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Uda K, Tanahashi K, Mamiya T, Kanamori F, Yokoyama K, Nishihori M, Izumi T, Araki Y, Saito R. Advantages of petrosectomy for superficial temporal artery to superior cerebellar artery bypass based on three-dimensional distance measurements using cadaver heads. Neurosurg Rev 2021; 45:1617-1624. [PMID: 34735687 PMCID: PMC8976806 DOI: 10.1007/s10143-021-01686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/28/2021] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
Superficial temporal artery (STA) to superior cerebellar artery (SCA) bypass is usually performed via the subtemporal approach (StA), anterior transpetrosal approach (ApA), or combined petrosal approach (CpA), but no study has yet reported a quantitative comparison of the operative field size provided by each approach, and the optimal approach is unclear. The objective of this study is to establish evidence for selecting the approach by using cadaver heads to measure the three-dimensional distances that represent the operative field size for STA-SCA bypass. Ten sides of 10 cadaver heads were used to perform the four approaches: StA, ApA with and without zygomatic arch osteotomy (ApA-ZO- and ApA-ZO+), and CpA. For each approach, the major-axis length and the minor-axis length at the anastomosis site (La-A and Li-A), the major-axis length and the minor-axis length at the brain surface (La-B and Li-B), the depth from the brain surface to the anastomosis site (Dp), and the operating angles of the major axis and the minor axis (OAa and OAi) were measured. Shallower Dp and wider operating angle were obtained in the order CpA, ApA-ZO+, ApA-ZO-, and StA. In all parameters, ApA-ZO- extended the operative field more than StA. ApA-ZO+ extended La-B and OAa more than ApA-ZO-, whereas it did not contribute to Dp and OAi. CpA significantly decreased Dp, and widened OAa and OAi more than ApA-ZO+. ApA and CpA greatly expanded the operative field compared with StA. These results provide criteria for selecting the optimal approach for STA-SCA bypass in light of an individual surgeon's anastomosis skill level.
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Affiliation(s)
- Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan.
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku Nagoya, Aichi, 466-8550, Japan
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Nakamura K, Kurabe S, Irie K, Shibuma S, Seo K, Sugai T, Kumagai T. Exertional Vertebrobasilar Insufficiency 6 Years after Vertebral Artery Dissection Treated with Occipital Artery-posterior Inferior Cerebellar Artery Anastomosis. NMC Case Rep J 2021; 8:1-5. [PMID: 34012741 PMCID: PMC8116930 DOI: 10.2176/nmccrj.cr.2020-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/02/2020] [Indexed: 11/20/2022] Open
Abstract
Exertional vertebrobasilar insufficiency (VBI) secondary to the non-atherosclerotic cause is uncommon. We herein report the case of a patient who developed exertional VBI long after extracranial right vertebral artery (VA) dissection. At the time of dissection, the right VA was completely occluded near its origin, but the distal flow was compensated by the collateral flow from the right deep cervical artery (DCA). After conservative management, the patient was discharged without neurologic deficit. Six years later, he developed recurrent VBI in association with the exertion of his right shoulder. A vascular evaluation revealed that the right proximal VA was still occluded, and there was no evidence of right subclavian artery lesions. The intracranial right VA flow was markedly reduced during the period, while branches of the right DCA were given off to the muscles of the right shoulder and neck. Then, occipital artery (OA)-posterior inferior cerebellar artery (PICA) anastomosis was performed. Intraoperative indocyanine green videoangiography (ICG) confirmed that the flow of the right PICA was predominantly supplied from the compensatory flow from the contralateral VA, and the antegrade flow in the right VA was clearly delayed in comparison to that of the left VA while there were prominent branches providing the blood flow to the medulla oblongata. After the anastomosis, these medullary branches provided the blood flow to the medulla oblongata more quickly and extensively than before. Postoperatively, VBI no longer occurred even after exertion. Surgical revascularization can be a viable option in the treatment of refractory VBI of the non-atherosclerotic cause.
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Affiliation(s)
- Kazuki Nakamura
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Satoshi Kurabe
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Katsutaka Irie
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Satoshi Shibuma
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Kyoichi Seo
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Tsutomu Sugai
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
| | - Takashi Kumagai
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
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Abstract
Disease of the vertebral (VA) and basilar arteries (BA) can lead to stroke of the posterior circulation and may warrant management strategies which differ from the anterior circulation. The mechanism and location of the disease determine its natural history and therefore affect the relative risks and benefits of the possible treatment options. Vertebrobasilar (VB) atherosclerotic disease is a source of both hemodynamic and embolic posterior circulation stroke. Advances in medical therapy have decreased the rate of stroke after initial symptomatic presentation. Antiplatelet therapy, blood pressure control, and optimization of secondary risk factors can reduce recurrent stroke risk in both intracranial and extracranial VB disease. However, symptomatic intracranial disease is still associated with a high risk of subsequent stroke, particularly those with hemodynamic compromise who represent a higher risk population. Patients with hemodynamic impairment may benefit from judicious application of endovascular and microsurgical interventions to augment blood flow. Stenting, angioplasty alone, bypass surgery, and endarterectomy, represent endovascular and surgical tools available to address medically refractory VB disease. Apart from atherosclerotic disease, dissection is another etiology of VB stroke, most frequently affecting the extracranial VA. Treatment is predominantly antithrombotic therapy although surgical or endovascular intervention can be required in rare cases of persistent embolism or hemodynamic compromise. In contrast, extrinsic compromise of the VA represents a separate extracranial pathology and is best treated with mechanistically targeted surgeries or extracranial bypass.
