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

2018 ◽  
Vol 15 (5) ◽  
pp. E67-E68 ◽  
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.

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

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.

scholarly journals Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization

2017 ◽  
Vol 127 (3) ◽  
pp. 463-479 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
Wendy Huang ◽  
Arnau Benet ◽  
Olivia Kola ◽  
Michael T. Lawton
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Algorithmic Approach ◽  
Complex Aneurysms ◽  
Bypass Patency ◽  
Mca Aneurysm ◽  
In Situ Bypass ◽  
Middle Cerebral Artery Aneurysms

OBJECTManagement of complex aneurysms of the middle cerebral artery (MCA) can be challenging. Lesions not amenable to endovascular techniques or direct clipping might require a bypass procedure with aneurysm obliteration. Various bypass techniques are available, but an algorithmic approach to classifying these lesions and determining the optimal bypass strategy has not been developed. The objective of this study was to propose a comprehensive and flexible algorithm based on MCA aneurysm location for selecting the best of multiple bypass options.METHODSAneurysms of the MCA that required bypass as part of treatment were identified from a large prospectively maintained database of vascular neurosurgeries. According to its location relative to the bifurcation, each aneurysm was classified as a prebifurcation, bifurcation, or postbifurcation aneurysm.RESULTSBetween 1998 and 2015, 30 patients were treated for 30 complex MCA aneurysms in 8 (27%) prebifurcation, 5 (17%) bifurcation, and 17 (56%) postbifurcation locations. Bypasses included 8 superficial temporal artery–MCA bypasses, 4 high-flow extracranial-to-intracranial (EC-IC) bypasses, 13 IC-IC bypasses (6 reanastomoses, 3 reimplantations, 3 interpositional grafts, and 1 in situ bypass), and 5 combination bypasses. The bypass strategy for prebifurcation aneurysms was determined by the involvement of lenticulostriate arteries, whereas the bypass strategy for bifurcation aneurysms was determined by rupture status. The location of the MCA aneurysm in the candelabra (Sylvian, insular, or opercular) determined the bypass strategy for postbifurcation aneurysms. No deaths that resulted from surgery were found, bypass patency was 90%, and the condition of 90% of the patients was improved or unchanged at the most recent follow-up.CONCLUSIONSThe bypass strategy used for an MCA aneurysm depends on the aneurysm location, lenticulostriate anatomy, and rupture status. A uniform bypass strategy for all MCA aneurysms does not exist, but the algorithm proposed here might guide selection of the optimal EC-IC or IC-IC bypass technique.

Endovascular stenting for rescue of a failed donor graft during superficial temporal artery to middle cerebral artery bypass surgery: case report

2019 ◽  
Vol 24 (5) ◽  
pp. 572-576
Author(s):  
Melissa A. LoPresti ◽  
Visish M. Srinivasan ◽  
Robert Y. North ◽  
Vijay M. Ravindra ◽  
Jeremiah Johnson ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Endovascular Management ◽  
Donor Graft ◽  
Mca Aneurysm ◽  
Direct Bypass

Direct bypass has been used to salvage failed endovascular treatment; however, little is known of the reversed role of endovascular management for failed bypass.The authors report the case of a 7-year-old patient who underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass for treatment of a giant MCA aneurysm and describe the role of endovascular rescue in this case. Post-bypass catheter angiogram showed occlusion of the proximal extracranial STA donor with patent anastomosis, possibly due to STA dissection. A self-expanding Neuroform Atlas stent was deployed across the dissection flap, and follow-up images showed revascularization of the STA with good MCA runoff.This case demonstrates that direct extracranial-intracranial bypass failure can infrequently originate from the STA donor vessel and that superselective angiogram can be useful for identification and treatment in such cases. With more advanced endovascular techniques the tide has turned in the treatment of complex cerebrovascular cases, with this case being an early example of successful rescue stenting for endovascular management of a failed donor after STA-MCA bypass.

scholarly journals Orbitozygomatic Craniotomy for Clipping a Complex Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E33-E33
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Sylvian Fissure ◽  
Parent Artery ◽  
Parent Vessel ◽  
Institutional Review ◽  
Vessel Patency ◽  
Mca Aneurysm

Abstract Middle cerebral artery (MCA) aneurysms pose a surgical challenge because of the large caliber of the parent artery and the common need to dissect the sylvian fissure to permit access to the proximal and distal control. The neck of the aneurysm should be generously dissected to permit visualization of any adjacent lenticulostriate perforators. This patient demonstrated a left-sided wide-necked bilobed MCA aneurysm at the M1 bifurcation. The aneurysm was approached using a left orbitozygomatic craniotomy with distal sylvian fissure dissection. A single curved clip was applied for aneurysm occlusion, and postoperative angiography demonstrated aneurysm obliteration with parent vessel patency. 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.

scholarly journals Clipping and STA-MCA bypass for unruptured AcomA aneurysm associated with unilateral MCA occlusion

