Treatment of a high extracranial carotid artery aneurysm with CCA-MCA bypass and carotid ligation. Case report

Intracranial aneurysms in adolescents

PURPOSE

Intracranial aneurysms are extremely uncommon in adolescents. This study was undertaken to assess the clinical and radiological characteristics and clarify the choice of therapeutic strategies of intracranial aneurysms in adolescents with age range from 15 to 18 years.

METHODS

From our dedicated aneurysmal databank between October 1985 and July 2008, we reviewed 16 consecutive adolescents who had 20 intracranial aneurysms.

RESULTS

Ten boys and six girls (male/female ratio = 1.67:1; mean age 16.78 ± 1.18 years) were included in the present study. Intracranial aneurysms in adolescents constituted 0.91% of all intracranial aneurysms. It was found that 25% of the lesions were in the posterior circulation, while 75% of the lesions were in the anterior circulation, and 25% developed on the middle cerebral artery (MCA). Half of the patients presented with subarachnoid hemorrhage and others mainly presented with mass effect such as weakness in the extremities, diplopia, and dysfunction of eye movement. Eight cases underwent endovascular treatment: including GDC therapy in five patients, parental artery occlusion in two patients, and cover stent implantation in one patient with pseudoaneurysm of the cavernous segment of the left internal carotid artery. Four patients received microsurgical therapy: aneurismal neck clipping for two patients and extracranial-intracranial (EC-IC) bypass and trapping of complex aneurysms in MCA for the other two patients. Four patients did not receive microsurgical or endovascular therapy, including a boy whose aneurysm spontaneously thrombosed preoperatively and a girl who died before operation because of rerupture of aneurysm. Two patients did not undergo therapy owing to the high operative risk. All of the patients who received therapy had favorable outcome (GOS 4 or 5) at discharge and at follow-up.

CONCLUSIONS

Intracranial aneurysms in adolescents differ from those in adults in many ways including the following: male predominance; high incidence of large or giant, traumatic, dissecting, and fusiform aneurysms; high incidence of aneurysms in the posterior circulation; high incidence of spontaneous thrombosis; better Hunt-Hess grade at presentation; and better therapeutic outcome. Both microsurgical approaches and endovascular treatment were effective. For some giant, complex intracranial aneurysms, parent artery occlusion or EC-IC bypass is the best treatment choice.

Radial Artery Graft for Bypass of the Maxillary to Proximal Middle Cerebral Artery: An Anatomic and Technical Study

OBJECTIVE

In this study, we aimed to investigate the use of a radial artery graft for bypass of the maxillary artery (MA) to the proximal middle cerebral artery (MCA) as an alternative to superficial temporal artery-to-MCA anastomosis or extracranial carotid-to-MCA bypass using long grafts.

METHODS

Five adult cadavers were used bilaterally. After a frontotemporal craniotomy and a zygomatic arch osteotomy, the MA was found easily 1 to 2 cm inferior to the infratemporal crest. A hole was created with a 4-mm-tip drill in the sphenoid bone 2 to 3 mm lateral to the foramen rotundum extradurally, and the dura over the hole was opened. After the carotid and sylvian cisterns had been opened, the M2 segment of the MCA was exposed. The graft was passed through the hole to reach the M2 segment. Then, the MA was freed from the surrounding tissue and was transected before the infraorbital artery branch. The radial artery graft was anastomosed end-to-end to the MA proximally and end-to-side to the M2 segment of the MCA distally.

RESULTS

The mean thickness of the MA before the infraorbital artery branch was 2.6 ± 0.3 mm. The mean thickness of the largest trunk of the MCA was 2.3 ± 0.3 mm. The average length of the graft was 36 ± 5.5 mm.

CONCLUSION

MA-to-MCA bypass is as feasible as proximal MCA revascularization using long vein grafts. The thickness of the MA provides sufficient flow; the length of the graft is short, and it has a straight course. MA-to-proximal MCA bypass may be an alternative to superficial temporal artery-to-MCA as well as extracranial carotid-to-MCA bypasses.

