Superficial temporal artery to middle cerebral artery (STA-MCA) bypass via retrograde arterial anastomosis in a patient with common carotid artery occlusion: a case report

  • Eric S. NussbaumEmail author
  • Geeta S. Paranjape
  • Jodi Lowary
  • Leslie A. Nussbaum
Case Report - Vascular Neurosurgery - Ischemia
Part of the following topical collections:
  1. Vascular Neurosurgery - Ischemia


The standard superficial temporal artery to middle cerebral artery (STA-MCA) bypass depends on adequate antegrade flow in the STA. In the setting of occlusion of the common or external carotid arteries, revascularization requires modification of the standard bypass procedure. A patient with prior history of irradiation for head and neck carcinoma presented with an ischemic injury and fluctuating neurologic deficit not responsive to medical therapy. His left common carotid artery was occluded, but angiographic evaluation demonstrated retrograde filling of his left STA. Reverse STA-MCA bypass was performed, taking advantage of spontaneous collateralization which allowed for retrograde filling of the STA.


Cerebral revascularization STA-MCA bypass Common carotid arterial disease Cerebral angiography 



The authors acknowledge Superior Medical Experts for research and drafting assistance.

Author contributions

All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and drafted the work or revised it critically for important intellectual content; and provided final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding information

This work was supported by a grant from the United Hospital Foundation.

Compliance with ethical standards

Conflict of interest

GP contracts with Superior Medical Experts. The authors declare that they have no conflict of interest.

Patient Consent

Consent to the public use of de-identified information was obtained from the patient prior to submission to the journal.


  1. 1.
    Aso K, Ogasawara K, Kobayashi M, Yoshida K (2010) Arterial bypass surgery using a spontaneously formed “bonnet” superficial temporal artery in a patient with symptomatic common carotid artery occlusion: case report. Neurosurgery 67:onsE316–onsE317; discussion onsE317. CrossRefPubMedGoogle Scholar
  2. 2.
    Ausman JI, Tiel RL, Mehta BA, Fuentes JD, Pearce JE, Diaz FG (1985) “Reverse” superficial temporal artery-middle cerebral artery bypass. Surg Neurol 23:614–616CrossRefGoogle Scholar
  3. 3.
    Cherian J, Srinivasan V, Kan P, Duckworth EAM (2018) Double-barrel superficial temporal artery-middle cerebral artery bypass: can it be considered “high-flow?”. Oper Neurosurg (Hagerstown) 14:288–294. CrossRefGoogle Scholar
  4. 4.
    Garrido E, Freed MH (1983) Fatal complication of the “bonnet bypass”: case report. Neurosurgery 13:320–321CrossRefGoogle Scholar
  5. 5.
    Levine SR, Welch KM (1989) Common carotid artery occlusion. Neurology 39:178–186CrossRefGoogle Scholar
  6. 6.
    Nagm A, Horiuchi T, Hasegawa T, Hongo K (2016) Intraoperative Evaluation of reverse bypass using a naturally formed “bonnet” superficial temporal artery: technical note. World Neurosurg 88:603–608. CrossRefGoogle Scholar
  7. 7.
    Nossek E, Langer DJ (2014) How I do it: combined direct (STA-MCA) and indirect (EDAS) EC-IC bypass. Acta Neurochir 156:2079–2084. CrossRefPubMedGoogle Scholar
  8. 8.
    Otani N, Wada K, Sakakibara F, Nagatani K, Takeuchi S, Tomura S, Osada H, Mizokami D, Yamashita T, Shiotani A, Mori K (2014) “Reverse” bypass using a naturally formed “bonnet” superficial temporal artery in symptomatic common carotid artery occlusion: a case report. Neurol Med Chir 54:851–853CrossRefGoogle Scholar
  9. 9.
    Reynolds MR, Derdeyn CP, Grubb RL Jr, Powers WJ, Zipfel GJ (2014) Extracranial-intracranial bypass for ischemic cerebrovascular disease: what have we learned from the Carotid Occlusion Surgery Study? Neurosurg Focus 36:E9. CrossRefPubMedGoogle Scholar
  10. 10.
    Spetzler RF, Roski RA, Rhodes RS, Modic MT (1980) The “bonnet bypass”. Case report. J Neurosurg 53:707–709. CrossRefPubMedGoogle Scholar
  11. 11.
    Stapleton CJ, Atwal GS, Hussein AE, Amin-Hanjani S, Charbel FT (2019) The cut flow index revisited: utility of intraoperative blood flow measurements in extracranial-intracranial bypass surgery for ischemic cerebrovascular disease. J Neurosurg:1-5. doi:
  12. 12.
    Thanapal S, Duvuru S, Sae-Ngow T, Kato Y, Takizawa K (2018) Direct cerebral revascularization: extracranial-intracranial bypass. Asian J Neurosurg 13:9–17. CrossRefGoogle Scholar
  13. 13.
    Zumofen D, Khan N, Roth P, Samma A, Yonekawa Y (2008) Bonnet bypass in multiple cerebrovascular occlusive disease. Acta Neurochir Suppl 103:103–107CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.National Brain Aneurysm & Tumor Center, Department of NeurosurgeryUnited HospitalTwin CitiesUSA
  2. 2.Minnesota Neurovascular & Skull Base SurgeryMinneapolisUSA
  3. 3.Continuing StudiesDuke UniversityDurhamUSA

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