Angiographic and Clinical Outcomes of Various Techniques of Intracranial-to-Intracranial Bypass for Complex Cases with a Review of Pertinent Literature and Illustrated Cases

BACKGROUND

We sought to determine the utility of intracranial-to-intracranial bypass (IIB) surgery and the available bypass options for complex cases.

METHODS

A total of 18 IIB cases were included. Each case was classified as IIB with or without an interposition graft. The clinical and angiographic status were evaluated pre- and postoperatively and at the last follow-up. Angiographic images were analyzed and reconstructed schematically. Postoperative angiography was used to measure the bypass patency and the presence of postoperative cerebral infarction. The recipient artery occlusion time for each bypass was measured.

RESULTS

Of the 18 patients, 14 had presented with a complex intracranial aneurysm (IA), 1 with vertebrobasilar dolichoectasia, and 3 with intracranial arterial steno-occlusive disease. Ten patients had an incidentally discovered IA. Seven patients had presented with neurological deficits due to ischemia or aneurysmal mass effects. Of the 18 cases, 10 were IIBs with an interposition graft, including 4 cases of superficial temporal artery and 6 of radial artery graft bypass, and 8 were IIBs with a noninterposition graft, including 3 cases of in situ bypass, 1 case of reanastomosis, and 4 cases of reimplantation. The pre- and postoperative modified Rankin scale score did not change or improve, and all the bypasses were patent. No patient had died during the mean follow-up period of 50.0 months. The mean occlusion time of the recipient artery was 59.5 minutes. A total of 8 patients experienced postoperative cerebral infarction but all had almost recovered at discharge.

CONCLUSIONS

With proper selection of the IIB type, IIB can be a suitable treatment option for some patients with complex IAs and intracranial arterial steno-occlusive disease when extracranial-to-intracranial bypass is not feasible.

A Practical Guide to Train the Side-to-side Anastomosis: Tips, Tricks and Technical Nuances

BACKGROUND

Microanastomosis presents a challenge in neurosurgical procedures, requiring specialized skills. Regular practice outside the operating room is crucial. This study aims to provide a detailed description of the side-to-side anastomosis technique and analyze its advantages in preventing failures compared with other variations.

METHODS

We examined the technique, characteristics, and outcomes of side-to-side bypass procedures for complex aneurysms in the anterior cerebral artery territory at our institution over the past decade. We compared our technique with those described in the literature by other groups.

RESULTS

The Far East Neurosurgical Institute (FENI) technique was used in 15 patients, with 17 side-to-side anastomoses performed. The average anastomosis time was 27.5 minutes, with 100% patency in follow-up. Our technique demonstrated safety and effectiveness in treating intracranial aneurysms, yielding satisfactory short- and long-term functionality outcomes. We highlight the importance of maintaining a curvilinear arteriotomy shape, at least 3 times the diameter of the artery, and utilizing an interrupted suturing technique on the anterior wall.

CONCLUSIONS

This paper presents the first comprehensive description of the side-to-side anastomosis technique, supported with images and videos for training and replicability. Our technique enhances flow dynamics and reduces the risk of acute thrombus formation. Training in simulators and microsurgery practice centers outside the operating room is essential for acquiring and refining microsurgical skills.

Clinical and Technical Outcomes of Intracranial-Intracranial Bypass for Treating Complex Intracranial Aneurysms: An Analysis of 255 Patients

BACKGROUND

Despite the recent increase in publications centered on intracranial-intracranial (IC-IC) bypasses for complex aneurysms, there is no systematic evidence regarding their outcomes. The purpose was to assess the outcomes of patients subjected to IC-IC bypass for aneurysms.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, a systematic review was conducted. Criteria for inclusion entailed studies with a cohort of at least 4 patients having undergone IC-IC bypass for aneurysms, detailing at least one outcome, such as patency, clinical outcomes, complications, and procedure-related mortality. When the study included patients who had undergone extracranial-intracranial (EC-IC) bypass, the authors extracted the patency and clinical data to juxtapose them with the results of IC-IC.

RESULTS

Of the 2509 shortlisted studies, 22 met our inclusion criteria, encompassing 255 patients and 263 IC-IC bypass procedures. The IC-IC bypass procedure exhibited a patency rate of 93% (95% confidence interval [CI]: 89%-95%). The patency rate of IC-IC and EC-IC bypasses did not significantly differ (odds ratio=0.60 [95% CI: 0.18-1.96]). Concerning clinical outcomes, 91% of the IC-IC patients had positive results (95% CI: 85%-97%), with no significant disparity between the IC-IC and EC-IC groups (odds ratio=1.29 [95% CI: 0.43-3.88]). After analysis, the complication rate was 11% (95% CI: 5%-18%). Procedure-related mortality was 1% (95% CI: 0%-4%).

CONCLUSIONS

IC-IC bypass is valuable for the treatment of complex intracranial aneurysms, boasting high patency and positive clinical outcomes. Complications are unusual, and procedure-related mortality is minimal. Comparing IC-IC and EC-IC led to no significant differences.

Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass versus Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Treating Posterior Circulation Aneurysms: A Systematic Review and Comparative Meta-Analysis

BACKGROUND

When traditional therapies are unsuitable, revascularization becomes essential for managing posterior inferior cerebellar artery (PICA) or vertebral artery aneurysms. Notably, the PICA-PICA bypass has emerged as a promising option, overshadowing the occipital artery-PICA (OA-PICA) bypass. The objective was to compare the safety and efficacy of OA-PICA and PICA-PICA bypasses.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of OA-PICA and PICA-PICA bypasses for treating posterior circulation aneurysms.

RESULTS

We analyzed 13 studies for the PICA-PICA bypass and 16 studies on the OA-PICA bypass, involving 84 and 110 patients, respectively. The median average follow-up for PICA-PICA bypass was 8 months (2-50.3 months), while for OA-PICA, it was 27.8 months (6-84 months). The patency rate for OA-PICA was 97% (95% confidence interval [CI]: 92%-100%) and 100% (95% CI: 95%-100%) for PICA-PICA. Complication rates were 29% (95% CI: 10%-47%) for OA-PICA and 12% (95% CI: 3%-21%) for PICA-PICA. Good clinical outcomes were observed in 71% (95% CI: 52%-90%) of OA-PICA patients and 87% (95% CI: 75%-100%) of PICA-PICA patients. Procedure-related mortality was 1% (95% CI: 0%-6%) for OA-PICA and 1% (95% CI: 0%-10%) for PICA-PICA.

CONCLUSIONS

Both procedures have demonstrated promising results in efficacy and safety. PICA-PICA exhibits slightly better patency rates, better clinical outcomes, and fewer complications, but with a lack of substantial follow-up and a smaller sample size. The choice between these procedures should be based on the surgeon's expertise and the patient's anatomy.

Proximal Clipping and Distal High-Flow Bypass in the Treatment of Giant/Complex Intracranial Aneurysm: An Opportunity or a Risk from a Fluid-Structural Interaction Analysis

OBJECTIVES

Conventional clipping and endovascular treatment are difficult to apply for some giant intracranial aneurysms (GIAs), and sometimes extracranial-to-intracranial (EC-IC) bypass becomes the optional choice. However, not all GIA patients can benefit from it. This study aims to recognize the underlying problems.

METHODS

We included eligible patients in our care. Then, we researched from three levels: a retrospective review of clinical data, fluid-structural analysis from two representative patient-specific models, and fluid-structural interaction analysis for idealized models to investigate the hemodynamic and biomechanical mechanisms.

