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Nurimanov C, Menlibayeva K. A novel intraoperative "Faucet" technique for assessing patency of superficial temporal artery to middle cerebral artery bypass and for prevention of microemboli. Acta Neurochir (Wien) 2024; 166:405. [PMID: 39397205 PMCID: PMC11471712 DOI: 10.1007/s00701-024-06305-6] [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: 08/22/2024] [Accepted: 10/07/2024] [Indexed: 10/15/2024]
Abstract
PURPOSE This technical note introduces the novel faucet technique, which enables neurosurgeons to evaluate the patency of a bypass during superficial temporal artery-middle cerebral artery bypass surgery. The technique is particularly useful when there is a lack of equipment such as micro-Doppler or indocyanine green in the operating rooms. This is often the case in Central Asian countries. METHODS The faucet technique involves carefully examining the graft by gently opening a valve, comparable to a faucet, to observe the blood flow through the bypassed vessel. Overall, 36 procedures underwent the faucet technique for assessing the superficial temporal artery-middle cerebral artery bypass patency. RESULTS The results indicate that the bypass remained patent in all cases, as confirmed through the intraoperative faucet technique, postoperative magnetic resonance angiography, or cerebral angiography. CONCLUSION By visually inspecting the blood flow through the faucet technique, surgeons can confirm the effectiveness of the graft and ensure that the bypass remains unobstructed during the surgery.
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Affiliation(s)
- Chingiz Nurimanov
- Vascular and Functional Neurosurgery Department, National Centre for Neurosurgery, Astana, Kazakhstan
| | - Karashash Menlibayeva
- Hospital Management Department, National Centre for Neurosurgery, Astana, Kazakhstan.
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Sekhar LN, Shenoy VS, Sen RD, Miller CA, Montoure A, Ghodke BV, Kim LJ. Current Indications, Trends, and Long-Term Results of 233 Bypasses to Treat Complex Intracranial Aneurysms: A Location-Specific Analysis. Neurosurgery 2024:00006123-990000000-01273. [PMID: 38984833 DOI: 10.1227/neu.0000000000003073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/10/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Advances in endovascular flow diverters have led to a secular shift in the management of brain aneurysms, causing debate on current bypass indications. We therefore sought to investigate the long-term results, current indications, and trends of bypasses for brain aneurysms. METHODS We retrospectively reviewed bypasses performed between 2005 and 2022 to treat brain aneurysms. Demographic, clinical, and radiological data were collected till the most recent follow-up. Aneurysm occlusion and graft patency was noted on cerebral angiogram in the immediate postoperative, 3-month, and most recent follow-up periods. Clinical outcomes (modified Rankin scores) and complications were assessed at 3 month and most recent follow-up. Trends in bypass volume and graft patency were assessed in 5-year epochs. Results were dichotomized based on aneurysm location to generate location-specific results and trends. RESULTS Overall, 203 patients (mean age 50 years, 57% female patients) with 207 cerebral aneurysms were treated with 233 cerebral bypasses with a mean follow-up of 2 years. Fusiform morphology was the most common bypass indication. Aneurysm occlusion on immediate postoperative and final follow-up angiogram was 89% (184/207) and 96% (198/207), respectively. Graft patency rate in the immediate postoperative period and most recent follow-up was 95% (222/233) and 92% (215/233), respectively. Of 207 aneurysms, 5 (2%) recurred. Of 203 patients, 81% (165) patients had modified Rankin scores of 0-2 at the 3-month follow-up and 11 patients died (mortality 5%). Although there was a steady decrease in the bypass volume over the study period, the proportion of bypasses for recurrent aneurysms increased serially. Posterior circulation aneurysms had lower rates of aneurysm occlusion and significantly higher incidence of postoperative strokes and deaths (P = .0035), with basilar artery aneurysms having the worst outcomes. CONCLUSION Bypass indications have evolved with the inception of novel flow diverters. However, they remain relevant in the cerebrovascular surgeon's armamentarium, and long-term results are excellent.
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Affiliation(s)
- Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Varadaraya S Shenoy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Innovation and Technology Commercialization, Co-Motion, University of Washington, Seattle, Washington, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Charles A Miller
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Neurological Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Andrew Montoure
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Western Neuro, Tucson, Arizona, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Rennert RC, Atai NA, Nguyen VN, Abedi A, Sternbach S, Chu J, Carey JN, Russin JJ. Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2024; 26:423-432. [PMID: 38084991 DOI: 10.1227/ons.0000000000001013] [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: 06/21/2023] [Accepted: 09/29/2023] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. METHODS Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. RESULTS Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. CONCLUSION The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jason Chu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles , California , USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
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Bocanegra-Becerra JE, Sánchez JLA. First-generation bypass surgery for a giant fusiform aneurysm of the middle cerebral artery: an illustrative case and surgical video. J Surg Case Rep 2024; 2024:rjae083. [PMID: 38404446 PMCID: PMC10884731 DOI: 10.1093/jscr/rjae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/04/2024] [Indexed: 02/27/2024] Open
Abstract
Giant fusiform aneurysms of the middle cerebral artery (MCA) are complex and rare vascular lesions with a poor natural history and challenging treatment decision-making. We report the case of a 46-year-old male with a history of chronic hypertension and a transient ischemic attack who presented with left-sided hemiparesis. A cerebral angiotomography revealed an unruptured giant fusiform aneurysm in the M2 segment of the right MCA. After carefully evaluating the procedure's risks and benefits with the patient, he underwent a low-flow bypass surgery. An anastomosis between the superficial temporal artery and the M3 segment was performed with proximal clipping of the M2 segment. The postoperative course was uneventful, with preserved bypass patency. At follow-up, the patient was neurologically intact. This report illustrates the nuances and operative techniques for treating a giant fusiform aneurysm of the M2 segment that accounted for a preserved bypass patency and optimal patient neurological recovery.
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Affiliation(s)
| | - José Luis Acha Sánchez
- Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru
- Universidad Nacional Mayor de San Marcos , Lima, Peru
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Chen Y, Chen P, Duan G, Li R, Li Z, Guo G. Extracranial-intracranial bypass surgery for intracranial aneurysm of the anterior cerebral circulation: A systematic review and meta-analysis. Front Neurol 2023; 14:1174088. [PMID: 37064185 PMCID: PMC10102499 DOI: 10.3389/fneur.2023.1174088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundThe 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 sourceWe constructed search strategies and comprehensively searched Pubmed, Medline, Embase, Web of science, and Cochrane library.MethodsThis 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.ResultThis 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).LimitationMost 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.ConclusionEC–IC therapy for anterior circulation IAs has a high safety profile. Higher level of evidence is still needed to support clinical decision.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396730, identifier: CRD42023396730.