Proximal superficial temporal artery to proximal middle cerebral artery bypass using a radial artery graft: an anatomic approach

We present the use of radial artery graft for bypass of the proximal superficial temporal artery to the proximal middle cerebral artery. Six adult cadaver sites were used bilaterally. After apterional incision, 2x2-cm minicraniectomy was performed which began 2 cm behind the zygomatic process of the frontal bone. The superficial temporal artery was transsected before exposing the zygomatico-orbital artery branch. The proximal side of the radial artery graft was anastomosed end-to-end to the proximal superficial temporal artery and the distal side end-to-side to the proximal middle cerebral artery. The mean calibers of the proximal superficial temporal artery and largest trunk of the middle cerebral artery were 2.25+/-0.35 mm and 2.3+/-0.3 mm, respectively. The average graft length was 85+/-5.5 mm. We conclude that such bypasses are simpler than proximal middle cerebral artery revascularization using long vein grafts. This method proves that the caliber of the proximal superficial temporal artery is more suited to providing sufficient flow than the distal superficial temporal artery, and the graft is short. Such bypasses to the middle cerebral artery may be an alternative to those from the distal superficial temporal artery or extracranial carotid artery.

Cerebral revascularization

During the last 10 years, there has been a revival of interest in cerebral revascularization procedures. Not only have significant progressions in surgical techniques been published, the use of more advanced diagnostic methods has led to a widening of the indications for cerebral bypass surgery. The purpose of this review is to outline the current techniques for extracranial-to-intracranial (EC/IC) and intracranial-to-intracranial (IC/IC) bypass surgery, as well as to identify the current indications for revascularization procedures based on the available literature. The excimer laser-assisted non-occlusive anastomosis (ELANA) technique is described in more detail because we think that this technique almost completely eliminates the risk of cerebral ischemia due to the temporary vessel occlusion which is currently used in conventional anastomosis techniques.

Selective cerebral revascularization as an adjunct in the treatment of giant anterior circulation aneurysms

Cerebral revascularization, an indispensable component of neurovascular surgery, has been performed in the treatment of cranial base tumors, complex cerebral aneurysms, and occlusive cerebrovascular disease. The goal of a revascularization procedure is to augment blood flow distally. It can therefore be used as an adjunctive measure in the treatment of complex neurosurgical disease processes that require parent artery sacrifice for definitive treatment. In the treatment of giant anterior circulation aneurysms, for instance, a cerebral revascularization procedure may be considered in patients in whom the collateral circulation is marginal and in whom lesions may be treated either using a Hunterian-based strategy or clip-assisted reconstruction requiring a prolonged period of temporary occlusion. To date, there is no entirely effective method known to produce long-term tolerance to carotid artery (CA) sacrifice and, largely for that reason, some neurovascular surgeons advocate universal revascularization. The authors of this report, however, prefer to perform revascularization only in the limited subset of patients in whom preoperative assessment has revealed risk factors for cerebral ischemia due to hypoperfusion. In this paper, the authors introduce their protocol for assessing cerebrovascular reserve capacity, indications for cerebral revascularization in the treatment of complex anterior circulation aneurysms, and discuss their rationale for choosing to practice selective, rather than universal, revascularization.

Extracranial-intracranial vein graft bypass for giant intracranial aneurysm surgery for pediatric patients: two technical case reports

OBJECTIVE AND IMPORTANCE

Herein we describe two cases of extracranial-intracranial vein graft bypasses for the treatment of giant intracranial aneurysms in prepubertal pediatric patients. One patient is, we think, the youngest patient reported in the literature to have been successfully treated in such a manner, with a good long-term outcome. Such grafts seem to enlarge longitudinally during the growth spurt, making such techniques reasonable long-term therapeutic options for the management of complex intracranial aneurysms in pediatric patients.