RESULTS

In this article, we report nine patients with GIA who underwent EC-IC surgery. Of them, three experienced dangerous postoperative hemorrhage, and one patient died. Among these three patients, two lacked the A1 segment of the anterior cerebral artery (ACA). The numerical simulation showed that after surgery, for the patient with an unruptured aneurysm and existence of ACA, the wall deformation, wall stress, pressure, and area of the oscillatory shear index (OSI) > 0.2 were decreased by 43%, 39%, 33%, and 13%, while the patient without A1 segment having postoperative hemorrhage showed 36%, 45%, 13%, and 55% increased, respectively. Thus, we postulated a dangerous "stump phenomenon" in such conditions and further demonstrated it from idealized models with different sizes of ACA. Finally, we found a larger anastomosis angle and smaller diameter of the graft can alleviate this effect.

CONCLUSIONS

Neurosurgeon should cautiously evaluate the opportunity and risk for such patients who have aplasia of the A1 segment of ACA when making clinical decisions.

Efficacy and Safety of Extracranial-Intracranial Bypass Surgery for Posterior Circulation Aneurysms: A Systematic Review and Single-Arm Meta-Analysis

OBJECTIVE

Treating complex posterior circulation aneurysms poses challenges, and extracranial to intracranial (EC-IC) bypass techniques are potential therapeutic options. However, the safety and efficacy of this approach for posterior circulation aneurysms remain unclear. The study's objective was to assess the safety and efficacy of EC-IC bypass in these aneurysms.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review on EC-IC revascularization for posterior circulation aneurysms. Included studies had at least 4 patients and reported data on mortality, patency, complications, or clinical outcomes. Favorable clinical outcomes were defined as modified Rankin Scale below 3 or Glasgow Outcome Scale above 3, and complications were any issues related to the bypass procedure.

RESULTS

From 3036 articles reviewed, 22 studies involving 196 patients who underwent 210 EC-IC bypass procedures for posterior circulation aneurysms were selected. The median follow-up period of 14 studies was 31.66 months (6-61 months). Final follow-up indicated a high bypass patency rate of 96% [95% confidence interval [CI]: 91%-100%; I2 = 12%], with a mortality rate of 5% [95% CI: 1%-9%; I2 = 0%]. Additionally, 83% [95% CI: 70%-96%; I2 = 77%] of patients showed good outcomes at the last follow-up. Complications were observed in 40% [95% CI: 26%-55%; I2 = 80%]. Heterogeneity was associated with specific studies.

CONCLUSIONS

EC-IC bypass procedures are a viable treatment option for posterior circulation aneurysms, with high bypass patency rates and favorable clinical outcomes. However, complications, especially neurological deficits, exist. Open revascularization remains essential for neurovascular surgeons dealing with complex aneurysms.

An objective skill assessment framework for microsurgical anastomosis based on ALI scores

INTRODUCTION

The current assessment and standardization of microsurgical skills are subjective, posing challenges in reliable skill evaluation. We aim to address these limitations by developing a quantitative and objective framework for accurately assessing and enhancing microsurgical anastomosis skills among surgical trainees. We hypothesize that this framework can differentiate the proficiency levels of microsurgeons, aligning with subjective assessments based on the ALI score.

METHODS

We select relevant performance metrics from the literature on laparoscopic skill assessment and human motor control studies, focusing on time, instrument kinematics, and tactile information. This information is measured and estimated by a set of sensors, including cameras, a motion capture system, and tactile sensors. The recorded data is analyzed offline using our proposed evaluation framework. Our study involves 12 participants of different ages ([Formula: see text] years) and genders (nine males and three females), including six novice and six intermediate subjects, who perform surgical anastomosis procedures on a chicken leg model.

RESULTS

We show that the proposed set of objective and quantitative metrics to assess skill proficiency aligns with subjective evaluations, particularly the ALI score method, and can effectively differentiate novices from more proficient microsurgeons. Furthermore, we find statistically significant disparities, where microsurgeons with intermediate level of skill proficiency surpassed novices in both task speed, reduced idle time, and smoother, briefer hand displacements.

CONCLUSION

The framework enables accurate skill assessment and provides objective feedback for improving microsurgical anastomosis skills among surgical trainees. By overcoming the subjectivity and limitations of current assessment methods, our approach contributes to the advancement of surgical education and the development of aspiring microsurgeons. Furthermore, our framework emerges to precisely distinguish and classify proficiency levels (novice and intermediate) exhibited by microsurgeons.

Intracranial-intracranial bypass strategies for the treatment of complex intracranial aneurysms: anatomical characteristics and surgical intervention

OBJECTIVE

The effectiveness of revascularization for complex aneurysms is well-established. This study aimed to describe the technical characteristics and clinical efficacy of intracranial-to-intracranial (IC-IC) bypass for the treatment of complex intracranial aneurysms.

METHODS

We retrospectively reviewed all patients with aneurysms who underwent a preplanned combination of surgical or endovascular treatment and IC-IC bypass at our institution between January 2006 and September 2023. IC-IC bypass techniques included four strategies: type A (end-to-end reanastomosis), type B (end-to-side reimplantation), type C (in situ side-to-side anastomosis), and type D (IC-IC bypass with a graft vessel).

RESULTS

During the study period, ten patients with aneurysms each underwent IC-IC bypass surgery. Aneurysms were located in the middle cerebral artery (60.0%), anterior temporal artery (10.0%), anterior cerebral artery (20.0%), and vertebral artery (10.0%). There were three saccular aneurysms (30.0%), two fusiform aneurysms (20.0%), one dissecting aneurysm (10.0%), and four pseudoaneurysms (40.0%). We performed the type A strategy on five patients (50.0%), type B on one (10.0%), type C on one (10.0%), and type D on three (30.0%). During a mean period of 68.3 months, good clinical outcomes (modified Rankin Scale score, 0-2) were observed in all patients. Follow-up angiography demonstrated complete aneurysmal obliteration in all patients and good bypass patency in nine of ten patients (90.0%).

CONCLUSION

The treatment of complex aneurysms remains a challenge with conventional surgical or endovascular treatments. IC-IC bypass surgery is a useful technique, associated with favorable clinical outcomes, for treating complex aneurysms.

Arterial Bypass in the Treatment of Complex Middle Cerebral Artery Aneurysms: Lessons Learned from Forty Patients

OBJECTIVE

Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience.

METHODS

Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization.

RESULTS

The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up.

CONCLUSIONS

Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.

Superficial temporal artery interposition bypass for the treatment of complex intracranial aneurysms: Flexible and creative options for flow preservation bypass

PURPOSE

Flow-preservation bypass is a treatment option for complex intracranial aneurysms (IAs) that cannot be managed with microsurgical clipping or endovascular treatment. Various bypass methods are available, including interposition grafts such as the radial artery or saphenous vein. Size discrepancy, invasiveness, and procedure complexity must be considered when using interposition grafts. We describe our experience of treating complex IAs using a superficial temporal artery (STA) interposition bypass.

METHODS

We retrospectively reviewed the medical records and operative videos of all patients who were treated for complex IAs at our center from January 2009 to December 2021 using cerebral revascularization. Clinical, radiological, and surgical findings of the cases that underwent STA interposition bypass were investigated.

RESULTS

Seventy-six bypass procedures were performed of which seven (9.2%) complex IAs were managed using STA interposition bypass. Of these 5 cases were of anterior cerebral artery, 1 of middle cerebral artery, and 1 of posterior inferior cerebellar artery aneurysm. There were no postoperative ischemic complications. Revision surgery for postoperative pseudomeningocele was performed in one case. The long-term bypass patency rate was 85.7% (6 out of 7) and good long-term aneurysm control was achieved in all cases, with a mean follow-up of 64 months.

CONCLUSIONS

When treating complex IAs, creative revascularization strategies are needed in selective cases for favorable outcomes. STA interposition graft bypass which can reduce the size discrepancy between the donor and recipient may be a less invasive, flexible, and practical option for treating complex IAs.