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Affiliation(s)
- Yang Chen
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Pengyu Chen
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Guosheng Duan
- Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, China
| | - Ren Li
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ziao Li
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Geng Guo
- Department of Emergency, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- *Correspondence: Geng Guo
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Salem MM, Ravindran K, Hoang AN, Doron O, Esparza R, Raper D, Jankowitz BT, Tanweer O, Lopes D, Langer D, Nossek E, Burkhardt JK. Sonolucent Cranioplasty in Extracranial to Intracranial Bypass Surgery: Early Multicenter Experience of 44 Cases. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00655. [PMID: 36929760 DOI: 10.1227/ons.0000000000000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 01/10/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The new sonolucent cranioplasty implant (clear polymethyl methacrylate, PMMA) adds functionality besides surgical reconstruction. One possible application uses the transcranioplasty ultrasound (TCUS) technique after PMMA cranioplasty to assess graft patency of extracranial-intracranial (EC-IC) bypass procedures. OBJECTIVE To report our early multicenter experience. METHODS This is a multicenter analysis of consecutive EC-IC bypass patients from 5 US centers (2019-2022) with closure postbypass using PMMA implant. RESULTS Forty-four patients (median age 53 years, 68.2% females) were included. The most common indication for bypass was Moyamoya disease/syndrome (77.3%), and superficial temporal artery to middle cerebral artery bypass was the most common procedure (79.5%). Pretreatment modified Rankin Scales of 0 and 1 to 2 were noted in 11.4% and 59.1% of patients, respectively. Intraoperative imaging for bypass patency involved a combination of modalities; Doppler was the most used modality (90.9%) followed by indocyanine green and catheter angiography (86.4% and 61.4%, respectively). Qualitative TCUS assessment of graft patency was feasible in all cases. Postoperative inpatient TCUS confirmation of bypass patency was recorded in 56.8% of the cases, and outpatient TCUS surveillance was recorded in 47.7%. There were no cases of bypass failure necessitating retreatment. Similarly, no implant-related complications were encountered in the cohort. Major complications requiring additional surgery occurred in 2 patients (4.6%) including epidural hematoma requiring evacuation (2.3%) and postoperative surgical site infection (2.3%) that was believed to be unrelated to the implant. CONCLUSION This multicenter study supports safety and feasibility of using sonolucent PMMA implant in EC-IC bypass surgery with the goal of monitoring bypass patency using TCUS.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Omer Doron
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Rogelio Esparza
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Daniel Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Demetrius Lopes
- Department of Neurosurgery, Advocate Aurora Health System, Chicago, Illinois, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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Chen JY, Ding YH, Li Y, Shi SS, Chen J, Tu XK. Assessment of bypass patency using transcranial Doppler sonography: correlations with computerized tomography angiography findings in patients with moyamoya disease. Neurosurg Rev 2023; 46:64. [PMID: 36877325 DOI: 10.1007/s10143-023-01970-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/08/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023]
Abstract
To explore the utility of transcranial Doppler (TCD) findings when assessing bypass patency in patients with Moyamoya disease (MMD). Computed tomography angiography (CTA) and TCD sonography (TCDS) were performed before and after surgery to evaluate bypass patency. The peak systolic flow velocity (PSV) of the superficial temporal artery (STA) and the pulsatility index (PI) were compared between the groups that achieved patency and not, and receiver operating characteristic (ROC) curve analyses were used to define the TCDS criteria revealing patency. This study included 35 hemispheres (15 women; mean age 47 years) with Moyamoya disease who underwent STA-middle carotid artery bypass in our institution between January 2022 and October 2022. The PSV first increased on postoperative days 4-5 and then decreased on postoperative days 6-7 and 7-8. Patients with transient neurological diseases (TNDs), compared to those without, evidenced a significantly lower PSV value (P < 0.05). Compared with the non-patency group, the PSV was higher (P < 0.001) in the patency group. The cutoff values reflecting patency with good sensitivity and specificity were PSV > 49.00; PSV ratio (postoperative/preoperative) > 1.218; PSV ratio (operation side/contralateral side) > 1.082; and PSV ratio (adjusted) > 1.202. In the patency group, the PSV and PI significantly increased (P < 0.001) and decreased (P < 0.001) respectively. Bypass patency can be noninvasively and accurately evaluated via TCDS, affording an objective basis for assessment of the effect of revascularization surgery on patients with MMD.
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Affiliation(s)
- Jing-Yi Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Yi-Hang Ding
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Yang Li
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Song-Sheng Shi
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China
| | - Jing Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China.
| | - Xian-Kun Tu
- Department of Neurosurgery, Fujian Medical University Union Hospital, Neurosurgery Research Institute of Fujian Province, 29# Xinquan Road, Fuzhou, 350001, Fujian, China.
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Tonetti DA, Raygor KP, Dubnicoff T, Abla AA. Side-to-Side M2-M2 Bypass for Revascularization and Trapping of Left M2 Origin Fusiform Aneurysm Presenting With Subarachnoid Hemorrhage: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e123. [PMID: 36637321 DOI: 10.1227/ons.0000000000000494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/06/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Daniel A Tonetti
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Farooq J, Piper K, Yeung E, Zhang J, van Loveren H, Agazzi S, Lau T. Outcomes of Arterial Bypass for Posterior Circulation Atherosclerosis: A Case Series. Oper Neurosurg (Hagerstown) 2023; 24:145-153. [PMID: 36637299 DOI: 10.1227/ons.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 08/29/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Extracranial-intracranial bypass is an effective treatment option for moyamoya disease and in well-selected cases of anterior circulation intracranial atherosclerotic disease; however, the effectiveness of bypass is less evident in posterior circulation atherosclerosis. Updated surgical techniques and clinical guidelines necessitate modern appraisal of arterial bypass for symptomatic patients with posterior circulation atherosclerotic disease who are refractory to medical management. OBJECTIVE To evaluate the complications, graft patency, and postoperative outcomes of arterial bypass for posterior circulation intracranial atherosclerotic disease. METHODS Perioperative records of consecutive bypass patients were retrospectively evaluated to determine the clinical course and surgical outcomes. RESULTS Arterial bypass was performed in 8 cases with a median age of 62 years. All 8 patients underwent direct bypass with an autologous occipital artery donor vessel. Recipient vessel selection varied on a case-by-case basis, with the superior cerebellar artery used in 4 cases, the posterior inferior cerebellar artery in 3 cases, and the anterior inferior cerebellar artery in 1 case. There were no significant intraoperative or postoperative complications. Postoperatively, all 8 patients displayed clinical improvement of their preoperative symptoms, with a significant decrease of 2.5 points on the modified Rankin Scale (P < .001). Postoperative imaging confirmed full graft patency in 7 patients and partial patency in 1 patient. CONCLUSION Excellent postoperative outcomes and no major complications after posterior circulation arterial bypass for intracranial atherosclerotic disease highlight the utility of this intervention for the treatment of medically refractory or symptomatic posterior circulation intracranial atherosclerotic disease. Larger studies may be valuable to validate these findings.
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Affiliation(s)
- Jeffrey Farooq
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Keaton Piper
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Elton Yeung
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Harry van Loveren
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Tsz Lau
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
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Rennert RC, Nguyen VN, Abedi A, Atai NA, Carey JN, Tenser M, Amar A, Mack WJ, Russin JJ. Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series. Front Neurol 2023; 14:1102496. [PMID: 37153667 PMCID: PMC10160605 DOI: 10.3389/fneur.2023.1102496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/29/2023] [Indexed: 05/10/2023] Open
Abstract
Background and purpose The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk. Materials and methods Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022. Results Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%). Conclusion A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.
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Affiliation(s)
- Robert C. Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Vincent N. Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nadia A. Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joseph N. Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Matthew Tenser
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Arun Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - William J. Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan J. Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Jonathan J. Russin,
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Lefevre E, Ganau M, Zaed I, de Macedo Machado-Filho G, Scibilia A, Mallereau CH, Bresson D, Todeschi J, Cebula H, Proust F, Vignes JL, Masquelet AC, Facca S, Livernaux P, Alfieri A, Ramos TCM, Magaldi M, Bruno C, Chibbaro S. Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study. Neurosurg Rev 2022; 45:3271-3280. [PMID: 36066661 DOI: 10.1007/s10143-022-01856-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/28/2022] [Accepted: 08/27/2022] [Indexed: 11/29/2022]
Abstract
Despite being a critical component of any cerebrovascular procedure, acquiring skills in microsurgical anastomosis is challenging for trainees. In this context, simulation models, especially laboratory training, enable trainees to master microsurgical techniques before performing real surgeries. The objective of this study was to identify the factors influencing the learning curve of microsurgical training. A prospective observational study was conducted during a 7-month diploma in microsurgical techniques carried out in the anatomy laboratory of the school of surgery. Training focused on end-to-end (ETE) and end-to-side (ETS) anastomoses performed on the abdominal aorta, vena cava, internal carotid and jugular vein, femoral artery and vein, caudal artery, etc. of Wistar strain rats under supervision of 2 expert anatomical trainers. Objective and subjective data were collected after each training session. The 44 microsurgical trainees enrolled in the course performed 1792 anastomoses (1577 ETE, 88%, vs. 215 ETS, 12%). The patency rate of 41% was independent from the trainees' surgical background and previous experience. The dissection and the temporary clamping time both significantly decreased over the months (p < 0.001). Technical mistakes were independently associated with thrombosis of the anastomoses, as assessed by the technical mistakes score (p < 0.01). The training duration (in weeks) at time of each anastomosis was the only significant predictor of permeability (p < 0.001). Training duration and technical mistakes constituted the two major factors driving the learning curve. Future studies should try and investigate other factors (such as access to wet laboratory, dedicated fellowships, mentoring during early years as junior consultant/attending) influencing the retention of surgical skills for our difficult and challenging discipline.
