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Cerebral angiogram shows the large aneurysm (1.5×1 cm) affecting the anterior communicating artery and proximal stems of anterior cerebral arteries
Source publication
Bilateral extracranial-intracranial (EC-IC) bypass-grafting of the cerebral circulation is uncommon. We report a case of anterior cerebral artery EC-IC bypass using the thoracodorsal axis artery-graft. The bifurcation of the thoracodorsal axis allows bypass of both anterior hemispheres, while matching appropriate small-vessel dimensions.
Context in source publication
Context 1
... 19-year-old man was referred to the regional neurosurgical center, having suffered two subarachnoid hemorrhages in the previous two months. A cerebral angiogram demonstrated a large aneurysm affecting the anterior communicating artery and the proximal ends of both the right and left anterior cerebral arteries [ Figure 1]. Due to the aneurysm's size and Bilateral extracranial-intracranial (EC-IC) bypass-grafting of the cerebral circulation is uncommon. We report a case of anterior cerebral artery EC-IC bypass using the thoracodorsal axis artery-graft. The bifurcation of the thoracodorsal axis allows bypass of both anterior hemispheres, while matching appropriate small-vessel ...
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Background
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Methods
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Citations
... First, a bypass for revascularization after or during aneurysm repair, which defines the final blood supply to the ACA, is commonly performed, as noted by all authors in our literature review. Second, a protective bypass is used by some authors, 3,4,[7][8][9]11,13,15,20 including ourselves, during the approach to the aneurysm as well as during additional revascularization, which is crucial when treating complex aneurysms. To approach these complex aneurysms, trapping is sometimes needed to identify the surrounding structure for thrombectomy and during complex revascularization. ...
... Occlusion of the aneurysm can be achieved by neck clipping with aneurysmectomy, 11,13,16,17,24 trapping with or without aneurysmectomy, 3-7,12,15-21,23,26,27 distal clipping, 3,7,8,25 proximal clipping, 3,8 or endovascular coil embolization 3,7,10,14,22 after a bypass (Tables 2e4). The outcomes of these treatments have been reported as good, with accomplishment of complete thrombosis. ...
Background:
Giant, or complex, aneurysms of the anterior cerebral artery (ACA) are rare, but their surgical treatment is important. The authors describe their experiences with bypasses for complex ACA aneurysms and discuss the new classification of ACA bypasses, the concept of using bypasses for insurance during the approach to the aneurysm, and simplifying the surgical algorithms for these complex ACA aneurysms.
Methods:
Over a 19-year period, 7 cases of complex ACA aneurysm were treated with bypasses and reviewed retrospectively. The bypasses were classified into 4 groups according to donor blood flow: internal carotid artery (IC)-ACA, external carotid artery (EC)-ACA, communicating bypass, and reconstruction bypass of the ipsilateral postcommunicating ACA.
Results:
The cases included 1 precommunicating aneurysm, 3 communicating aneurysms, 2 postcommunicating aneurysms, and 1 double aneurysm (communicating and postcommunicating). The types of bypass included 1 IC-ACA, 6 communicating bypasses, 3 EC-ACAs, and 2 reconstruction bypass of the postcommunicating ACA. Postoperative modified Rankin Scale scores were 0 (6 cases) and 3 (1 case of a communicating aneurysm with complicated memory disturbance because of infarction). One case revealed asymptomatic infarction.
Conclusion:
Surgical treatment of complex ACA aneurysms requires knowledge of a variety of bypass techniques. Although the type of bypass should be selected according to patient-specific anatomy and the neurosurgeon's preference, the new classification of bypass-specified ACA aneurysms may alter the way surgeons think about ACA bypasses, and in combination with the concept of the protective bypass, can be used to establish a comprehensive algorithm for each type of complex ACA aneurysm.
Despite the evolution of indications, cerebral bypass remains an important treatment for selected patients with moyamoya disease, steno-occlusive cerebrovascular disease, complex aneurysms, and tumors. Ongoing advancements in patient selection and recent strategic, technical, and technological innovations are facilitating more tailored constructs with lower complication rates and continue to reshape the field. The consolidation of cerebral bypass to specialized centers will likely continue as the complexity of both the pathologies requiring treatment and the revascularization constructs performed increases.
Background:
When performing extracranial to intracranial (EC-IC) and intracranial to intracranial (IC-IC) bypass, the choice of donor vessel and interposition graft depends on several factors: vessel size and accessibility, desired blood flow augmentation, revascularization site anatomy, and pathology. The descending branch of the lateral circumflex femoral artery (DLCFA) is an attractive conduit for cerebrovascular bypass.
Objective:
To present our institutional experience using DLCFA grafts for cerebral revascularization.
Methods:
Retrospective review of perioperative data and outcomes for patients undergoing cerebrovascular bypass surgery using a DLCFA graft from 2016 to 2019.
Results:
Twenty consecutive patients underwent EC-IC bypass using a DLCFA interposition graft. Bypass indications included 13 (65%) intracranial aneurysms, 4 (20%) medically refractory atherosclerotic large artery occlusions (internal carotid artery or middle cerebral artery), 2 (10%) internal carotid artery dissections, and 1 (5%) patient with moyamoya disease. Most commonly, a donor superior temporal artery was bypassed to a recipient middle cerebral artery (14 of 20; 70%). Two cases demonstrated graft spasm. Graft occlusion occurred in one patient and was asymptomatic. Perioperative bypass surgery-related ischemia occurred in 3 patients: 1 patient with insufficient bypass flow, 1 patient with graft stenosis because of an adventitial band, and 1 patient with focal status epilepticus in the bypassed territory resulting in cortical ischemia. One donor site hematoma occurred. The median (range) modified Rankin scale (mRS) score on follow-up was 1.5 (1-4) at 7.8 (1-27) months, with most patients achieving good functional outcomes (mRS ≤2).
