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PubMed1998

Cerebral revascularization using omentum and muscle free flap for ischemic cerebrovascular disease.

BACKGROUND: Indirect cerebral revascularization has been generally accepted in the management of brain ischemia in moyamoya disease. We performed indirect cerebral revascularization by using omental flap and muscle flap techniques for the treatment of ischemic cerebrovascular disease. METHODS: Ten patients with ischemic cerebrovascular disease including three with adult moyamoya disease underwent this procedure (omental flap on eight sides and muscle flap on five sides). The muscle used for the flap was the serratus anterior muscle on two sides and shaved latissimus dorsi muscle on three sides. Angiography and cerebral blood flow studies were performed in all patients preoperatively and postoperatively. All patients demonstrated severely impaired cerebrovascular reserve capacity due to occlusive disease. RESULTS: There was one patient each with perioperative death and intracranial infection following omental flap loss, and two patients had perioperative strokes. The average follow-up period was 23.2 months. Of the nine surviving patients, all eight except for the one with flap loss had good outcome with complete resolution of neurologic episodes. CONCLUSIONS: It is concluded that this method seems to be effective in selected patients with ischemic cerebrovascular disease.

Adult↗
PubMed2003

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.

Carotid Artery, Internal↗
PubMed2005

[Cerebral revascularization in treatment of intractable aneurysms].

OBJECTIVE: To evaluate the effectiveness of cerebral revascularization in the treatment of intractable aneurysms and to discuss the indications, surgical techniques, and the outcome of the revascularization. METHODS: During the recent 4-year period, 9 radical artery grafts were performed in patients with intractable or giant internal carotid artery (ICA) aneurysms. The indications for cerebral revascularization included parent vessel occlusion during the treatment of the intractable aneurysms with poor collateral circulation or the young patients. Modified techniques were taken to use the main trunk of superficial temporal artery (STA) as donor, while M3 branches near the bifurcation of the M2 segment of the middle cerebral artery (MCA) were chosen as the recipient arteries. STA-Radial artery (RA)-MCA bypass was followed by parent vessel occlusion via chronic cervical ICA ligation or balloon occlusion. RESULTS: Postoperative angiography demonstrated the patency of the grafts in eight cases. The procedure of the parent vessels occlusion was uneventful in these patients. Follow-up showed the patients were in excellent conditions after successful treatment of aneurysms. Significantly delayed filling of the graft was revealed in one patient, who could not tolerate balloon occlusion test and occlusion of parent artery failed. CONCLUSIONS: Extracranial-to-intracranial bypass followed by parent vessel occlusion is a safe and effective method to treat intractable ICA aneurysms. Radical artery as graft can offer high-flow revascularization with less complications. Combined surgical and endovascular treatment might be the future direction for the treatment of the difficult aneurysms.

Adolescent↗
PubMed1982

Angiographic demonstration of cerebral revascularization after encephalo-duro-arterio-synangiosis (EDAS) performed on pediatric moyamoya patients.

For the treatment of the moyamoya disease, we developed a surgical procedure of Encephalo-duro-aterio-synangiosis (EDAS), which was conducted in 15 cases on 23 sides. As a result we obtained improvement in cerebral vascularization as well as in neurological and electroencephalographic findings in all cases. This report describes an introduction of the procedure and a review of the postoperative cerebral angiograms. Cerebral revascularization by EDAS proceeded on the following steps, and it was confirmed that efficient cerebral revascularization could be obtained 6 months after the operation in almost all cases following the steps: 1) dilatation and increase of dural artery, 2) dilatation of donor scalp artery, 3) cerebral revascularization with the development of visible fine spontaneous anastomoses between the donor scalp artery and the cerebral arteries and 4) further dilatation of the donor scalp artery and retraction of the abnormal rete vasculosum at the base of the brain.

Adult↗
PubMed1987

Neuropsychological deficits and real-world dysfunction in cerebral revascularization candidates.

An assessment strategy using multiple levels of observation permitted description of problems in everyday living experienced by cerebral revascularization candidates. We contrasted the neuropsychological deficits and real-world dysfunction displayed by candidates for cerebral revascularization with that manifested by patients with severe spinal complaints. Correlations between selected neuropsychological scores and life quality measures were modest. Prediction of real-world performance in individuals likely will require multivariate combinations of measures. Relationships between life quality measures and neuropsychological scores may differ for patients with known or suspected neurological disease and patients with disorders which do not threaten cognitive functioning.

Activities of Daily Living↗
PubMed1979

Pentothal protection for delay cerebral revascularization.

Thiopentone (20 mg/kg/bolus and 20 mg/kg/three hours) was effective in preventing infarction in five dogs with six hours of middle cerebral occlusion. Nine control animals sustained massive to large infarctions. Utilizing this regime therapeutic blood levels were rapidly attained for over 12 hours without side effects. From the experimental and human experience with focal cerebral ischaemia, there appears to be a finite grace period in which cerebral revascularization can be undertaken. In canine and primate models this time has been about five hours, following which the infarction process may not be reversible (Sundt et al. 1977, Laha et al. 1978). Seeking to prolong this grace period, thiopentone was selected as an ideal drug for this purpose, and its effect on the revascularized canine middle cerebral distribution was evaluated at six hours following embolectomy.