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Affiliation(s)
- Etienne Lefevre
- Department of Neurosurgery, University Hospital "Pitié-Salpêtrière", Paris, France
| | - Mario Ganau
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Ismail Zaed
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France.
| | | | - Antonino Scibilia
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Charles-Henry Mallereau
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Damien Bresson
- Department of Neurosurgery, University Hospital "Henri Mondor", Créteil, France
| | - Julien Todeschi
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Francois Proust
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Jean-Luc Vignes
- Microsurgery Laboratory of "Assistance Publique Hopitaux Paris", Fer a moulin, Paris, France
| | - Alain-Charles Masquelet
- Microsurgery Laboratory of "Assistance Publique Hopitaux Paris", Fer a moulin, Paris, France.,Department of Orthopedics, University Hospital "Saint-Antoine", Paris, France
| | - Sybille Facca
- Department of Orthopedics (Hand Surgery Unit), University Hospital "Hautepierre II", Strasbourg, France
| | - Philippe Livernaux
- Department of Orthopedics (Hand Surgery Unit), University Hospital "Hautepierre II", Strasbourg, France
| | - Alex Alfieri
- Department of Neurosurgery, Winterthur Hospital, Winterthur, Switzerland
| | - Taise Cruz Mosso Ramos
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Marcelo Magaldi
- Department of Neurosurgery, "Hospital das Clinicas", Belo Horizonte, Brazil
| | - Carmen Bruno
- Neurosurgery Department, Bonomo Hospital, Andria, Italy
| | - Salvatore Chibbaro
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
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12
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Housley SB, Vakharia K, Gong AD, Waqas M, Rho K, Levy EI, Davies JM, Siddiqui AH. Extracranial-to-Intracranial Bypass for Distal Internal Carotid Artery and/or Proximal Middle Cerebral Artery Steno-Occlusive Disease: A Case Series of Clinical Outcomes at a Single, High-Volume Cerebrovascular Center. Oper Neurosurg (Hagerstown) 2022; 23:177-181. [PMID: 35972078 DOI: 10.1227/ons.0000000000000280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 03/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extracranial-to-intracranial (EC-IC) bypass was first described by Yasargil in the 1960s for treatment of symptomatic distal internal carotid artery (ICA) and/or proximal middle cerebral artery (MCA) steno-occlusive disease through direct anastomosis. Subsequent bypass trials failed to demonstrate benefit for overall outcomes and stroke rates compared with best medical therapy. However, the procedure remained in the neurosurgeon's armament, with studies showing benefits in select patient populations. With advancements in technology, patient selection has become more comprehensive. OBJECTIVE To provide a contemporary evaluation of EC-IC bypass from our high-volume cerebrovascular center, focusing on associated clinical outcomes. METHODS Consecutive patients who underwent direct EC-IC bypass surgeries for symptomatic distal ICA and/or proximal MCA steno-occlusive disease between April 2015 and September 2019 were identified retrospectively. Medical records were reviewed to collect demographics, clinical presentation, computed tomography perfusion imaging findings, transcranial Doppler results, procedure indication, donor vessel types, anastomosis site, bypass patency, periprocedural complications, postprocedural complications, symptom recrudescence, repeat or new interventions, subjective improvements, and modified Rankin Scale scores. RESULTS We identified 27 patients who underwent 32 EC-IC bypass procedures. The rate of ipsilateral stroke was 9.4%, with a median follow-up of 8 months (IQR, 4-13 months). Patients experienced a 22.3% improvement in modified Rankin Scale scores, and 70.3% of patients reported subjective improvement and satisfaction at follow-up. CONCLUSION Direct EC-IC bypass remains a viable option for revascularization in symptomatic patients with distal ICA and/or proximal MCA steno-occlusive disease.
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Affiliation(s)
- Steven B Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
| | - Andrew D Gong
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
| | - Kyungduk Rho
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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13
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Zhang J, Yu J, Xin C, Fujimura M, Lau TY, Hu M, Tian X, Luo M, Tao T, Li L, Wang C, Wei W, Li X, Chen J. A flow self-regulating superficial temporal artery–middle cerebral artery bypass based on side-to-side anastomosis for adult patients with moyamoya disease. J Neurosurg 2022; 138:1347-1356. [PMID: 36461841 DOI: 10.3171/2022.8.jns221379] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Side-to-side (S-S) superficial temporal artery–middle cerebral artery (STA-MCA) bypass was reportedly used to treat a special moyamoya disease (MMD) patient with collaterals arising from the donor STA. However, the S-S technique is not routinely performed to date, and its benefits are still unknown for adult MMD. The purpose of this study was to investigate the possibility of routine use of the S-S technique for adult MMD.
METHODS
The authors retrospectively analyzed the clinical data of 50 adult patients (65 hemispheres, including 30 in the end-to-side [E-S] group and 35 in the S-S group) with MMD who underwent STA-MCA bypass. The patient demographic characteristics, clinical courses, technical details, intraoperative blood flow data, postoperative and preoperative relative cerebral blood flow (rCBF) values, modified Rankin Scale (mRS) scores, and short-term revascularization results were compared between the 2 groups.
RESULTS
There were no significant differences observed in terms of the baseline characteristics, bypass patency rates, postoperative/preoperative rCBF values, incidence of cerebral hyperperfusion syndrome (CHS), mRS scores, and short-term revascularization results between the 2 groups (all p > 0.05). Intraoperative blood flow analysis showed that the increase of STA flow in the E-S group was significantly higher than that of proximal STA flow in the S-S group (p = 0.008). Although the increases of proximal and distal recipient flow in the E-S group seemed greater than those in the S-S group, the results were not statistically significant (p = 0.086 for proximal flow and p = 0.076 for distal flow). CHS symptoms in the S-S group were milder and with much shorter duration. The follow-up angiographic data of the representative case demonstrated that both frontal and parietal STA branches and the occipital artery participated in postoperative collateralization.
CONCLUSIONS
S-S anastomosis can achieve comparable clinical effects to standard E-S construction. S-S anastomosis used in adult MMD demonstrated mild CHS symptoms with short duration and had the potential to arouse all scalp arteries as donor sources for revascularization through the intact distal STA branch via flow self-regulation.
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Affiliation(s)
- Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Can Xin
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsz Yeung Lau
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Miao Hu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiao Tian
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Mingrui Luo
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tianshu Tao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ling Li
- Department of Nuclear Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China; and
| | - Changyin Wang
- Department of Nuclear Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China; and
| | - Wei Wei
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Medical Research Institute, Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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14
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Lee RP, Tamargo RJ. Commentary: Left Callosomarginal to Right Pericallosal In Situ Bypass, Partial Trapping, and Thrombectomy of a Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e163-e165. [PMID: 35972095 DOI: 10.1227/ons.0000000000000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Park S, Choi ES, Jung HW, Lee JY, Park JW, Bang JS, Jeon YT. Preoperative Serum Alkaline Phosphatase and Neurological Outcome of Cerebrovascular Surgery. J Clin Med 2022; 11:2981. [PMID: 35683370 PMCID: PMC9181655 DOI: 10.3390/jcm11112981] [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: 04/26/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/02/2022] Open
Abstract
This study evaluated the relationship between the preoperative alkaline phosphatase (ALP) level and major postoperative neurological complications in patients undergoing cerebral bypass surgery. This was a retrospective analysis of a prospective database of all patients undergoing cerebral bypass surgery after a diagnosis of cerebrovascular stenosis or occlusion between May 2003 and August 2017. The patients were divided into tertiles based on serum alkaline phosphatase (ALP) levels (low: <63, intermediate: 63~79, and high: ALP > 79 IU/mL). The incidence of neurological events according to ALP level was analyzed. The study analyzed 211 cases. The incidence of acute infarction was highest in the third serum ALP tertile (5.7% vs. 2.9% vs. 16.9% in the first, second, and third tertile, respectively, p = 0.007). Logistic regression analysis showed that the third tertile of serum ALP was an independent predictor of acute cerebral infarction (odds ratio 3.346, 95% confidence interval 1.026−10.984, p = 0.045). On Kaplan−Meier time-to-event curves, the incidence of acute infarction increased significantly with ALP (log rank = 0.048). Preoperative serum ALP level can be used as a biomarker to predict acute cerebral infarction in patients undergoing cerebral bypass surgery for vascular stenosis or occlusion.
