Temporal Artery-middle Cerebral Artery Anastomosis Research Articles

視力障害で発症した内頸動脈閉塞症の検討

Visual disturbance is not necessarily included in the common symptoms of internal carotid artery occlusive disease although it is occasionally the only clinical sign of this disease. We analyze the clinical features of the internal carotid artery occlusion and stenosis presenting visual acuity disturbance and the role of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for ameliorating visual problems.We summarize 10 cases of internal carotid occlusive disease that presented visual disturbance as their first symptom retrospectively. Seven patients were seen by ophthalmologists initially and consulted a neurosurgeon for a second evaluation. On average, 56 weeks were required for the patients whose only symptom was visual disturbance to be diagnosed as internal carotid artery occlusive disease. All patients suffered retinal ischemia on the affected side, and secondary neovascular glaucoma was seen in most cases. All cases showed decreased cerebral blood flow on SPECT. Retrograde blood flow of the ophthalmic artery was recognized in 9 cases. STA-MCA anastomosis was performed for the patients who showed decreased cerebral blood flow and cerebral circulation reserve capacity on single photon emission computed tomography.STA-MCA anastomosis was performed in 5 patients. Improvement of visual acuity was not apparently recognized in any patients after the surgery although decrease of iridic neovasculization and improved retinal circulation was confirmed.Visual disturbance of internal carotid occlusive disease might be caused by retinal blood steal by chronic ischemic brain. STA-MCA anastomosis might be effective for such a condition because of reduction of steal flow to the brain. Early diagnosis and treatment are essential to obtain recovery of visual acuity. More coordination with ophthalmologists is essential to raise the quality of treatment.

治療困難な病変に対する内頚動脈閉塞術後の血行再建

The internal carotid artery (ICA) is sometimes involved with neck and skull base tumors or aneurysms, requiring elective ICA occlusion. This paper describes our strategy for vascular reconstruction after the ICA occlusion and the long-term follow-up results.Elective ICA occlusion was performed in 24 patients with unclippable aneurysms or tumors more than 2 years ago. The series comprises 5 males and 19 females, ranging in age from 32 to 75 (a mean age of 54.3). The lesions involved 5 tumors involving the ICA and 19 unclippable ICA aneurysms. Vascular reconstruction was determined by flowchart based on the balloon occlusion test with monitoring by clinical evaluation, EEG and cerebral blood flow (CBF) measurements. High-flow external carotid-internal carotid (EC-IC) bypass (including skull base bypass) was performed in 18 cases, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in 4, and replacement using vascular prosthesis in 1. Bypass was not performed in 1 aged patient because adequate CBF was preserved. All bypass grafts have remained patent postoperatively. Two patients have developed mild ischemic complications in the 4.0-year follow-up.Hemodynamic stroke risk should be examined before elective ICA occlusion when low flow (STA-MCA) bypass or no reconstruction is chosen. Vascular reconstruction is an effective surgical approach in the treatment of tumors involving the ICA and unclippable aneurysms to prevent late ischemic complications.

Cerebral Revascularization for Moyamoya Disease in Children

Ninety-four patients with moyamoya disease (56 in the pediatric age group and 38 adults) were treated by revascularization surgery in the past 21 years (1979--2000). Combined surgery of the superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect revascularization of encaphalo-duro-arterio-myo-synangiosis (EDAMS) was performed. Ischemic attacks disappeared in most patients within 1 year (mean) after surgery in pediatric cases. No morbidity or mortality was experienced in the pediatric group. Some children with cerebral infarction before the surgery, however, had mild mental retardation even after the surgery. Early diagnosis and proper prophylactic surgical treatment is indispensable for pediatric patients with moyamoya. MR angiography is an important diagnostic modality for the screening and longitudinal follow-up of moyamoya disease.

もやもや病に対する直接バイパスの長期予後

We assessed the posttreatment clinical course of 113 patients with moyamoya disease. All of them were treated with superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis with or without encephalo-myo-synangiosis. The mean follow-up duration was 14.4 years. Complete disappearance of the ischemic episodes was obtained in 110 patients (97.3%). Independent daily life activities were possible for 100 patients. Fifteen patients were incapable of social lives because of their mental retardation, although they can take care of themselves in their daily life. All of them suffered from preoperative completed stroke. Therepeutic time lag should be minimized to prevent these preoperative strokes.

