Long-term outcomes after a transcranial microsurgical approach to craniopharyngiomas: a 20-year clinical follow-up study.

Craniopharyngioma (CP) is a mostly benign tumor that is nonetheless one of most formidable skull base lesions. CP tends to recur, and scarce clinical results are available regarding its long-term outcomes. From February 1996 to April 2002, craniopharyngiomas primarily resected by open surgery in a single-center and single-surgeon practice were screened. Medical information regarding patients' baseline, tumor parameters, endocrinological results, complications, and quality of life in those patients with a follow-up longer than 20 years were reviewed. Nineteen out of 187 patients who met the inclusion criteria were eligible, and 78.9% of the patients were admitted due to visual deficits. The transcranial approach was mostly applied for the first attempt of opening resection, with 94.7% gross total resection. The size of the tumor ranged from 25 to 45 mm with a mean maximal diameter of 34.7 mm. Although 7 out of 19 patients received an extra procedure, 6 patients (31.5%) regained fertility, with 3 women bearing a total of 5 children and 3 men fathering a total of 4 children, during the 21.4-year follow-up (range: 20.0-23.3 years). The mean Karnofsky Performance Status (KPS) score was 97.9 (range: 80-100) at the last follow-up, and the physical and mental 36-Item Short Form Health Survey (SF-36) scores were 88.0 and 80.5, respectively. The tumor sizes of the patients who regained fertility were not significantly different from those of the patients who remained infertile (t = 1.29, P > 0.2). The time interval from prior surgery to tumor resection for recurrent cases ranged from 0.3 to 17.4 years (mean, 7.3 years). There was no significant difference in the time until tumor recurrence in the patients who underwent a second surgery, a third surgery, or a fourth surgery. The satisfactory results in the present study revealed favorable long-term outcomes following the transcranial management of CPs, with acceptable endocrinological function and tumor-free survival. A decisive policy of open surgery with the objective of radical tumor removal remains a valid method for the primary treatment of CPs, aiming to avoid retreatment after tumor recurrence involving vital hypothalamic structures or hydrocephalus.

How I do it: internal maxillary artery to middle cerebral artery bypass to manage giant thrombosed internal carotid artery aneurysm.

BACKGROUND: Internal maxillary artery (IMA) bypass has become popularized due to its medium-to-high blood flow, short graft length, and well-matched arterial caliber between donor and recipient vessels. METHOD: We described an open surgery of a NEW "workhorse," the IMA bypass, to treat a giant, thrombosed cerebral aneurysm. The extracranial middle infratemporal fossa (EMITF) approach was used to unveil the pterygoid segment of the IMA for cerebral revascularization. CONCLUSION: Although this technique is technically challenging, the variations in IMA can be effectively identified and sufficiently exposed in this technique to achieve favorable clinical outcomes with a high bypass patency rate.

Treatment of chronic internal carotid artery occlusion by ipsilateral external carotid endarterectomy.

Chronic complete occlusion of the internal carotid artery (ICA) is a common and important cause of ischemic cerebrovascular disease, which can be treated in many ways: antithrombotic and anticoagulant agents, direct or indirect procedure for revascularization. However, there is still no evidence to prove which method is the most effective. Here we reported a case showed the successful endarterectomy of the external carotid artery (ECA) for a chronic complete occlusion of ICA patient. A 50-year-old male patient presented with progressively aggravated left-sided limb weakness and limb cold feeling. Digital subtraction angiography (DSA) showed ICA occlusion and ipsilateral ECA stenosis. The right ECA compensated for blood supply to the middle cerebral artery (MCA) through the accessory meningeal artery and ophthalmic artery. The patient was treated by endarterectomy of ipsilateral ECA (ECEA). In the second day after operation, the symptom was improved significantly. Surprisingly, both ICA and ECA were recanalized and the metabolism of the affected brain tissue was also increased. In conclusion, patients with chronic complete occlusion, ECEA would also be an effective therapeutic method.

Cerebral glucose metabolism changes in chronic ischemia patients following subcranial-intracranial bypass.