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Affiliation(s)
- Seongjoo Park
- Department of Anaesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea;
| | - Eun-Su Choi
- Department of Anaesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan 15355, Korea; (E.-S.C.); (H.-W.J.)
| | - Hee-Won Jung
- Department of Anaesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan 15355, Korea; (E.-S.C.); (H.-W.J.)
| | - Ji-Youn Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-Y.L.); (J.-W.P.)
| | - Jin-Woo Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-Y.L.); (J.-W.P.)
| | - Jae-Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Yeong-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-Y.L.); (J.-W.P.)
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
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16
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Krůpa P, Krajina A, Lojík M, Adamkov J, Česák T. Flow Preserving Endovascular Treatment of Traumatic Pseudoaneurysms of the Distal Anterior Cerebral Artery-Case Reports and Review of Literature. Brain Sci 2022; 12:634. [PMID: 35625019 PMCID: PMC9139790 DOI: 10.3390/brainsci12050634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 12/05/2022] Open
Abstract
Traumatic intracranial pseudoaneurysms (tIPAs) are a very rare pathology caused by blunt or penetrating head trauma. Diagnostic and therapeutic challenges of tIPAs are due to their unpredictable onset during the initial injury, or in a delayed manner, their unclear traumatic mechanism. Moreover, the presence of subarachnoid, subdural, or intraventricular hematoma may often cause them to be overlooked, which can potentially be followed by lethal rebleeding. Treatment of these lesions is controversial and on a case-by-case basis with regard to endovascular therapy or open surgery. We report two cases of three tIPAs of the distal anterior cerebral artery (dACA) with immediate and delayed onset after the trauma. Endovascular therapy resulted in complete obliteration of lesions with flow preservation in the parent artery using the flow diverter-assisted coiling strategy. The aim of this manuscript is to discuss the mechanism, angioanatomical characteristics, and current treatment options for these exceptional lesions.
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Affiliation(s)
- Petr Krůpa
- Department of Neurosurgery, Faculty Hospital, Faculty of Medicine in Hradec Kralove, Charles University, 50346 Hradec Kralove, Czech Republic; (J.A.); (T.Č.)
- Department of Neuroregeneration, Institute of Experimental Medicine, Czech Academy of Sciences, 14220 Prague, Czech Republic
| | - Antonín Krajina
- Department of Radiology, Faculty Hospital, Faculty of Medicine in Hradec Kralove, Charles University, 50346 Hradec Kralove, Czech Republic; (A.K.); (M.L.)
| | - Miroslav Lojík
- Department of Radiology, Faculty Hospital, Faculty of Medicine in Hradec Kralove, Charles University, 50346 Hradec Kralove, Czech Republic; (A.K.); (M.L.)
| | - Jaroslav Adamkov
- Department of Neurosurgery, Faculty Hospital, Faculty of Medicine in Hradec Kralove, Charles University, 50346 Hradec Kralove, Czech Republic; (J.A.); (T.Č.)
| | - Tomas Česák
- Department of Neurosurgery, Faculty Hospital, Faculty of Medicine in Hradec Kralove, Charles University, 50346 Hradec Kralove, Czech Republic; (J.A.); (T.Č.)
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17
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Farooq J, Heller RS, Noureldine MHA, Wang ZJ, Wei G, Mhaskar R, Ren Z, van Loveren H, Lau T, Agazzi S. Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience. Oper Neurosurg (Hagerstown) 2022; 22:355-363. [DOI: 10.1227/ons.0000000000000177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
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18
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Ren S, Wu W, Su C, Zhu Q, Schmidt M, Sun Y, Forman C, Speier P, Hong X, Lu S. High-resolution compressed sensing time-of-flight MR angiography outperforms CT angiography for evaluating patients with Moyamoya disease after surgical revascularization. BMC Med Imaging 2022; 22:64. [PMID: 35387607 PMCID: PMC8988403 DOI: 10.1186/s12880-022-00790-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/28/2022] [Indexed: 12/12/2022] Open
Abstract
Background To evaluate the utility of high-resolution compressed sensing time-of-fight MR angiography (CS TOF-MRA) for assessing patients with moyamoya disease (MMD) after surgical revascularization, by comparison with computer tomography angiography (CTA). Methods Twenty patients with MMD after surgical revascularizations who underwent CS TOF-MRA and CTA were collected. The scan time of CS TOF-MRA was 5 min and 4 s, with a reconstructed resolution of 0.4 × 0.4 × 0.4 mm3. Visualization of superficial temporal artery and middle cerebral artery (STA–MCA) bypass, neovascularization into the brain pial surface and Moyamoya vessels (MMVs) were independently ranked by two neuroradiologists on CS TOF-MRA and CTA, respectively. The patency of anastomosis was assessed as patent or occluded, using digital subtraction angiography and expert’s consensus as ground truth. Interobserver agreement was calculated using the weighted kappa statistic. Wilcoxon signed-rank or Chi-square test was performed to investigate diagnostic difference between CS TOF-MRA and CTA. Results Twenty-two hemispheres from 20 patients were analyzed. The inter-reader agreement for evaluating STA–MCA bypass, neovascularization and anastomosis patency was good to excellent (κCS TOF-MRA, 0.738–1.000; κCTA, 0.743–0.909). The STA–MCA bypass and MMVs were better visualized on CS TOF-MRA than CTA (both P < 0.05). CS TOF-MRA had a higher sensitivity than CTA (94.7% vs. 73.7%) for visualizing anastomoses. Neovascularization was better observed in 13 (59.1%) sides on CS TOF-MRA, in comparison to 7 (31.8%) sides on CTA images (P = 0.005). Conclusion High-resolution CS TOF-MRA outperforms CTA for visualization of STA–MCA bypass, neovascularization and MMVs within a clinically reasonable time in MMD patients after revascularization.
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Affiliation(s)
- Shujing Ren
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chunqiu Su
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Qianmiao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | | | - Yi Sun
- MR Collaboration NE Asia, Siemens Healthcare, Shanghai, China
| | | | | | - Xunning Hong
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shanshan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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19
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Kuribara T, Akiyama Y, Mikami T, Komatsu K, Kimura Y, Takahashi Y, Sakashita K, Chiba R, Mikuni N. Macrohistory of Moyamoya Disease Analyzed Using Artificial Intelligence. Cerebrovasc Dis 2022; 51:413-426. [PMID: 35104814 DOI: 10.1159/000520099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease is characterized by progressive stenotic changes in the terminal segment of the internal carotid artery and the development of abnormal vascular networks called moyamoya vessels. The objective of this review was to provide a holistic view of the epidemiology, etiology, clinical findings, treatment, and pathogenesis of moyamoya disease. A literature search was performed in PubMed using the term "moyamoya disease," for articles published until 2021. RESULTS Artificial intelligence (AI) clustering was used to classify the articles into 5 clusters: (1) pathophysiology (23.5%); (2) clinical background (37.3%); (3) imaging (13.2%); (4) treatment (17.3%); and (5) genetics (8.7%). Many articles in the "clinical background" cluster were published from the 1970s. However, in the "treatment" and "genetics" clusters, the articles were published from the 2010s through 2021. In 2011, it was confirmed that a gene called Ringin protein 213 (RNF213) is a susceptibility gene for moyamoya disease. Since then, tremendous progress in genomic, transcriptomic, and epigenetic profiling (e.g., methylation profiling) has resulted in new concepts for classifying moyamoya disease. Our literature survey revealed that the pathogenesis involves aberrations of multiple signaling pathways through genetic mutations and altered gene expression. CONCLUSION We analyzed the content vectors in abstracts using AI, and reviewed the pathophysiology, clinical background, radiological features, treatments, and genetic peculiarity of moyamoya disease.
