurysms

Abstract BACKGROUND: Giant middle cerebral artery (MCA) aneurysms pose management challenges. OBJECTIVE: To review the outcomes of patients with giant MCA aneurysms not amenable to clipping or vessel reconstruction treated with extracranial-intracranial (EC-IC) bypass and vessel sacrifice. METHODS: We retrospectively reviewed a database of aneurysms treated at our institution between 1983 and 2011. RESULTS: Sixteen patients (11 males, 5 females) were identified. There were 10 saccular, 4 fusiform, and 2 serpentine aneurysms. The aneurysms predominantly involved the M1 segment in 5 cases, M2 in 9 cases, and both M1 and M2 in 2 cases. The EC-IC bypasses performed included 13 superficial temporal artery-MCA, 1 saphenous vein graft-MCA, and 2 radial artery grafts-MCA. The postoperative bypass patency rate was 93.8% (15/16). There were 3 cerebrovascular accidents (18.8%), but no perioperative deaths (0% mortality). The mean follow-up was 58.4 months (range, 1-265; median, 23.5 months). In 75% (12/16) of cases the aneurysms were occluded successfully. A small residual was noted in 3 cases with the use of this treatment strategy, and they were re-treated. In a fourth case treated with partial distal occlusion, reduced flow through the aneurysm was noted postoperatively, but the patient did not undergo further treatment. The mean modified Rankin scale and mean Glasgow Outcome Scale scores at last follow-up were 1.6 (range, 1-4; median, 1) and 4.8 (range, 3-5; median, 5), respectively. CONCLUSION: Giant MCA aneurysms are challenging lesions. EC-IC bypass with parent vessel occlusion can provide a durable form of treatment with acceptable rates of morbidity and mortality.

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Targeted Extracranial-Intracranial Bypass With Intra-Aneurysmal Administration of Indocyanine Green: Case Report

Operative Neurosurgery ◽

10.1227/neu.0b013e3181f8889e ◽

2010 ◽

Vol 67 (suppl_2) ◽

pp. onsE527-onsE531 ◽

Cited By ~ 3

Author(s):

Mark D. Bain ◽

Shaye I. Moskowitz ◽

Peter A. Rasmussen ◽

Ferdinand K. Hui

Keyword(s):

Indocyanine Green ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Giant Aneurysm ◽

Temporal Artery ◽

Endovascular Embolization ◽

Parent Vessel ◽

Bypass Patency ◽

The Right

ABSTRACT BACKGROUND AND IMPORTANCE: Early origin of the middle cerebral artery M2 segment is a normal variant. When such a vessel is occluded proximally, the parenchyma distal to the vessel may become ischemic. Targeted extracranial to intracranial bypass to such a specific branch may preserve perfusion to the end organ. We describe the use of intra-aneurysmal injection of indocyanine green to identify a target middle cerebral artery branch (MCA) for bypass, immediately followed by proximal parent vessel sacrifice via endovascular embolization. CLINICAL PRESENTATION: A 45-year-old woman presented to an outside hospital with headaches. Magnetic resonance imaging revealed a giant aneurysm of the right MCA. The aneurysm gave rise to an M2 branch that supplied the right anterior frontal operculum, as well as the anterolateral portion of the superior temporal gyri. Balloon test occlusion was nondiagnostic because of the territory involved, and the risk of sizable infarction after vessel sacrifice was thought to be high. Craniotomy and targeted extracranial to intracranial bypass to an M4 opercular branch was performed with intra-aneurysmal injection of indocyanine green. In our combined endovascular/open cerebrovascular suite, an opercular MCA branch that fluoresced during the first-pass arterial circulation of indocyanine green was identified, and a superficial temporal artery to MCA bypass was performed. Angiographic verification of bypass patency was confirmed, followed by embolic occlusion of the giant aneurysm with preservation of flow to the parenchyma at risk through the bypass. CONCLUSION: Targeted bypass to distal branches is feasible with intra-arterial and intra-aneurysmal injection of indocyanine green, allowing confident preservation of blood supply to areas distal to the sacrificed vessel.

