1
|
Santhumayor BA, White TG, Golub D, Rivera M, Turpin J, Golombeck D, Ryu B, Shah K, Ortiz R, Black K, Katz JM, Dehdashti AR, Langer DJ. Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Unilateral Moyamoya Disease Using Quantitative Magnetic Resonance Angiography. Neurosurgery 2024; 95:596-604. [PMID: 38501815 DOI: 10.1227/neu.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Moyamoya disease (MMD) is a chronic steno-occlusive disease of the intracranial circulation that depends on neoangiogenesis of collateral vessels to maintain cerebral perfusion and is primarily managed with cerebral revascularization surgery. A quantitative assessment of preoperative and postoperative collateral flow using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA) was used to illustrate the impact of revascularization on cerebral flow distribution. METHODS A retrospective review of patients with unilateral MMD who underwent direct, indirect, or combined direct/indirect cerebral revascularization surgery was conducted between 2011 and 2020. Using NOVA, flow was measured at the anterior cerebral artery (ACA), ACA distal to the anterior communicating artery (A2), middle cerebral artery (MCA), posterior cerebral artery (PCA), and PCA distal to the posterior communicating artery (P2). Pial flow (A2 + P2) and collateral flow (ipsilateral [A2 + P2])-(contralateral [A2 + P2]) were measured and compared before and after revascularization surgery. Total hemispheric flow (MCA + A2 + P2) with the addition of the bypass graft flow postoperatively was likewise measured. RESULTS Thirty-four patients with unilateral MMD underwent cerebral revascularization. Median collateral flow significantly decreased from 68 to 39.5 mL/min ( P = .007) after bypass. Hemispheres with maintained measurable bypass signal on postoperative NOVA demonstrated significant reduction in median collateral flow after bypass ( P = .002). Median total hemispheric flow significantly increased from 227 mL/min to 247 mL/min ( P = .007) after bypass. Only one patient suffered an ipsilateral ischemic stroke, and no patients suffered a hemorrhage during follow-up. CONCLUSION NOVA measurements demonstrate a reduction in pial collateral flow and an increase in total hemispheric flow after bypass for MMD, likely representing a decrease in leptomeningeal collateral stress on the distal ACA and PCA territories. Further studies with these measures in larger cohorts may elucidate a role for NOVA in predicting the risk of ischemic and hemorrhagic events in MMD.
Collapse
Affiliation(s)
- Brandon A Santhumayor
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Danielle Golub
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Moses Rivera
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - David Golombeck
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Rafael Ortiz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
- Current Affiliation: Department of Neurosurgery, White Plains Hospital, White Plains , New York , USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - David J Langer
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| |
Collapse
|
2
|
Cekic E, Surme MB, Akbulut F, Ozturk R, Ustun ME. Secondary Benefits of Microsurgical Intervention on the Vertebral Artery (V1 Segment) for Refractory Vertebrobasilar Insufficiency: Alleviation of Parkinsonism-Like Symptoms. World Neurosurg 2024; 187:e551-e559. [PMID: 38677645 DOI: 10.1016/j.wneu.2024.04.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE The objective of this study was to investigate the outcomes of microneurosurgical interventions on V1 segment of the vertebral artery in patients with refractory vertebrobasilar insufficiency (VBI) due to dolicoarteriopathy and external compressions and to assess the secondary benefits of Parkinsonism-like symptoms. METHODS Retrospective analysis encompassed 101 patients treated for vertebral artery dolicoarteriopathy or compression-related refractory VBI from 2016 to 2023. Of these, 16 patients exhibited drug-resistant Parkinsonism-like symptoms. The diagnostic evaluation included cerebral computed tomography/magnetic resonance angiography or digital subtraction angiography and brain computed tomography or magnetic resonance perfusion studies, corroborated by preoperative and 6- and 12-month postoperative Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part 3 assessments. Data were analyzed through Turkey's "E-nabız" system, employing Stata16 for statistical scrutiny. RESULTS A significant reduction in Movement Disorder Society-Unified Parkinson's Disease Rating Scale scores was observed (preoperative: 26.75±10.91; 6 months: 23.09±9.24; 12 months: 22.5±8.73; P < 0.001). Postoperative follow-up denoted that 43.7% of patients ceased medication and 50% reduced antiparkinsonian drugs. The microneurosurgical approach resulted in complete remission of VBI-related symptoms in 84.6% of patients, with the rest showing partial or marked improvement. At 6 months postoperation, perfusion studies revealed posterior border zone or cerebellar perfusion enhancements in 81% (13 out of 16) of patients, with full symptom resolution, while the remaining 19% (3 out of 16) showed partial perfusion and clinical improvements, particularly in regions supplied by the posterior cerebellar artery or posterior inferior cerebellar artery. The absence of operative mortality and minimal transient morbidities underscored the procedure's safety. CONCLUSIONS Microneurosurgery for vertebral artery anomalies in refractory VBI patients, particularly those with concomitant parkinsonian-like syndromes, has demonstrated potential in symptom remission and medication reduction.
