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Brain Bypass Surgery: Outcomes and Progress

Cerebral Revascularization Using Radial Artery Grafts for the Treatment of Complex Intracranial Aneurysms: Techniques and Outcomes for 17 patients

Bypass Surgery for Complex Brain Aneurysms: An Assessment of Intracranial-Intracranial Bypass

  • Comparison between newer IC-IC bypasses to conventional EC-IC bypasses
  • IC-IC: reanastomose parent arteries, revascularize efferent branches with in situ donor arteries or reimplantation, and reconstruct bifurcated anatomy with entirely intracranial grafts
  • Over 10 years, 82 patients
  • Common locations of aneurysms: Cavernous internal carotid, MCA and PICA
  • 47 patients (57%): EC-IC; 35 patients (43%): IC-IC
  • Aneurysm obliteration rates comparable to EC-IC and IC-IC (97.9% vs. 97.1%)
  • Bypass patency rates comparable as well (94% EC-IC vs 89% IC-IC)
  • 90% good outcomes on Glasgow scale at a mean follow up of 41 months
  • Change in glasgow scale favor IC-IC (6% worse vs EC-IC's 14% worse)
  • IC-IC more favorable in terms of: aneurysm obliteration rates, bypass patency rates & neurological outcomes
  • Aimed to describe a new "pressure distention technique" to eliminate postoperative vasospasm (common problem)
  • 5 patients surgically treated without pressure distension technique
  • 12 patients technique used to reduce postop vasospasm
  • 14 patients had anterior circulation
  • 3 had posterior circulation aneurysms
  • Satisfactory outcomes, considering the complexity of the aneurysms and their "inoperability," with respect to direct clipping
  • Aneurysms completely obliterated for all patients
  • Grafts were patent for all except 1 patient on post-op angiograms
  • 2 deaths (unrelated to treatment)
  • Glasgow Outcome Scale scores: either better or same as preoperative scores
  • Vasospasm wasn't observed for any of 12 patients for whom pressure distension was used
  • Investigators concluded: RAG as alternative to saphenous vein and superficial temporal artery grafts
  • Problem of vasospasm of artery has been solved with pressure distension technique

Internal Maxillary Artery-Middle Cerebral Artery Bypass: Infratemporal Approach for Subcranial-Intracranial (SC-IC) Bypass

Data Points

  • Location of Aneurysm
  • Types of endovascular and surgical treatments
  • Types of bypass surgery (what type of graft used?)
  • Follow up results (independent, dependent, alive, dead)
  • If dead: from aneurysm or unrelated?
  • Treatment associated complications

Treatment of Giant Intracranial Aneurysms with Saphenous Vein Extracranial-to-Intracranial Bypass Grafting: Indications, Operative Technique and Results in 29 Patients

  • SC-IC Imax used in 4 cases
  • 1 case: flow augmentation bypass (Imax to internal carotid artery)
  • 2 cases: giant MCA aneurysm not amendable to endovascular treatment or direct microsurgical clipping; both underwent SC-IC bypass and endovascular trapping of aneurysms
  • 1 case: treated for recurrent partially thrombosed giant MCA aneurysm; presented with severe brain edema after coiling before this SC-IC treatment
  • All patients tolerated IMAX SC-IC bypass well
  • Post-op angiogram showed good filling of graft with robust distal flow in all cases

Distinct advantages of Imax-MCA over EC-IC bypass:

  • SC-IC graft much shorter than typical length required when using EC-IC graft (not as prone to mechanical disruption, i.e kinking and compression)
  • Short graft length permits use of brachiocephalic vein, which has few, if any, valves, which improves overall donor quality
  • In SC-IC, entire intracranial graft (proximal & distal anastamoses) is visualized within the same microsurgical field: allows for immediate inspection of graft; improves safety and efficiency of operation
  • 29 patients
  • Underwent 30 Saphenous Vein bypass grafts followed by immediate parent vessel occlusion
  • 11 men, 18 women with mean followup period of 62 months
  • 25 patients: internal carotid aneurysm
  • 2 patients: MCA
  • 2 patients: Basilar Artery
  • Used Serial Cerebral/Magnetic Resonance Angiography to assess graft patency and aneurysm obliteration
  • All 30 aneurysms were excluded from cerebral circulation; 28 vein grafts remaining patent
  • Surgical complications: 1 death (cerebral infarction), temporary hemiparesis and 2 patients with graft occlusions
  • Concluded that: saphenous vein EC-IC bypass followed by acute parent vessel occlusion is safe and effective in treating giant intracranial aneurysms
  • High rate of graft patency and adequate cerebral blood flow can be achieved
  • Continuing source of complications: thrombosis of perforating arteries due to altered blood flow

In situ bypass in management of complex intracranial aneurysms: technique application in 13 patients

  • In situ: brings together parallel intracranial donor and recipient arteries that are in close proximity
  • 5 patients: Middle Cerebral Artery (MCA)
  • 3 patients: Posteroinferior Cerebellar Artery (PICA)
  • 3 patients: Vertebral Artery
  • 2 patients: Anterior Communicating artery
  • Side to side anastamosis: 8 patients
  • Aneurysm excision with end to end re-anastamosis of parent artery: 5 patients
  • Angiography: all aneurysms completely obliterated and 12 bypasses were patent
  • Safe and effective alternative to EC-IC bypasses and high-flow bypasses using saphenous vein/radial artery grafts
  • Although, in situ bypasses are more technically demanding, they don't require harvesting a donor artery, are less vulnerable to injury and occlusion, and can be accomplished with 1 anastamosis

Imaging

Serial Cerebral Angiograms

  • Pre-op diagnostic tool; to detect/eva aneurysmal multiplicity

MRA

  • Both blood flow and condition of blood vessel walls can be seen

MRI

  • Provides additional details about regional anatomy, size, shape and content of aneurysms

CTA

  • Visualize arterial and venous vessels throughout the body

PET/CT

  • Usually used when Sub arachnoid hemorrhage is suspected
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