Ahead of Print: Double Barrel Bypass for Cerebral Ischemia

Background: In selected patients, extracranial-intracranial bypass remains an important treatment for the prevention of stroke. Traditionally, superficial temporal artery to middle cerebral artery (STA-MCA) bypass utilizes one STA branch. We have adopted a “double-barrel” technique, where both branches are joined with MCA recipients in distinct vascular territories.

Objective: To assess the feasibility of routinely utilizing both branches of the STA for cerebral revascularization.

Methods: Ten consecutive patients underwent double-barrel bypass. Patients were selected if they demonstrated symptomatic MCA hypoperfusion resistant to medical therapy, or had symptomatic Moyamoya disease. “Flow-directed” bypass was performed to augment flow to the territories most at risk in each case, based on preoperative and intraoperative data. CT perfusion was routinely obtained to evaluate baseline deficits and post-operative augmentation. Clinical data were analyzed to assess patient demographics and outcomes.

Ahead of Print: The Simplified Azygos Anterior Cerebral Bypass

Background and Importance: Trapping with distal revascularization is a therapeutic option for giant aneurysms that cannot be clipped or coiled. In skull base lesions, such as meningiomas, arterial encasement is often present, requiring, in some cases, revascularization procedures: EC-IC bypass and more recently IC-IC techniques. These techniques are used only in exceptional cases of tumors in other localizations.

Clinical Presentation: We report a case of a recurrent malignant frontal falx meningioma with encasement of both pericallosal arteries (PcaAs). During the resection of the lesion, the left PcaA was sectioned and the right PcaA was occluded for the manipulation and coagulation of the tumor. The occlusion was diagnosed using indocyanine green (ICG) videoangiography. A Y-shaped superficial temporal artery (STA) graft was obtained in the right side and the anterior cerebral artery (ACA) circulation was reconstructed using an IC-IC bypass in the following fashion: Right A2- STA Y shaped graft – both PcaAs. The patient’s postoperative period was uneventful with no deficit, and the angioCT showed the preservation of both PcaAS.

Ahead of Print: Cerebral Bypasses for Complex Aneurysms and Tumors

Background: Various techniques of cerebral bypasses are used in the treatment of aneurysms and tumors.

Objective: To study long-term clinical and radiological outcome of various bypass types, and analyze techniques used in the management of long-term graft problems.

Methods: A consecutive series of patients who underwent revascularization during a five-year period was analyzed for indications, graft patency, and neurological outcomes. Potential risk factors for bypass problems and the management of bypass stenosis were studied.

Ahead of Print: Curve-planar Reformation and Cerebral Revascularization

Background and Importance: Cerebral revascularization continues to be an important technique for the treatment of cerebrovascular and vaso-occlusive diseases, and determination of appropriate graft sources and recipients are paramount to the success of the procedure. A tension-free anastomosis requires that harvested grafts be of an appropriate length to avoid complications. Volume-rendered contrast-enhanced CT datasets may be useful in determining the desired length and path of the bypass graft and in the evaluation of appropriate recipient vessels. Curved-planar reformation techniques may allow these properties to be determined in a novel, inexpensive and efficient manner.

Clinical Presentation: A 63-year-old patient with a left hemispheric perfusion deficit and without an external carotid artery was in need of high-flow cerebral revascularization. A radial artery graft spanning from the vertebral artery to the MCA was proposed. Preoperative determination of graft length necessary and most efficient subcutaneous placement was desired. A standard CT angiogram of the head and neck was obtained and imported into a computer workstation with curved-planar reformatting capabilities.