Cerebral revascularization for moyamoya disease

Eighty-four patients with moyamoya disease, including 36 pediatric cases and 48 adult cases, were treated by revascularization surgery. Ischemic onset is a good indication for surgical revascularization in both pediatric and adult cases. Combined surgery of superficial temporal artery-middle cerebral artery anastomosis and indirect revascularization of encephalo-duro-arterio-myo-synangiosis (EDAMS) or encephalo-duro-myo-arterio-pericranio-synangiosis (EDAMPS), which is a minor modification of EDAMS, was performed. Ischemic attacks disappeared in most patients within 1 year (mean) after surgery. However, in adult cases with hemorrhagic onset, rebleeding was seen in 6 of 48 cases (12.5%; mean follow-up, 6 years). Recent advances in clinical and basic studies of moyamoya disease are reviewed.

<SUP>133</SUP>Xe SPECTによる定量的評価に基づいた慢性期内頸動脈系閉塞性病変に対するバイパス術の効果

To evaluate the efficacy of bypass surgery, we analyzed the clinical outcome and cerebral hemodynamics of patients treated with bypass surgery.Over a 3-year period, 21 patients were defined by clinical and laboratory criteria as suffering from hemodynamic cerebral ischemia. All patients had one or more episodes of focal cerebral ischemia due to unilateral internal carotid or middle cerebral artery occlusion. Computerized tomography scans either were normal or showed evidence of watershed infarction. The baseline cerebral blood flow (CBF) and cerebral vasodilatory capacity (CVC) were studied using 133Xe single-photon emission CT and acetazolamide test, and both were found to be significantly reduced in all patients. Based on these criteria, superficial temporal artery-middle cerebral artery anastomosis was performed. One patient suffered a postoperative stroke with complete recovery, resulting in a morbidity rate of 4.8%. Over a mean follow-up period of 20 months, no patient had another episode of cerebral ischemia. Follow-up studies of baseline CBF and CVC showed significant improvement of the latter while the former was essentially unchanged. In view of these findings, we conclude that bypass surgery constitutes appropriate therapy for patients with hemodynamic cerebral ischemia, defined using the strict selection criteria employed in this study.

Long-term outcome after STA-MCA anastomosis for moyamoya disease

A long-term assessment was performed to determine the posttreatment clinical course of 113 patients with moyamoya disease. All patients sustained cerebral ischemic attacks and underwent superficial temporal artery-middle cerebral artery anastomosis with or without temporal muscle grafting. The follow-up duration was 3 to 24 years (mean 14.4 +/- 5.8 [standard deviation]). Complete cessation of the ischemic episodes was obtained in 110 of 113 patients. One hundred patients were able to return to independent acitvities of daily living. Intellectual delays prevented 24 patients from engaging in an independent social life . Although intracranial bleeding is one of the common manifestations in moyamoya disease, hemorrhage was not detected in the 113 patients who underwent cerebral revascularization.

An indirect revascularization method in the surgical treatment of moyamoya disease--various kinds of indirect procedures and a multiple combined indirect procedure.

The indirect non-anastomotic bypass procedures for moyamoya disease are herein reviewed, and our multiple combined indirect procedure, i.e. a fronto-parieto-temporal combined indirect bypass procedure, is also introduced. Direct procedures such as superficial temporal artery-middle cerebral artery anastomosis are able to form collaterals with a high reliability, but these procedures are often difficult to technically perform in small children, and complications, when they occur, tend to be severe. Indirect procedures, such as encephalo-duro-arterio-synangiosis (EDAS), encephalo-myo-synangiosis (EMS), and encephalo-myo-arterio-synangiosis (EMAS) etc., are safe and easy and also successfully form collaterals especially in children with moyamoya disease. However, there are a few drawbacks with such procedures. They do not always form sufficient collaterals. The area where the original EDAS using the posterior branch of the superficial temporal artery can be done is also limited. Moreover, because the area covered by each single procedure is small, the collateral formation obtained by a single procedure is not always satisfactory. For these reasons we developed a fronto-temporoparietal combined indirect bypass procedure for child patients in order to overcome these problems. This multiple combined indirect procedure can cover a wider area of the ischemic brain through the EMAS in the frontal and the EDAS and EMS in the temporo-parietal regions. It is also safe and easy to perform, and one or two of these three procedures form sufficient collaterals with a relatively high reliability. This technique is described and the results are presented.