The use of the internal maxillary artery (IMA) in intracranial artery bypass or subcranial-intracranial (SC-IC) bypass has recently been described as an alternative to traditional bypass. This study explores cerebral glucose metabolism characteristics of SC-IC bypass. Ten crescendo transient ischemic attack (TIA) patients with chronic occlusion of the middle cerebral artery (MCA) received bypass surgery of IMA with the radial artery graft (RAG) to the branch of MCA. The graft's flow volume (FV) was measured by operative intraoperative duplex ultrasonography. Positron emission tomography (PET)/computed tomography (CT) was used to calculate the preoperational and postoperational average of the standard uptake value (SUVavg) of the 18-fluoro-2-deoxy-D-glucose (18F-FDG) in the region of interest (ROI). The asymmetric index (AI) is recommended to reflect the SUVavg changes, and subsequently, cerebral glucose metabolism changes are supposedly clarified. Patent IMA-RAG-MCA bypass in ten chronic ischemia patients was confirmed by angiography after surgery. The intraoperative FV measurement value was 65.64 ± 10.52 (58.11-73.17) ml/min. Before the operation, the SUVavg of the ROI in the ischemic hemisphere (4.76 ± 2.35 (3.08-6.04)) clearly decreased compared to the one (5.99 ± 2.63 (4.11-7.87)) in the contralateral mirror region (P = 0.003). The result of AI of preoperation minus AI of postoperation was more than 10% (P = 0.031), which indicated suspicious significant changes in cerebral metabolism. All symptoms of study patients having crescendo ischemia were resolved in 1 month after the operation. In the cerebral hypoperfusion territory, uptake of 18F-FDG deceased. Improving the flow volume via SC-IC bypass makes available an elevated uptake of 18F-FDG.

Natural history and clinical outcomes in patients with complex intracranial aneurysms: a review of 115 bypass cases and 22 nonsurgical cases.

The purpose of this study was to evaluate the natural history of patients with these heterogeneous aneurysms to provide guidance for their treatment. This retrospective analysis was performed at a single institution and included 137 patients with complex intracranial aneurysms who underwent a natural history evaluation. Among the 115 patients who underwent bypass surgery, stroke (n = 39, 33.9%) was the most common clinical symptom followed by progressively severe headaches (n = 25, 21.7%). Of the 104 patients with follow-up information, 87 (83.7%) returned to a normal life within a mean follow-up of 4.17 ± 2.09 years. Ten deaths (9.6%) occurred after a mean of 1.3 ± 0.9 years. Among the 22 patients who selected nonsurgical treatment, mass effect (n = 9, 40.9%) was the most common clinical presentation, and 14 deaths (63.6%) occurred after a mean of 3.3 ± 2.5 years. The modified Rankin scale (mRS) scores of 5 survivors (5/22, 22.7%) progressed from 0-2 at initial presentation to 3-4. Bypass surgical treatment for these aneurysms appears to be effective and can achieve good clinical outcomes without additional limitations related to individual aneurysms despite the impact of recent endovascular techniques on vascular surgery.

The re-anastomosis end-to-end bypass technique: a comprehensive review of the technical characteristics and surgical experience.

Re-anastomosis end-to-end bypass is a straightforward subtype of intracranial-intracranial reconstruction technique that has been utilized to treat complex aneurysms and skull base tumors. This simple technique involves connecting the cut ends of an afferent and efferent artery under added tension after excising the lesion. The current study aims to provide a detailed description of the technical pitfalls, ideal anatomical sites and indications, and clinical outcomes for intracranial complex disorders. A literature search was performed using the terms "intracranial-intracranial bypass," "re-anastomosis bypass," "reconstructive bypass," "end-to-end bypass," and "end-to-end anastomosis" to identify pertinent articles. Articles involving end-to-end re-anastomosis combined with other bypass methods were excluded. Computer-tablet-drawn illustrations of this technique are provided to enhance comprehension. Eighty-six patients who met our search and inclusion criteria were identified between 1978 and the present. However, comprehensive descriptions of medical records and neuroimaging were available in only 41 cases (40 complex aneurysms and a skull base tumor). Of 40 reported cases of complex cerebral aneurysms treated by this technique, the overall rate of full recovery without complication is 87.5% (35/40). Meanwhile, all aneurysms were completely eliminated from the circulation, with 92.5% of bypasses being patent. End-to-end re-anastomosis remains a simple modality in the microsurgical bypass armamentarium. Safe and effective surgical outcomes can be achieved in select cases that rarely involve perforators or branches.

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms.

OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10-37 mm), and the patients had a mean age of 31.7 years (range 14-56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2-74 months) and 53.1 months (range 19-82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.

Serpentine aneurysm of the posterior cerebral artery treated by internal maxillary artery bypass followed by parent artery occlusion: a case report and literature review.

Serpentine aneurysms of the posterior cerebral artery (PCA) treated by the internal maxillary artery (IMA) bypass are rare. Here, the authors report the case of a 34-year-old male patient who presented with a half-year history of gradual severe headache and right-sided limb monoparesis and paresthesia lasting for 1 week. Preoperative angiograms showed a serpentine aneurysm in the left distal PCA, which was treated with internal maxillary artery-radial artery-posterior cerebral artery (IMA-RA-PCA) bypass followed by parent artery occlusion (PAO). The postoperative course was uneventful; radiological images revealed that the aneurysm disappeared, and there was good graft patency and excellent perfusion of the distal PCA territories. To the authors' knowledge, this is the first and only case of distal PCA serpentine aneurysm to be treated by IMA-RA-PCA bypass followed by proximal PAO. These findings suggest that IMA bypass surgery is a good and feasible treatment option for serpentine aneurysms of the PCA that can preserve the parent artery. Moreover, the anatomic segments of the PCA and different treatment options available for PCA serpentine aneurysms are also discussed in this study.

