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

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. onsE527-onsE531 ◽  
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.

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.

Giant Pediatric Aneurysm Treated with Ligation of the Middle Cerebral Artery with the Drake Tourniquet and Extracranial-Intracranial Bypass

Neurosurgery ◽  
1989 ◽  
Vol 25 (1) ◽  
pp. 81-85 ◽  
Author(s):  
Thomas A. Lansen ◽  
Samuel S. Kasoff ◽  
Joseph H. Arguelles
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Superficial Temporal Artery ◽  
Giant Aneurysm ◽  
Temporal Artery ◽  
Giant Aneurysms ◽  
The Right ◽  
Pediatric Aneurysm

Abstract Saccular intracranial aneurysms occur infrequently in children, and the incidence of pediatric giant aneurysms is statistically in the same proportion as in adults. The management of these giant aneurysms can be treacherous. This paper presents a case of a 9-year-old boy with a giant aneurysm of the right middle cerebral artery that was successfully managed by ligation of the middle cerebral artery using a Drake tourniquet with the patient awake and by augmentation of the middle cerebral artery circulation with superficial temporal artery-middle cerebral artery anastomosis without excision of the lesion.

scholarly journals Treatment of a Giant Aneurysm of the Right Middle Cerebral Artery with GDCs after Extracranial to Intracranial Bypass

1999 ◽  
Vol 5 (1) ◽  
pp. 51-56 ◽  
Author(s):  
E. Castro ◽  
F. Fortea ◽  
F. Villoria ◽  
L. Muñoz ◽  
C Benito ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Giant Aneurysm ◽  
Endovascular Procedure ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Balloon Test Occlusion ◽  
Parent Vessel Occlusion ◽  
Detachable Coils ◽  
The Right

A case of a giant aneurysm of the right middle cerebral artery treated with Guglielmi detachable coils is reported. Extracranial to intracranial bypass had previously been performed and surgical trapping had been attempted. During the endovascular procedure, balloon test occlusion of the middle cerebral artery was performed in order to demonstrate clinical and angiographic tolerance to parent vessel occlusion. A previous occlusion test in the right common carotid artery did not show sufficient flow through the bypass to perform safe parent vessel occlusion. Diagnostic imaging, the endovascular procedure, and haemodynamic aspects in cases in which parent vessel occlusion is required after extracranial-intracranial bypass are described and the literature is reviewed.

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 Bonnet Bypass for Left Superficial Temporal Artery Bifurcation to Right Middle Cerebral Artery: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E201-E202 ◽  
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.

Dissecting aneurysms of the anterior circle of Willis arteries

1987 ◽  
Vol 67 (2) ◽  
pp. 296-300 ◽  
Author(s):  
Ryuichi Kitani ◽  
Tooru Itouji ◽  
Yatsugi Noda ◽  
Makoto Kimura ◽  
Satoshi Uchida
Keyword(s):  
Cerebral Infarction ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Dissecting Aneurysm ◽  
Collateral Flow ◽  
Content Type ◽  
Initial Symptoms ◽  
The Right

✓ Two cases of spontaneous dissecting aneurysm extending from the supraclinoid portion of the internal carotid artery to the middle cerebral artery are reported in two teenaged patients. Both patients collapsed with a headache on the right side, left hemiparesis, and altered consciousness due to cerebral ischemia. One patient became alert in 2 days; however, his condition rapidly deteriorated 4 days later and he died on the 8th day from massive cerebral infarction. The other patient received a right superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis 50 hours after his initial symptoms. He improved gradually and is able to walk without help. Cerebral angiograms 3 months after the operation disclosed progressive attenuation of the MCA and dilatation of the anastomosed STA. Artificial collateral flow demonstrated in the postoperative angiogram may have been useful in preventing massive cerebral infarction.

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.

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