Low cerebral blood flow and perfusion reserve induce hyperperfusion after surgical revascularization: Case reports and analysis of cerebral hemodynamics

Hyperperfusion syndrome after surgical revascularization is a rare complication and there has not been any systematic study on factors that induce hyperperfusion after surgery. In this paper, we retrospectively analyzed the factors related to this syndrome. We performed 46 cases of surgical revascularization including 33 cases of carotid endarterectomy (CEA) and 13 cases of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis during the past 5 years. Among these, we encountered three cases of hyperperfusion syndrome despite well-controlled blood pressure postoperatively. To evaluate factors related to the occurrence of hyperperfusion syndrome, we examined four parameters: (1) regional cerebral blood flow (rCBF), (2) the increase in the ratio of the postoperative rCBF compared to the preoperative rCBF (increase ratio), (3) cerebral perfusion reserve presented by the increase of rCBF after acetazolamide administration (delta rCBF), and (4) the difference in mean blood pressure between the preoperative and postoperative state (delta BP). Preoperative rCBF was significantly lower in cases of hyperperfusion syndrome than the control cases (p < 0.01 Mann-Whitney U-test). Moreover delta rCBF was evidently lower in the hyperperfusion cases than the control (p < 0.05 Fisher's exact method). However, there was no significant difference in the delta BP between the hyperperfusion cases and the control cases. In cases of marked low perfusion (low rCBF) with poor perfusion reserve (low delta rCBF), hyperperfusion after surgical revascularization can occur even if blood pressure is adequately controlled.

P-1-122 - Surgery of the anomalles of the vertebral artery

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis has been used in moyamoya disease (MD) and non-moyamoya ischemic stroke (non-MD). It is important to monitor hemodynamic changes caused by bypass surgery for postoperative management. We evaluated the bypass blood flow during STA-MCA anastomosis by using indocyanine green (ICG) fluorescence angiography.We evaluated the bypass blood flow in 13 MD and 21 non-MD patients during STA-MCA anastomosis by means of ICG angiography with injection of ICG into the anastomosed STA. The ICG perfusion area was calculated when the ICG fluorescence intensity reached maximum. We measured cortical oxygen saturation before anastomosis by means of visual light spectroscopy.ICG angiography demonstrated bypass blood flow from the anastomosed STA to the cortical vessels in all patients. The ICG perfusion area in MD (20.7 ± 6.6 cm2) was significantly larger than that in non-MD (8.4 ± 9.1 cm2, P < 0.05). The cortical oxygen saturation (58.9% ± 8.3%) in MD was significantly lower than that in non-MD (73.4% ± 9.5%, P < 0.05).ICG angiography with injection of ICG into the bypass artery allowed quantitative assessment of bypass blood flow. The bypass supplies blood flow to a greater extent in MD than in non-MD during surgery. This might be caused by a larger pressure gradient between the anastomosed STA and recipient vessels in MD. These observations indicate that MD requires careful control of systemic blood pressure after surgery to avoid cerebral hyperperfusion syndrome. ICG angiography is considered useful for facilitating safe and accurate bypass surgery and providing information for postoperative management.

P-1-123 - Arterial reconstruction for vertebral artery stenosis at the origin

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis has been used in moyamoya disease (MD) and non-moyamoya ischemic stroke (non-MD). It is important to monitor hemodynamic changes caused by bypass surgery for postoperative management. We evaluated the bypass blood flow during STA-MCA anastomosis by using indocyanine green (ICG) fluorescence angiography.We evaluated the bypass blood flow in 13 MD and 21 non-MD patients during STA-MCA anastomosis by means of ICG angiography with injection of ICG into the anastomosed STA. The ICG perfusion area was calculated when the ICG fluorescence intensity reached maximum. We measured cortical oxygen saturation before anastomosis by means of visual light spectroscopy.ICG angiography demonstrated bypass blood flow from the anastomosed STA to the cortical vessels in all patients. The ICG perfusion area in MD (20.7 ± 6.6 cm2) was significantly larger than that in non-MD (8.4 ± 9.1 cm2, P < 0.05). The cortical oxygen saturation (58.9% ± 8.3%) in MD was significantly lower than that in non-MD (73.4% ± 9.5%, P < 0.05).ICG angiography with injection of ICG into the bypass artery allowed quantitative assessment of bypass blood flow. The bypass supplies blood flow to a greater extent in MD than in non-MD during surgery. This might be caused by a larger pressure gradient between the anastomosed STA and recipient vessels in MD. These observations indicate that MD requires careful control of systemic blood pressure after surgery to avoid cerebral hyperperfusion syndrome. ICG angiography is considered useful for facilitating safe and accurate bypass surgery and providing information for postoperative management.