The surgical strategy and technical nuances of in situ side-to-side bypass for the management of complex intracranial aneurysms

Background

Despite continuous advances in microsurgical and endovascular techniques, the treatment of complex aneurysms remains challenging. Aneurysms that are dilemmatic for conventional clipping or endovascular coiling often require bypass as part of a strategy to reduce the risk of ischemic complications. In anatomically favorable sites, the intracranial-intracranial in situ bypass may be an appealing choice. This article details the surgical strategies, operative nuances, and clinical outcomes of this technique with a consecutive series in our department.

Methods

A retrospective review of a prospectively maintained neurosurgical patient database was performed to identify all patients treated with side-to-side in situ bypass from January 2016 to June 2022. In total, 12 consecutive patients, including 12 aneurysms, were identified and included in the series. The medical records, surgical videos, neuroimaging studies, and follow-up clinic notes were reviewed for every patient.

Results

Of the 12 aneurysms, there were 5 middle cerebral artery aneurysms, 4 anterior cerebral artery aneurysms, and 3 posterior inferior cerebellar artery aneurysms. The morphology of the aneurysms was fusiform in 8 patients and saccular in the remaining 4 patients. There were 3 patients presented with subarachnoid hemorrhage. The treatment modality was simple in situ bypass in 8 cases and in situ bypass combined with other modalities in 4 cases. Bypass patency was confirmed in all cases by intraoperative micro-doppler probe and (or) infrared indocyanine green (ICG) video angiography intraoperatively and with digital subtraction angiography (DSA) or computed tomography angiography (CTA) postoperatively. None of the patients developed a clinically manifested stroke due to the procedure though a callosomarginal artery was intentionally removed in one patient. The median follow-up period was 16.2 months (6-36). All patients had achieved improved or unchanged modified Rankin scale scores at the final follow-ups.

Conclusion

Cerebral revascularization technique remains an essential skill for the treatment of complex aneurysms. The in situ bypass is one of the most effective techniques to revascularize efferent territory when vital artery sacrifice or occlusion is unavoidable. The configuration of in situ bypass should be carefully tailored to each case, with consideration of variations in anatomy and pathology of the complex aneurysms.

Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system

The intracranial vertebrobasilar artery system has a unique hemodynamic pattern (vessel trunk converged bilateral flow with three groups of perforators directly arising from it), is embedded within intense osseous constraints, and is located far from conventional donor vessels. Two major traditional modalities of posterior circulation revascularization encompass the superficial temporal artery to the superior cerebellar artery and the occipital artery to the posteroinferior cerebellar artery anastomosis, which are extracranial-intracranial low-flow bypass with donor arteries belonging to the anterior circulation and mainly supply focal perforators and distal vascular territories. As our understanding of flow hemodynamics has improved, the extracranial vertebral artery-related bypass has further evolved to improve the cerebral revascularization system. In this article, we propose the concept of "vascular reconstruction related to the extracranial vertebral artery" and review the design philosophy of the available innovative modalities in the respective segments. V1 transposition overcomes the issue of high rates of in-stent restenosis and provides a durable complementary alternative to endovascular treatment. V2 bypass serves as an extracranial communication pathway between the anterior and posterior circulation, providing the advantages of high-flow, short interposition grafts, orthograde flow in the vertebrobasilar system, and avoiding complex skull base manipulation. V3 bypass is characterized by profound and simultaneous vascular reconstruction of the posterior circulation, which is achieved by intracranial-intracranial or multiple bypasses in conjunction with skull base techniques. These posterior circulation vessels not only play a pivotal role in the bypass modalities designed for vertebrobasilar lesions but can also be implemented to revascularize the anterior circulation, thereby becoming a systematic methodology.

Extracranial-intracranial bypass surgery for intracranial aneurysm of the anterior cerebral circulation: A systematic review and meta-analysis

Background

The safety of extracranial–intracranial (EC–IC) bypass in the management of anterior circulation intracranial aneurysms (IAs) remains to be determined. This systematic review aims to summarize the existing evidence and provide guidance for the precise management of IAs.

Data source

We constructed search strategies and comprehensively searched Pubmed, Medline, Embase, Web of science, and Cochrane library.

Methods

This systematic review was actualized according to the PRISMA statement. We evaluated study quality using the methodological index for non-randomized study (MINORS). Effect sizes were pooled using a random-effects model. Heterogeneity between studies was assessed using the I2 test. Publication bias was assessed using the Egger's test. The registration number for this systematic review is CRD42023396730.

Result

This systematic review included a total of 21 articles, involving 915 patients. Postoperative bypass patency rate was 99% (95% CI 0.98–1.00); short-term follow-up was 98% (95% CI 0.94–1.00); long-term follow-up was 95% (95% CI 0.93–0.97). The long-term follow-up occlusion rate of saphenous vein was higher than that of radial artery (OR 6.10 95% CI 1.04–35.59). Short-term surgery-related mortality was 0.3% (95% CI 0.000–0.012); long-term follow-up was 0.4% (95% CI 0.000–0.013); The proportion of patients with a score of 0–2 on the modified Rankin Scale (mRS) during long-term follow-up was 92% (95% CI 0.86–0.98). The incidence rates of long-term follow-up complications were: ischemic 3% (95% CI 0.01–0.06); hemorrhagic 1% (95% CI 0.00–0.03); neurological deficit 1% (95% CI 0.00–0.03); other 3% (95% CI 0.01–0.06).

Limitation

Most of the included studies were retrospective studies. Studies reporting preoperative status were not sufficient to demonstrate postoperative improvement. Lack of sufficient subgroup information such as aneurysm rupture status.

Conclusion

EC–IC therapy for anterior circulation IAs has a high safety profile. Higher level of evidence is still needed to support clinical decision.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396730, identifier: CRD42023396730.

Interposition Intracranial-Intracranial Bypass Based on Anterior Cerebral Artery A1 Donor Anastomosis: Technical Advances, Outcomes, and Literature Review

BACKGROUND

The bypass technique is important for treating complex intracranial aneurysms and is infrequently performed. Intracranial-intracranial (IC-IC) bypass has shown many advantages in recent years.

OBJECTIVE

To review the techniques and outcomes of bypass based on anterior cerebral artery (ACA) A1 donor anastomosis in patients with intracranial aneurysm.

METHODS

We retrospectively reviewed the clinical and imaging data, surgical strategy, and follow-up outcomes of 7 patients treated from 2019 to 2022. Neurological function was assessed by the modified Rankin Scale (mRS). A literature review was performed using PubMed.

RESULTS

All 7 patients (3 male patients and 4 female patients; mean age, 50.4 ± 15.5 years) underwent aneurysm trapping or clipping using interposition IC-IC bypass based on ACA-A1 donor anastomosis. There were 6 middle cerebral artery (MCA) aneurysms and 1 posterior cerebral aneurysm in the series. One IC-IC bypass failed and was changed to extracranial-intracranial bypass. Three patients with MCA M1 aneurysm showed perforator-related infarction after the operation. The modified Rankin Scale score was 0 in 4 patients, 2 in 2 patients, and 1 in 1 patient. The long-term graft patency rate was 100%.

CONCLUSION

Interposition IC-IC bypass based on ACA-A1 donor anastomosis provides an effective way to achieve blood flow reconstruction in the treatment of complex aneurysms. This technique provides better caliber and volume compatibility and diminishes neck incision. Perforator-related infarction was the main complication because of involvement of the MCA M1 aneurysm location. Proximal clipping is preferred to avoid perforator-related infarction.