Collapse
Affiliation(s)
- Efecan Cekic
- Department of Neurosurgery, Polatli Duatepe State Hospital, Ankara, Turkey.
| | | | - Fatih Akbulut
- Department of Neurosurgery, Marmara University, Istanbul, Turkey
| | - Rustem Ozturk
- Department of Neurology, Private Atlas Hospital, Istanbul, Turkey
| | | |
Collapse
|
3
|
Zitek H, Hejcl A, Sadeh M, Charbel FT, Sames M. Occipital artery to vertebral artery bypass for treatment of bilateral vertebral artery occlusion with QMRA as an adjunct to diagnostic assessment. Acta Neurochir (Wien) 2024; 166:203. [PMID: 38713241 PMCID: PMC11076335 DOI: 10.1007/s00701-024-06099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE Stroke, the second leading cause of death globally, often involves ischemia in the vertebrobasilar territory. This condition is underexplored, despite significant morbidity and mortality risks. The purpose of this study is to present a case of occipital artery to V3 segment vertebral artery bypass, emphasizing the role of quantitative magnetic resonance angiography (qMRA) in assessing flow and guiding surgical intervention. METHODS A 66-year-old man with bilateral vertebral artery occlusion presented acute symptoms. qMRA was employed to evaluate flow dynamics and determine the feasibility of a flow augmentation bypass surgery. The occipital artery to left vertebral artery bypass (OA-to-VA) was performed, utilizing an inverted hockey-stick incision and an antegrade inside-out technique. The patency of the bypass was confirmed using both Doppler probe and Indocyanine green. RESULTS Postoperative assessments, including computed tomography angiography (CTA) and qMRA, demonstrated the patency of the bypass with improved flow in the basilar artery and left vertebral artery. The patient's condition remained stable postoperatively, with residual peripheral palsy of the left facial nerve. CONCLUSION In conclusion, the presented case illustrates the efficacy of the OA-to-VA bypass in addressing symptomatic bilateral vertebral artery occlusion. The study underscores the pivotal role of qMRA in pre- and postoperative assessments, providing noninvasive flow quantification for diagnostic considerations and long-term follow-up in patients with vertebrobasilar insufficiency.
Collapse
Affiliation(s)
- Hynek Zitek
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic.
| | - Ales Hejcl
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Morteza Sadeh
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Fady T Charbel
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Martin Sames
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Nisson PL, Ding X, Tayebi Meybodi A, Palsma R, Benet A, Lawton MT. Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites. Oper Neurosurg (Hagerstown) 2020; 19:E122-E129. [PMID: 32107553 DOI: 10.1093/ons/opaa023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/01/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location. OBJECTIVE To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass. METHODS The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared. RESULTS OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001). CONCLUSION Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.