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Affiliation(s)
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ryohei Chiba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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20
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Haddad RN, Bonnet D, Malekzadeh-Milani S. Embolization of vascular abnormalities in children with congenital heart diseases using medtronic micro vascular plugs. Heart Vessels 2022; 37:1271-1282. [PMID: 35088203 DOI: 10.1007/s00380-021-02007-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/03/2021] [Indexed: 11/04/2022]
Abstract
This study aimed at evaluating our experience with Micro Vascular Plug (MVP) for embolization of vascular abnormalities in children with congenital heart diseases (CHDs). MVP is one of the most recent additions to the armamentarium for peripheral embolization. Data on its use in congenital cardiology are scarce. Medical records of children with CHDs who had embolizations with MVPs between April 2015 and September 2020 were reviewed. Immediate and follow-up data were assessed. A total of 153 patients underwent 172 procedures during which 240 embolizations using 259 MVPs were attempted. Median age and weight were 34.9 months (IQR, 4-75 months) and 12.5 kg (IQR, 4.8-19.4 kg), respectively. Targets were abnormal systemic arteries (n = 163), patent arterial ducts (n = 26), venous (n = 45), and coronary-cameral fistulas (n = 6). Median vessel diameter was 3.3 mm (IQR, 2.5-4 mm). Veins were larger than arteries (2.3 mm > 2.1 mm, p < 0.01). MVPs were implanted in narrower diameters compared to manufacturer's recommendations. Compared to veins, solitary implanted MVPs in arteries were additionally oversized at 12.4%, 5.1%, and 7.9% for MVP-3Q, 5Q, and 7Q, respectively. Additional occlusion material (16.7%) and 2 MVPs (5.8%) were needed at the same site for complete closure. Implantation and procedure success rates were 99.2% and 96.7%, respectively. Five complications were treated percutaneously (n = 4) and surgically (n = 1). Efficacy of vascular embolization using MVPs was demonstrated in the largest cohort of children with CHDs and a variety of clinical settings. Immediate and stable closure is obtained with a single device in most cases. Detailed device selection chart according to vessel type and diameter is proposed to achieve intended outcomes.
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Affiliation(s)
- Raymond N Haddad
- Service de Cardiologie Congénitale et Pédiatrique, Centre de Référence Des Malformations Cardiaques Congénitales Complexes - M3C, Hôpital Universitaire Necker-Enfants Malades, 149, rue de Sèvres, 75015, Paris, France.
| | - Damien Bonnet
- Service de Cardiologie Congénitale et Pédiatrique, Centre de Référence Des Malformations Cardiaques Congénitales Complexes - M3C, Hôpital Universitaire Necker-Enfants Malades, 149, rue de Sèvres, 75015, Paris, France.,Université de Paris, Paris, France
| | - Sophie Malekzadeh-Milani
- Service de Cardiologie Congénitale et Pédiatrique, Centre de Référence Des Malformations Cardiaques Congénitales Complexes - M3C, Hôpital Universitaire Necker-Enfants Malades, 149, rue de Sèvres, 75015, Paris, France
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21
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Murai Y, Sekine T, Ishisaka E, Tsukiyama A, Kubota A, Matano F, Ando T, Nakae R, Morita A. Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study. Neurosurgery 2022; 90:426-433. [PMID: 35064659 DOI: 10.1227/neu.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited. OBJECTIVE To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass. METHODS Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI. RESULTS The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA. CONCLUSION Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases.
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Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Tetsuro Sekine
- Department of Radiology, Musashi-Kosugi Hospital, Nippon Medical School, Kanagawa, Japan
| | - Eitaro Ishisaka
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Atsushi Tsukiyama
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Asami Kubota
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Takahiro Ando
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
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22
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Lu J, Xue C, Hu X, Zhao Y, Zhang D, Chen X, Zhao JZ. Quantitative angiographic haemodynamic evaluation of bypasses for complex aneurysms: a preliminary study. Stroke Vasc Neurol 2021; 7:54-61. [PMID: 34642254 PMCID: PMC8899645 DOI: 10.1136/svn-2021-000858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Open microsurgery, often with bypass techniques, is indispensable for complex aneurysms. To date, it remains unknown whether arterial anatomy or quantitative blood flow measurements can predict insufficient flow-related stroke (IRS). The present study aimed to evaluate the risk factors for IRS in patients treated with open microsurgery with bypass procedures for complex internal carotid artery aneurysms. Methods Patients with complex aneurysms undergoing bypass surgery were retrospectively reviewed. The recipient/donor flow index (RDFI) was preoperatively evaluated using colour-coding angiography. RDFI was defined as the ratio of the cerebral blood volume of the recipient and donor arteries. The sizes of the recipient and donor arteries were measured. The recipient/donor diameter index (RDDI) was then calculated. IRS was defined as the presence of new postoperative neurological deficits and infarction on postoperative CT scans. We assessed the association between RDFI and other variables and the IRS. Results Twenty patients (38±12 years) were analysed. IRS was observed in 12 patients (60%). Patients with postoperative IRS had a higher RDFI than those without postoperative IRS (p<0.001). RDDI was not significantly different between patients with and without IRS (p=0.905). Patients with RDFI >2.3 were more likely to develop IRS (p<0.001). Conclusion Quantitative digital subtraction angiography enables preoperative evaluation of cerebral blood volume. RDFI >2.3, rather than RDDI, was significantly associated with postoperative IRS. This preoperative evaluation allows appropriate decisions regarding the treatment strategy for preventing postoperative IRS.
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Affiliation(s)
- Junlin Lu
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China
| | - Chao Xue
- Department of Industrial Engineering, Tsinghua University, Beijing, People's Republic of China
| | - Xulin Hu
- Chengdu Institute of Organic Chemistry, Chinese Academy of Sciences, Chengdu, People's Republic of China.,University of the Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Yuanli Zhao
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, People's Republic of China
| | - Dong Zhang
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Xiaolin Chen
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China
| | - Ji Zong Zhao
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, People's Republic of China
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23
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Rumalla K, Srinivasan VM, Gaddis M, Kan P, Lawton MT, Burkhardt JK. Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes. J Neurosurg 2021; 135:431-439. [PMID: 33157529 DOI: 10.3171/2020.6.jns202117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms. METHODS The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes. RESULTS In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction). CONCLUSIONS Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.
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Affiliation(s)
- Kavelin Rumalla
- 1School of Medicine, University of Missouri-Kansas City, Missouri
| | | | - Monica Gaddis
- 1School of Medicine, University of Missouri-Kansas City, Missouri
| | - Peter Kan
- 3Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas
| | - Michael T Lawton
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Jan-Karl Burkhardt
- 5Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Nouri M, Schneider JR, Shah K, White TG, Katz JM, Dehdashti AR. Cerebral Bypass for Aneurysms in the Era of Flow Diversion: Single-Surgeon Case Series. Oper Neurosurg (Hagerstown) 2021; 21:303-311. [PMID: 34245142 DOI: 10.1093/ons/opab215] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 04/29/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND With recent advances in endovascular treatments of brain aneurysms such as flow diverters, the role of cerebral revascularization needs to be re-evaluated. OBJECTIVE To evaluate the contemporary indications and outcomes of cerebral revascularization for brain aneurysms. METHODS A retrospective evaluation of a prospectively maintained database was performed to review clinical and imaging data of all the patients who underwent cerebral revascularization for brain aneurysms over the past 10 yr. RESULTS Among 174 cerebral revascularizations, 40 (in 36 patients) were done for the treatment of aneurysms. In total, 9 patients underwent combined endovascular treatment and surgical revascularization. Immediate aneurysm occlusion was achieved in 30 patients (83.3%). Immediate postoperative bypass patency was confirmed in 33 patients (92%). Postoperative neurological deficit was observed in 4 patients (11.1%). There were 2 mortalities in the postoperative period. Aneurysm total occlusion rate was 91% at 1 yr. Thirty patients had 1 yr clinical and radiological follow-up. Clinical evaluations showed modified Rankin Scale 2 or less in 25 patients at 1 yr. Bypass patency was confirmed in 27 (90%). Patients with fair/poor outcome were all in the subarachnoid hemorrhage group. Twenty-one patients had follow-up studies for 3 yr or beyond with no evidence of stroke or aneurysm recurrence. CONCLUSION Our results support that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity. Cerebral bypass should be offered in selected cases where standard endovascular or surgical treatment is not efficacious or curative.