Surgical revascularization (bypass surgery) in the treatment of complicated cerebral aneurysms

The aim of surgical treatment of any cerebral aneurysm is to achieve its total exclusion from the bloodstream. Although the progress in the development and implementation of microsurgical and the latest endovascular technologies, in many cases, the treatment of complex cerebral aneurysms is not an easy task. Unsatisfactory results of the exclusion of complicated cerebral aneurysms are due to many factors, for instance: gigantic size, fusiform or dolichoectatic configuration of the cerebral aneurysm, the presence of atherosclerotic changes, anatomical features of the departure of functionally important arteries directly from the cerebral aneurysm. Such cerebral aneurysms are quite problematic both for microsurgical remodeling clipping and for endovascular exclusion. At the current stage, the introduction and use of the microanastomosis technique provides additional options and expands the possibilities of surgical treatment of complex cerebral aneurysms.Objective ‒ to analyze the possibilities and results of surgical treatment of complicated cerebral aneurysms using the technique of surgical revascularization (bypass surgery).Materials and methods. An analysis of the results of the examination and surgical treatment of 16 patients with complicated cerebral aneurysms for the period from 2016 to 2020, who were treated and operated on in the emergency vascular neurosurgery department with the X-ray operating department Romodanov Institute of Neurosurgery of NAMS of Ukraine. All patients diagnosed with complicated cerebral aneurysms had gigantic sizes. All cases of surgical intervention included placement of extra-intracranial microanastomosis or intra-intracranial anastomosis, sometimes a combination of it, to ensure normal blood supply to the vessel of complicated cerebral aneurysm that were planned to be devascularized. In 14 observations, one-time anastomosis and exclusion of complicated cerebral aneurysms were performed. In 2 observations, the first stage was an anastomosis without exclusion of the complicated cerebral aneurysms due to insufficient vascularization of the distal arterial branch for deconstructive exclusion of aneurysm.Results. Satisfactory results of surgical treatment (grade 1 and 2 of Modified Rankin Scale (MRS)) in the general group of patients were observed in 13 (81 %) patients with complicated cerebral aneurysms. Unsatisfactory results of surgical treatment occurred in 3 (19 %) observations. Profound disability (MRS grade 5) as a result of surgical treatment was recorded in 1 (6 %) patient. Cases that ended fatally occurred in 2 (13 %) observations of the total group of patients. In the group of patients with surgical revascularization and excluded complicated cerebral aneurysms, satisfactory results were observed in 13 (92.9 %) patients. Fatal results of surgical treatment were recorded in 2 patients with a hemorrhagic course of complicated cerebral aneurysms, in which surgical revascularization was performed as first stage and scheduled removal of complicated cerebral aneurysms was planned.Conclusions. The introduction and use of the microanastomosis technique expands the possibilities of surgical treatment of complicated cerebral aneurysms. Revascularization surgical interventions are highly effective in the prevention of ischemic complications when complicated cerebral aneurysms are excluded. Recommendations (indications) for revascularization should be considered in impossibility and high risks of ischemic complications during remodeling clipping or endovascular exclusion of complicated cerebral aneurysms.

High-resolution medical image reconstruction based on residual neural network for diagnosis of cerebral aneurysm

Objective

Cerebral aneurysms are classified as severe cerebrovascular diseases due to hidden and critical onset, which seriously threaten life and health. An effective strategy to control intracranial aneurysms is the regular diagnosis and timely treatment by CT angiography (CTA) imaging technology. However, unpredictable patient movements make it challenging to capture sub-millimeter-level ultra-high resolution images in a CTA scan. In order to improve the doctor's judgment, it is necessary to improve the clarity of the cerebral aneurysm medical image algorithm.

Methods

This paper mainly focuses on researching a three-dimensional medical image super-resolution algorithm applied to cerebral aneurysms. Although some scholars have proposed super-resolution reconstruction methods, there are problems such as poor effect and too much reconstruction time. Therefore, this paper designs a lightweight super-resolution network based on a residual neural network. The residual block structure removes the B.N. layer, which can effectively solve the gradient problem. Considering the high-resolution reconstruction needs to take the complete image as the research object and the fidelity of information, this paper selects the channel domain attention mechanism to improve the performance of the residual neural network.

Results

The new data set of cerebral aneurysms in this paper was obtained by CTA imaging technology of patients in the Department of neurosurgery, the second affiliated of Guizhou Medical University Hospital. The proposed model was evaluated from objective evaluation, model effect, model performance, and detection comparison. On the brain aneurysm data set, we tested the PSNR and SSIM values of 2 and 4 magnification factors, and the scores of our method were 33.01, 28.39, 33.06, and 28.41, respectively, which were better than those of the traditional SRCNN, ESPCN and FSRCNN. Subsequently, the model is applied to practice in this paper, and the effect, performance index and diagnosis of auxiliary doctors are obtained. The experimental results show that the high-resolution image reconstruction model based on the residual neural network designed in this paper plays a more influential role than other image classification methods. This method has higher robustness, accuracy and intuition.

Conclusion

With the wide application of CTA images in the clinical diagnosis of cerebral aneurysms and the increasing number of application samples, this method is expected to become an additional diagnostic tool that can effectively improve the diagnostic accuracy of cerebral aneurysms.

The need to consider return to work as a main outcome in patients undergoing surgery for diffuse low-grade glioma: a systematic review

OBJECTIVE

For a long time, return to work (RTW) has been neglected in patients harboring a diffuse low-grade glioma (LGG). However, a majority of LGG patients worked at time of diagnosis. Moreover, these patients now live longer given current treatment paradigms, especially thanks to early maximal surgery.

METHODS

We systematically searched available medical databases for studies that reported data on RTW in patients who underwent resection for LGG.

RESULTS

A total of 30 studies were selected: 19 considered RTW (especially rate and timing) as an outcome and 11 used scales of health-related quality of life (HRQoL) which included work-related aspects. Series that considered RTW as a main endpoint were composed of 1014 patients, with postoperative RTW rates ranging from 31 to 97.1% (mean 73.1%). Timing to RTW ranged from 15 days to 22 months (mean 6.3 months). Factors related to an increased proportion of RTW were: younger age, better neurologic status, having a white-collar occupation, working pre-operatively, being the sole breadwinner, the use of awake surgery, and greater extent of resection. Female sex, older age, poor neurologic status, pre-operative history of work absences, slow lexical access speed, and postoperative seizures were negatively related to RTW. No studies that used HRQoL scales directly investigated RTW rate or timing.

CONCLUSIONS

RTW was scarcely analyzed in LGG patients who underwent resection. However, because they are usually young, with no or only mild functional deficits and have a longer life expectancy, postoperative RTW should be assessed more systematically and accurately as a main outcome. As majority (61.5-100%) of LGG patients were working at time of surgery, the responsibility of neurosurgeons is to bring these patients back to their previous activities according to his/her wishes. RTW might also be included as a critical endpoint for future prospective studies and randomized control trials on LGGs.

Surgical Treatment of Large and Giant Anterior Cerebral Artery Aneurysms in the Endovascular Era: Analysis of Large Clinical Series

OBJECTIVE

Analysis of results of surgical treatment of 112 patients with large and giant anterior cerebral artery (ACA) aneurysms.

METHODS

This is the largest clinical series of large and giant ACA aneurysms ever reported. Retrospective analysis of medical charts, radiographic studies, and intraoperative videos was performed. Univariate and multivariate analysis of relations among 3 types of outcomes (complete aneurysm occlusion, ischemic complications, and clinical outcomes) and predicting factors was performed.

RESULTS

Most aneurysms were communicant (84.8%). Aneurysms of the A1 segment and distal segments (A2-A5) were encountered rarely. Complete aneurysm occlusion (class I) was shown in 95 cases (90.5%). In 4 patients, only exploration and wrapping were performed because of severe atherosclerosis and chronic intraluminal thrombi. Partial occlusion (class III) was shown in 2 patients, and neck residual (class II) in 4 patients. Cerebral ischemia developed in 29 patients postoperatively. Occlusion or injury of the A1 segment and anterior communicating artery perforators and recurrent branch of Heubner were the most common reason for ischemic complications. At follow-up, 97 patients (86.6%) had favorable outcomes. Ten patients (8.9%) had unfavorable outcomes because of postoperative complications.