Animals↗
PubMed1985

Complications of cerebral revascularization with autogenous vein grafts.

Autogenous veins were used for cerebral revascularization 29 times. There were 17 long grafts to the cortex and 12 shorter grafts for reconstruction of cervical vessels. Of the long cortical grafts, 5 occluded and 3 patients developed intracerebral hemorrhage. With the shorter grafts, all remained patent and there were no hemorrhagic complications. A combination of a relatively low flow rate and endothelial damage in the graft was thought to be largely responsible for early graft failure. Revascularization of an infarct and hypertension were implicated in cases with intracerebral hemorrhage.

Cerebral Angiography↗
PubMed1994

Case management in cerebral revascularization.

PURPOSE: We examined the clinical and financial outcomes of case management coupled with the initiation of selective use of the intensive care unit (ICU) in all cerebral revascularization procedures. METHODS: Three hundred eighty-four procedures in 331 patients were retrospectively reviewed. Morbidity and mortality rates, hospital length of stay, cost, and ICU or hospital readmissions were examined. Hypertension was examined as an independent variable for its effect on patient outcome. RESULTS: Cerebral revascularization, including carotid endarterectomy, vertebral-carotid artery transposition, and subclavian-carotid artery transposition, yielded a 0.78% stroke rate and 0.26% perioperative death rate in this series. ICU admission was necessary in nine patients (2.3%) for cardiac or respiratory instability. Three patients (0.78%) required transfer to the ICU for management of hypertension or hypotension. The mean hospital length of stay after institution of case management was reduced by 2.1 days, and the mean cost was decreased by $1987, a savings of 28.9% of total hospital cost. CONCLUSION: The dual approach of case management and selective use of the ICU promotes quality patient care, conserves financial resources without adversely affecting morbidity or mortality rates, enhances physician/nurse collaboration, and improves patient satisfaction.

Aged↗
PubMed1985

Cerebral revascularization to a main limb of the middle cerebral artery in the Sylvian fissure. An alternative approach to conventional anastomosis.

Thirteen patients underwent an anastomosis of the superficial temporal artery (STA) or a saphenous vein graft to one of the secondary trunks of the middle cerebral artery (MCA). They included five patients with giant MCA trifurcation aneurysms, four patients in whom an earlier conventional STA-MCA anastomosis had become occluded, two patients who had stenosis of one of the secondary limbs of the MCA, and one patient who had a carotid-cavernous fistula. One patient had a saphenous vein graft from the common carotid artery to a secondary trunk of the MCA to bypass an occluded internal carotid artery and severely stenosed external carotid artery. The primary advantages of this procedure are that a large-caliber anastomosis to one of the secondary limbs of the MCA immediately restores flow into the MCA tree with a larger amount of vessel filling than with a standard cortical bypass, and large vessels can be used for the anastomosis. The disadvantages are that one of the secondary branches of the MCA must be occluded, the cerebral hemisphere around the Sylvian fissure must be retracted, a lumbar subarachnoid drain is needed, and the anastomosis must be performed deep within the Sylvian fissure. The procedure is a satisfactory alternative in cases in which a conventional STA-MCA anastomosis has either failed or would be less likely to succeed.

Adult↗
PubMed1997

Cerebral revascularization using latissimus dorsi muscle free flap transfer--technical note.

A method for cerebral revascularization using latissimus dorsi muscle free flap transfer is described. Latissimus dorsi muscle is harvested with thoracodorsal vessels after completion of craniotomy and exposure of superficial temporal vessels. The size of muscle belly which is harvested is dependent on the area where the revascularization is necessary. Microvascular anastomoses of superficial temporal vessels and thoracodorsal vessels are performed in end-to-end fashion. A 31-year-old male patient with moyamoya syndrome was treated by this method. Postoperative angiography demonstrated successful revascularization in the affected hemisphere, with improved perfusion reserve capacity shown by cerebral blood flow study. This type of encephalo-myo-synangiosis (with free muscle flap) is a possible method when vascular reconstruction of an extensive ischemic area which involves anterior and posterior cerebral artery territories is needed in a patient with moyamoya disease or other similar ischemic conditions.

Adult↗
PubMed2002

Cerebral revascularization performed using posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. Report of four cases and literature review.

Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)-PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA-PICA by-passes to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5-49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.

Adult↗
PubMed2005

Cerebral revascularization in skull base tumors.

Skull base tumors involving the carotid artery pose a difficult surgical challenge. The potential for bypass grafting for cerebral revascularization carries inherent risks but may aid in tumor resection and control in those who warrant carotid sacrifice but have inappropriate natural cerebrovascular reserve. We include a review of the literature discussing the indications for carotid resection as part of skull base tumor surgery, indications for cerebral revascularization, balloon test occlusion, graft types and operative technique, complications, and results.

Journal Article↗
PubMedDate not supplied

Cerebral revascularization: common carotid to distal middle cerebral artery bypass.

