- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
DOI:10.4103/2152-7806.157949Copyright: © 2015 Takeuchi S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Takeuchi S, Tanikawa R, Tsuboi T, Noda K, Oda J, Miyata S, Ota N, Yoshikane T, Kamiyama H. Superficial temporal artery to proximal posterior cerebral artery bypass through the anterior temporal approach. Surg Neurol Int 01-Jun-2015;6:95
How to cite this URL: Takeuchi S, Tanikawa R, Tsuboi T, Noda K, Oda J, Miyata S, Ota N, Yoshikane T, Kamiyama H. Superficial temporal artery to proximal posterior cerebral artery bypass through the anterior temporal approach. Surg Neurol Int 01-Jun-2015;6:95. Available from: http://surgicalneurologyint.com/surgicalint_articles/superficial-temporal-artery-proximal-posterior-cerebral-artery/
Background:The superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) (P2 segment) bypass is one of the most difficult procedures to perform because the proximal PCA is located deep and high within the ambient cistern. STA to proximal PCA bypass is usually performed through a subtemporal approach or posterior transpetrosal approach, and rarely through a transsylvian approach. The aim of this study was to describe the operative technique of STA to proximal PCA bypass through a modified transsylvian approach (anterior temporal approach).
Methods:STA to proximal PCA bypass was performed through an anterior temporal approach in three patients with intracranial aneurysm. We describe the details of the surgical technique.
Results:The STA was successfully anastomosed to the proximal PCA in all cases. One patient suffered hemiparesis and aphasia due to infarction in the anterior thalamoperforating artery territory.
Conclusions:STA to proximal PCA bypass can be performed through an anterior temporal approach in selected patients. We recommend that every precaution, including complete hemostasis, placement of cellulose sponges beneath the recipient artery to elevate the site of the anastomosis, and placement of a continuous drainage tube at the bottom of the operative field to avoid blood contamination during the anastomosis, should be taken to shorten the temporary occlusion time.
Keywords: Anterior temporal approach, bypass, posterior cerebral artery, superficial temporal artery, transsylvian approach
Clipping of complex or giant aneurysms may be difficult or even impossible because such aneurysms often incorporate the parent artery or adjacent arterial branches into their base or fundus.[
Selection of the cerebral revascularization procedure depends on several factors, including the patient's symptoms, the site of the lesion, the collateral circulation, and the required surgical skill.[
STA to P2 segment of PCA (STA-P2) bypass is usually performed through a subtemporal approach or posterior transpetrosal approach, and rarely through a transsylvian approach.[
In the current study, we describe the operative technique of STA-P2 bypass through the anterior temporal approach.
MATERIAL AND METHODS
This study was conducted with the approval of the ethics committee of the National Defense Medical College. The committee concluded that written informed consent was not required because of the retrospective nature of the investigation. STA-P2 bypass was performed through an anterior temporal approach in three patients with intracranial aneurysm.
Technique: Anterior temporal approach[ 8 11 18 20 ]
The patient is placed in the supine position with the head turned approximately 45° to the opposite side and tilted toward the floor. The head should be placed slightly above the level of the heart. A frontotemporal skin incision is performed, and the STA is carefully dissected out. The skin flap is separated from the temporal fascia down to the fat pad over the zygoma. The muscle is cut anteriorly and inferiorly and is retracted posteriorly. The bone flap includes the anterior temporal squama down to the temporal floor anteriorly. The sphenoid ridge is removed as far as the superior orbital fissure. After opening the dura, the superficial sylvian veins are separated from the temporal lobe and moved to the frontal lobe. The anterior temporal artery is completely separated from the medial surface of the temporal lobe. The temporal lobe is retracted posteriorly. The arachnoid is cut between the uncus and the anterior choroidal artery as well as between the uncus and oculomotor nerve. The carotid, crural, ambient, and interpeduncular cisterns are completely opened, and then the basilar artery, SCA, and PCA are identified.