CONCLUSIONS

Microsurgery provides effective and relatively safe occlusion of complex ACA aneurysms. Direct clipping can be applied in most cases independent of their precise location. In certain cases, alternative methods can be safely used. According to multivariate analysis, giant aneurysm size, aneurysm-related mass effect, involvement of large arterial branches in the aneurysm wall, and intraoperative complications were significant predicting factors for ischemic complications.

Evolution of Intracranial-Intracranial Bypass Surgery: A Bibliometric Analysis

OBJECTIVE

Modern cerebrovascular bypass surgery uses either extracranial-intracranial (EC-IC) or intracranial-intracranial (IC-IC) approaches. Compared with EC-IC bypasses, IC-IC bypasses allow neurosurgeons to safely address tumors, aneurysms, and other lesions using shorter grafts that are well matched to the size of recipient vessels. Fewer than 100 articles have been published on IC-IC bypasses compared with more than 1000 on EC-IC bypasses. This study examined the increase of interest and innovation in IC-IC bypass.

METHODS

PubMed and Web of Science were searched using keywords specific to IC-IC bypass, yielding 717 articles supplemented with 36 reports from other databases and gray literature. The articles were reviewed, and 98 articles were selected for further evaluation. Final articles were categorized as innovations or retrospective studies. Publication metrics were passed through an analytic program to assess statistical measures of growth.

RESULTS

The number of publications describing innovations (n = 52) and retrospective studies (n = 46) in IC-IC surgical techniques increased exponentially (R2 = 0.983 and R2 = 0.993, respectively), with both interest and research in the field increasing. The rate of publications in each group also increased. In recent years, increasing numbers of global institutions have researched and published on IC-IC bypasses.

CONCLUSIONS

As more work is undertaken on IC-IC bypasses, it is critical for knowledge to be shared through research, collaboration, publication, and early teaching within residency training programs. This field has increased exponentially in the past 2 decades and has yet to reach an inflection point, indicating possible additional interest and growth over time.

Computed Tomography Perfusion Imaging Study of Intracranial Complex Aneurysms Treated by Internal Maxillary Artery Bypass Grafting

BACKGROUND

Cerebral revascularization strategies through extracranial to intracranial bypass have been adopted in the management of complex intracranial aneurysms. The internal maxillary artery used as a donor in a bypass is an effective method. At present, there are few quantitative analyses of cerebral blood flow perfusion. The main focus of this study was to evaluate the effectiveness of blood perfusion after bypass grafting.

METHODS

From April 2015 to December 2017, 19 patients who underwent internal maxillary artery radial artery middle cerebral artery bypass surgery with unobstructed bypass vessels were selected. Cerebral blood flow perfusion before and after bypass surgery was quantitatively evaluated by computed tomography perfusion imaging. The cerebral blood perfusion in the region of interest was measured by computed tomography perfusion.

RESULTS

The aneurysms were excised after trapping in 2 cases with mass effects and neural compression. Proximal occlusion of the parent artery was performed in 9 cases of fusiform or giant dissecting aneurysms. Trapping was performed after bypass surgery in 8 cases. Within 3 months after surgery, 17 patients had good outcomes. After the hypothesis test, there was a significant difference between the preoperative △cerebral blood volume and postoperative △cerebral blood volume in the anterior area of the semioval center cross section (P = 0.001 < 0.05).

CONCLUSIONS

The internal maxillary artery as a bypass donor is an effective method that can provide sufficient intracranial blood perfusion, and there is usually no cerebral ischemia in the surrounding area.

Unsuccessful bypass and trapping of a giant dolichoectatic thrombotic basilar trunk aneurysm. What went wrong?

Aneurysms of the basilar trunk represent an exceptional challenge to the neurosurgeon, due to high mortality and surgical morbidity. We present a 69-year-old man with a giant dolichoectatic thrombotic basilar trunk aneurysm (BTA), who underwent right orbitozygomatic craniotomy, posterior cerebral artery (PCA) to right middle cerebral artery (MCA) bypass and trapping of the BTA. Unfortunately, patient died after surgery due to multiple foci of intraparenchymal haemorrhage and thrombosis of a short segment proximal to aneurysm trapped and his body was donated to the hospital, giving us the unique opportunity to compare intraoperative details with anatomical dissection findings, according to our previously published cadaveric neurosurgical research. The great and unique opportunity of this reported case, to learn by watching and watching again what has been done during surgery, to observe small vessels and brainstem perforators and to look at stiches of the bypass, SVG and the position of the clips, permits to refine the theoretical and practical skills for the treatment of complex aneurysms such as that one reported.

Clinical Trials of Microsurgery for Cerebral Aneurysms: Past and Future

BACKGROUND

New findings and research regarding the microsurgical treatment of intracerebral aneurysms (IAs) continue to advance even in the era of endovascular therapies. Research in the past 2 decades has continued to revolve around the question of whether open surgery or endovascular treatment is preferable. The answer remains both complex and in flux.

OBJECTIVE

This review focuses on microsurgery, reflects on the research decisions of previous landmark studies, and proposes future study designs that may further our understanding of IAs and how best to treat them.

RESULTS

The future of IA research may include a combination of pragmatic trials, artificial intelligence integrated tools, and mining of large data sets, in addition to the publication of high-quality single-center studies.

CONCLUSIONS

The future will likely emphasize testing innovative techniques, looking at granular patient data, and considering every patient encounter as a potential source of knowledge, creating a system in which data are updated daily because each patient interaction contributes to answering important research questions.

Surgical Anatomy of the Middle Communicating Artery and Guidelines for Predicting the Feasibility of M2-M2 End-to-End Reimplantation

BACKGROUND

M2-M2 end-to-end reimplantation that creates a middle communicating artery has recently been proposed as a reconstruction technique to treat complex aneurysms of the middle cerebral artery that are not amenable to clipping.

OBJECTIVE

To examine the surgical anatomy, define anatomic variables, and explore the feasibility of this bypass.

METHODS

Sixteen cadaver heads were prepared for bypass simulation. After the middle cerebral artery bifurcation was approached, the proximal insular (M2) segments and perforators were explored. To define the maximal distance between the M2 segments that allows the bypass to be performed, the M2 segments were mobilized and reimplanted in an end-to-end fashion.

RESULTS

Successful reimplantation was performed in all specimens. The mean maximal distance between the M2 segments to create the proposed reimplantation was 9.1 ± 3.2 mm. The mean vessel displacement was significantly greater for the superior (6.0 ± 2.3 mm) M2 segment than for the inferior (3.2 ± 1.4 mm) M2 segment (P < .001).

CONCLUSION

In this cadaveric study, the stumps of the M2 segments located at a distance of ≤9.1 mm could be approximated to create a feasible M2-M2 end-to-end anastomosis. Intraoperative inspection of the M2 segments and their perforators could allow further assessment of the feasibility of the procedure before final revascularization decisions are made.

Intracranial-Intracranial Bypass for Aneurysms: Quantitative Intraoperative Assessment of Flow Preservation

BACKGROUND

Intraoperative flow measurement has proven utility in extracranial-intracranial bypass, particularly in assessing the adequacy of donors by measurement of cut flow. The nature of intracranial-intracranial (IC-IC) bypass precludes cut flow measurement, but quantitative intraoperative flow measurements may evaluate augment assessment of the bypass.

OBJECTIVE

To retrospectively evaluate flow measurements performed in IC-IC bypass to determine the adequacy of the constructs in preserving flow.

METHODS

With institutional review board approval, we performed a retrospective review of our bypass database from 2001 to 2021 for aneurysms treated with IC-IC bypass and with intraoperative flow measurements. Patients' preoperative characteristics, bypass indications, prebypass and postbypass intraoperative flow measurements, and patient outcomes were recorded.

