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Predicting Cerebral Hyperperfusion Syndrome Following Superficial Temporal Artery to Middle Cerebral Artery Bypass based on Intraoperative Perfusion-Weighted Magnetic Resonance Imaging.

ABSTRACT: Moyamoya disease leads to the formation of stenosis in the cerebrovasculature. A superficial temporal artery to middle cerebral artery (STA-MCA) bypass is an effective treatment for the disease, yet it is usually associated with postoperative cerebral hyperperfusion syndrome (CHS). This study aimed to evaluate cerebral hemodynamic changes immediately after surgery and assess whether a semiquantitative analysis of an intraoperative magnetic resonance perfusion-weighted image (PWI) is useful for predicting postoperative CHS. Fourteen patients who underwent the STA-MCA bypass surgery were included in this study. An atlas-based registration method was employed for studying hemodynamics in different cerebral regions. Pre- versus intraoperative and group-wise comparisons were conducted to evaluate the hemodynamic changes. A postoperative increase in relative cerebral blood flow (CBF) at the terminal MCA territory (P = 0.035) and drop in relative mean-time-transit at the central MCA territory (P = 0.012) were observed in all patients. However, a significant raise in the increasing ratio of relative-CBF at the terminal MCA territory was only found in CHS patients (P = 0.023). The cerebrovascular changes of the patients after revascularization treatment were confirmed. Intraoperative PWI might be helpful in predicting the change in relative-CBF at MCA terminal territory which might indicate a risk of CHS.

SUBMITTER: Wang D

PROVIDER: S-EPMC4568478 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Can Evoked Potential Changes during the Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery Predict Postoperative Improvement of Cerebral Perfusion and Functional Status?

Project description:We investigated evoked potential (EP) changes during superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery and their correlations with imaging and clinical findings postoperatively. This retrospective study included patients who underwent STA-MCA bypass surgery due to ischemic stroke with large artery occlusion (MB group). Patients who underwent unruptured MCA aneurysm clipping were enrolled in the control group (MC group). Median and tibial somatosensory evoked potentials (SSEP), and motor evoked potentials recorded from the abductor pollicis brevis (APB-MEP) and abductor hallucis (AH-MEP) were measured intraoperatively. Modified Rankin scale (mRS) and perfusion-weighted imaging (PWI) related variables, i.e., mean transit time (MTT) and time to peak (TTP), were assessed. Δmedian SSEP, ΔAPB-MEP, and ΔAH-MEP were significantly higher in the MB group than in the MC group (p = 0.027, p = 0.006, and p = 0.015, respectively). APB-MEP and AH-MEP amplitudes were significantly increased at the final measurement (p = 0.010 and p < 0.001, respectively). The ΔTTP asymmetry index was moderately correlated with ΔAPB-MEP (r = 0.573, p = 0.005) and ΔAH-MEP (r = 0.617, p = 0.002). ΔAPB-MEP was moderately correlated with ΔMTT (r = 0.429, p = 0.047) and ΔmRS at 1 month (r = 0.514, p = 0.015). MEP improvement during STA-MCA bypass surgery was partially correlated with PWI and mRS and could reflect the recovery in cerebral perfusion.

| S-EPMC8615961 | biostudies-literature

Changes in computed tomography perfusion parameters after superficial temporal artery to middle cerebral artery bypass: an analysis of 29 cases.

Project description:Introduction Analysis of computed tomography perfusion (CTP) studies before and after superficial temporal artery to middle cerebral artery (STA-MCA) bypass is warranted to better understand cerebral steno-occlusive pathology. Methods Retrospective review was performed of STA-MCA bypass patients with steno-occlusive disease with CTP before and after surgery. CTP parameters were evaluated for change after STA-MCA bypass. Results A total of 29 hemispheres were bypassed in 23 patients. After STA-MCA bypass, mean transit time (MTT) and time to peak (TTP) improved. When analyzed as a ratio to the contralateral hemisphere, MTT, TTP, and cerebral blood flow (CBF) improved. There was no effect of gender, double vessel versus single vessel bypass, or time until postoperative CTP study to changes in CTP parameters after bypass. Conclusions Blood flow augmentation after STA-MCA bypass may best be assessed by CTP using baseline MTT or TTP and ratios of MTT, TTP, or CBF to the contralateral hemisphere. The failure of cerebrovascular reserve to improve after cerebral bypass may indicate irreversible loss of autoregulation with chronic cerebral vasodilation or the inability of CTP to detect these improvements.

| S-EPMC4240763 | biostudies-other

Effect of Adventitial Dissection of Superficial Temporal Artery on the Outcome of Superficial Temporal Artery-Middle Cerebral Artery Bypass in Moyamoya Disease.

