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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 65
Fig. 2.5d Three-dimensional CT reconstruction
demonstrates the serpiginous channel and the residual
lumen of the partially thrombosed aneurysm.
Fig. 2.5e Axial MR images show the large mass with
the fl ow channels in the MCA aneurysm.
f
Fig. 2.5f, g Anteroposterior and lateral angiograms show the serpiginous channel through the MCA
fi lling the distal left MCA branches.
g
66 Color Atlas of Cerebral Revascularization
Fig. 2.5h Three-dimensional reconstruction
demonstrates the serpiginous vessel ending in two
distal MCA branches fi lling the left hemisphere.
Fig. 2.5i The two branches of the STA are prepared, and the fi rst MCA branch is opened to proceed with the fi rst
anastomosis.
Fig. 2.5j The fi rst stitch is placed at one end of the MCA opening and then through one end of the fi shmouthed STA.
STA-to-MCA Bypass 67
Fig. 2.5k In the second anastomosis, a toe stitch extends from the MCA to the end of the fi shmouthed STA.
Fig. 2.5l The loops of the running suture are tightened to complete the second anastomosis.
Fig. 2.5m A clip partially occludes the fi rst channel.
68 Color Atlas of Cerebral Revascularization
Fig. 2.5n A second clip partially occludes the second channel, reducing fl ow through the aneurysm by 90% and creating
fl ow demand for the bypass.
Fig. 2.5o Overview of the two branches of the STA anastomosed to the MCA branches.
Fig. 2.5p Intraoperative ECA angiogram demonstrates good fl ow
through the two STA branches.
STA-to-MCA Bypass 69
Fig. 2.5q ICA angiogram demonstrates continued fl ow into the
MCA channel.
Fig. 2.5r Postoperative MR image demonstrates no
ischemic lesions.
70 Color Atlas of Cerebral Revascularization
Fig. 2.5s Five days after surgery, an anteroposterior angiogram is
obtained in preparation for a balloon occlusion test.
Fig. 2.5t The balloon is infl ated in the
residual aneurysm lumen to test the
bypass.
STA-to-MCA Bypass 71
Fig. 2.5u With the balloon infl ated, the patency of the bypass is confi rmed, as is
the signifi cant diameter of the bypass vessels.
Fig. 2.5v Anteroposterior angiographic projection
shows the coils in the channel of the MCA
aneurysm occluding the residual lumen of the
lesion.
72 Color Atlas of Cerebral Revascularization
Fig. 2.5w Lateral angiogram confi rms absence
of fl ow in the aneurysm and patency of the
bypass.
STA-to-MCA Bypass 73
Case 2-6
Diagnosis: Giant left MCA aneurysm
Bypass: Double-barrel STA-to-MCA
Approach: Left pterional
During an evaluation for headache, a giant MCA aneurysm was discovered in a 14-year-old boy.
Fig. 2.6a Axial CT scan of the head with contrast shows
a giant serpentine MCA aneurysm.
74 Color Atlas of Cerebral Revascularization
Fig. 2.6b Axial T2-weighted MR
images of the brain better defi ne the
extremely large area of the mass,
which crosses the midline. The variable
signal intensity indicates the presence
of thrombus in the dome of the
aneurysm.
Fig. 2.6c Lateral left ICA angiogram
shows that only a small portion of this
massive aneurysm fi lls. Note the bowing
of the ACA circulation.
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