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Affiliation(s)
- Richard Bram
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
| | - Alfred P See
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA -
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Duan H, Mo D, Zhang Y, Zhang J, Li L. Carotid-vertebral artery bypass with saphenous vein graft for symptomatic vertebrobasilar insufficiency. Neurosurg Focus 2020; 46:E8. [PMID: 30717073 DOI: 10.3171/2018.11.focus18360] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVESymptomatic steno-occlusion of the proximal vertebral artery (VA) or subclavian artery (ScA) heralds a poor prognosis and high risk of stroke recurrence despite medical therapy, including antiplatelet or anticoagulant drugs. In some cases, the V2 segment of the cervical VA is patent and perfused via collateral vessels. The authors describe 7 patients who were successfully treated by external carotid artery (ECA)-saphenous vein (SV)-VA bypass.METHODSSeven cases involving symptomatic patients were retrospectively studied: 3 cases of V1 segment occlusion, 2 cases of severe in-stent restenosis in the V1 segment, and 2 cases of occlusion of the proximal ScA. All patients underwent ECA-SV-VA bypass. The ECA was isolated and retracted, and the anterior wall of the transverse foramen was unroofed. The VA was exposed, and then the 2 ends of the SV were anastomosed to the VA and ECA in an end-to-side fashion.RESULTSSurgical procedures were all performed as planned, with no intraoperative complications. There were 2 postoperative complications (severe laryngeal edema in one case and shoulder weakness in another), but both patients recovered fully and measures were taken to minimize laryngeal edema and its effects in subsequent cases. All patients experienced improvement of their symptoms. No new neurological deficits were reported. Postoperative angiography demonstrated that the anastomoses were all patent, and analysis of follow-up data (range of follow-up 12-78 months) revealed no further ischemic events in the vertebrobasilar territory.CONCLUSIONSThe ECA-SV-VA bypass is a useful treatment for patients who suffer medically refractory ischemic events in the vertebrobasilar territory when the proximal part of the VA or ScA is severely stenosed or occluded but the V2 segment of the cervical VA is patent.
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Affiliation(s)
- Hongzhou Duan
- 1Department of Neurosurgery, Peking University First Hospital; and
| | - Dapeng Mo
- 1Department of Neurosurgery, Peking University First Hospital; and.,2Department of the Interventional Neuroradiology, Beijing Tiantan Hospital Affiliated to the Capital Medical University, Beijing, China
| | - Yang Zhang
- 1Department of Neurosurgery, Peking University First Hospital; and
| | - Jiayong Zhang
- 1Department of Neurosurgery, Peking University First Hospital; and
| | - Liang Li
- 1Department of Neurosurgery, Peking University First Hospital; and
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Rennert RC, Steinberg JA, Strickland BA, Ravina K, Bakhsheshian J, Fredrickson V, Pannell JS, Khalessi AA, Russin JJ. Extracranial-to-Intracranial Bypass for Refractory Vertebrobasilar Insufficiency. World Neurosurg 2019; 126:552-559. [PMID: 30926554 DOI: 10.1016/j.wneu.2019.03.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/16/2019] [Accepted: 03/18/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND Vertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset. METHODS A multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded. RESULTS Five patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter. CONCLUSIONS Refractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kristine Ravina
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vance Fredrickson
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - J Scott Pannell
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Postoperative Antiplatelet Therapy in the Treatment of Complex Basilar Apex Aneurysms Implementing Hunterian Ligation and Extracranial-to-Intracranial Bypass: Review of the Literature with an Illustrative Case Report. World Neurosurg 2018; 123:113-122. [PMID: 30537547 DOI: 10.1016/j.wneu.2018.11.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/22/2022]
Abstract
Large broad-based basilar artery (BA) apex aneurysms involving multiple arterial origins are complex lesions commonly not amenable to direct clipping or endovascular management. BA proximal (Hunterian) occlusion with extracranial-to-intracranial bypass is a supported strategy if 1 or both posterior communicating arteries are small. Hunterian ligation risks sudden aneurysm thrombosis and thromboembolism in the perforator-rich BA apex. There currently exist no guidelines for antiplatelet and anticoagulant therapy after Hunterian ligation for complex BA apex aneurysm treatment. We present a literature review and an illustrative case of an 18-year-old man who presented with progressive headaches and was found to have a large unruptured BA apex aneurysm involving the origins of the bilateral superior cerebellar and posterior cerebral arteries. Given the small posterior communicating arteries and complexity of the aneurysm, proximal BA occlusion with unilateral superficial temporal artery-to-superior cerebellar artery bypass was recommended. Despite antiplatelet treatment with acetylsalicylic acid before and after operation, the patient experienced acute ischemia of the brainstem and cerebellum and an embolic left temporal lobe infarct. The patient received dual antiplatelet therapy starting on postoperative day 6, after which he experienced no new infarcts and made a significant neurologic recovery. The current evidence suggests that proximal BA occlusion in complex BA apex aneurysm cases is thrombogenic and can be especially dangerous if thrombosis occurs suddenly in aneurysms without pre-existing intraluminal thrombus. Dual antiplatelet therapy during the first postoperative week presents a possible strategy for reducing the risk of ischemia due to sudden aneurysm thrombosis.