Collapse
Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,Department of Neurosurgery, Cedar Sinai, Beverly Hills, California
| | - Xinmin Ding
- ShanXi Province People's Hospital, Yinze District, Taiyuan, China
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ryan Palsma
- College of Medicine, University of Arizona, Tucson, Arizona
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
6
|
Rahme R, Sudhakar TD, Alimi M, White TG, Ortiz RA, Langer DJ. Cerebral Hyperperfusion Syndrome by the Numbers: Transient Focal Neurological Deficit, Imaging-Proven Focal Hyperperfusion, and High Graft Flow Rate Following Superficial Temporal Artery-Middle Cerebral Artery bypass in a Patient With Symptomatic Carotid Occlusion—Case Report. Oper Neurosurg (Hagerstown) 2018. [DOI: 10.1093/ons/opy010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Cerebral hyperperfusion syndrome (CHS) is a well-known complication of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass for ischemic cerebrovascular disease. While this argues against “low flow” in the bypass construct, flow rates in the graft have not been previously quantified in the setting of CHS.
CLINICAL PRESENTATION
A 58-yr-old man presented with recurrent left hemispheric ischemic strokes and fluctuating right hemiparesis and aphasia. Vascular imaging revealed left cervical internal carotid artery occlusion and perfusion imaging confirmed left hemispheric hypoperfusion. After failing to respond to maximal medical therapy, the patient underwent single-barrel STA-MCA bypass. Postoperatively, his symptoms resolved and blood pressure (BP) was strictly controlled within normal range. However, 2 d later, he developed severe expressive aphasia. CTA demonstrated a patent bypass graft and SPECT showed focal hyperperfusion in Broca's speech area. Seizure activity was ruled out. A high graft flow rate of 52 mL/min was documented by quantitative magnetic resonance angiography (MRA). Thus, the diagnosis of CHS was made and managed with strict BP control. The patient exhibited complete recovery of speech over a period of days and was discharged home. Repeat SPECT at 4 mo showed resolution of hyperperfusion and quantitative MRA demonstrated reduction of graft flow rate to 34 mL/min.
CONCLUSION
This is the first case of perfusion imaging-proven CHS after STA-MCA bypass, where high graft flow rates are objectively documented. Our observations constitute irrefutable evidence challenging the classic belief that the STA-MCA bypass is a low-flow construct.
Collapse
Affiliation(s)
- Ralph Rahme
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
- Division of Neurosurgery, SBH Health System, Bronx, New York
| | - Tejaswi D Sudhakar
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
| | - Marjan Alimi
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
| | - Timothy G White
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
| | - Rafael A Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, New York
| |
Collapse
|
7
|
Lu X, Ma Y, Yang B, Gao P, Wang Y, Jiao L. Hybrid Technique for the Treatment of Refractory Vertebrobasilar Insufficiencies. World Neurosurg 2017; 107:1051.e13-1051.e17. [PMID: 28843759 DOI: 10.1016/j.wneu.2017.08.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Tortuous or occluded vertebral arteries (VAs) can make the endovascular treatment of vertebrobasilar insufficiency impractical. Bypass surgery is an option, but a craniotomy of the posterior fossa is complicated when physiologic vessels must be abandoned. We report 3 cases of refractory vertebrobasilar insufficiency with different presentations requiring problematic approaches in which the patients were treated by different hybrid strategies. CASE DESCRIPTION Patient 1 had severe stenosis of right VA ostium with right V1 segment tortuosity and was treated by right VA ostium transposition during which the proximal subclavian artery was blocked by a balloon guide catheter. Patient 2 had severe stenosis of the basilar artery and bilateral VA tortuosity. The V1 segment was exposed and cut open so that an available approach for endovascular procedures was created. Patient 3 had bilateral VA occlusion. After exposure of the left V1 segment, recanalization of the left VA was performed by an interventional radiologist and surgeon working together. All patients had improved hemodynamics and symptoms alleviated without major complications. CONCLUSIONS For refractory vertebrobasilar insufficiencies, hybrid operations that combine surgical manipulation of the V1 segment and endovascular techniques can be safe and effective.
Collapse
Affiliation(s)
- Xia Lu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.
| |
Collapse
|
8
|
Matsushima K, Matsuo S, Komune N, Kohno M, Lister JR. Variations of Occipital Artery-Posterior Inferior Cerebellar Artery Bypass: Anatomic Consideration. Oper Neurosurg (Hagerstown) 2017; 14:563-571. [DOI: 10.1093/ons/opx152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/31/2017] [Indexed: 11/15/2022] Open
Abstract
Abstract
BACKGROUND
Advances in diagnosis of posterior inferior cerebellar artery (PICA) aneurysms have revealed the high frequency of distal and/or dissecting PICA aneurysms. Surgical treatment of such aneurysms often requires revascularization of the PICA including but not limited to its caudal loop.