RESULTS

Of 346 bypasses, 21 cases using 22 IC-IC bypasses were included. The median age was 55 years; 13 of 21 cases were ruptured aneurysms. Aneurysms involved posterior inferior cerebellar artery (n = 7), middle cerebral artery (n = 6), distal anterior cerebral artery (n = 5), and anterior communicating artery (n = 3). Six bypasses were end-to-side (ETS), 10 were side-to-side (STS), and 6 were excisional with reanastomosis (end-to-end, ETE). Intraoperatively, 21 of the bypasses were patent; the postbypass/prebypass flow index averaged 1.15 (±0.32): ETE (n = 6) 1.22 ± 0.34 and ETS/STS bypasses (n = 15) 1.11 ± 0.32. All intraoperatively patent bypasses were patent on postoperative angiography. One occluded on delayed angiography without clinical sequelae.

CONCLUSION

Despite advances in endovascular therapy, IC-IC bypass remains essential to the treatment of large and fusiform aneurysms. We demonstrate quantitatively that IC-IC donors provide adequate direct (ETE) and redistributed (STS ETS) flow to the recipient territory. Flow measurement provides valuable information regarding the patency and adequacy of IC-IC bypass for flow preservation.

Management of Complex Cerebral Aneurysms

BACKGROUND

Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.

METHODS

Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible.

RESULTS

Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery.

CONCLUSIONS

Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome.

Giant Aneurysm Management

The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.

Bypass Surgery Management of Complex Proximal and Distal Posterior Inferior Cerebellar Artery Aneurysms

BACKGROUND

For the complex posterior inferior cerebellar artery (PICA) aneurysms, standard microsurgical or endovascular technical options were not feasible. To determine the efficacy and outcomes of bypass surgery for complex PICA aneurysms, the authors herein review our recent surgical experience for complex PICA aneurysms.

METHODS

The authors retrospectively reviewed our experience of extracranial-intracranial bypass and intracranial-intracranial bypass surgery in treatment of proximal and distal complex PICA aneurysms at our institution from 2016 to 2020.

RESULTS

Twelve patients harboring 12 complex PICA aneurysms received bypass surgery at our institution. Seven (58.3%) patients with proximal PICA aneurysms underwent extracranial-intracranial bypass. Five (41.7%) patients with distal PICA aneurysms accepted intracranial-intracranial bypass. The postoperative symptom improvement: Of the 6 patients with preoperative hypoperfusion or ischemic of the cerebellar hemisphere, the symptom resolved in 5 patients, improved in 1 patient, of 5 patients with preoperative mass effect, the symptom resolved in 5 patients. During the follow-up period, ten patients had a modified Rankin scale (mRS) score of 0 to 1, and 1 patient had an mRS score of 2. One patient had an mRS score of 3. The long-term graft patency rate was 91.7%. All patients had no recurrence of intracranial aneurysm.

CONCLUSIONS

Base on the complexity of anatomy structure and the vascular architecture, an individualized strategy was proposed for each patient. The use of different types of bypass procedures (occipital artery-PICA end-to-end bypass, PICA-PICA end-to-end anastomosis, and/or occipital artery graft) can safely and effectively manage these complex PICA aneurysms.

Coding cerebral bypasses: a proposed nomenclature to better describe bypass constructs and revascularization techniques

OBJECTIVE

Bypass surgery has evolved into a complex surgical art with a variety of donor arteries, recipient arteries, interpositional grafts, anastomoses, and suturing techniques. Although innovation in contemporary bypasses has increased, the literal descriptions of these new bypasses have not kept pace. The existing nomenclature that joins donor and recipient arteries with a hyphen is simplistic, underinformative, and in need of improvement. This article proposes a nomenclature that systematically incorporates anatomical and technical details with alphanumeric abbreviations and is a clear, concise, and practical "code" for bypass surgery.

METHODS

Detailed descriptions and illustrations of the proposed nomenclature, which consists of abbreviations for donor and recipient arteries, arterial segments, arteriotomies, and sides (left or right), with hyphens and parentheses to denote the arteriotomies joined in the anastomosis and brackets and other symbols for combination bypasses, are presented. The literature was searched for articles describing bypasses, and descriptive nomenclature was categorized as donor and recipient arteries (donor-recipient), donor-recipient with additional details, less detail than donor-recipient, and complete, ambiguous, or descriptive text.

RESULTS

In 483 publications, most bypass descriptions were categorized as donor-recipient (335, 69%), with superficial temporal artery-middle cerebral artery bypass described most frequently (299, 62%). Ninety-seven articles (20%) used donor-recipient descriptions with additional details, 45 (9%) were categorized as ambiguous, and none contained a complete bypass description. The authors found the proposed nomenclature to be easily applicable to the more complex bypasses reported in the literature.

CONCLUSIONS

The authors propose a comprehensive nomenclature based on segmental anatomy and additional anastomotic details that allows bypasses to be coded simply, succinctly, and accurately. This alphanumeric shorthand allows greater precision in describing bypasses and clarifying technical details, which may improve reporting in the literature and thus help to advance the field of bypass surgery.

Endovascular management of middle cerebral artery aneurysms (single-center case series study)

Background

Middle cerebral artery (MCA) aneurysms were usually subjected to treatment by surgery, while endovascular treatment (EVT) was performed only in chosen patients. We assessed the efficacy, safety, and durability in addition to the clinical outcome of EVT when it is regarded as the first-line treatment modality for MCA aneurysms.

Results

We recruited 30 patients with MCA aneurysms who underwent definitive management from July 2017 to July 2018. All those patients were treated endovascularly; 22 patients (73.3%) presented with subarachnoid hemorrhage, and 8 patients (26.7%) had different presentations, including isolated headaches and seizures. EVT was performed for all patients and required the use of a balloon, stent, or double catheter techniques in 13 cases and flow diverter stents alone in two cases. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 3 months. Angiographic follow-up was done by a conventional angiography at 6 months and after 1 year. EVT was efficiently conducted, leading to an outstanding accomplishment (mRS = 1–2) in 29 patients. However, one patient had a thromboembolic complication, followed by death after severe chest infection that was not related to the procedure. Immediate anatomical results included complete aneurysmal occlusion with the establishment of normal cerebral circulation. Angiographic follow-up revealed 24 unchanged occlusions and 5 cases with recanalization that required further treatment.

Conclusion

EVT of MCA aneurysms is a viable treatment option with positive outcomes in most cases. Nevertheless, the employment of long-term imaging follow-up is compulsory for validating such early results, often with respect to anatomical and functional stability.

How I do it? Posterior inferior cerebellar artery-intracranial vertebral artery reimplantation bypass and trapping of dissecting aneurysm involving the proximal posterior inferior cerebellar artery

BACKGROUND

Proximal posterior inferior cerebellar artery (PICA) aneurysms are surgically challenging due to the high variability in the anatomy of the PICA origin, their deep-seated nature, and their entanglement with the lower cranial nerves. Direct or reconstructive clipping may not be achievable if the aneurysm is large, or dissecting, or exhibits atherosclerosis or calcification.

METHOD

We present a case of a proximal PICA lateral medullary segment (P2) aneurysm that was successfully cured by trapping the aneurysm and reconstructing the PICA using the PICA-intracranial vertebral artery (PICA-V4) via end-to-side reimplantation bypass with the far lateral approach.

CONCLUSION

This case demonstrates the feasibility and safety of PICA-V4 reimplantation bypass, especially if the origin of the PICA is highly seated and the intracranial VA, or V4 segment, is long enough and well-exposed supra or under hypoglossal nerves.

The Intersection Between the Sternocleidomastoid and Splenius Capitis as the Anatomical Landmark to Facilitate Occipital Artery Harvest: A Retrospective Clinical Study

BACKGROUND

Occipital artery (OA)-posterior inferior cerebellar artery (PICA) bypass is a challenging procedure and is not frequently performed owing to the difficulty of OA harvest. To facilitate harvest, the intersection between the sternocleidomastoid and splenius capitis (the OA triangle) is used as the anatomical landmark to identify the OA segment that carries the highest risk of damage. This clinical study aimed to demonstrate efficacy and safety of OA harvest using this landmark.