Project description:Superficial temporal artery-middle cerebral artery (STA-MCA) has been used for the treatment of occlusive cerebrovascular disease including moyamoya disease. The effect of STA-MCA bypass depends not only on the patency of anastomosis, but also on integrity and functional capacity of the donor artery. In the present prospective study, we investigated the effect of extensive stripping STA adventitia and fasciae on hemodynamic function in STA-MCA bypass of moyamoya disease patients. Twenty patients (n=8 in control group, n=12 in stripping group) of moyamoya disease were subjected to STA-MCA end-to-side direct anastomosis. Perfusion unit (PU) values of the cortex were measured and recorded using a Laser Doppler flowmetry (LDF) for 5 days. Computed tomography perfusion was performed to determine blood flow before and after bypass. No patient experienced significant neurologic deficits associated with neurosurgical complications. LDF demonstrated that adventitial stripping group had higher cerebral blood flow increase than control group. The adventitia stripping group tends to have higher rate of increased cerebral perfusion after bypass than non-stripping group. Furthermore, the ultrasound examination at 3 days after bypass demonstrated that the adventitial stripping group has a tendency of bigger STA and higher peak systolic velocity than control group. Our result suggests that stripping adventitia of STA improves hemodynamics of STA-MCA bypass in moyamoya disease.

| S-EPMC5524801 | biostudies-other

Trapping, dome puncture, and direct suction decompression in conjunction with assistant superficial temporal artery- middle cerebral artery bypass to clip giant internal carotid artery bifurcation aneurysm.

Project description:BackgroundVery large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult.Case descriptionTwo cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping.ConclusionTrapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.

| S-EPMC6826317 | biostudies-literature

Emergent surgical embolectomy in conjunction with cervical internal carotid ligation and superficial temporal artery-middle cerebral artery bypass to treat acute tandem internal carotid and middle cerebral artery occlusion due to cervical internal carotid artery dissection.

Project description:BackgroundAcute tandem cervical dissecting internal carotid artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating, and the optimal treatment strategy for this condition has not been established yet.Case descriptionA 45-year-old male presented with aphasia and right hemiparesis preceded by neck pain. Computed tomography showed a high-density signal along the left MCA, suggesting extensive emboli. Magnetic resonance angiography demonstrated tandem occlusion of the left cervical ICA and intracranial MCA with minimal diffusion-weighted imaging lesion. Emergent surgical embolectomy was performed, and long intracranial MCA emboli were retrieved with collateral cross-flow restoration. The cervical ICA was exposed, and dissection was confirmed. The cervical ICA was ligated, and superficial temporal artery (STA)-MCA anastomosis was added. Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia. At the 6(th) postoperative month, follow-up studies demonstrated a robustly patent STA-MCA bypass and no additional ischemic lesion on T2-weighted imaging.ConclusionsSurgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

| S-EPMC4697205 | biostudies-literature

Distal superficial temporal artery to proximal posterior cerebral artery bypass by posterior oblique transzygomatic subtemporal approach.

Project description:This article investigates the possibility for the distal superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) direct bypass by subtemporal oblique posterior transzygomatic approach. Five adult cadaveric specimens were dissected. Cadeveric dissection protocol was approved by the Research Ethics Committee. A preauricular vertical skin incision was made, the trunk of STA was identified, and bifurcation, frontal, and parietal branches of the STA were followed distally. Posterior zygomatic arch osteotomy and microcraniotomy were then performed, and the dura was opened. The temporal lobe was retracted, interpeduncular and ambient cisterns were opened, and the P2 segment of the PCA was exposed. Parietal branch of STA and P2 segment of the PCA was anastomosed. The average length of the transected STA from the bifurcation and the zygomatic arch were 47.3 ± 2.1 mm and 71.4 ± 2.3 mm, respectively. The mean calibers of the parietal and frontal branch of the STA at this distance were 1.6 ± 0.1 and 1.4 ± 0.2, respectively. The mean diameter of the P2 was 2.1 ± 0.2 mm. Because of the calibers of the parietal branch of the STA and proximal PCA are over 1.5 mm and 2.0 mm, respectively, this direct end-to-side bypass technique may be a reasonable alternative in suitable cases.

| S-EPMC3134812 | biostudies-other

Double bypass for mycotic middle cerebral artery aneurysm

Project description:Background: Ruptured intracranial mycotic aneurysms have high morbidity and mortality and present unique surgical challenges because of vessel friability.[1] Flow-preserving strategies are needed for more proximal lesions that cannot be treated with vessel sacrifice. Case Description: A 33-year-old man with no medical history who presented with fevers and peripheral septic emboli was found to have infective cardiac valve vegetations. He reported headaches and left arm weakness; an irregular 7 × 8 × 9 mm bilobed middle cerebral artery mycotic aneurysm involving multiple M3 branches with subarachnoid hemorrhage was found on cranial imaging. Multifocal and small intraparenchymal hemorrhages from septic emboli were also seen. Clip trapping and revascularization were recommended. A right frontotemporal craniectomy was performed, preserving the superficial temporal artery. After extradural exposure, a hole was drilled in the middle fossa floor lateral to the foramen ovale. The Sylvian fissure was split and the larger M3 branch was isolated. An endoscopically harvested saphenous vein graft was anastomosed to the cervical external carotid artery, tunneled through the middle fossa floor, and anastomosed end-to-side to the larger M3. The aneurysm was clip trapped and the involved smaller M3 was transected and anastomosed end-toend to the superficial temporal artery. Indocyanine green videoangiography confirmed patency of both bypasses. Postoperatively, the patient received antibiotics and a mitral valve replacement. He was neurologically intact on 1-month and 2-year follow-up. Conclusion: Although technically demanding, tailored revascularization and clipping of ruptured mycotic cerebral aneurysms are a viable treatment option for these complex lesions.

| S-EPMC9479689 | biostudies-literature

Lenticulostriate Artery Involvement is Predictive of Poor Outcomes in Superficial Middle Cerebral Artery Territory Infarction.