OBJECTIVE
To examine the microsurgical anatomy involved in occipital artery (OA)-PICA anastomosis at various anatomic segments of the PICA.
METHODS
Twenty-eight PICAs in 15 cadaveric heads were examined with the operating microscope to take morphometric measurements and explore the specific anatomy of bypass procedures.
RESULTS
OA bypass to the p2, p3, p4, or p5 segment was feasible with a recipient vessel of sufficient diameter. The loop wandering near the jugular foramen in the p2 segment provided sufficient length without requiring cauterization of any perforating arteries to the brainstem. Wide dissection of the cerebellomedullary fissure provided sufficient exposure for the examination of some p3 segments and all p4 segments hidden by the tonsil. OA-p5 bypass was placed at the main trunk before the bifurcation in 5 hemispheres and at the larger hemispheric trunk in others.
CONCLUSION
Understanding the possible variations of OA-PICA bypass may enable revascularization of the appropriate portion of the PICA when the parent artery must be occluded. A detailed anatomic understanding of each segment clarifies important technical nuances for the bypass on each segment. Dissection of the cerebellomedullary fissure helps to achieve sufficient exposure for the bypass procedures on most of the segments.
Collapse
Affiliation(s)
- Ken Matsushima
- Lillian S. Wells Department of Neuro-logical Surgery, University of Florida, Gainesville, Florida
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Satoshi Matsuo
- Lillian S. Wells Department of Neuro-logical Surgery, University of Florida, Gainesville, Florida
| | - Noritaka Komune
- Lillian S. Wells Department of Neuro-logical Surgery, University of Florida, Gainesville, Florida
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - J Richard Lister
- Lillian S. Wells Department of Neuro-logical Surgery, University of Florida, Gainesville, Florida
| |
Collapse
|
9
|
Measuring Cerebral Blood Flow in Moyamoya Angiopathy by Quantitative Magnetic Resonance Angiography Noninvasive Optimal Vessel Analysis. Neurosurgery 2017; 81:921-927. [DOI: 10.1093/neuros/nyw122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/08/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Moyamoya disease causes progressive occlusion of the supraclinoidal internal carotid artery, and middle, anterior, and less frequently the posterior cerebral arteries, carrying the risk of stroke. Blood flow is often partially reconstituted by compensatory moyamoya collaterals and sometimes the posterior circulation. Cerebral revascularization can further augment blood flow. These changes to blood flow within the cerebral vessels, however, are not well characterized.
OBJECTIVE
To evaluate blood flow changes resulting from the disease process and revascularization surgery using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA).
METHODS
We retrospectively analyzed 190 preoperative and postoperative imaging scans in 66 moyamoya patients after revascularization surgery. Images were analyzed for blood flow using NOVA and compared with preoperative angiographic staging and postoperative blood flow. Blood flow rates within superficial temporal artery grafts were compared based on angiographic evidence of patency.
RESULTS
Diseased vessels had lower blood flow, correlating with angiographic staging. Flow in posterior cererbal and basilar arteries increased with disease severity, particularly when both the anterior and middle cerebral arteries were occluded. Basilar artery flow and ipsilateral internal carotid artery flow decreased after surgery. Flow rates were different between angiographically robust and poor direct bypass grafts, as well as between robust and patent grafts.
CONCLUSION
Preoperative changes in cerebral vessel flow as measured by NOVA correlated with angiographic disease progression. NOVA demonstrated that preoperative augmentation of the posterior circulation decreased after surgery. This report is the first to quantify the shift in collateral supply from the posterior circulation to the bypass graft.
Collapse
|
10
|
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.
Collapse
|
11
|
Rafael H. Revascularization of the brainstem and cerebellum. Neurosurgery 2010; 67:E521; author reply E521. [PMID: 20644393 DOI: 10.1227/01.neu.0000384042.80164.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|