A right common carotid to distal middle cerebral artery bypass utilizing a saphenous vein graft was performed in a patient with episodic cerebral ischemia and reversible ischemic neurological deficit. The patient was relieved of his symptoms, and there was improved motor function in the left hand. Postoperative angiography revealed flow through the graft with excellent filling of the middle cerebral circulation, both retrograde and antegrade. This bypass procedure provided an immediate source of high volume blood flow and thereby provided immediate protection to the hemisphere.

Adult↗
PubMed1997

Cerebral revascularization by omental free flap using contralateral superficial temporal vessels as recipient vessels: case report.

BACKGROUND: Although the most common technique of cerebral revascularization is superficial temporal artery to middle cerebral artery bypass, we occasionally encounter a situation in which the ipsilateral superficial temporal artery is not available. Treatment may require several techniques including long vein graft bypass. METHODS: A 54-year-old man experienced transient ischemic attacks, and cerebral angiography revealed occlusion of the right common carotid artery. Cerebral blood flow study revealed reduced perfusion reserve capacity of the right cerebral hemisphere. We applied an omental free flap to the brain surface using the contralateral superficial temporal vessels as recipient vessels. RESULTS: Cerebral blood flow study revealed improvement of perfusion reserve capacity. Cerebral angiography revealed good collateral circulation from the omentum to the brain. The patient has not experienced a transient ischemic attack, following additional ligation of the occipital artery 13 months after the first operation. CONCLUSIONS: Because an omental flap has a long pedicle and its circulation can be monitored easily, this method is safe and as effective as a long bypass graft in a patient such as ours in whom the ipsilateral superficial temporal artery is not available for anastomoses.

Anastomosis, Surgical↗
PubMed2003

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.

Animals↗
PubMed1989

Cerebral revascularization: a review.

A review of the development and current methods of surgical revascularization of the cerebral circulation is presented. In addition to the conventional superficial temporal artery to middle cerebral artery (STA-MCA) bypass, the techniques of interposition vein grafting and vertebrobasilar revascularization are discussed. The results and implications of the International Cooperative Study are reviewed. Extracranial-intracranial (EC-IC) bypass grafting remains an essential procedure in the treatment of many cerebrovascular conditions, including Moya Moya disease and giant intracranial aneurysms. The efficacy of interposition vein grafts, as well as the EC-IC bypass in the treatment of vertebrobasilar insufficiency, acute cerebral ischemia, cerebral vasospasm, and multi-infarct dementia, remains to be determined. Several alternative revascularization procedures, including proximal MCA anastomosis and omental transposition, are in development.

Brain Diseases↗
PubMed2005

Staged cerebral revascularization in a patient with an occluded common carotid artery.

BACKGROUND AND PURPOSE: We report a management strategy for cerebral revascularization in a patient with an occluded common carotid artery by first performing a subclavian to external carotid artery bypass, followed by superficial temporal artery middle cerebral artery (STA-MCA) bypass. METHODS: The patient presented with symptomatic left hemispheric hemodynamic insufficiency, associated with occlusion of the ipsilateral internal and common carotid arteries. The STA was not detectable. The patient was treated initially with a subclavian to external carotid artery bypass, with partial improvement in symptoms. RESULTS: Angiography demonstrated improvement in perfusion and STA filling, which was used for STA-MCA bypass, with resolution of symptoms. CONCLUSIONS: Our experience with this case has led us to consider a staged approach for management of patients with an occluded common carotid artery.

Angiography↗
PubMed2005

Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation.

OBJECT: Revascularization is an important component of treatment for complex aneurysms, skull base tumors, and vertebrobasilar ischemia in the posterior circulation. In this study, the authors examined the microsurgical anatomy related to cerebral revascularization in the posterior circulation and demonstrate various procedures for bypass surgery. METHODS: The microsurgical anatomy of cerebral and cerebellar vessels as they relate to revascularization procedure and techniques, including extracranial-to-intracranial bypass grafting, arterial interposition grafting, and side-to-side anastomosis, were examined by performing stepwise dissections in 22 adult cadaveric specimens. The arteries and veins in the specimens were perfused with colored silicone. Dominant cerebral and cerebellar revascularization procedures in the posterior circulations include superficial temporal artery (STA)-posterior cerebral artery (PCA), STA-superior cerebellar artery (SCA), occipital artery (OA)-anterior inferior cerebellar artery, OA-posterior inferior cerebellar artery (PICA), and PICA-PICA anastomoses. These procedures are effective in relatively small but critical areas including the brainstem and cerebellum. For revascularization of larger areas a saphenous vein graft is used to create a bypass between the PCA and the external carotid artery. Surgical procedures are generally difficult to perform in deep and narrow operative spaces near critical vital structures. CONCLUSIONS: Although a clear guideline for cerebral revascularization procedures has not yet been established, it is important to understand various microsurgical techniques and their related anatomical structures. This will help surgeons consider surgical indications for treatment of patients with vertebrobasilar ischemia caused by aneurysms, tumors, or atherosclerotic diseases in the posterior circulation.

Anastomosis, Surgical↗