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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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STA-to-MCA Bypass 75
Fig. 2.6d Later phase lateral angiogram
shows a large serpiginous channel through
the aneurysm.
Fig. 2.6e Anteroposterior angiogram shows
that the fi lling portion of this left MCA
aneurysm is pushed across the midline to
the right. The serpiginous channel crosses to
the left side, eventually fi lling the cortical M4
vessels.
76 Color Atlas of Cerebral Revascularization
Fig. 2.6f Later phase angiogram shows the blush
of cortical vessels, which confi rms that the vessels
arising from the aneurysm provide signifi cant
distal perfusion.
Fig. 2.6g Intraoperative photograph shows the distal MCA vessels arising from the wall of the aneurysm and
stretched across its dome.
Fig. 2.6h A double-barrel end-to-end STA-to-MCA bypass was performed with the two MCA branches where they
exited the aneurysm. Part of the thrombus was removed. A clip placed on the MCA as it entered the aneurysm spared
the lenticulostriate arteries. Most of the aneurysm was left in situ.
Fig. 2.6i During the second-stage procedure 1 week later, the aneurysm was exposed and incised. The two aneurysm
clips placed during the fi rst stage were removed. One of the anastomoses is shown.
Fig. 2.6j A temporary clip is placed across the MCA. The perforating branches are identifi ed and preserved. A permanent
clip will be placed on the MCA distal to the perforating branches at the base of the aneurysm.
78 Color Atlas of Cerebral Revascularization
Fig. 2.6k Lateral postoperative
angiogram shows no further fi lling of the
aneurysm. The lenticulostriate arteries
are visible ( arrow ).
Fig. 2.6l Lateral left ECA angiogram
confi rms patency of the double-barrel
bypass. The discontinuity in the STA is
from the shadow of the aneurysm clip
( arrow ). The MCA vessels, which had
been stretched by the aneurysm, were
elevated and straightened.
STA-to-MCA Bypass 79
m
n
o
Fig. 2.6m–p Preoperative ( m ) and late follow-up ( n, o, p ) CT images show the great reduction in the size of the
residual aneurysm. The patient remained completely asymptomatic.
p
80 Color Atlas of Cerebral Revascularization
q
s
Fig. 2.6q–t Postoperative ( q ) and late follow-up ( r, s, t ) angiograms show the robust fi lling of the MCA territory
through the double-barrel bypass and demonstrate the longevity of this artery-to-artery anastomosis. ( Fig. 2.6r and t
used with permission from Springer-Verlag Wien.)
r
t
STA-to-MCA Bypass 81
Case 2-7
Diagnosis: Left MCA dissecting fusiform aneurysm
Bypass: STA-to-MCA with endovascular occlusion
of aneurysm
Approach: Left frontotemporal
Fig. 2.7a, b Sagittal and axial MR images demonstrate mass eff ect from a dissecting fusiform aneurysm on the left
MCA. This dissecting aneurysm, which had been followed for 7 years, showed growth over a 6-month period. The
patient’s symptoms included fl uctuating periodic aphasia.
ba
Fig. 2.7c Angiogram demonstrates a fusiform vessel
in the distribution of the left MCA.
82 Color Atlas of Cerebral Revascularization
Fig. 2.7d After a frontotemporal craniotomy is
performed, the MCA segment distal to the aneurysm
is freed from the arachnoid and temporarily clipped.
The STA is tacked to the opened MCA with heel and
toe stitches and running sutures are loosely placed in
one wall.
Fig. 2.7e The sutures are tightened and tied to the
heel knot.
Fig. 2.7f The remainder of the loose running sutures are placed.
STA-to-MCA Bypass 83
Fig. 2.7g The completed bypass fi lls robustly.
Fig. 2.7h Overview of the completed STA-to-MCA bypass.
Fig. 2.7i Selective injection of the external vessels on the
left demonstrates patency of the bypass.
84 Color Atlas of Cerebral Revascularization
Fig. 2.7j Selective catheterization of the
MCA branch involved with the aneurysm
is performed. Coils were placed into the
vessel until it was obstructed completely.
Fig. 2.7k Postoperative ICA angiogram
demonstrates the absence of the
aneurysm. The patient had no neurologic
defi cits.
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