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Katsuno M, Ishisaka E, Toyota K, Kawasaki K, Inaba I. Emergency Superficial Temporal Artery-Superior Cerebellar Artery Bypass for the Refractory Vertebrobasilar Insufficiency with Partial Mastoidectomy. World Neurosurg 2018; 118:75-80. [PMID: 30010066 DOI: 10.1016/j.wneu.2018.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although it is well-known that vertebrobasilar insufficiency (VBI) because of atherothrombosis with bilateral vertebral artery (VA) occlusion is resistant to medical treatment from the acute to subacute stages, the most appropriate treatment for progressive infarction at these stages remains unclear. Here, we described a patient with VBI who underwent emergency superficial temporal artery-superior cerebellar artery (STA-SCA) bypass under partial mastoidectomy after confirming mismatch between diffusion-weighted imaging (DWI) findings and clinical symptoms. The patient showed a good outcome with this approach. To our knowledge, our surgical strategy has not been previously reported. CASE DESCRIPTION The patient was a 71-year-old woman with progressive infarction because of atherothrombosis with bilateral VA occlusions resistant to maximum medical treatment. Emergency STA-SCA bypass under partial mastoidectomy was performed after confirming DWI findings and symptom mismatch. A good outcome was archived, and no additional cerebral infarctions were noted. CONCLUSIONS Emergency bypass should be considered as a treatment option for VBI that is resistant to maximal medical treatment after confirming DWI findings and symptom mismatch. Our approach involving partial mastoidectomy provides a wide and shallow operative field for STA-SCA bypass, which allows accurate bypass with good outcomes.
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Affiliation(s)
- Makoto Katsuno
- Department of Neurosurgery, Doutou Neurosurgical Hospital, Kitami, Hokkaido, Japan.
| | - Eitaro Ishisaka
- Department of Neurosurgery, Doutou Neurosurgical Hospital, Kitami, Hokkaido, Japan
| | - Kiyotaka Toyota
- Department of Neurosurgery, Doutou Neurosurgical Hospital, Kitami, Hokkaido, Japan
| | - Kazutsune Kawasaki
- Department of Neurosurgery, Doutou Neurosurgical Hospital, Kitami, Hokkaido, Japan
| | - Izumi Inaba
- Department of Neurosurgery, Doutou Neurosurgical Hospital, Kitami, Hokkaido, Japan
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Hokari M, Asaoka K, Shimbo D, Uchida K, Itamoto K. Superficial Temporal Artery–Superior Cerebellar Artery Bypass with Anterior Petrosectomy. World Neurosurg 2018; 114:179-186. [DOI: 10.1016/j.wneu.2018.03.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 11/24/2022]
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Intraoperative visualization of bilateral thrombosis in the posterior inferior cerebellar artery apparent in the telovelomedullary segment. Case Rep Neurol Med 2014; 2014:247652. [PMID: 25328728 PMCID: PMC4195263 DOI: 10.1155/2014/247652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 09/15/2014] [Accepted: 09/15/2014] [Indexed: 12/22/2022] Open
Abstract
Unilateral posterior inferior cerebellar artery (PICA) thrombosis is frequent. However, bilateral PICA thrombosis is rare. Herein we report about an intraoperative visualization of a bilateral thrombosis of the telovelomedullary segment of the PICA. A 74-year-old woman was admitted to our department on day two of a bilateral PICA thrombosis with developing cerebellar infarction. Her Glasgow Coma Scale score dropped from 15 to 13, and cranial computed tomography revealed compression of the fourth ventricle with consecutive occlusive hydrocephalus. After the insertion of an external ventricular drainage, the patient underwent urgent suboccipital decompressive craniectomy with removal of infarcted cerebellar tonsils, which allowed the bilateral visualization of the thrombosed telovelomedullary segments. The surgical access may offer surgical therapeutic options in a hyperacute occlusion, such as thromb-/embolectomy or bypass procedures.
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Ecker RD, Tsujiura CA, Baker CB, Cushing D. Endovascular reconstruction of vertebral artery occlusion prior to basilar thrombectomy in a series of six patients presenting with acute symptomatic basilar thrombosis. J Neurointerv Surg 2013; 6:379-83. [DOI: 10.1136/neurintsurg-2013-010719] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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