Technique: STA-P2 bypass
The PCA is dissected free from the arachnoid, and the P2 segment of the PCA is exposed. A portion with no perforating vessels is selected as the site for the anastomosis. The fascial layer is stripped from the severed end of the STA. The tip of the STA is then cut into a shape matching the anastomotic site. Cellulose sponges are placed beneath the recipient artery to lift the site for the anastomosis. A 5 Fr. silastic feeding tube is placed at the bottom of the operative field to avoid blood contamination during the anastomosis. The recipient artery is prepared by placing temporary clips across the vessel and performing a small arteriotomy. After two stay sutures have been placed, anastomosis of the STA to P2 is performed using 10-0 nylon interrupted sutures.
A 30-year-old male underwent clipping through an anterior temporal approach for an unruptured intracranial aneurysm at the right P2 segment of the PCA [
A 75-year-old female underwent clipping of an unruptured basilar tip aneurysm through a right pterional approach in 1994 in another hospital. The patient suffered subarachnoid hemorrhage in 1998. Angiography revealed ruptured IC-PC aneurysm and neck remnant of the basilar tip aneurysm. Clipping of the IC-PC aneurysm and coating of the basilar tip aneurysm were performed through a left subtemporal approach in another hospital. The patient also underwent ventriculo-peritoneal shunting for normal pressure hydrocephalus. Regrowth of the basilar tip aneurysm was detected in 2012 [
A 70-year-old female was incidentally diagnosed with a large aneurysm at the left C1 portion of the internal carotid artery and was admitted to our hospital [
The current study indicated that STA-P2 bypass procedures can be successfully performed via the anterior temporal approach, the same surgical approach used for clipping, parent artery proximal occlusion, and trapping.
Only one previous patient has been treated by STA-P2 bypass by other than the subtemporal approach and posterior transpetrosal approach. The pretemporal approach described by de Oliveira et al.[
The anterior temporal approach offers excellent exposure of the interpeduncular and crural cisterns, P1, P2A, and medical posterior choroidal artery, but the P2P is difficult to access.[
In our series, the temporary occlusion time ranged from 25 to 51 min (mean, 38 min). The PCA territory contains rich collateral vascular networks.[
STA-P2 bypass can be performed via an anterior temporal approach in selected patients. We recommend that every precaution, including complete hemostasis, placement of cellulose sponges beneath the recipient artery to elevate the site of the anastomosis, and placement of a continuous drainage tube at the bottom of the operative field to avoid blood contamination during the anastomosis, should be taken to shorten the temporary occlusion time.
1. Ausman JI, Diaz FG, de los Reyes RA, Pak H, Patel S, Mehta B. Posterior circulation revascularization. Superficial temporal artery to superior cerebellar artery anastomosis. J Neurosurg. 1982. 56: 766-76
2. Ausman JI, Diaz FG, Vacca DF, Sadasivan B. Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency. J Neurosurg. 1990. 72: 554-8
3. Ausman JI, Lee MC, Chater N, Latchaw RE. Superficial temporal artery to superior cerebellar artery anastomosis for distal basilar artery stenosis. Surg Neurol. 1979. 12: 277-82
4. Ausman JI, Lee MC, Klassen AC, Seljeskog EL, Chou SN. Stroke: What's new? Cerebral revascularization. Minn Med. 1976. 59: 223-7
5. Coert BA, Chang SD, Marks MP, Steinberg GK. Revascularization of the posterior circulation. Skull Base. 2005. 15: 43-62
6. de Oliveira E, Tedeschi H, Siqueira MG, Peace DA. The pretemporal approach to the interpeduncular and petroclival regions. Acta Neurochir (Wien). 1995. 136: 204-11
