Executive functions are complex cognitive control functions that include cognitive flexibility, inhibition (self-control, self-regulation), and working memory. Bilateral frontal lobe ischemia is associated with cognitive impairment, especially in the context of dysexecutive syndrome. This report describes two patients who underwent bilateral anterior cerebral artery (ACA) reconstruction by A3-A3 anastomosis in conjunction with superficial temporal artery (STA)-radial artery (RA) graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia accompanying cognitive and executive dysfunction.
A 74-year-old woman and a 73-year-old woman were admitted to our hospital for unilateral cerebral infarction in the frontal lobe. Magnetic resonance angiogram (MRA) demonstrated severe bilateral ACA steno-occlusive pathology in both patients. Considering the presence of impaired cognitive function with dysexecutive syndrome as well as hemodynamic compromise shown by single photon emission computed tomography (SPECT), we proceeded with A3-A3 anastomosis in conjunction with STA-RA-A3 bypass. Various neuropsychiatric tests were performed before and after the surgery.
We confirmed good bypass patency without periprocedural complications. One patient recovered from apallic and bedridden status and regained ambulatory condition and ability to take in an oral diet. Another patient demonstrated improved scores in several cognitive tests with some persistent executive dysfunction.
Bilateral ACA revascularization was technically feasible in two patients. This bypass surgery could have some positive effects in some basic cognitive function, such as memory, attention, and concentration by bilateral ACA hemodynamic improvement, although executive function, which is specific to prefrontal function, might not be reversible.
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Conflicts of interest
This manuscript highlights a rare but interesting indication of using the bonnet bypass and ACA side-to-side anastomosis for bilateral ACA occlusion/stenosis. Although the indication is rare, the technical description and consideration of this option in treatment of intracranial occlusive disease are of interest to vascular neurosurgeons. Preoperative flow measurement by NOVA MRA would be another important adjunct to preoperative assessment of these patients.
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The right superficial temporal artery was harvested under a microscope. The bilateral A3s were exposed. Severe atherosclerosis was admitted. Bilateral A3s were anastomosed in a side-to-side manner with 8-0 nylon. The radial artery graft and another A3 were anastomosed in a side-to-end manner, approximating to the A3-to-A3 bypass. A suitable groove for embedding the graft vessel was made via drilling. Anastomosis of the superficial temporal artery and the radial artery graft was performed with 8-0 nylon in an end-to-end fashion. Finally, good bypass patency was confirmed with a Doppler flowmeter. (MPG 41,698 kb)
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Kiyofuji, S., Inoue, T., Hasegawa, H. et al. A3-A3 anastomosis and superficial temporal artery-radial artery graft-A3 bypass to treat bilateral ACA steno-occlusive hemodynamic ischemia with cognitive and executive dysfunction: a technical note. Acta Neurochir 156, 2085–2093 (2014) doi:10.1007/s00701-014-2228-0
- Bonnet bypass
- Cerebral infarction
- Cerebral revascularization
- Executive function
- Frontal lobe