High flow 血行再建術術後のhyperperfusion syndrome

It is well known that hyperperfusion syndromes sometimes occur after high flow bypass or carotid endarterectomy (CEA). In this paper we discuss cases that showed hyperperfusion syndrome after CEA and high flow bypass using radial artery graft (RA graft). Twenty cases that were treated between April 1993 and January 1996 were selected for this study. All patients complained of TIA, RIND, or minor completed stroke. Their cerebral angiograms demonstrated severe stenosis or occlusion in the ipsilateral internal carotid artery or middle cerebral artery. The regional cerebral blood flow (rCBF) was measured with 123I-IMP single emission computed tomography (SPECT), and measured after administration of 1 gram of acetazolamide intravenously. For these 20 patients 15 cases of CEA and 5 cases of RA graft were performed. Three cases of hyperperfusion syndrome were observed: 1 case was seizure after RA graft, and 2 cases were hemorrhage (1 patient was after CEA and the other was after RA graft). This hyperperfusion syndrome group (H group) showed hypoperfusion at rest and markedly decreased acetazolamide reactivity before operation. On the other hand the rCBF was not decreased in non-hyperperfusion group (N group) after acetazolamide administration. In the N group all patients were uneventful after surgery. According to Kuroda's classification, the cases who have decreased resting rCBF and impaired acetazolamide reactivity are classified as“Type 3.”In our study the H group cases showed markedly decreased acetazolamide reactivity compared with the“Type 3”cases of the N group. The cerebral blood vesseles of this H group may be paralytic and have no vasocontraction ability. We propose the“vasoparalytic type”for these cases. They have decreased resting rCBF and severely impaired acetazolamide reactivity. For these patients superficial temporal artery-middle cerebral artery anastomosis or PTA should be performed prior to CEA and RA graft.

STA-MCA吻合術部に生じた脳動脈瘤の1例

We report an aneurysm that developed at the superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. A 52-year-old woman, who had a history of subarachnoid hemorrhage (SAH) 10 years before, was admitted with headache. At the previous SAH, 3 cerebral aneurysms were identified and 2 of them were successfully treated with neck clipping. The remaining right internal carotid giant aneurysm was treated with the proximal occlusion of the right internal carotid artery following the right STA-MCA anastomosis. She had gone well without neurological deficit until the current admission. CT scan on admission revealed intracerebral hemorrhage in the right frontal region. Angiography disclosed a saccular aneurysm at the site of the anastomosis. The aneurysm was successfully treated by neck clipping. The intraoperative findings showed that the aneurysm raised from the MCA wall opposite to the STA orifice. Histological examination of the aneurysm wall indicated a true aneurysmal formation. Congenital factors, as suggested by her history of multiple aneurysms, and hemodynamic stress to the recipient artery may have contributed to the aneurysm development.

Subdural Hemorrhage Caused by De Novo Aneurysm Complicating Extracranial-Intracranial Bypass Surgery: Case Report

A case of a de novo aneurysm leading to subdural hemorrhage after right extracranial-intracranial bypass surgery is described. After an uneventful 2-month postoperative course, the patient experienced sudden onset of occipital headache with vomiting. Radiological study disclosed an acute subdural hematoma in the right temporo-occipital region and a newly formed aneurysm at the site of patent superficial temporal artery-middle cerebral artery anastomosis. The anastomotic portion with the ruptured aneurysm was resected en bloc after alternative occipital artery-middle cerebral artery bypass, and the cut end of the superficial temporal artery was successfully used for end-to-side reanastomosis to the other middle cerebral artery branch. The histological examination of the ruptured aneurysm revealed the features of a true aneurysm.