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Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree

Journal of Neurosurgery ◽

10.3171/2013.10.jns13738 ◽

2014 ◽

Vol 120 (2) ◽

pp. 398-408 ◽

Cited By ~ 34

Author(s):

Leena Kivipelto ◽

Mika Niemelä ◽

Torstein Meling ◽

Martin Lehecka ◽

Hanna Lehto ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Scale Score ◽

Cerebral Artery ◽

Parent Artery ◽

Parent Vessel ◽

Vessel Occlusion ◽

Parent Vessel Occlusion ◽

The Mean ◽

Middle Cerebral Artery Aneurysms

Object The object of this study was to describe the authors' institutional experience in the treatment of complex middle cerebral artery (MCA) aneurysms necessitating bypass and vessel sacrifice. Methods Cases in which patients with MCA aneurysms were treated with a combination of bypass and parent artery sacrifice were reviewed retrospectively. Results The authors identified 24 patients (mean age 46 years) who were treated with bypass and parent artery sacrifice. The aneurysms were located in the M1 segment in 7 patients, MCA bifurcation in 8, and more distally in 9. The mean aneurysm diameter was 30 mm (range 7–60 mm, median 26 mm). There were 8 saccular and 16 fusiform aneurysms. Twenty-one extracranial-intracranial and 4 intracranial-intracranial bypasses were performed. Partial or total trapping (only) of the parent artery was performed in 17 cases, trapping with resection of aneurysm in 3, and aneurysm clipping with sacrifice of an M2 branch in 4. The mean follow-up period was 27 months. The aneurysm obliteration rate was 100%. No recanalization of the aneurysms was detected during follow-up. There was 1 perioperative death (4% mortality rate) and 6 cerebrovascular accidents, causing permanent morbidity in 5 patients. The median modified Rankin Scale score of patients with an M1 aneurysm increased from 0 preoperatively to 2 at latest follow-up, while the score was unchanged in other patients. Most of the permanent deficits were associated with M1 aneurysms. Twenty-one patients (88%) had good outcome as defined by a Glasgow Outcome Scale score of 4 or 5. Conclusions Bypass in combination with parent vessel occlusion is a useful technique with acceptable frequencies of morbidity and mortality for complex MCA aneurysms when conventional surgical or endovascular techniques are not feasible. The location of the aneurysm should be considered when planning the type of bypass and the site of vessel occlusion. Flow alteration by partial trapping may be preferable to total trapping for the M1 aneurysms.

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

Neurosurgery ◽

10.1227/01.neu.0000109533.72250.e0 ◽

2004 ◽

Vol 54 (3) ◽

pp. 667-671 ◽

Cited By ~ 30

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.

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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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Double-Barrel Superficial Temporal Artery-M2 Middle Cerebral Artery Bypass and Creation of a Middle Communicating Artery via M2-M2 End-to-End Reimplantation for Trapping of a Dolichoectatic Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa159 ◽

2020 ◽

Vol 19 (5) ◽

pp. E521-E522

Author(s):

Joshua S Catapano ◽

Fabio A Frisoli ◽

Megan S Cadigan ◽

Dara S Farhadi ◽

Candice L Nguyen ◽

...

Keyword(s):

Family History ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Bypass Patency ◽

History Of ◽

End To End

Abstract Large dolichoectatic aneurysms of middle cerebral artery (MCA) trifurcations are rare and often require trapping and revascularization of the region with a bypass.1-9 This video describes the treatment of an MCA trifurcation aneurysm by clip trapping and double-barrel superficial temporal artery (STA) to M2-MCA bypass followed by M2-M2 end-to-end reimplantation to create a middle communicating artery (MCoA). The patient, a 60-yr-old woman, presented with headache, a history of smoking, and a family history of ruptured aneurysms. Angiography demonstrated a 1.7-cm dolichoectatic aneurysm of the MCA trifurcation. While the natural history of these lesions is unclear, the aneurysm size and family history of aneurysmal subarachnoid hemorrhage were factors in proceeding with treatment. Informed written consent was obtained from the patient and her family. The STA branches were harvested microsurgically, a pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. The two STA branches were anastomosed end-to-side to the middle and inferior trunks of the MCA. Due to the significant mismatch between the donor and recipient vessel calibers, we were concerned that the donors might provide insufficient flow in isolation. Therefore, we decided to transect both M2 trunks from the aneurysm, proximal to the inflow of the bypass, and reimplant them end-to-end. This reimplantation created an MCoA, allowing the two donor arteries to supply the new communication between the inferior and middle trunks, redistributing blood flow through the MCoA according to cerebral demand. Bypass patency and aneurysm obliteration were confirmed on postoperative angiography. At the 6-mo follow-up, the patient's modified Rankin Scale (mRS) score was 0. The MCoA is a novel construct that, like natural communicating arteries, redistributes flow in response to shifting demand, without the need for additional ischemia time during the bypass. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Moyamoya Disease Superficial Temporal Artery-to-Middle Cerebral Artery Onlay: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa039 ◽

2020 ◽

Vol 18 (6) ◽

pp. E229-E229

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Moyamoya Disease ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Video Recording ◽

