Ipsilateral Superficial Temporal Artery Research Articles

Single Step Resection-Reconstruction Using Precurved Titanium Mesh of a Giant Intradiploic Meningioma Mimicking Bone Malignancy: Technical Note.

Intradiploic meningiomas are rare neoplasms, often mistaken for metastases or malignant bone tumors. Surgical management can be challenging, considering their diffusive bony invasion. Two main critical decisions need to be taken: the timing for cranial vault reconstruction and the choice of the adequate material for cranioplasty. We believe that this case underscores the complexity of such lesions, the importance of a prompt devascularization, and the pivotal role of an immediate reconstruction to avoid the additional morbidity of a re-do surgery. We report a case of 68-year-old men who presented with slow growing right parietal bone swelling he noted many years before, but for which he didn't seek medical attentions, associated with mild contralateral hemiparesis. Neuroradiological examinations revealed a giant extradural intradiploic tumor affecting the right temporo-parietal bone and conditioning significant compression of the underlying brain. We planned a surgical strategy to deafferent the tumor and to reduce the intraoperative bleeding. At first, a circumferential craniectomy centered upon the lesion was performed, then it was devascularized by means of surgical ligation of the ipsilateral superficial temporal artery (STA) and middle meningeal artery (MMA); these steps allowed a subsequent en block tumor excision, despite its large size, without significant blood loss and respecting the oncological principles. At the end, a contextual calvarial reconstruction was performed using a precurved titanium mesh. Was discharged seven days after surgery with complete recovery of the left-sided motor deficit. Thereafter, he underwent scheduled outpatient evaluations and radiological exams. After 1 year, the Modified Rankin Scale (MRS) was 1, with no evidence of recurrent disease. Surgical complications can be reduced adopting an optimal preoperative work-up and a tailored surgical strategy focused on early tumor deafferentation. Moreover, an immediate cranial vault reconstruction avoids the risks related to a second procedure.

The Value of Preoperative Phase-Contrast MRI in Predicting the Clinical Outcome of Moyamoya Disease after Encephalo-Duro-Arterial Synangiosis Surgery.

In patients with Moyamoya disease, the relationship between preoperative hemodynamic status and prognosis after encephalo-duro-arterial synangiosis (EDAS) surgery was unclear. We aimed to explore the value of the preoperative hemodynamic status acquired by cine phase-contrast MR imaging in predicting collateral formation and clinical outcomes after EDAS surgery in patients with Moyamoya disease. Participants with Moyamoya disease were prospectively recruited and underwent preoperative phase-contrast MR imaging. All participants were classified into good and poor groups according to the collateral formation after EDAS surgery. On the basis of the change in the mRS system, participants were classified into the improved mRS group and the poor response group. Hemodynamic status including mean velocity, peak velocity, and blood volume flow of the superficial temporal artery was compared between groups. Logistic regression was performed to relate the phase-contrast MR imaging parameters to collateral formation and clinical outcomes. A total of 45 patients with Moyamoya disease with unilateral EDAS surgery were finally included. Mean velocity, peak velocity, and blood volume flow of the ipsilateral superficial temporal artery were significantly greater in patients with good collateral formation compared with those with poor collateral formation (P = .011, .004, and .013, respectively). The mean velocity, peak velocity, and blood volume flow were independently associated with postoperative collateral formation after adjusting for confounding factors. Furthermore, the peak velocity of the ipsilateral superficial temporal artery was also significantly associated with improvement of the mRS score. Good hemodynamic status of the ipsilateral superficial temporal artery as a donor artery evaluated by phase-contrast MR imaging was significantly associated with better collateral formation and improved mRS after EDAS surgery in patients with Moyamoya disease.

Postoperative vascular event prediction using angiography and ultrasonography in patients with Moyamoya disease