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Affiliation(s)
- Mohsen Nouri
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Julia R Schneider
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Kevin Shah
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
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25
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Lu J, Shi G, Zhao Y, Wang R, Zhang D, Chen X, Wang H, Zhao JZ. Effects and safety of aspirin use in patients after cerebrovascular bypass procedures. Stroke Vasc Neurol 2021; 6:624-630. [PMID: 34039715 PMCID: PMC8717793 DOI: 10.1136/svn-2020-000770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/07/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
Object Superficial temporal artery to middle cerebral artery (STA-MCA) bypass is the most effective treatment for Moyamoya disease (MMD). In this study, we aimed to assess whether aspirin improves STA-MCA bypass patency and is safe in patients with MMD. Methods We performed a retrospective medical record review of patients with ischaemic-onset MMD who had undergone STA-MCA bypass at two hospitals between January 2011 and August 2018, to clarify the effects and safety of aspirin following STA-MCA bypass. The neurological status at the last follow-up (FU) was compared between patients with FU bypass patency and occlusion. Results Among 217 identified patients (238 hemispheres), the mean age was 41.4±10.2 years, and 51.8% were male; the indications for STA-MCA bypass were stroke (48.2%), followed by a transient ischaemic attack (44.0%). Immediate bypass patency was confirmed in all cases. During the FU period (1.5±1.5 y), 15 cases were occluded at FU imaging, resulting in an overall cumulative patency rate of 94%. The patency rates were 93% and 94% in the short-term FU group (n=131, mean FU time 0.5±0.2 years) and long-term FU group (n=107, mean FU time 4.1±3.5 years), respectively. The STA-MCA bypass patency rate in the aspirin group was higher than that in the non-aspirin group (98.7% vs 89.7%; HR 1.57; 95% CI 1.106 to 2.235; p=0.012). No significant difference in the FU haemorrhagic events was observed between the aspirin and non-aspirin groups. Conclusions Among adult patients with ischaemic-onset MMD undergoing STA-MCA bypass procedures, aspirin might increase the bypass patency rate, without increasing the bleeding risk. FU bypass patency may be associated with a better outcome. Additional studies, especially carefully designed prospective studies, are needed to address the role of aspirin after bypass procedures.
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Affiliation(s)
- Junlin Lu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangchao Shi
- Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yuanli Zhao
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neurosurgery, Peking University International Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Rong Wang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neurosurgery, Peking University International Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Wang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Ji Zong Zhao
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
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26
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Color Doppler ultrasonography for predicting the patency of anastomosis after superficial temporal to middle cerebral artery bypass surgery. Acta Neurochir (Wien) 2021; 163:1503-1513. [PMID: 33404878 DOI: 10.1007/s00701-020-04669-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Color Doppler ultrasonography (CDUS) is used to evaluate the surgical success and postoperative hemodynamic changes of patients who receive superficial temporal to middle cerebral artery (STA-MCA) bypass surgery. Previous studies enrolled small populations, and difficulties interpreting the results have limited their use in clinical settings. OBJECTIVE We attempted to determine the feasibility of using CDUS to evaluate STA hemodynamics and identify the most reliable parameter as a new clinical implication for determining bypass patency. METHOD Twenty-six patients who underwent STA-MCA bypass surgery were prospectively enrolled. Four times CDUS and two times digital subtraction angiography (DSA) were performed. The CDUS parameters were compensated using the ratio of the operated to the non-operated sides (R1) and compared before and after surgery (R2). The CDUS parameters are then compared with the patency on DSA by statistical analyses. RESULTS Increased CDUS parameters of the mean flow rate (MFR) and cross-sectional diameter (CSD) showed significant correlations with good patency on DSA. The R2 at 1 month was identified as the most reliable parameter for predicting the patency in both MFR and CSD. Their cutoff values were 1.475 and 1.15, respectively. CONCLUSION CDUS can be utilized for predicting the patency after STA-MCA bypass surgery; if the postoperative (compensated and compared) CDUS parameters increased by more than 47.5% in the MFR or 15% in the CSD, the patency of the anastomosis on DSA would be good.
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27
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Delayed Anastomotic Occlusion after Direct Revascularization in Adult Hemorrhagic Moyamoya Disease. Brain Sci 2021; 11:brainsci11050536. [PMID: 33923268 PMCID: PMC8145476 DOI: 10.3390/brainsci11050536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/18/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
Delayed anastomotic occlusion occurred in a considerable proportion of hemorrhagic moyamoya disease (MMD) patients undergoing direct revascularization. This study aimed to investigate the predictors and outcomes of delayed anastomotic occlusion in adult hemorrhagic MMD. The authors retrospectively reviewed 87 adult hemorrhagic MMD patients. Univariate and multivariate logistic regression analyses were performed. After an average of 9.1 ± 6.9 months of angiographic follow-up, the long-term graft patency rates were 79.8%. The occluded group had significantly worse angiogenesis than the non-occluded group (p < 0.001). However, the improvement of dilated anterior choroidal artery–posterior communicating artery was similar (p = 0.090). After an average of 4.0 ± 2.5 years of clinical follow-up, the neurological statues and postoperative annualized rupture risk were similar between the occluded and non-occluded groups (p = 0.750; p = 0.679; respectively). In the multivariate logistic regression analysis, collateral circulation Grade III (OR, 4.772; 95% CI, 1.184–19.230; p = 0.028) and preoperative computed tomography perfusion (CTP) Grade I–II (OR, 4.129; 95% CI, 1.294–13.175; p = 0.017) were independent predictors of delayed anastomotic occlusion. Delayed anastomotic occlusion in adult hemorrhagic MMD might be a benign phenomenon. Good collateral circulation (Grade III) and compensable preoperative intracranial perfusion (CTP Grade I–II) are independent predictors for this phenomenon. Moreover, the delayed anastomotic occlusion has no significant correlations with the long-term angiographic and neurological outcomes, except neoangiogenesis.
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28
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Hurth H, Hauser TK, Haas P, Wang S, Mengel A, Tatagiba M, Ernemann U, Khan N, Roder C. Early Post-operative CT-Angiography Imaging After EC-IC Bypass Surgery in Moyamoya Patients. Front Neurol 2021; 12:655943. [PMID: 33868157 PMCID: PMC8044757 DOI: 10.3389/fneur.2021.655943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the clinical value of early post-operative computed tomographic angiography (CTA) after direct extracranial-intracranial (EC-IC) bypass surgery in moyamoya patients. Methods: A retrospective analysis of all adult moyamoya patients treated at our center from 2013 to 2019 with a direct EC-IC bypass was performed. Early post-operative CTA (within 24 h after surgery) was compared with conventional digital subtraction angiography (DSA) 6-12 months after surgery. If available, magnetic resonance time-of-flight angiography (MR-TOF) was evaluated 3 months and 6-12 months post-operatively as well. Imaging results were analyzed and compared with CTA, MR-TOF and DSA, whereat DSA was used as the final and definite modality to decide on bypass patency. Results: A total of 103 direct EC-IC bypasses in 63 moyamoya patients were analyzed. All inclusion criteria were met in 32 patients (53 direct bypasses). In 84.9% the bypass appeared definitively, in 5.7% uncertainly and in 9.4% not patent according to early post-operative CTA. MR-TOF suggested definitive bypass patency in 86.8% 3 months after surgery and in 93.5% 6-12 months after surgery. DSA 6-12 months post-operatively showed a patency in 98.1% of all bypasses. The positive predictive value (to correctly detect an occluded bypass) on post-operative CTA was 12.5%, the negative predictive value (to correctly detect a patent bypass) was 100% with a sensitivity of 100% and a specificity of 86.5%. Conclusion: Early post-operative CTA has a high predictive value to confirm the patency of a bypass. On the other hand, a high false positive rate of (according to CTA) occluded bypasses after direct EC-IC bypass surgery can be seen. This must be considered critically when initiating possible therapeutic measures.