Preoperative and Postoperative Evaluation of Cerebral Perfusion and Vasodilatory Capacity With 99m Tc-HMPAO SPECT and Acetazolamide in Childhood Moyamoya Disease

The results of long-term follow-up studies of cerebral perfusion and vasodilatory capacity following administration of acetazolamide after serial vascular reconstructions in 25 patients with childhood moyamoya disease are reported. Cerebral perfusion was measured with 99mTc-hexamethylpropyleneamine oxime single-photon emission CT before and after IV administration of 10 mg/kg acetazolamide, which was performed both before and after vascular reconstruction by superficial temporal artery-middle cerebral artery anastomosis and encephalomyosynangiosis (first and second operations) and/or omental transplantation to the brain (third operation). Follow-up periods ranged between 12 and 24 months (mean +/- SD, 18.5 +/- 3.2 months) after the first operation. Repetitive transient ischemic attacks disappeared completely after serial vascular reconstructions in all patients. Before the first operation, cerebral perfusion in the territory of the middle cerebral artery on the side of initial operation was 83.9 +/- 4.7% and was significantly lower than that in the contralateral side (88.3 +/- 4.9%, n = 25; P < .0001, paired t test). Vasodilatory capacity on the side of the first operation was -18.4 +/- 2.5% and that on the contralateral side -14.4 +/- 2.1%. The former value was significantly lower than the latter value (n = 25; P < .0001, paired t test). After the first operation, cerebral perfusion and vasodilatory capacity on the side of initial operation were markedly improved, to 87.8 +/- 4.5% and -14.7 +/- 2.7%, respectively (n = 25; P < .0001, both cases, paired t test). Before the second operation, cerebral perfusion and vasodilatory capacity on the side of the second operation were 76.6 +/- 4.1% and -20.1 +/- 1.9%, respectively, and significantly lower than those before the first operation (n = 25; P < .0001, both cases, paired t test). Eight patients subsequently required bifrontal omental transplantation for repetitive paraparetic transient ischemic attacks after the second operation; they had low cerebral perfusion and vasodilatory capacity bilaterally in the territories of the anterior cerebral arteries (72.4 +/- 2.7% and -18.6 +/- 1.7%, respectively). After omental transplantation, both were significantly increased, to 81.9 +/- 3.4% and -11.8 +/- 1.9%, respectively (n = 25; P < .0001, both cases, paired t test). Hemodynamic compromise existed in patients with childhood moyamoya disease and was a major cause of development of ischemic symptoms. Regions in which hemodynamic compromise was present could be determined by measuring regional cerebral perfusion and vasodilatory capacity.

Percutaneous transluminal angioplasty for severe stenosis of the posterior cerebral artery: Case report

The Stealth dilation catheter was used for the intravascular treatment of a patient who had hemodynamically significant stenosis of the posterior cerebral artery and had a history of recurrent transient ischemic attacks associated with right hemiparesis and ipsilateral hemianopia dating from March 1993. Cerebral perfusion studies prior to and after the intravenous administration of acetazolamide demonstrated regions of moderately low perfusion and low hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. Cerebral angiograms demonstrated severe stenosis of the left posterior cerebral artery and occlusions of both middle cerebral arteries, which had leptomeningeal anastomoses with the posterior cerebral arteries. Percutaneous transluminal angioplasty (PTA) was performed using the Stealth catheter on the stenotic segment of the left posterior cerebral artery after left superficial temporal artery-middle cerebral artery anastomosis. The patient manifested marked improvement in her neurologic condition just after PTA, in association with marked increase in cerebral perfusion and hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. We have presented evidence that PTA can be used to treat patients with stenosis of the first segment of the posterior cerebral artery and hemodynamic compromise in the territory that artery supplies.

Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in patients with ICA occlusion and hemodynamic cerebral ischemia