METHODS

The study included 18 patients who underwent OA harvest using the OA triangle as a landmark for treatment of vertebral artery and PICA aneurysms. Patients were retrospectively evaluated for safety and patency of OA after harvest and OA-PICA bypass.

RESULTS

Of 18 patients with ruptured and unruptured vertebral artery and PICA aneurysms, 13 (72.2%) underwent OA-PICA bypass and 5 (27.8%) did not undergo bypass. The OA was completely harvested without damage in all patients. After harvest, the OA was patent in 17 patients (94.4%) and was occluded in 1 patient owing to vasospasm; this patient then underwent recanalization resulting in good patency of the OA-PICA bypass. The patency rate of the OA-PICA bypass was 100%.

CONCLUSIONS

The OA triangle, which is the anatomical landmark of the proximal end of the transitional segment of the OA, facilitated OA harvest using the distal-to-proximal harvest technique with safety and good patency. To the best of our knowledge, this is the first study of OA harvest in clinical cases.

Multiple overlapping stent-assisted coiling improves efficacy and safety of treatment for complex intracranial aneurysms: a randomized trial

BACKGROUND

Intracranial aneurysm rupture is the main cause of subarachnoid hemorrhage, leading to high disability and mortality. This study aimed to evaluate the clinical treatment effects of multiple overlapping stent-assisted coiling for complex intracranial aneurysms.

METHODS

We conducted a randomized, controlled, single-blinded clinical trial among 168 patients diagnosed with complex intracranial aneurysms. Treatment allocation to either single stent (SS) group or multiple stent (MS) group was randomized at 1:1 ratio using a Web-based platform. The O'Kelly-Marotta (OKM) grading scale was used to evaluate the degree of aneurysm occlusion after operation and during follow-up. Good aneurysm occlusion was defined as OKM grade C-D. The modified Rankin Scale (mRS) was used to evaluate the neurological status and the clinical outcome of patients.

RESULTS

Efficacy comparative analysis demonstrated that major recurrence of aneurysms was significantly reduced in the MS group (P = 0.012). In addition, the MS group displayed significantly reduced number of patients with mRS between 3 and 6 (P = 0.007) and increased number of patients with mRS between 0 and 1 (P = 0.034). Furthermore, the MS group showed increased percentage of patients with OKM grade C-D (P = 0.041). Compared with the SS group, the MS group exhibited decreased mortality (P = 0.037) and morbidity (P = 0.035).

CONCLUSIONS

Multiple overlapping stent-assisted coiling significantly improved the clinical treatment effects and provided a new method for complex intracranial aneurysms.

Single institute experience of bypass surgery for complex anterior cerebral artery aneurysms: paying special attention to the spatial and diameter relationship between the efferent arteries

Single institute experience with bypass surgery of complex ACA aneurysm was retrospectively reviewed over a 6-year period. Eight patients with complex ACA aneurysms were treated with bypass, including five females and three males, with mean age of 34.2 years old. There were three pre-communicating aneurysms, one communicating artery aneurysm, and four post-communicating aneurysms (two in A2 and two in A3). A3-A3 side-to-side in situ bypass was applied in six cases. A3-radial artery-A3 interpositional bypass was used in one case with far apart A3s, and A3-A3 transplantation in the other with unparalleled aligned A3s. Three aneurysms were secured with proximal clipping, one with distal clipping, one with direct clipping, one with isolation, and two with embolization. Aneurysm obliteration was achieved in all cases. Only one in situ bypass from smaller donor artery towards larger recipient artery failed with minor postoperative infarction. Intraoperative bleeding from the site of anastomosis occurred in one case during embolization. All the patients showed complete recovery with normal neurological function during follow-up at out-of-patient clinics. A simplified surgical algorithm for complex ACA aneurysm is established based on the geometrical and spatial relationship between efferent arteries. The reasons of bypass failure and hemorrhagic complication are also discussed.

Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms

INTRODUCTION

Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery.

METHODS

The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies.

RESULTS

In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity.

CONCLUSIONS

Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.

In Situ Side-to-Side Pericallosal-Pericallosal Artery and Callosomarginal-Callosomarginal Artery Bypasses for Complex Distal Anterior Cerebral Artery Aneurysms: A Technical Note

BACKGROUND

Despite surgical and endovascular technical improvements over the last decades, the treatment of complex aneurysms of the distal anterior cerebral artery (ACA) is very challenging for both vascular neurosurgeons and interventional neuroradiologists. Furthermore, the interpersonal anatomic variability requires, most of the time, a tailored planning.

OBJECTIVE

To describe a novel technique of bypasses in the territory of ACA to protect the brain territory distal to the aneurysm.

METHODS

A 53-yr-old male with a large complex fusiform aneurysm of the left distal A2 segment of the ACA, involving the origin of the callosomarginal and pericallosal arteries, was judged not suitable for a single procedure (endovascular or neurosurgical). Two side-to-side bypasses were performed in a single surgery to connect the pericallosal and callosomarginal arteries of both sides, distally to the aneurysm. Subsequently, an endovascular embolization of the aneurysm was achieved with coils.

RESULTS

The patency of the microanastomoses, performed in the anterior interhemispheric fissure, was positively evaluated intraoperatively with indocyanine green and fluorescein videoangiography. The aneurysm sac, together with proximal A2 segment, was completely occluded with platinum coils. At the last follow-up, computed tomography angiography confirmed the patency of both bypasses, without any sign of aneurysm recanalization. The patients never complained of any focal neurological deficits or worsening of clinical status.

CONCLUSION

We present an elegant and innovative solution to completely protect the distal ACA territory in cases of complex aneurysm involving the origin of both callosomarginal and pericallosal arteries.

Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series

Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.

The middle communicating artery: a novel fourth-generation bypass for revascularizing trapped middle cerebral artery bifurcation aneurysms in 2 cases

The anterior and posterior communicating arteries are natural connections between arteries that enable different adjacent circulations to redistribute blood flow instantly in response to changing supply and demand. An analogous communication does not exist in the middle cerebral circulation. A middle communicating artery (MCoA) can be created microsurgically between separate middle cerebral artery (MCA) trunks, enabling flow to redistribute in response to changing supply and demand. The MCoA would draw blood flow from an adjacent circulation such as the external carotid circulation. The MCoA requires the application of fourth-generation techniques to reconstruct bi- and trifurcations after occluding complex MCA trunk aneurysms. In this report, the authors describe two recent cases of complex MCA bi- and trifurcation aneurysms in which the occluded efferent trunks were revascularized by creating an MCoA. The first MCoA was created with a "double-barrel" superficial temporal artery-M2 segment bypass and end-to-end reimplantation of the middle and inferior MCA trunks. The second MCoA was created with an external carotid artery-radial artery graft-M2 segment interpositional bypass and end-to-side reimplantation of the inferior trunk onto the superior trunk. Both aneurysms were occluded, and both patients experienced good outcomes. This report introduces the concept of the MCoA and demonstrates two variations. Angioarchitectural and technical elements include the donation of flow from an adjacent circulation, a communicating bypass, the application of fourth-generation bypass techniques, and a minimized ischemia time. The MCoA construct is ideally suited for rebuilding bi- and trifurcated anatomy after trapping or distally occluding complex MCA aneurysms.

The evolution of intracranial aneurysm treatment techniques and future directions

Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.

Cerebrovascular bypass for ruptured aneurysms: A case series

In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.

An Expedited Transition to the Back Wall Suturing for Side-to-Side In Situ Microvascular Anastomosis: A Technique Update

BACKGROUND

The side-to-side in situ microvascular anastomosis is an important tool in the cerebrovascular neurosurgeon's armamentarium. The execution of the side-to-side anastomosis, however, can be limited by the inability to acquire sufficient visualization and approximation of the recipient and donor vessels.