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Affiliation(s)
- Helene Hurth
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany
| | - Till-Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Patrick Haas
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany
| | - Sophie Wang
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany
| | - Annerose Mengel
- Department of Vascular Neurology, University Hospital Tuebingen, Tuebingen, Germany.,Center for Neurovascular Diseases ZNET, University Hospital Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany.,Center for Neurovascular Diseases ZNET, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Tuebingen, Germany.,Center for Neurovascular Diseases ZNET, University Hospital Tuebingen, Tuebingen, Germany
| | - Nadia Khan
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany.,Moyamoya Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Constantin Roder
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Center for Moyamoya and Cerebral Revascularization, University Hospital Tuebingen, Tuebingen, Germany.,Center for Neurovascular Diseases ZNET, University Hospital Tuebingen, Tuebingen, Germany
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29
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Guo X, Gao L, Yu H, Chen W, Yang Y, Jin F, Hu Y, Chong Z, Liu D, Sun Z, Chen Y. Computed tomographic angiography may be used for assessing the dilatation of the anterior choroidal and posterior communicating arteries in patients with moyamoya syndrome. Eur Radiol 2021; 31:5544-5551. [PMID: 33564956 DOI: 10.1007/s00330-021-07722-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/27/2020] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the feasibility of CT angiography (CTA) for assessing anterior choroidal artery (AChA) and posterior communicating artery (PComA) dilatation in patients with moyamoya syndrome (MMS). METHODS Eighty-eight MMS patients who underwent digital subtraction angiography (DSA) and CTA within 1 month were enrolled. The AChA was graded using both DSA and CTA. Given the features of dual blood supply, DSA was firstly used for grading of the PComA. Then, the calibers of PComA, P1 or P2 segment of the posterior cerebral artery (PCA), were recorded from CTA. Taking DSA as a reference standard, the optimal cutoff values of the PComA/P1 or PComA/P2 were calculated to determine the dilatation of PComA. Both the AChA and PComA were classified as extreme dilatation (ED, grade 2) or non-extreme dilatation (NED, grade 0 or 1). RESULTS The AChA was evaluated in 149 affected hemispheres of 88 patients while the PComA was evaluated in 70 affected hemispheres of 49 patients. The sensitivity and specificity of CTA in diagnosing AChA-ED were 92% and 93.5% respectively. Both the PComA/P1 (p < 0.001) and PComA/P2 (p = 0.4) ratios were increased in the PComA-ED group with the former yielding a better detecting performance than the latter (AUC = 0.92 vs 0.85, p = 0.046). When using 0.71 as a cutoff value, the sensitivity and specificity of the PComA/P1 ratio for diagnosis of PComA-ED cases were 91.3% and 83.3% respectively. CONCLUSIONS CTA could be used for the AChA classification in MMS patients, while a PComA/P1 ratio greater than 0.71 indicates the existence of PComA-ED. KEY POINTS • CTA showed a high sensitivity, specificity, and accuracy in diagnosing AChA-ED in patients with MMS. • PComA/P1 ratio greater than 0.71 on CTA signified an extremely dilated PComA. • CTA could be used to assess the dilatation of AChA and PComA in MMS patients, especially for routine postoperative follow-up.
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Affiliation(s)
- Xiang Guo
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Lingyun Gao
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Hao Yu
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Weijian Chen
- Department of Medical Imaging, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yunjun Yang
- Department of Medical Imaging, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feng Jin
- Department of Neurosurgery, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Yawei Hu
- Department of Neurosurgery, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Zhen Chong
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Deguo Liu
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Zhanguo Sun
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China
| | - Yueqin Chen
- Department of Radiology, the Affiliated Hospital of Jining Medical University, Jining, China.
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30
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Abstract
Disease of the vertebral (VA) and basilar arteries (BA) can lead to stroke of the posterior circulation and may warrant management strategies which differ from the anterior circulation. The mechanism and location of the disease determine its natural history and therefore affect the relative risks and benefits of the possible treatment options. Vertebrobasilar (VB) atherosclerotic disease is a source of both hemodynamic and embolic posterior circulation stroke. Advances in medical therapy have decreased the rate of stroke after initial symptomatic presentation. Antiplatelet therapy, blood pressure control, and optimization of secondary risk factors can reduce recurrent stroke risk in both intracranial and extracranial VB disease. However, symptomatic intracranial disease is still associated with a high risk of subsequent stroke, particularly those with hemodynamic compromise who represent a higher risk population. Patients with hemodynamic impairment may benefit from judicious application of endovascular and microsurgical interventions to augment blood flow. Stenting, angioplasty alone, bypass surgery, and endarterectomy, represent endovascular and surgical tools available to address medically refractory VB disease. Apart from atherosclerotic disease, dissection is another etiology of VB stroke, most frequently affecting the extracranial VA. Treatment is predominantly antithrombotic therapy although surgical or endovascular intervention can be required in rare cases of persistent embolism or hemodynamic compromise. In contrast, extrinsic compromise of the VA represents a separate extracranial pathology and is best treated with mechanistically targeted surgeries or extracranial bypass.
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Affiliation(s)
- Richard Bram
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
| | - Alfred P See
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA -
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31
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Induced Moyamoya vessels after extra-intracranial bypass for a giant middle cerebral artery aneurysm exclusion: Case report. Clin Neurol Neurosurg 2021; 201:106475. [PMID: 33429265 DOI: 10.1016/j.clineuro.2021.106475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022]
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32
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Wang M, Yang Y, Wang Y, Li M, Zhang J, Zhang B. Vessel-selective 4D MRA based on ASL might potentially show better performance than 3D TOF MRA for treatment evaluation in patients with intra-extracranial bypass surgery: a prospective study. Eur Radiol 2021; 31:5263-5271. [PMID: 33386981 DOI: 10.1007/s00330-020-07503-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/24/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare bypass patency and intracranial collaterals from the external carotid artery (ECA) by four-dimensional MR angiography (MRA) based on super-selective pseudo-continuous arterial spin labeling (pCASL) combined with the keyhole and view-sharing techniques (4D-sPACK) versus three-dimensional time-of-flight (3D TOF) MRA in patients with extra-intracranial revascularization. METHODS The MR data of 45 patients administered bypass surgery were collected. The image quality of 4D-sPACK was evaluated using a 4-point grading system according to whether the diagnosis of intracranial collaterals was affected. Anastomosis patency and intracranial collateral visualization from ECA were assessed by two radiologists on 4D-sPACK and 3D TOF MRA, with digital subtraction angiography (DSA) findings as reference. Intracranial collateral assessment employed another 4-point grading system according to the number of vessels shown. Interobserver agreement was assessed with the weighted kappa statistic. RESULTS Fifty hemispheres in 43 patients were included. The image quality of 4D-sPACK was good in 47 (47/50, 94.0%) hemispheres. 4D-sPACK had a higher sensitivity than 3D TOF MRA (97.73% vs 79.55%) for visualizing anastomoses. There were significant differences between 4D-sPACK (scores, 3.22 ± 1.15) and 3D TOF MRA (scores, 1.80 ± 0.67) in the visualization of intracranial collaterals from ECA (p < 0.001). The interobserver agreement was substantial for intracranial collateral assessment (κ4D-sPACK = 0.788; κ3D TOF MRA = 0.800) and almost perfect for bypass patency (κ4D-sPACK = 0.912; κ3D TOF MRA = 0.816; κDSA = 0.811). CONCLUSION This pilot study shows that, 4D-sPACK has a better performance than 3D TOF MRA in treatment evaluation of patients after bypass surgery, and has high consistency with DSA. KEY POINTS • 4D-sPACK is a non-contrast-enhanced dynamic MRA method for the visualization of intracranial vessels. • 4D-sPACK has higher specificity for the diagnosis of anastomosis occlusion. • 4D-sPACK is better than 3D TOF MRA in the visualization of intracranial collaterals in patients after bypass surgery.
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Affiliation(s)
- Maoxue Wang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Drum Tower District, Nanjing, Jiangsu Province, 210002, China
| | - Yongbo Yang
- Department of Neurosurgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yi Wang
- Department of Neurosurgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ming Li
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Drum Tower District, Nanjing, Jiangsu Province, 210002, China
| | | | - Bing Zhang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Drum Tower District, Nanjing, Jiangsu Province, 210002, China.
- Institute of Brain Science, Nanjing University, Nanjing, Jiangsu, China.
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33
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Letter to the Editor Regarding "Clinical Prediction of Surgical Revascularization Outcome in Moyamoya Disease Via Transcranial Color Sonography". J Stroke Cerebrovasc Dis 2020; 30:105545. [PMID: 33334679 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/05/2020] [Indexed: 11/22/2022] Open
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34
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Shabaev AR, Kazantsev AN, Tarasov RS, Ruban EV, Lider RI, Iakhnis EI, Solobuev AI, Volkov AN, Mironov AV. [Surgical treatment of a patient with saccular arterial aneurysm of the cavernous-ophthalmic segment]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 25:131-138. [PMID: 31855210 DOI: 10.33529/angio2019412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Presented in the article are the results of surgical management of a patient with an extremely rare pathology - a saccular arterial aneurysm of the cavernous-ophthalmic segment of the left internal carotid artery. We performed multistage open surgical intervention in the following scope: osteoplastic pterional craniotomy on the left, creation of a wide-lumen anastomosis between the left external carotid artery and M2 segment of the left middle cerebral artery with the use of the radial artery, ligation of the cervical portion of the left internal carotid artery and clipping of its supraclinoid portion. The chosen surgical policy made it possible to create sufficient volumetric blood flow through the shunt, comparable to the blood flow through the internal carotid artery, which helped avoid ischaemic stroke after exclusion of the aneurysm from circulation. A conclusion was drawn on efficacy of this method of treatment.