Since the negative results of the international Bypass Study, extracranial-intracranial (EC-IC) bypass surgery is infrequently employed in the treatment of patients with cerebral ischemia. Newly acquired evidence concerning the pathophysiology of cerebral ischemia, however, has facilitated the identification of a small subgroup of patients with "hemodynamic" cerebral ischemia. Characteristically, these patients demonstrate severely impaired cerebrovascular reserve capacity due to occlusive disease and insufficient collateral blood supply. Over an 8-year period, 28 patients were defined by clinical and laboratory criteria as suffering from hemodynamic cerebral ischemia. All patients had recurring episodes of focal cerebral ischemia due to unilateral internal carotid artery occlusion. Computerized tomography (CT) scans either were normal or showed evidence of border zone infarction. The cerebrovascular reserve capacity was studied using 133Xe single-photon emission CT and acetazolamide challenge and was found to be significantly impaired in all patients. Based on these criteria, superficial temporal artery-middle cerebral artery anastomosis was performed to augment collateral flow to the ischemic hemispheres. Two patients died from myocardial infarction, one 4 days and the other 2 months postoperatively. One patient died from massive brain infarction and another suffered a postoperative stroke with incomplete recovery, resulting in a major morbidity and mortality rate of 14%. Minor morbidity included one patient with a subdural hematoma who subsequently recovered completely. The postoperative course was uneventful in 23 patients (82%). Over a mean follow-up period of almost 3 years, no patient had another episode of brain ischemia. Bypass patency was confirmed by postoperative angiography in 26 patients. Follow-up studies of cerebral blood flow (CBF) and cerebrovascular reserve capacity showed significant improvement of the latter while the resting CBF was essentially unchanged. In view of these findings, the authors conclude that EC-IC bypass surgery constitutes appropriate therapy for a subgroup of patients with recurrent focal cerebral ischemia, defined using the strict selection criteria employed in this study.

Efficacy of superficial temporal to middle cerebral artery anastomosis against hemodynamic stroke.

The effect of superficial temporal artery-middle cerebral artery anastomosis on regional cerebral blood flow (rCBF) was measured on 31 patients with ischemic cerebrovascular diseases. rCBF was measured on the precentral and superior temporal gyri during surgery using the thermal diffusion technique. The mean rCBF was significantly lower than controls before anastomosis, but increased significantly after. Severer clinical symptoms were associated with lower rCBF. The rCBF increased significantly in patients with transient ischemic attack, reversible ischemic neurological deficit, and minor and major completed stroke. All 31 patients demonstrated dysautoregulation, both before and after anastomosis. However, the rCBF had increased above the ischemic threshold during hypotension, achieving a reserve capacity to prevent hemodynamic stroke.

吸収性縫合糸polydioxanone (PDS) を用いた連続縫合によるSTA-MCA吻合術

To minimize the temporary occlusion time during bypass surgery, continuous absorbable sutures with 9-0 polydioxanone (PDS) were employed in the superficial temporal artery-middle cerebral artery (STA-MCA) anastomoses. Two cases of internal carotid artery occlusion and 4 cases of its stenosis were operated on in the chronic stage, and one case of MCA occlusion in the superacute stage. In all cases, a cold xenon-enhanced CT revealed the reduction of local cerebral blood flow (LCBF) preoperatively. Postoperative courses were uneventful and there were no anastomotic complications. The follow-up period ranged from 6 to 14 months. In 5 of the 6 cases in the chronic stage, all STAs and anastomotic sites grew remarkably in diameter 3 months after the surgery, when PDS had already lost tensile strength, and thereafter gradually increased in size. These changes were correlated with the improvement of LCBF. In the remaining one in the chronic stage, the STA showed less growing due to increased collateral flow via the external carotid artery system. In the case of MCA occlusion, growing of STA did not occur due to the low bypass-flow that resulted from the spontaneous recanalization of the occluded MCA. Previous studies suggested that absorbable PDS does not elicit inflammatory response, wall thickening, hyalinoid degeneration or calcification, which occasionally occur in use of nonabsorbable polypropylene sutures. In conclusion, PDS seems to be suitable for anastomosing small vessels and continuous PDS sutures are available for extracranial-intracranial arterial bypass surgery in which anastomotic sites grow corresponding to the increases of the bypass-flow.

Direct surgery for giant aneurysm exhibiting progressive enlargement after intraaneurysmal balloon embolization

A case of giant intracranial carotid artery aneurysm exhibiting progressive enlargement after incomplete intraaneurysmal balloon embolization is presented. The patient was successfully treated by the trapping and decompression of the aneurysm with a superficial temporal artery-middle cerebral artery anastomosis. The thrombus surrounding the intraluminal balloons was very soft and poorly organized. Either direct surgery with extracranial-intracranial arterial bypass or complete intravascular surgery should be performed for giant aneurysms when direct clipping is impossible.