ObjectiveIndirect revascularization surgery reduce the risk of recurrent vascular events in patients with moyamoya disease (MMD), but the roles of postoperative angiography and ultrasonography in predicting these events remain unclear. MethodsThis prospective study enrolled patients with MMD who would undergo their first unilateral indirect revascularization surgery. They received preoperative and postoperative ultrasound examination at 1, 3, and 6 months and conventional cerebral angiography. On ultrasonography, postoperative emerging flow (PEF) in an intracranial artery was defined as emerging flow postoperatively with absence of flow preoperatively. Predictors of vascular event frequency reduction were identified from angiographic and ultrasonographic parameters. ResultsIn total, 52 patients (including 24 pediatric and 24 male patients), who underwent 52 preoperative and 82 postoperative ultrasound examinations, were enrolled. Significant postoperative changes were noted in all the ultrasonographic parameters of ipsilateral superficial temporal artery (STA) and the end-diastolic velocity and flow volume in contralateral STA. During a median follow-up of 5.3 years, indirect revascularization surgery significantly reduced the occurrence of ipsilateral vascular events. Predictors of vascular event frequency reduction included Matsushima grade A or B on the ipsilateral side on angiography (odds ratio [OR] = 22.00, P = 0.002) and lower resistance index (RI) in ipsilateral STA (OR = 0.0001, P = 0.012) but no PEF pattern in ipsilateral middle cerebral artery (OR = 0.14, P = 0.029) on ultrasonography performed within 6 months. ConclusionsReduction of long-term vascular event frequency probably can be predicted through postoperative angiography and ultrasonography within 6 months after indirect revascularization surgery.

One-Stage Revascularization to the Ipsilateral Middle Cerebral Artery and Contralateral Anterior Cerebral Artery Territories

Patients with multiple intracranial atherosclerotic stenoses often present with hemodynamic instability in 2 remote regions without a reciprocal vascular network. In this situation, revascularization to each region may be required. In this report, 2 patients who had coexisting unilateral middle cerebral artery (MCA) and contralateral anterior cerebral artery territory ischemia were treated by using ipsilateral superficial temporal artery (STA)-radial artery graft-contralateral A3 bypass and ipsilateral STA-MCA bypass in one stage. Postoperatively, the bypass conduit was well established, and the patients' hemodynamic instability was improved. In patients with severe hemodynamic instability in the remote unilateral MCA and contralateral anterior cerebral artery regions, as in our 2 cases, ipsilateral STA-MCA and ipsilateral STA-radial artery graft-contralateral A3 bypasses in one stage can be a treatment option.

Cross-Comparison of 4-Dimensional Flow Magnetic Resonance Imaging and Intraoperative Middle Cerebral Artery Pressure Measurements Before and After Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery.

The hemodynamic changes after superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery are unclear. To clarify the hemodynamics by comparing flow parameters obtained by 4-dimensional (4D) flow magnetic resonance imaging (MRI) and intraoperative MCA pressure measurement. We recruited 23 patients who underwent STA-MCA bypass surgery for internal carotid artery (ICA) or MCA stenosis. We monitored intraoperative MCA, STA, and radial artery (RA) pressure. All patients underwent 4D flow MRI preoperatively and 3 wk after surgery to quantify the blood flow volume (BFV) of the ipsilateral ICA (BFViICA), contralateral ICA (BFVcICA), basilar artery (BFVBA), ipsilateral STA (BFViSTA), and contralateral STA (BFVcSTA). The sum of intracranial BFV was defined as BFVtotal. We compared BFV parameters and intraoperative pressure. BFViSTA significantly increased after surgery (P<.001). BFViICA and BFVBA significantly decreased after surgery (BFViICAP=.005; BFVBAP=.02). No significant difference was observed between BFVcICA before and after surgery. As a result, BFVtotal postoperatively increased by 6.8%; however, no significant difference was observed. Flow direction at M1 changed from antegrade to unclear after surgery in 5 patients. Intraoperative MCA pressure and MCA/RA pressure ratio significantly increased after surgery (P<.001). We found a stronger positive correlation between MCA pressure increase ratio and BFVtotal increase ratio in patients with lower pre-MCA pressure (r=0.907, P<.001). The visual and quantitative assessment of 4D flow MRI revealed that intracranial blood flow changes complementarily after STA-MCA bypass surgery. 4D flow MRI may detect the improvement of cerebral perfusion pressure.

Excision of a Large Complex Left Middle Cerebral Artery Aneurysm With a Middle Cerebral Artery-Middle Cerebral Artery and Superficial Temporal Artery-Middle Cerebral Artery Bypass: 2-Dimensional Operative Video.

Revascularization techniques for microsurgical manage-ment of middle cerebral artery (MCA) bifurcation aneurysms are often necessary for treatment of fusiform or giant aneurysms. Augmentation of the standard pterional approach to include an extended orbitozygomatic or modified orbitozygomatic approach provides a wider and more favorable approach to the MCA when attempting revascularization. Direct excision of a giant aneurysm (aneurysmectomy) with mobilization and reanastomosis of the MCA afterward has been reported. This patient had a giant MCA bifurcation aneurysm for which aneurysmectomy and distal reanastomosis were performed between the M1 and two M2 branches via a modified orbitozygomatic craniotomy. A second bypass between a third M2 branch at the ipsilateral superficial temporal artery was performed. Postoperative angiography confirmed patency of the bypasses. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Revascularization for Cerebral Ischemia, Step-by-Step Demonstration of Bonnet Bypass: 3-Dimensional Operative Video.