CLINICAL PRESENTATION

Patient 1, a 13-year-old boy, presented with headaches and rapidly progressive right cavernous sinus syndrome. Computed tomography and cerebral angiography revealed a giant, fusiform, right intracavernous internal carotid artery aneurysm. Patient 2, a 23-month-old girl, was discovered to harbor an asymptomatic, recurrent, giant, fusiform, left M1 middle cerebral artery aneurysm 1 year after presenting with seizures related to subarachnoid hemorrhage from the aneurysm, for which she had been treated with clipping and an M2-M2 anastomosis.

INTERVENTION

Both patients underwent craniotomies, with sacrifice of the proximal parent vessel (the distal cervical internal carotid artery and the proximal middle cerebral artery, respectively), combined with cerebral revascularization through extracranial-intracranial saphenous vein bypass grafts. Both patients experienced excellent long-term clinical outcomes, have undergone significant growth, and exhibit excellent long-term graft patency and aneurysm obliteration.

CONCLUSION

These two cases highlight the safety and efficacy of extracranial-intracranial vein graft bypasses among prepubertal pediatric patients. The indications for bypass procedures to treat giant intracranial aneurysms are discussed, and the technical aspects of maximizing vein bypass graft patency are reviewed.

Saphenous vein graft for bypass of the maxillary to supraclinoid internal carotid artery: an anatomical short study

The use of a saphenous vein graft for bypass of the maxillary artery (MA) to the supraclinoid internal carotid artery (ICA) in internal carotid occlusions is investigated. Five adult cadaver sides were used. Dissection required zygomatic arch osteotomy and a pterional craniotomy with extensive removal of the floor of the middle cranial fossa. The MA was found easily medial to infratemporal crest. The clinoidal segment of the ICA was exposed with the removal of the anterior clinoid process intradurally. The bypass graft was 4 to 5 cm long and was sutured end-to-end to the MA and end-to-side to the supraclinoid ICA. When high blood flow is needed in cases with ICA occlusion, such a bypass may be an alternative to superficial temporal (STA)-to-middle cerebral artery (MCA) bypass as well as to common carotid-to-MCA or-ICA bypass, which needs a long vein graft. This type of bypass will provide the opportunity to clip the ICA proximal to the origin of ophthalmic artery, which may inhibit distal embolization.

Long-term patency of radial artery graft bypass for reconstruction of the internal carotid artery. Technical note

Reconstruction of the carotid artery by using a radial artery graft is a useful option that can produce reliable long-term patency for the surgical treatment of giant and/or large aneurysms of the cavernous and paraclinoid internal carotid artery (ICA). During the past 10 years, 43 patients with intracavernous and paraclinoid giant aneurysms of the ICA have been treated by reconstruction of the ICA with radial artery grafts after ligation of the cervical ICA. The long-term patency of the grafted radial artery was evaluated over more than a 5-year period (mean 7.2 years) in 20 of these patients by using magnetic resonance angiography or conventional angiography. There was no late occlusion of the graft in any of these cases. Stenotic graft changes were observed in two cases.

Surgical aspects of fusiform and saccular extracranial carotid artery aneurysms

The purpose of this paper is to analyse surgical aspects of aneurysms of the distal extracranial internal carotid artery. Nine cases of extracranial carotid artery aneurysm are reported. Five were fusiform, located at the carotid bifurcation, and four were saccular, confined to the internal carotid artery. An end-to-end plication technique and Dacron patch angioplasty were employed for all fusiform aneurysms. In three saccular lesions, resection and 4-mm polytetrafluoroethylene (PTFE) graft interposition were carried out. In one case with a high lesion, ligation of the carotid artery was performed. Ligation resulted in severe postoperative stroke and fatal outcome. One patient with a saccular lesion developed a transient ischaemic attack after the operation. In other patients no central neurological deficit was produced by the surgery itself. Transient cranial nerve damage occurred in four patients (two hypoglossal nerve: two superior laryngeal nerve). As demonstrated by these cases, synthetic material may be used in restoration of the carotid artery. It is concluded that, according to type, location of the aneurysm and adequacy of contralateral cerebral blood flow, selective management is necessary.