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