The superficial temporal artery (STA) to the middle cerebral artery (MCA) bypass is the most common bypass type for revascularization to treat cerebral ischemia. If the ipsilateral STA is not available for anastomosis, various options for bypass conduits can be exercised. When the entire ipsilateral external carotid and its branches are not available, the contralateral STA may be used as a donor artery through an interposition graft. This technique is known as a "bonnet bypass." In this video, we demonstrate the utilization of a bonnet bypass in a 48-yr-old man with protein S deficiency, and right carotid artery occlusion with recurrent strokes and transient ischemic attacks (TIA). After exhausting nonsurgical options by treating with 2 antiplatelet drugs and supportive lifestyle changes, the patient continued to experience TIAs and watershed strokes in the right hemisphere. Angiography showed that the right anterior artery and the MCA were filled through the Circle of Willis, but the ipsilateral STA and entire external and common carotid arteries were not patent for potential use as a bypass donor. Since the ipsilateral bypass options were not available, we elected to perform a bypass from the contralateral STA trunk to the ipsilateral M2 with a saphenous vein interposition graft, for a so-called bonnet bypass. The patient did well after surgery and has remained symptom-free for 19 mo post bypass. The surgical technique and each step in performing this bonnet bypass are demonstrated in this 3-dimensional video. The patient consented to the publication of his operative video.

The Hybrid Technical Management of Large and Complicated Traumatic Arteriovenous Fistula of Preauricular Region.

Background:Arteriovenous fistula (AVF) is defined as an abnormal communication between the high flow arterial system and the low flow venous network, which directly connects the arterial feeding vessels and the near draining veins without normal intervening capillary bed. Arteriovenous fistula incurs in preauricular region is exceeding rare. Most of these fistulae occur as a result of an iatrogenic injury, the volume is small, feeding and draining vessels of feeding and draining are simple, and can be cured easily. However, the treatment of the large and complicated AVF after incidental trauma in preauricular region is a challenge even for senior neurosurgeon. In this study, the authors discuss the management of a traumatic AVF through combined therapeutic method of surgical ligation and transarterial embolization. It is fed by ipsilateral superficial temporal artery, internal maxillary artery, posterior auricular artery, and their accessory branches and is drained by ipsilateral common facial vein and external jugular vein. Also the etiology, clinical manifestations, pathology, diagnosis, and management are summarized.Conclusion:Large and complicated traumatic AVF in preauricular region is rare, often due from an injury in maxillofacial region, combined therapy needed.

Use of lateral upper arm free flaps for soft-tissue reconstruction of the contracted eye socket.

Severe orbital soft-tissue loss and contracted eye sockets often present in patients who have had enucleation, exenteration, or other ocular diseases. In this article, the authors report a novel contracted eye socket reconstruction technique using lateral upper arm free flaps and review the surgical outcome in patients with severe orbital soft-tissue loss and contracted eye sockets. Twenty-four patients with severe orbital soft-tissue loss and contracted eye sockets were included in this study. A free flap from the lateral upper arm of the patient was inserted into the eye socket, with the artery and vein of the flap pedicle attached to the ipsilateral superficial temporal artery and vein, respectively. Eye socket reconstruction was performed 2 weeks after the first operation. Patients were fitted with a piece of prosthesis 3 months later. Most patients needed a second operation for eyelid and eye socket reconstruction, including lower eyelid laxity and retraction correction, medial and lateral canthoplasty, and upper or lower fornix reconstruction. Postoperative improvement in appearance was evaluated, including texture and color of the flaps, sensation and mobility of the forearm and elbow, and visibility of the surgical scar. All 24 patients were followed up for 6 months to 5 years. Donor sites healed with linear scars, and no sensory or movement loss was found in any of the patients. The reconstructed area appeared good, patients were satisfied with recovering results, and the prosthesis fit well. The skin from the lateral upper arm has consistent blood vessels and suitable thickness to serve as a source for orbital soft-tissue and contracted eye socket reconstruction, with good cosmetic outcomes. Therapeutic, IV.