2015 ◽  
Vol 38 (videosuppl1) ◽  
pp. Video2 ◽  
Author(s):  
Tomohiro Inoue ◽  
Hiroki Yoshida ◽  
Akira Tamura ◽  
Isamu Saito
Keyword(s):  
Surgical Technique ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Sylvian Fissure ◽  
Anterior Communicating Artery ◽  
Mca Occlusion ◽  
Interhemispheric Fissure ◽  
Good Exposure

The authors show a surgical technique of clipping in conjunction with superficial temporal artery (STA)–middle cerebral artery (MCA) bypass to treat unruptured anterior communicating artery (AcomA) aneurysm associated with unilateral MCA occlusion. First, through MCA occlusion side, fronto-temporal craniotomy, extra-dural drilling of lesser sphenoid wing, and followed by wide exposure of Sylvian fissure, STA–MCA bypass was performed. Then, through trans-Sylvian, fronto-basal, and lateral trajectory, interhemispheric fissure was dissected from the base, which enabled good exposure and clipping of high positioned AcomA aneurysm.The video can be found here: http://youtu.be/GWItnRSs3m4.

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

Neurosurgery ◽  
2012 ◽  
Vol 72 (3) ◽  
pp. 428-436 ◽  
Author(s):  
M. Yashar S. Kalani ◽  
Joseph M. Zabramski ◽  
Yin C. Hu ◽  
Robert F. Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Saphenous Vein Graft ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Bypass Patency ◽  
The Mean

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.

scholarly journals Treatment of middle cerebral artery aneurysm associated with Moyamoya disease: literature review

2021 ◽  
Author(s):  
Luciano Bambini Manzato ◽  
José Ricardo Vanzin ◽  
Octávio Ruschel Karam ◽  
Victor Emanuel Angeliero ◽  
Artur Eduardo Martio ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Pediatric Patient ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Artery Aneurysm ◽  
Temporal Artery ◽  
Mesh Terms ◽  
Indirect Revascularization ◽  
Cerebral Artery Aneurysm

Background:Moyamoya disease (MMD) is a steno-occlusive cerebral angiopathy. The incidence of intracranial aneurysms (IA) associated with MMD is high (3.4-14.8%) when compared to the general population (1-3%). IA in the middle cerebral artery (MCA) associated with MMD are rare, with only 25 cases described in the literature. Methods:Search on the PubMed platform, in English, with the MeSH terms “Moyamoya Disease”, “Intracranial Aneurysm” and “Middle Cerebral Artery”. There were 151 results, of which 7 were included in the review. Results:Sumi et al. and Larson et al. reported non-ruptured IA of the M1 segment, treated by surgical clipping and wrapping, respectively. Endo et al. chose to clip a ruptured IA in the M1 segment, followed by anastomosis between the superficial temporal artery and the MCA, excluding the IA . Liu et al. reported a non-ruptured MCA IA in a pediatric patient, treated through an encephalo-duro-arterio-synangiosis; the IA was excluded. Peltier et al. performed an indirect revascularization using the multiple bur-hole technique in a pediatric patient with non-ruptured IA in the M1 segment, excluding the IA. Rivera et al. opted for the conservative approach of a ruptured IA in the M1 segment, which was successful. Yan et al. described 19 IA in the MCA associated with the MMD, without specifying the adopted therapeutic. Conclusion:Due to the low number of cases, no recommendation can be made, and treatment should be individualized.

Microsurgical Clipping and Bypass for Fusiform Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Nickalus R Khan ◽  
Stephanie H Chen ◽  
Jacques J Morcos
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Artery Aneurysm ◽  
Patient Discharge ◽  
Temporal Artery ◽  
Surgical Anatomy ◽  
Microsurgical Treatment ◽  
Microsurgical Clipping

Abstract Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate complex endovascular or microsurgical treatment. We present a case of a 25-yr-old female with an incidentally discovered left 14-mm fusiform MCA aneurysm incorporating the frontal MCA trunk origin in its dome. The location and anatomy were not favorable for endovascular treatment with flow diversion.  The patient was offered continued observation or microsurgical treatment. Direct clipping of this aneurysm was not possible. After a thorough discussion of the risks, benefits, indications, and natural history of the lesion, the patient desired to have the aneurysm treated given her young age, location, size of the aneurysm, and the significant clinical experience of the treating team in bypass surgery.  The patient underwent superficial temporal artery to frontal M2 (STA-FM2) direct bypass for flow replacement followed by microsurgical trapping and clip ligation. The patient was maintained on antiplatelet therapy preoperatively and postoperatively. The patient had a transient aphasia and mild right upper extremity weakness (4/5) in the immediate postoperative period, which fully recovered by the time of patient discharge. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The different strategies for bypass and clip ligation are reviewed with particular focus on the anatomic constraints for each bypass configuration. The outcomes of bypass surgery for MCA aneurysms are reviewed.1-7 The patient gave verbal consent for participating in the procedure, surgical video, and publication of their image.

scholarly journals 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

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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