Practical Application of 3-D Multifusion Imaging for STA-MCA “Tailored” Bypass

Abstract

Summary:Background: The indication of extracranial-intracranial (EC-IC) bypass surgery is likely to be limited, because the prognosis for ischemic stroke improves with better outcomes with medical therapy. Therefore, to achieve the maximum benefit in selected cases, an individualized surgical plan tailored to anatomical differences and the purpose of the surgery is necessary. We describe our practical application of 3-D multifusion imaging for "tailored" bypass surgery. Methods:We selected the ideal recipient artery and simulated the craniotomy preoperatively using 3-D multifusion imaging on a general purpose workstation in 13 cases of EC-IC bypass treated in Kokura Memorial Hospital between October 2011 and October 2012. We identified discrepancies between imaging and the actual intra-operative view, and modified the image editing and operative procedure.Results: In all 13 cases, bypass flow was maintained. There were positional deviations between the simulated craniotomy and the intra-operative view in two cases initially. In another two cases, we could not select the recipient artery because of insufficient visualization of the brain surface.Both problems were correctable. Conclusion:We accurately identified the recipient artery that we had selected pre-operatively.This technique can be a stepping stone to "tailored bypass" and could be applied to various cerebrovascular surgeries.

Is Precise Targeting of the Recipient Artery in a Superficial Temporal Artery–Middle Cerebral Artery Anastomosis Crucial?

“…Even the previously mentioned research groups that used other modalities to target the artery preoperatively ultimately used DSA after the surgery to confirm the anastomoses. 11,12 In light of this, if precise preoperative targeting of the recipient artery has little impact on the postoperative rCBF levels or outcome, then accurate confirmation of the anastomosed vessels by DSA would also be of little value. As might be expected, patients who require bypass surgery would have several atherosclerotic risk factors (►Table 1) that may also present a risk during the postoperative DSA.…”

“…There are, however, some differences among surgeons in operative methods and the perioperative assessment for such cases. In particular, some surgeons are meticulous about the selection of the recipient artery and insist on anastomosing the artery in the exact area that exhibited low perfusion preoperatively, 11,12 whereas other surgeons simply follow the concept that bypassed blood naturally flows to where it is in demand. The former group of surgeons tend routinely to confirm the anastomosed artery precisely after the operation by digital subtraction angiography (DSA), whereas the latter group generally do not perform this confirmation.…”