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How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm

  • How I Do it - Vascular Neurosurgery - Aneurysm
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Abstract

Background

Giant middle cerebral artery aneurysms are frequently anatomically complicated. Trapping may yield poor outcome, and bypass revascularization is often necessary as an adjunctive treatment to preserve flow.

Method

The technical nuances of superficial temporal artery to middle cerebral artery bypass are described in the setting of clip reconstruction of giant middle cerebral artery (MCA) aneurysm. In addition to an operative video, the anatomy and surgical technique are demonstrated in virtual reality to enhance the didactic clarity.

Conclusion

Meticulous technique is paramount for successful superficial temporal artery MCA bypass. Along with clip reconstruction, it is a critical part of the treatment of complex, giant MCA aneurysms.

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Abbreviations

ICG:

Indocyanine green

MCA:

Middle cerebral artery

STA:

Superficial temporal artery

VR:

Virtual reality

References

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, George Washington University, Washington, DC, USA

    Walter C. Jean

  2. George Washington University Medical Faculty Assoc., 2150 Pennsylvania Ave NW, 7th Floor, Washington, DC, 20038, USA

    Walter C. Jean

  3. Department of Neurosurgery, Georgtown University, Washington, DC, USA

    Daniel R. Felbaum

  4. Department of Neurosurgery, Viet Duc Hospital, Hanoi, Vietnam

    Hung M. Ngo

Authors
  1. Walter C. Jean
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  2. Daniel R. Felbaum
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  3. Hung M. Ngo
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Corresponding author

Correspondence to Walter C. Jean.

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Key Points

1. Detailed review of preoperative anatomy is crucial for identification of the inflow-outflow of the aneurysm and potential recipients of the bypass graft.

2. Donor vessels must be harvested patiently with sufficient length to avoid tension at the anastomosis.

3. Fish-mouthing the donor vessel aids in increasing surface area for blood flow.

4. Although interrupted suture requires more time, it keeps the operative less cluttered and has a lower risk of constricting the anastomosis.

5. A wide fissure dissection helps with aneurysm exposure, identification of parent artery, critical perforators, and recipient vessels. This allows for safer trapping of the aneurysm.

6. De-magnetized instruments and technical proficiency in microsurgical anastomosis are paramount to successful revascularization.

7. Intraoperative flow assessment, including ICG, Doppler, and angiogram, should be liberally used to assess patency of the bypass and critical branches. Adjustments of the clip reconstruction are often necessary based on this assessment.

8. Confirming immaculate hemostasis and patency of the graft minimizes postoperative complications.

9. Postoperative strict blood pressure control, hydration, and the use of heparin/aspirin can mitigate postoperative complications.

10. Preoperative examination in virtual reality may prove useful to clarify the anatomy and plan for the configuration of the necessary clips and for the bypass.

This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm

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Jean, W.C., Felbaum, D.R. & Ngo, H.M. How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm. Acta Neurochir 162, 593–596 (2020). https://doi.org/10.1007/s00701-019-04202-x

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  • DOI: https://doi.org/10.1007/s00701-019-04202-x

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