Temporal Artery ◽

Low Flow ◽

Institutional Review ◽

Direct Anastomosis

Abstract The most frequently performed low-flow bypass procedure is the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. If available, a suitable M2 or M3 cortical branch is anastomosed to the donor vessel. This patient had severe moyamoya disease with an ipsilateral perfusion deficit and transient ischemic attacks. Given the need for revascularization, an STA-to-MCA bypass was performed. There was no suitable recipient M3 branch for direct anastomosis, and therefore an indirect bypass was performed by onlaying the STA onto the cortical surface and suturing the adventitia of the STA to the arachnoid of the underlying cortex. The dural leaflets were then inverted to potentiate further revascularization of the underlying cortex. The patient remained at their neurological baseline and demonstrated an enhanced perfusion of the ipsilateral MCA territory on follow-up evaluation. 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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Bonnet Bypass for Left Superficial Temporal Artery Bifurcation to Right Middle Cerebral Artery: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz245 ◽

2019 ◽

Vol 17 (5) ◽

pp. E201-E202 ◽

Cited By ~ 1

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Saphenous Vein ◽

Superficial Temporal Artery ◽

Video Recording ◽

Temporal Artery ◽

Interposition Graft ◽

Institutional Review ◽

Bypass Patency ◽

Pass Through

Abstract A bonnet bypass is a long interposition graft bypass used for extracranial to intracranial revascularization, which is useful in patients who do not have a suitable ipsilateral donor or in whom the ipsilateral donor must be sacrificed. This interposition graft is commonly the radial artery or saphenous vein. The only practical difference in this technique for revascularization is that an interposition graft must pass through the subgaleal space to the contralateral scalp to allow for reimplantation at the desired contralateral point of anastomosis. This patient underwent a bonnet bypass for revascularization of the middle cerebral artery (MCA) perfusion territory utilizing the contralateral superficial temporal artery (STA). A saphenous vein was used as the interposition graft, which was anastomosed to an M2 segment bifurcation. The graft was then temporarily occluded and passed within a calvarial trough to the contralateral frontoparietal region. The graft was then anastomosed to the contralateral STA at a bifurcation to accommodate the graft size mismatch. The patient tolerated the bypass procedure well and demonstrated bypass patency on postoperative angiographic imaging. 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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Combination Superficial Temporal Artery-Middle Cerebral Artery Bypass and M2–M2 Reanastomosis With Trapping of a Stented Distal Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy097 ◽

2018 ◽

Vol 15 (5) ◽

pp. E67-E68 ◽

Cited By ~ 1

Author(s):

Jan-Karl Burkhardt ◽

Sonia Yousef ◽

Halima Tabani ◽

Arnau Benet ◽

Roberto Rodriguez Rubio ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Sylvian Fissure ◽

Neurological Deficits ◽

Bypass Patency ◽

Mca Aneurysm ◽

Distal Middle Cerebral Artery

Abstract Distal middle cerebral artery (MCA) aneurysms often have non-saccular morphology and cannot be clipped, requiring revascularization and trapping instead. Combination bypasses are needed when 2 arteries exit the aneurysm, and extracranial–intracranial and intracranial–intracranial bypasses can be used. This video demonstrates a combination bypass used to treat a previously stented distal MCA aneurysm with both a superficial temporal artery (STA)-to-MCA bypass and an M2-to-M2 reanastomosis. This 56-yr-old man presented with distal left-sided MCA aneurysm 2 years earlier and attempted stent-assisted coiling was aborted after the aneurysm was perforated with stenting alone. Follow-up angiography demonstrated progressive aneurysm enlargement, and he was referred for surgery. The patient consented for the procedure and a pterional craniotomy extended posteriorly exposed the distal Sylvian fissure and efferent M4-cortical arteries. After splitting the Sylvian fissure, the “flash fluorescence” technique with indocyanine green (ICG) videoangiography identified an M4 recipient artery from the deeper of 2 exiting branches for STA–MCA bypass.1 The aneurysm was then trapped, and inflow and the more superficial outflow arteries were anastomosed end to end (M2–M2 in-situ bypass). A platelet plug that developed at the reanastomosis site was broken apart with mechanical manipulation, and ICG videoangiography demonstrated patency of both bypasses. The patient recovered without any neurological deficits, and postoperative computed tomography angiography confirmed bypass patency. Combination bypasses are needed when unclippable bifurcation aneurysms require revascularization. Careful intraoperative evaluation of patency of the bypass is imperative and helps identifying and addressing any potential early bypass occlusion.

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