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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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Fig. 1.4o The front walls are joined with loose running loops, tightened, and tied to the fi rst knot.
ACA Bypass 25
Fig. 1.4p The temporary clips are removed, restoring blood fl ow.
Fig. 1.4q After a temporary clip has been placed on the vessel
to be sacrifi ced, ICG angiography shows the patency of the
bypass.
26 Color Atlas of Cerebral Revascularization
Fig. 1.4r Postoperative threedimensional reconstructed CT angiogram
shows the clip in place with no fi lling of
the aneurysm. The distal bypass ( arrow )
is open.
ACA Bypass 27
Case 1-5
Diagnosis: Right A2 giant aneurysm
Bypass: A3-to-A3 side-to-side
Approach: Interhemispheric, and right pterional
for clipping second right MCA bifurcation aneurysm and endovascular sacrifi ce of right A2
a
Fig. 1.5a–c Axial ( a ), sagittal ( b ), and coronal ( c ) MR
images show a giant thrombosed A2 aneurysm exerting
c
mass eff ect.
b
28 Color Atlas of Cerebral Revascularization
Fig. 1.5d Lateral angiogram shows the serpiginous
channel through the thrombosed aneurysm ( arrow ).
Fig. 1.5e Anteroposterior angiogram shows the
complex ACA aneurysm ( arrow ) as well as an MCA
aneurysm ( arrowhead ).
Fig. 1.5f Later phase anteroposterior angiogram
shows the serpiginous vessel ( arrow ) and the intact
contralateral ACA.
ACA Bypass 29
Fig. 1.5g With the patient’s head in a horizontal position, the two pericallosal arteries are exposed through
an interhemispheric approach.
Fig. 1.5h The two pericallosal arteries are placed side by side over a dam and temporarily occluded in
preparation for the bypass.
Fig. 1.5i The back wall of the anastomosis is completed.
30 Color Atlas of Cerebral Revascularization
Fig. 1.5j The front wall of the bypass is completed.
Fig. 1.5k The clips are removed, showing the side-to-side anastomosis.
Fig. 1.5l The distal clip on the right ACA, as it exits the giant aneurysm, is visible.
ACA Bypass 31
Fig. 1.5m The aneurysm is incised so that some of the thrombosis can be debulked to minimize the mass eff ect.
Fig. 1.5n After debulking is completed, an opening is visible in the aneurysm.
Fig. 1.5o The thrombosis has been evacuated.
32 Color Atlas of Cerebral Revascularization
Fig. 1.5p Anteroposterior angiographic projection shows the clip
on the distal portion of the aneurysm.
Fig. 1.5q Anteroposterior angiographic projection shows
no further fi lling of the aneurysm and good patency of the
side-to-side anastomosis.
ACA Bypass 33
Case 1-6
Diagnosis: Giant suprasellar tumor with ICA tear
Bypass: ICA repair
Approach: Right orbitozygomatic with sacrifi ce of
right A1
Fig. 1.6a MR images show a large pituitary tumor.
Fig. 1.6b The tumor is being resected. The right CN II is visible.
34 Color Atlas of Cerebral Revascularization
Fig. 1.6c As tumor resection progresses, the ICA is mobilized.
Fig. 1.6d During tumor resection, a tear in the ICA occurs and tamponade is applied.
Fig. 1.6e The vascular neurosurgeon has been called and temporary clips are applied.
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