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Localization of the Internal Maxillary Artery for Extracranial-to-Intracranial Bypass through the Middle Cranial Fossa: A Cadaveric Study.

ABSTRACT: The internal maxillary artery (IMAX) is a promising arterial pedicle to function as a donor vessel for extracranial-to-intracranial (EC-IC) bypass procedures. The access to the IMAX through the anterior portion of the middle cranial fossa floor allows a much shorter interposition graft to be used to create a bypass to the ipsilateral middle cerebral artery and prevents a second incision in the neck. One of the challenges of this technique, however, is the difficulty to find the IMAX through an intracranial approach. The purpose of this cadaveric study is to establish a reliable method to localize the IMAX through a middle fossa floor approach based on skull base bone landmarks. In this study 5 latex-injected fixated cadaveric specimens were dissected bilaterally (providing a total of 10 IMAX dissections) to determine the precise location of the IMAX in the pterygopalatine fossa in relationship to bone landmarks of the middle fossa floor as seen through an intracranial approach. Drilling of the middle fossa floor was undertaken through both the originally described "anteromedial" approach, and a new "anterolateral" approach. Measurements were taken correlating the position of the IMAX to ipsilateral foramen rotundum, ipsilateral foramen ovale, posterior wall of the maxillary sinus, and distal V2 branches. Median and standard deviation were calculated for each dataset. The IMAX was found, within the pterygopalatine fossa, by drilling the greater wing of the sphenoid bone on average 10 mm anteriorly and 5 mm laterally to foramen rotundum, at an average depth of 8 mm. The IMAX was also found inferiorly to the maxillary nerve and laterally to the pterygoid head of the lateral pterygoid muscle. A more laterally oriented approach, consisting of drilling the greater wing of the sphenoid bone from a point perpendicular to foramen rotundum posteriorly to the sphenotemporal suture anteriorly, allowed for a longer segment of the IMAX to be easily identified and exposed facilitating its use as a donor vessel in bypass procedures. This cadaveric study provides a reliable and reproducible set of measurements to localize the IMAX within the pterygopalatine fossa through an intracranial middle fossa approach. The ability to find the IMAX consistently is an important step in exploring the possibility of using the IMAX as a routine donor vessel for EC-IC bypass procedures.

SUBMITTER: Eller JL

PROVIDER: S-EPMC3424021 | biostudies-other | 2012 Feb

REPOSITORIES: biostudies-other

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Project description:ImportancePrior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection.ObjectiveTo evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection.Design, setting, and participantsThis was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020).InterventionsEC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control.Main outcomes and measuresThe primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years.ResultsAmong 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08).Conclusions and relevanceAmong patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years.Trial registrationClinicalTrials.gov Identifier: NCT01758614.

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Localization of the Internal Maxillary Artery for Extracranial-to-Intracranial Bypass through the Middle Cranial Fossa: A Cadaveric Study.

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