Conclusion:
The DLCFA is a versatile graft for cerebral revascularization surgery, demonstrating good outcomes with minimal graft harvest site morbidity and an acceptable graft patency rate.
Surgical brain revascularization is an important treatment for acute or chronic ischemia, intracranial aneurysms and skull base tumors. Individual anatomy of brain vessels should be clearly understood for this procedure. Variants of collateral cerebral blood flow in patients with cerebrovascular diseases depend on individual characteristics of circle of Willis and reserve mechanisms of collateral circulation. These anatomical variations require careful preoperative planning to choose the optimal revascularization option.
Simulation training in neurosurgery /
the monograph expounds the stages of practical training in neurosurgery from the stand point of simulation-based education. the simulation models for develop- ment of surgical skills in the field of vascular neurosurgery are described. the book presents methods of creating a simulation model of arterial aneurysm with its sub- sequent clipping using different techniques, creation of low-flow and high-flow vas- cular anastomoses, and performing a carotid endarterectomy using placenta vessels. special emphasis is placed on the surgical treatment of cerebrovascular pathology: arterial aneurysms, stenotic lesions of brachiocephalic arteries, and moyamoya di- sease. the described nosological forms are supplemented by thorough past history, clinical, laboratory, instrumental data, surgical techniques and treatment outcomes of illustrative clinical examples.
the book is intended for neurosurgeons, residents, and medical students. tabl. 18. Fig. 69. Ref. 439.
Background:
A variety of methods for tackling complex anterior cerebral artery (ACA) aneurysms are available; however, there is substantial variation among methods because of various aneurysm locations, the relationship of the aneurysm to arterial branches, aneurysm size and other morphological characteristics, and/or the diameters of the parent or branching arteries.
Methods:
We review complex ACA aneurysm cases based on both our own experience as well as the available literature. Each unique case is analyzed in terms of the characteristics of the aneurysm, along with an analysis and classification of the revascularization method used. Computer tablet-drawn illustrations of every unique technique are provided for easy comprehension and application in various possible situations.
Results:
Over the prior six years, we have treated a total of five cases of complex ACA aneurysms (one precommunicating, one communicating, one postcommunicating, and two precallosal-supracallosal segment) with revascularization. Side-to-side anastomosis was performed between A3-A3 in three cases, between A4-A4 in another case, and between the ipsilateral callosomarginal artery-pericallosal in the remaining case. Final modified Rankin scale was 0 in four of the five cases, and three in one case. Six treatment strategies were used for the precommunicating case, eight for the communicating case, seven for the postcommunicating case, and nine for the two precallosal-supracallosal segment aneurysms.
Conclusion:
Treatment of complex ACA aneurysms should be tailored according to the location and nature of the aneurysm, as well as collateral circulation. Viable and feasible treatment strategies must be established by the neurovascular surgeon.
Object:
The authors describe their experience with intracranial-to-intracranial (IC-IC) bypasses for complex anterior cerebral artery (ACA) aneurysms with giant size, dolichoectatic morphology, or intraluminal thrombus; they determine how others have addressed the limitations of ACA bypass; and they discuss clinical indications and microsurgical technique.
Methods:
A consecutive, single-surgeon experience with ACA aneurysms and bypasses over a 16-year period was retrospectively reviewed. Bypasses for ACA aneurysms reported in the literature were also reviewed.
Results:
Ten patients had aneurysms that were treated with ACA bypass as part of their surgical intervention. Four patients presented with subarachnoid hemorrhage and 3 patients with mass effect symptoms from giant aneurysms; 1 patient with bacterial endocarditis had a mycotic aneurysm, and 1 patient's meningioma resection was complicated by an iatrogenic pseudoaneurysm. One patient had his aneurysm discovered incidentally. There were 2 precommunicating aneurysms (A1 segment of the ACA), 5 communicating aneurysms (ACoA), and 3 postcommunicating (A2-A3 segments of the ACA). In situ bypasses were used in 4 patients (A3-A3 bypass), interposition bypasses in 4 patients, reimplantation in 1 patient (pericallosal artery-to-callosomarginal artery), and reanastomosis in 1 patient (pericallosal artery). Complete aneurysm obliteration was demonstrated in 8 patients, and bypass patency was demonstrated in 8 patients. One bypass thrombosed, but 4 years later. There were no operative deaths, and permanent neurological morbidity was observed in 2 patients. At last follow-up, 8 patients (80%) were improved or unchanged. In a review of the 29 relevant reports, the A3-A3 in situ bypass was used most commonly, extracranial (EC)-IC interpositional bypasses were the second most common, and reanastomosis and reimplantation were used the least.
Conclusions:
Anterior cerebral artery aneurysms requiring bypass are rare and can be revascularized in a variety of ways. Anterior cerebral artery aneurysms, more than any other aneurysms, require a thorough survey of patient-specific anatomy and microsurgical options before deciding on an individualized management strategy. The authors' experience demonstrates a preference for IC-IC reconstruction, but EC-IC bypasses are reported frequently in the literature. The authors conclude that ACA bypass with indirect aneurysm occlusion is a good alternative to direct clip reconstruction for complex ACA aneurysms.