The Final SAMMPRIS Results: A Review

To report a newly developed intraluminal triple-balloon shunt designed to preserve the blood flow of both the internal carotid artery (ICA) and the external carotid artery (ECA) during carotid endarterectomy in patients with a previous ipsilateral extracranial-intracranial bypass, in whom hemodynamic cerebral ischemia might be caused by cross-clamping at the ICA as well as the ECA.The novel device consists of 3 silicone tubes equipped with balloons at each end. The design facilitates insertion proximally to the common carotid artery and distally to both the ICA and the ECA.The new shunt tube was used in 3 patients, each of whom had previously undergone ipsilateral superficial temporal artery–middle cerebral artery bypass for proximal middle cerebral artery occlusion. The blood flow of the middle cerebral artery and anterior cerebral artery was supplied independently from the ECA via the bypass and from the ICA, respectively. There were no shunt-related complications.This novel shunt device can be used safely and effectively in cases requiring preservation of the blood supply to both the ICA and the ECA during carotid endarterectomy.

Searching for the Light: Fluorescence Guidance in Glioma Resection

To report a newly developed intraluminal triple-balloon shunt designed to preserve the blood flow of both the internal carotid artery (ICA) and the external carotid artery (ECA) during carotid endarterectomy in patients with a previous ipsilateral extracranial-intracranial bypass, in whom hemodynamic cerebral ischemia might be caused by cross-clamping at the ICA as well as the ECA.The novel device consists of 3 silicone tubes equipped with balloons at each end. The design facilitates insertion proximally to the common carotid artery and distally to both the ICA and the ECA.The new shunt tube was used in 3 patients, each of whom had previously undergone ipsilateral superficial temporal artery–middle cerebral artery bypass for proximal middle cerebral artery occlusion. The blood flow of the middle cerebral artery and anterior cerebral artery was supplied independently from the ECA via the bypass and from the ICA, respectively. There were no shunt-related complications.This novel shunt device can be used safely and effectively in cases requiring preservation of the blood supply to both the ICA and the ECA during carotid endarterectomy.

Arterial Bypass Surgery Using a Spontaneously Formed “Bonnet” Superficial Temporal Artery in a Patient With Symptomatic Common Carotid Artery Occlusion

Common carotid artery (CCA) occlusive disease may cause hemodynamic cerebral ischemia resulting in the development of ischemic symptoms. The blood flow in the superficial temporal artery (STA) ipsilateral to the occluded CCA is usually poor, which limits its use as a donor artery for extracranial-intracranial arterial bypass surgery. Despite antiplatelet therapy, recurrent transient ischemic attacks manifesting as motor aphasia developed in a 72-year-old man. Neuroradiological imaging revealed misery perfusion in the bilateral cerebral hemispheres caused by left CCA occlusion and right internal carotid artery occlusion. Blood flow from the STA contralateral to the occluded CCA perfused the ipsilateral STA over the midline in a retrograde fashion. After confirming the direction and the pressure of the blood flow in the spontaneously formed "bonnet" STA, the STA was anastomosed to a cortical artery in the symptomatic frontal lobe so that blood flow in the ipsilateral STA was supplied from the contralateral STA. The procedure was accomplished without difficulty, and no further ischemic symptoms developed after surgery. Postoperative cerebral angiography demonstrated an increase in collateral flow to the anastomosed bonnet STA and perfusion to an entire territory of the upper trunk of the symptomatic middle cerebral artery via the anastomosis. This case suggests that arterial bypass surgery can be performed using a spontaneously formed bonnet STA as a donor in a patient with symptomatic CCA occlusion.

Postoperative Evaluation of Changes in Extracranial-Intracranial Bypass Graft Using Superficial Temporal Artery Duplex Ultrasonography

Extracranial-intracranial (ECIC) bypass grafts have been assessed postoperatively by various neuroradiologic techniques. The aim of this prospective study was to evaluate postoperative changes in ECIC bypass graft by using superficial temporal artery duplex ultrasonography (STDU). Furthermore, this study assessed the ability of STDU to predict cerebrovascular reserve capacity (CVR). Forty-five consecutive patients who underwent ECIC bypass procedure for atherosclerotic internal carotid artery occlusion were enrolled in this prospective study. All patients underwent single-photon emission CT and STDU preoperatively, 14 days after, 3 months after, 1 year after, and 2 years after ECIC bypass. The diameter and flow velocities of the ipsilateral superficial temporal artery (STA), and regional cerebral blood flow (rCBF) showed increase during the first 2 weeks and then remained stable, whereas CVR showed a constant improvement up to 2 years after surgery. The STA diameter and mean STA flow velocity correlated significantly with CVR at 1 year after surgery (r2 = 0.1232 and r2 = 0.08716, respectively; P < .05). A cutoff value of 1.8 mm STA diameter was determined as the most reliable value to predict CVR greater than 10% at 1 year after surgery. The positive predictive value was calculated as 96.6%, the negative predictive value as 43.8%, the sensitivity as 75.7%, the specificity as 87.5%, and the likelihood ratio as 6.056. ECIC bypass grafts can be assessed postoperatively in a noninvasive fashion with STDU. This technique provides information regarding patency as well as quantitative assessment of bypass function. Moreover, STDU is useful to predict CVR improvement.