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Affiliation(s)
- A R Shabaev
- Kemerovo Regional Clinical Cardiological Dispensary named after Academician L.S. Barbarash, Kemerovo, Russia; Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - A N Kazantsev
- Kemerovo Regional Clinical Cardiological Dispensary named after Academician L.S. Barbarash, Kemerovo, Russia; Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - E V Ruban
- Kemerovo Regional Clinical Cardiological Dispensary named after Academician L.S. Barbarash, Kemerovo, Russia
| | - R Iu Lider
- Kemerovo State Medical University of the RF Ministry of Public Health, Kemerovo, Russia
| | - E Ia Iakhnis
- Kemerovo State Medical University of the RF Ministry of Public Health, Kemerovo, Russia
| | - A I Solobuev
- Kemerovo State Medical University of the RF Ministry of Public Health, Kemerovo, Russia
| | - A N Volkov
- Kemerovo Regional Clinical Cardiological Dispensary named after Academician L.S. Barbarash, Kemerovo, Russia
| | - A V Mironov
- Kemerovo Regional Clinical Cardiological Dispensary named after Academician L.S. Barbarash, Kemerovo, Russia; Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
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35
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Ge P, Ye X, Liu X, Deng X, Wang J, Wang R, Zhang Y, Zhang D, Zhang Q, Zhao J. Angiographic Outcomes of Direct and Combined Bypass Surgery in Moyamoya Disease. Front Neurol 2019; 10:1267. [PMID: 31849825 PMCID: PMC6903770 DOI: 10.3389/fneur.2019.01267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 11/15/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To identify associated risk factors for the angiographic outcomes after direct and combined bypass surgery in moyamoya disease (MMD). Methods: All direct and combined bypass procedures performed from June 2009 to May 2015 were screened in this prospective cohort study. Patients who acquired presurgical and follow-up catheter angiography were included. Bypass patency and postoperative collateral formation were evaluated. Univariate and multivariate logistic regression analyses were performed to determine the influence factors for bypass patency and postoperative collateral formation. Results: In total, 188 consecutive bypass procedures were included. After an 18-month median follow-up, the anastomosis patency rate was 88.3%. Postoperative collateral formation was associated with the patency of the anastomosis (Gamma = 0.891, p < 0.001). Multivariate logistic regression analysis showed that presence of hemorrhage (OR, 0.298; 95% CI, 0.125–0.709; p = 0.006) was associated with obstructed anastomosis. Among the 188 bypass surgeries, 125 (63.2%) hemispheres had good postoperative collateral formation and 85 (36.8%) had poor postoperative collateral formation. Multivariate logistic regression analysis showed that younger age at operation (OR, 2.396; 95% CI, 1.231–4.664; p = 0.010) was associated with good postoperative collateral formation, while the poor postoperative collateral formation was related to presence of hemorrhage (OR, 0.329; 95% CI, 0.143–0.758; p = 0.009) and dilated anterior choroidal artery (OR, 0.472; 95% CI, 0.240–0.929; p = 0.030). Conclusions: This study has demonstrated that presence of hemorrhage predicts lower patency rates. Younger age at operation was associated with good postoperative collateral formation, while the poor postoperative collateral formation was related to presence of hemorrhage and dilated anterior choroidal artery.
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Affiliation(s)
- Peicong Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xingju Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Jia Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
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36
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Cavallo C, Gandhi S, Zhao X, Belykh E, Valli D, Nakaji P, Preul MC, Lawton MT. Applications of Microscope-Integrated Indocyanine Green Videoangiography in Cerebral Revascularization Procedures. Front Surg 2019; 6:59. [PMID: 31850362 PMCID: PMC6902023 DOI: 10.3389/fsurg.2019.00059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/02/2019] [Indexed: 11/13/2022] Open
Abstract
Indocyanine green videoangiography (ICG-VA) is a near-infrared range fluorescent marker used for intraoperative real-time assessment of flow in cerebrovascular surgery. Given its high spatial and temporal resolution, ICG-VA has been widely established as a useful technique to perform a qualitative analysis of the graft patency during revascularization procedures. In addition, this fluorescent modality can also provide valuable qualitative and quantitative information regarding the cerebral blood flow within the bypass graft and in the territories supplied. Digital subtraction angiography (DSA) is considered to be the gold standard diagnostic modality for postoperative bypass graft patency assessment. However, this technique is time and labor intensive and an expensive interventional procedure. In contrast, ICG-VA can be performed intraoperatively with no significant addition to the total operative time and, when used correctly, can accurately show acute occlusion. Such time-sensitive ischemic injury detection is critical for flow reestablishment through direct surgical management. In addition, ICG has an excellent safety profile, with few adverse events reported in the literature. This review outlines the chemical behavior, technical aspects, and clinical implications of this tool as an intraoperative adjunct in revascularization procedures.
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Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Sirin Gandhi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Daniel Valli
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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37
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LoPresti MA, Srinivasan VM, North RY, Ravindra VM, Johnson J, Burkhardt JK, Lam SK, Kan P. Endovascular stenting for rescue of a failed donor graft during superficial temporal artery to middle cerebral artery bypass surgery: case report. J Neurosurg Pediatr 2019; 24:572-576. [PMID: 31398698 DOI: 10.3171/2019.5.peds1977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
Direct bypass has been used to salvage failed endovascular treatment; however, little is known of the reversed role of endovascular management for failed bypass.The authors report the case of a 7-year-old patient who underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass for treatment of a giant MCA aneurysm and describe the role of endovascular rescue in this case. Post-bypass catheter angiogram showed occlusion of the proximal extracranial STA donor with patent anastomosis, possibly due to STA dissection. A self-expanding Neuroform Atlas stent was deployed across the dissection flap, and follow-up images showed revascularization of the STA with good MCA runoff.This case demonstrates that direct extracranial-intracranial bypass failure can infrequently originate from the STA donor vessel and that superselective angiogram can be useful for identification and treatment in such cases. With more advanced endovascular techniques the tide has turned in the treatment of complex cerebrovascular cases, with this case being an early example of successful rescue stenting for endovascular management of a failed donor after STA-MCA bypass.
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Affiliation(s)
- Melissa A LoPresti
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish M Srinivasan
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Robert Y North
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Vijay M Ravindra
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeremiah Johnson
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jan-Karl Burkhardt
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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38
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Hafez A, Huhtakangas J, Muhammad S, Lawton MT, Tanikawa R, Niemelä M. The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard. World Neurosurg 2018; 121:e119-e128. [PMID: 30218800 DOI: 10.1016/j.wneu.2018.09.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/01/2018] [Accepted: 09/04/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several factors associated with interrupted and continuous suturing techniques affect the quality of bypass anastomosis. It is difficult to determine the impact of these factors during surgery. The primary objective of this study was to evaluate factors with the potential to influence the quality of bypass anastomosis using either interrupted or continuous suturing. A secondary objective was to evaluate the usefulness of a practical scale when comparing interrupted and continuous suturing techniques to improve bypass anastomosis. METHODS Interrupted (n = 100) and continuous (n = 100) suturing techniques were used in 200 end-to-side bypasses to a depth of 3 cm and were assessed by 5 neurosurgeons. RESULTS Vessel closing time (P < 0.001), stitch distribution (P < 0.001), intima-intima attachment (P < 0.001), and size of the orifice (P < 0.001) had a significant impact on the quality of the bypass regardless of the suturing technique used. The suturing technique used (interrupted or continuous) and positioning of the recipient vessel (vertical or horizontal) did not significantly influence the quality of anastomosis. Using multivariate analysis, the highest statistical significance with regard to bypass quality was attributed to the large size of the orifice and intimal attachment. CONCLUSIONS There were advantages and disadvantages to both suturing techniques. The scale was a practical way to measure and improve performance.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. /
| | - Justiina Huhtakangas
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Rokuya Tanikawa
- Sapporo Stroke Center Hiroyasu Kamiyama, Brain Disease Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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