7. Dusick JR, Gonzalez NR, Martin NA, Winn HR.editors. Revascularization techniques for complex aneurysms and skull base tumors. Youmans Neurological Surgery. Philadelphia: Elsevier Saunders; 2011. p. 3978-90
8. Heros RC, Lee SH. The combined pterional/anterior temporal approach for aneurysms of the upper basilar complex: Technical report. Neurosurgery. 1993. 33: 244-50
9. Hopkins LN, Budny JL. Complications of intracranial bypass for vertebrobasilar insufficiency. J Neurosurg. 1989. 70: 207-11
10. Ito M, Kinoshita A, Takemoto O, Kohmura E, Hayakawa T. Superficial temporal artery to superior cerebellar artery anastomosis via the presigmoid retrolabyrinthine transtentorial approach. Surg Neurol. 1995. 43: 360-2
11. Katsuno M, Tanikawa R, Miyazaki T, Ota N, Noda K, Izumi N. The limits and countermeasures of the anterior temporal approach for unruptured upper basilar artery aneurysms. No Shinkei Geka. 2013. 41: 311-8
12. Kawashima M, Rhoton AL, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part II: Posterior circulation. J Neurosurg. 2005. 102: 132-47
13. Khodadad G. Occipital artery-posterior inferior cerebellar artery anastomosis. Surg Neurol. 1976. 5: 225-7
14. King WA, Black KL, Martin NA, Canalis RF, Becker DP. The petrosal approach with hearing preservation. J Neurosurg. 1993. 79: 508-14
15. Motoyama Y, Ohnishi H, Koshimae N, Kanemoto Y, Kim YJ, Yamada T. Direct clipping of a large basilar trunk aneurysm via the posterior petrosal (extended retrolabyrinthine presigmoid) approach--case report. Neurol Med Chir (Tokyo). 2000. 40: 632-6
16. Párraga RG, Ribas GC, Andrade SE, de Oliveira E. Microsurgical anatomy of the posterior cerebral artery in three-dimensional images. World Neurosurg. 2011. 75: 233-57
17. Pessin MS, Lathi ES, Cohen MB, Kwan ES, Hedges TR, Caplan LR. Clinical features and mechanism of occipital infarction. Ann Neurol. 1987. 21: 290-9
18. Sano K. Temporo-polar approach to aneurysms of the basilar artery at and around the distal bifurcation: Technical note. Neurol Res. 1980. 2: 361-7
19. Spetzler RF, Daspit CP, Pappas CT. The combined supra- and infratentorial approach for lesions of the petrous and clival regions: Experience with 46 cases. J Neurosurg. 1992. 76: 588-99
20. Sundt TM, Piepgras DG, Fode NC, Meyer FB.editors. Techniques, results and complications of occipital and temporal artery bypass pedicles to branches of the vertebral and basilar arteries. Sundt's Occlusive Cerebrovascular Disease. Philadelphia, PA: WB Saunders Co; 1994. p. 456-65
21. Tanikawa R, Sugimura T, Hino K, Izumi N, Mitsui N, Yamauchi T. Surgical application of skull base technique for EC-IC bypass to P2 segment. Surg Cereb Stroke (Jpn). 2006. 34: 440-4
22. Tanikawa R, Wada H, Ishizaki T, Izumi N, Fujita T, Hashimoto M. Anterior temporal approach for basilar bifurcation aneurysms as a modified distal transsylvian approach. Surg Cereb Stroke (Jpn). 1998. 26: 259-64
23. Terasaka S, Sawamura Y, Kamiyama H, Fukushima T. Surgical approaches for the treatment of aneurysms on the P2 segment of the posterior cerebral artery. Neurosurgery. 2000. 47: 359-64
24. Ulku CH, Ustun ME, Buyukmumcu M. Distal superficial temporal artery to proximal posterior cerebral artery bypass by posterior oblique transzygomatic subtemporal approach. Skull Base. 2010. 20: 415-20
25. Ulm AJ, Tanriover N, Kawashima M, Campero A, Bova FJ, Rhoton A. Microsurgical approaches to the perimesencephalic cisterns and related segments of the posterior cerebral artery: Comparison using a novel application of image guidance. Neurosurgery. 2004. 54: 1313-27
26. Zador Z, Lu DC, Arnold CM, Lawton MT. Deep bypasses to the distal posterior circulation: Anatomical and clinical comparison of pretemporal and subtemporal approaches. Neurosurgery. 2010. 66: 92-100
27. Zeal AA, Rhoton AL. Microsurgical anatomy of the posterior cerebral artery. J Neurosurg. 1978. 48: 534-59