Project description:PurposePatients with superficial middle cerebral artery (MCA) territory infarction may have concomitant lenticulostriate artery (LSA) territory infarction. We investigated the mechanisms thereof and the outcomes of patients with superficial MCA territory infarction according to the presence or absence of LSA involvement.Materials and methodsConsecutive patients with first-ever infarction in the unilateral superficial MCA territory were included in this study. They were divided into the superficial MCA only (SM) group and the superficial MCA plus LSA (SM+L) group.ResultsOf the 398 patients, 84 patients (21.1%) had LSA involvement (SM+L group). The SM+L group more frequently had significant stenosis of the proximal MCA or carotid artery and high-risk cardioembolic sources. Stroke severity and outcomes were remarkably different between the groups. The SM+L group showed more severe neurologic deficits (National Institute of Health Stroke Scale score 10.8±7.1 vs. 4.0±5.0, p<0.001) and larger infarct in the superficial MCA territory (40.8±62.6 cm³ vs. 10.8±21.8 cm³, p<0.001) than the SM group. A poor functional outcome (mRS >2) at 3 months was more common in the SM+L group (64.3% vs. 15.9%, p<0.001). During a mean follow-up of 26 months, 67 patients died. All-cause (hazard ratio, 2.246) and stroke (hazard ratio, 9.193) mortalities were higher in the SM+L group than the SM group. In multivariate analyses, LSA involvement was an independent predictor of poor functional outcomes and stroke mortality.ConclusionLSA territory involvement is predictive of poor long-term outcomes in patients with superficial MCA territory infarction.

| S-EPMC5122627 | biostudies-literature

Effects of Combined Remote Ischemic Pre-and Post-Conditioning on Neurologic Complications in Moyamoya Disease Patients Undergoing Superficial Temporal Artery-Middle Cerebral Artery Anastomosis.

Project description:Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the most commonly used treatment for Moyamoya disease. During the perioperative period, however, these patients are vulnerable to ischemic injury or hyperperfusion syndrome. This study investigated the ability of combined remote ischemic pre-conditioning (RIPC) and remote ischemic post-conditioning (RIPostC) to reduce the occurrence of major neurologic complications in Moyamoya patients undergoing STA-MCA anastomosis. The 108 patients were randomly assigned to a RIPC with RIPostC group (n = 54) or a control group (n = 54). Patients in the RIPC with RIPostC group were treated with four cycles of 5-min ischemia and 5-min reperfusion before craniotomy and after STA-MCA anastomosis (RIPostC). The incidence of postoperative neurologic complications and the duration of hospital stay were determined. The overall incidence of neurologic complication was significantly higher in the control group than in the RIPC with RIPostC group (13 vs. 3, p = 0.013). The duration of hospital stay was significantly longer in the control group than in the RIPC with RIPostC group (17.8 (11.3) vs. 13.8 (5.9) days, p = 0.023). Combined remote ischemic pre- and post-conditioning can be effective in reducing neurologic complications and the duration of hospitalization in Moyamoya patients undergoing STA-MCA anastomosis.

| S-EPMC6572043 | biostudies-literature

Middle cerebral artery dissection causing subarachnoid hemorrhage and cerebral infarction: Trapping with high-flow bypass preserving the lenticulostriate artery.

Project description:BackgroundSpontaneous intracranial arterial dissection (IAD) is an increasingly important cause of stroke, such as subarachnoid hemorrhage (SAH) and hemodynamic or thromboembolic cerebral ischemia. IAD usually occurs in the posterior circulation, and is relatively rare in the anterior circulation including the middle cerebral artery (MCA). Various surgical and endovascular methods to reduce blood flow in the dissected lesion have been proposed, but no optimum treatment has been established.Case descriptionAn 80-year-old woman with dissection in the M1 portion of the MCA manifesting as SAH presented with repeated hemorrhage and cerebral infarction in the area of the inferior trunk of the MCA. High-flow bypass to the MCA was performed and the dissecting lesion was trapped. Prevention of repeated hemorrhage was achieved, and blood flow was preserved to the lenticulostriate artery as well as the MCA area distal to the lesion.ConclusionsTreatment strategy for IAD of the MCA should be planned for each patient and condition, and surgery should be performed promptly to prevent critical rebleeding given the high recurrence rate. In addition, preventing re-rupture of the IAD, and preserving important perforators around the lesion and blood flow distal to the dissection should be targeted by the treatment strategy.

| S-EPMC5535565 | biostudies-literature

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