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

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. 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. 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. 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.

The Vascular Anatomy of the Galeal Flap in the Interparietal and Midline Regions

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

The Vascular Anatomy of the Galeal Flap in the Interparietal and Midline Regions

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

Preoperative evaluation of patients with extracranial carotid disease. Plethysmographic criteria for the use of a shunt, and for avoidance of surgery.

Eighty five angiographically studied patients (mean age 52) with carotid artery disease were preoperatively evaluated for the type and adequacy of their collateral circulation by the use of supraorbital photo-electric plethysmography (SPP). According to certain criteria we identified the candidates for surgery with or without shunt or for conservative treatment. Sixty patients presented evidence of extracranial collateral mainly from the ipsilateral superficial temporal artery (49 of 60), 11 patients revealed evidence of intracranial collateral mainly from the contralateral internal carotid artery (9 of 11), while in the rest, 14 patients, the source of the collateral circulation was undeterminable. Furthermore, an adequate circle of Willis was found in 67 patients and an inadequate one in the rest 7 (4 of 60, and 3 of 14). The majority of the surgically treated patients (74 of 81) were subjected to surgery without shunt (91%) while only 7 necessitated the use of a shunt (9%). No neurological complication was encountered and the single death (1.3%) was not directly related to the surgery itself. According to the present study, the careful preoperative determination of the collateral circulation, with the simple technique of SPP and the identification of patients at high risk under certain criteria could help the surgeon to decide about the advisability of a shunt or not and about the avoidance of surgery as well. This technique may be valuable where other more sophisticated forms of monitoring, such as EEG, evoked potentials or blood flow, are not readily available.

Management of High Cervical-Intracranial Internal Carotid Artery Traumatic Aneurysms

The successful surgical management of a patient with a traumatic aneurysm of the internal carotid artery (ICA) at the base of the skull and a second traumatic aneurysm of the ipsilateral superficial temporal artery is described. EC-IC bypass was not necessary, and graded occlusion of the ICA was employed. Direct repair was not chosen because of its high risk of distal embolization. Electrophysiologic monitoring techniques are helpful in predicting hemispheric ischemia.

Ultrasound screening for internal carotid disease—I. The temporal artery occlusion test—Which periorbital artery?

Using continuous wave Doppler-shifted ultrasound and spectral analysis the response to the temporal artery occlusion test was compared when insonating the supraorbital and supratrochlear arteries of 203 internal carotid pathways. The test involved monitoring the periorbital artery whilst simultaneously compressing a single branch of the external carotid artery, the ipsilateral superficial temporal artery. In 41 instances carotid angiography demonstrated severe disease of the internal carotid artery, that is lesions of 75% or more reduction in lumen diameter. A positive response to the temporal artery occlusion test, when performed on the supraorbital artery, indicated severe disease with a sensitivity of 90% and a specificity of 89%. When this test was performed on the supratrochlear artery a low sensitivity of 36% was obtained, although specificity was high at 96%.

The creation of a scalp A‐V fistula followed by an STA‐MCA vein graft bypass: A case report

A thirty-two-year-old male developed multiple neurologic symptoms. Medical evaluation disclosed hypertension, obesity, and a type IV hyperlipoprotein electrophoresis. A nuclear cerebral arteriogram showed reduced flow in the right middle cerebral artery. Arteriographic examination revealed an occlusion at the origin of this artery. The ipsilateral superficial temporal artery was too small to be used in an EC-IC bypass procedure. To correct these conditions, a two-stage procedure was performed. First, an arteriovenous fistula was created between the superficial temporal artery and its accompanying vein. Second, four and one-half months later, the temporal vein, which had by then enlarged, was resected and grafted from the proximal superficial temporal artery to the right angular artery. Angiography three months after the latter procedure showed that the anastomosis was patent.