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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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MCA-to-MCA Bypass 125
Fig. 4.5o A permanent clip is placed on the MCA distal to the exit of the normal MCA branch and proximal to the MCA
aneurysm.
Fig. 4.5p ICG angiogram confi rms patency of the
bypass (arrow).
Fig. 4.5q A later view of the ICG angiogram
shows good fi lling of the hemisphere through the
bypass (arrow) and proximal branch of the MCA
(arrowhead).
126 Color Atlas of Cerebral Revascularization
Fig. 4.5r Anteroposterior angiogram
demonstrates absence of the aneurysm and
patency of the anterior temporal artery.
Fig. 4.5s An orange line has been
placed over the anterior temporal artery
demonstrating the anastomosis (arrow).
The patient had no postoperative defi cits.
MCA-to-MCA Bypass 127
Case 4-6
Diagnosis: Giant left MCA aneurysm
Bypass: Direct MCA-to-MCA and STA-to-MCA
Approach: Left pterional
a b
Fig. 4.6a, b Axial CT and MR images demonstrate a complex MCA aneurysm in a 22-year-old man who experienced the
sudden onset of headache, aphasia, and weakness, which all improved over several weeks.
Fig. 4.6c CT angiogram shows two complex MCA
aneurysms.
128 Color Atlas of Cerebral Revascularization
d e
Fig. 4.6d, e Lateral and oblique angiograms show two complex MCA aneurysms on the angular branch of the left MCA.
Fig. 4.6f The distal sylvian fi ssure is opened and the aneurysms are exposed.
Fig. 4.6g The large MCA aneurysm has been incised to assess the feasibility of clip reconstruction, which is impossible.
MCA-to-MCA Bypass 129
Fig. 4.6h The infl ow and outfl ow branches of the giant MCA aneurysm have been cut and anastomosed end to end.
Fig. 4.6i ICG angiogram confi rms patency of the
direct anastomosis although a clump of platelets
appears at the anastomotic site (arrow).
Fig. 4.6j Intraoperative angiogram
demonstrated occlusion (arrow) of the direct
anastomosis of the MCA-to-MCA branches. The
anastomosis was reexamined and patency was
reestablished.
130 Color Atlas of Cerebral Revascularization
Fig. 4.6k After the anastomosis was reopened,
a repeat intraoperative angiogram again
demonstrates occlusion (arrow) of the direct
anastomosis.
Fig. 4.6l Because the direct MCA anastomosis twice failed to maintain patency, an STA bypass was anastomosed to
the angular MCA branch distal to the direct anastomosis. The direct anastomosis was also reopened.
Fig. 4.6m Postoperative angiogram
demonstrates that the previously occluded direct
anastomosis (arrow) is now patent.
MCA-to-MCA Bypass 131
Fig. 4.6n ECA angiogram also
confi rms patency of the STA-to-MCA
bypass (arrow).
Fig. 4.6o Postoperative CT shows the residual portion
of the thrombosed aneurysm and absence of any
infarction. The patient’s postoperative course was
uncomplicated.
132 Color Atlas of Cerebral Revascularization
Case 4-7
Diagnosis: Large complex left MCA aneurysm
Bypass: Excision of aneurysm, direct MCA-to-MCA
and STA–to–distal MCA
Approach: Left orbitozygomatic
a
Fig. 4.7a, b Parasagittal and axial MR images of a 39-year-old man with memory loss and fl uctuating aphasia show a
large complex left MCA aneurysm.
b
MCA-to-MCA Bypass 133
c
d
e
Fig. 4.7c–f Anteroposterior (c, d, e) and lateral (f) views of a large left M2 aneurysm.
f
134 Color Atlas of Cerebral Revascularization
Fig. 4.7g Through a left orbitozygomatic approach, the sylvian fi ssure is opened, exposing the large aneurysm,
feeding vessel, and three outfl ow vessels.
Fig. 4.7h The MCA feeding branch and the distal MCA outfl ow branches are clipped.
Fig. 4.7i The MCA feeding branch and the distal MCA outfl ow branches are cut.
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