OBJECTIVE

To expedite the transition to the back wall suturing of the donor and recipient vessels during side-to-side in situ microvascular anastomosis.

METHODS

Incorporation of the first suture throw from the outside to the inside of the vessel lumen with the initial stay suture at the proximal apex of the arteriotomy is described. The apical knot is tied between one limb of the resultant loop and the free end of the suture. The remainder of side-to-side anastomosis can then be completed in a standard fashion starting from the inside of the lumen.

RESULTS

This modification allows for an expedited transition to the back wall suturing of the 2 arterial segments and avoids difficulties associated with taking the first bite from behind the knot at the proximal apex of the arteriotomy or the transfer of the needle between the approximated vessels. This updated technique is illustrated with a case example, illustration, and video.

CONCLUSION

This technical modification for the side-to-side anastomosis helps optimize microsurgical efficiency by limiting needle, suture, and vessel handling after the initial suture placement, which has classically been a challenge of this bypass.

Comparative Assessment of Extracranial-to-Intracranial and Intracranial-to-Intracranial In Situ Bypass for Complex Intracranial Aneurysm Treatment Based on Rupture Status: A Case Series

BACKGROUND

Comparative outcomes of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass for complex aneurysm treatment based on rupture status are not well described in the literature. In this study, we compare outcomes of EC-IC and IC-IC bypass for complex intracranial aneurysm treatment based on rupture status.

METHODS

A prospective neurosurgical patient database was retrospectively reviewed. Sixty-three consecutive patients with aneurysm managed with revascularization were identified between July 2014 and December 2018.

RESULTS

During the study period, 41 patients with aneurysm underwent EC-IC bypass (65%; 24 [58.5%] ruptured, 17 [41.5%] unruptured) and 22 patients with aneurysm underwent IC-IC bypass (34.9%; 13 [59.1%] ruptured, 9 [40.9%] unruptured). Graft spasm occurred in 4 patients (9.8%) in the EC-IC group (all ruptured aneurysms) and all anastomoses were patent on immediate postoperative imaging. Perioperative mortality occurred in 5 patients who underwent EC-IC bypass (12.2%; 3 ruptured, 2 unruptured) EC-IC and 2 patients who underwent IC-IC bypass (9.1%; both ruptured); (P = 0.709). Bypass-related complications occurred only in patients with ruptured aneurysm (2 [8.3%] in the EC-IC group and 0 [0%] in the IC-IC group; P = 0.285). For unruptured aneurysms, the overall complication rate was lower in IC-IC compared with the EC-IC group (P = 0.006). Modified Rankin Scale scores on discharge were significantly lower in IC-IC compared with EC-IC bypass for unruptured aneurysms (P = 0.008). There was a trend for shorter temporary occlusion and hospitalization times and overall better outcomes with IC-IC compared with EC-IC bypass.

CONCLUSIONS

Although often considered riskier than EC-IC bypass, IC-IC in situ bypass showd a favorable technical and safety profile for the treatment of complex, unruptured aneurysms.

A3-A3 Anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: Experience With in Situ Bypass and Lessons Learned From Pseudoaneurysm Cases

BACKGROUND

A3-A3 side-to-side bypass is an intracranial-to-intracranial (IC-IC) revascularization option when aneurysm treatment involves occlusion of one anterior cerebral artery (ACA).

OBJECTIVE

To describe applications of A3-A3 side-to-side bypass in the management of ACA true and pseudoaneurysms along with a review of pertinent literature.

METHODS

Six consecutive patients undergoing an A3-A3 bypass as part of their aneurysm management, representing a single-surgeon experience in a 2-yr period, were included in this retrospective review of a prospectively collected database.

RESULTS

Three male and three female patients with a median (range) age of 41.5 (11-69) years representing four ruptured and two unruptured aneurysms were included. Two of the aneurysms were communicating while four were postcommunicating from which three were pseudoaneurysms. Complete aneurysm obliteration was achieved in 5/6 cases. Bypass patency was evaluated in all cases intra- and postoperatively. Good outcomes (modified Rankin Scale score ≤ 2) at follow-up were observed in 4/6 patients. An improvement in mRS scores at the most recent follow-up as compared to preoperative status was achieved in three while scores remained the same in two patients. Ischemic complications related to aneurysm treatment were observed in two patients, both of which achieved good functional recovery upon follow-up. One patient deceased postoperatively due to progression of vasospasm-related infarcts.

CONCLUSION

A3-A3 bypass in the management of true as well as pseudoaneurysms of the ACA can achieve good postoperative outcomes in selected patients. Prompt diagnosis and aggressive surgical treatment needs to be pursued if a vessel injury with pseudoaneurysm formation is suspected.

Intraoperative Assessment of Cortical Perfusion After Intracranial-To-Intracranial and Extracranial-To-Intracranial Bypass for Complex Cerebral Aneurysms Using Flow 800

BACKGROUND

Revascularization strategies for complex cerebral aneurysms are largely based on subjective interpretation of flow demands, or indirect measures of perfusion in at-risk territories. Indocyanine Green -based flow analyses ((ICG-BFA); Flow 800, Carl Zeiss, Oberkochen, Germany) provide a real-time, semiquantitative measure of intraoperative cortical perfusion during cerebral bypass surgery for complex aneurysms.

OBJECTIVE

To determine the utility of intraoperative ICG-BFA for assessing cortical perfusion in at-risk territories during cerebral bypass for complex aneurysms requiring vessel sacrifice.

METHODS

Retrospective analysis of consecutive patients from a prospective, single-institution open cerebrovascular database.

RESULTS

Intraoperative ICG-BFA confirmed adequate cortical perfusion in 2 patients with fusiform posterior circulation aneurysms, treated with a posterior inferior cerebellar artery (PICA)-PICA and occipital artery (OA)-to-third segment of the posterior cerebral artery (P3) bypass with proximal vessel sacrifice, respectively. ICG-BFA was used in a third patient that underwent clip reconstruction/ intracranial-to-intracranial bypass for a large middle cerebral artery (MCA) bifurcation aneurysm requiring sacrifice of the temporal M2 branch. In this case, a frontal M3 to temporal M3 side-to-side anastomosis was created to arborize the MCA tree and allow filling of both M2 territories through a single M2 branch. After aneurysm reconstruction, ICG-BFA identified an inadvertent occlusion of the frontal M2 that left the entire MCA distribution reliant on collateral flow but did not cause a neuromonitoring change. Repeat ICG-BFA after clip re-arrangement demonstrated aneurysm occlusion and equal flow in both frontal and temporal MCA cortical distributions from the arborization.

CONCLUSION

ICG-BFA is a useful adjunct for intraoperative cortical flow assessment during cerebral revascularization for complex aneurysms requiring vessel sacrifice.

Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites

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.

Occipital artery to p3 segment of posterior inferior cerebellar artery bypass in treating a complex fusiform aneurysm

We provide a case report of a 58-year-old man who presented with a ruptured fusiform dissecting aneurysm located at the junction of the vertebral artery and posterior inferior cerebellar artery (PICA). Due to the lesion's complexity, a two-step approach was planned for revascularisation of PICA using the occipital artery (OA) prior to coiling embolisation. An end-to-side OA-PICA bypass was performed with implantation at the caudal loop of the p3 PICA segment. Fifteen days after the procedure, the aneurysm underwent stent-assisted coiling for successful obliteration of the aneurysm. The patient tolerated this procedure well and now at 1.5 years of follow-up remains free from any neurological deficits (modified Rankin Score 0). This case report illustrates one of the unique scenarios where both the vascular territory involved and morphological features of the aneurysm prohibited the use of more conventional means, necessitating the use of an arterial bypass graft for successful treatment of this lesion. As open vascular surgery is becoming less common in the age of endovascular coiling, our article uniquely reports on the combined use of both endovascular and microsurgical techniques to treat a complex aneurysm of the posterior circulation.