Flow reversal bypass surgery: a treatment option for giant serpentine and dolichoectatic aneurysms-internal maxillary artery bypass with an interposed radial artery graft followed by parent artery occlusion.

Giant serpentine and dolichoectatic aneurysms (GSDAs) are a small subgroup of intracranial aneurysms that often have poor clinical outcomes and are hardly to be treated by either conservative or endovascular management. We assessed seven patients who underwent internal maxillary artery bypass using radial artery graft interposition followed by parent artery occlusion to treat GSDAs. Intraoperative Doppler ultrasonography was used to assess the patency of the graft. CT angiogram or DSA were used postoperatively. The patients received follow-up after discharge and their neurological outcomes were measured using the Glasgow Outcome Score. Postoperative angiogram demonstrated that all the grafted conduits were patent, and the aneurysms were absent in two and collapsed or shrank in five of the patients. The rate of normal life or independent daily activities after internal maxillary artery bypass in the anterior and posterior GSDA patients was 66.7 and 75 %, respectively. One patient experienced postoperative frontal ischemia and was managed conservatively. His symptoms had completely resolved at discharge. No patient encountered perforator's occlusion in the series. During 2.6 years follow-up, six patients experienced favorable outcomes. One patient died in the third year after discharge attribute to unrelated disease. Based on the mechanism of flow reversal, internal maxillary artery bypass with radial artery graft followed by patent artery occlusion is an effective, minimally invasive treatment modality for select patients with GSDAs.

Measurement of Blood Flow in an Intracranial Artery Bypass From the Internal Maxillary Artery by Intraoperative Duplex Sonography.

This study explored the hemodynamic characteristics of a subcranial-intracranial bypass from the internal maxillary artery by measuring blood flow on intraoperative duplex sonography. The hemodynamic parameters of the internal maxillary artery (n = 20), radial artery (n = 20), internal maxillary artery-middle cerebral artery bypass (n = 42), and internal maxillary artery-posterior cerebral artery bypass (n = 9) were measured by intraoperative duplex sonography. There was no significant difference in the internal diameters of the internal maxillary and radial arteries (mean ± SD, 2.51 ± 0.34 versus 2.56 ± 0.22 mm; P = .648). The mean radial artery graft length for subcranial-intracranial bypasses was 88.5 ± 12.78 mm (95% confidence interval [CI], 80.8-90.2 mm). Internal maxillary artery-middle cerebral artery bypasses required a shorter radial artery graft than internal maxillary artery-posterior cerebral artery bypasses (77.8 ± 2.47 versus 104.8 ± 4.77 mm; P = .001). The mean flow volumes were 85.3 ± 18.5 mL/min (95% CI, 76.6-93.9 mL/min) for the internal maxillary artery, 72.6 ± 26.4 mL/min (95% CI, 64.3-80.9 mL/min) for internal maxillary artery-middle cerebral artery bypasses, and 45.4 ± 6.7 mL/min (95% CI, 40.7-50.0 mL/min) for internal maxillary artery-posterior cerebral artery bypasses. All grafts were opened after the success of the salvage procedures had been established, and the early patency rates (1 month after the operation) were 95% for internal maxillary artery-middle cerebral artery bypasses and 100% the internal maxillary artery-posterior cerebral artery bypasses. Measurement of blood flow by intraoperative sonography can be helpful in decision making and predicting graft patency and success after neurosurgical bypass procedures.

Bilateral cavernous carotid aneurysms treated by two-stage extracranial-intracranial bypass followed by parent artery occlusion: case report and literature review.

Bilateral cavernous carotid aneurysms (CCAs) are often not amenable to neurosurgical clipping or endovascular coiling. Here, we report the case of a 50-year-old female who presented with a 1-year history of gradual severe headache. Preoperative angiograms revealed bilateral CCAs. Among these findings, the right giant CCA had been trapped after the external carotid artery-saphenous vein-middle cerebral artery (ECA-SV-MCA) bypass 8 years prior. Additionally, the left CCA was again trapped after the internal maxillary artery-radial artery-middle cerebral artery (IMA-RA-MCA) bypass, followed by parent artery occlusion (PAO), because of the enlargement of a 0.4-cm aneurysm to a 1.3-cm aneurysm during the 5th to 8th years following surgery. Postoperative radiologic findings proved that the aneurysms disappeared with good graft patency of the bilateral anastomoses and excellent filling of the bilateral MCA territories. This is the first case of bilateral CCAs treated with two stages of bilateral high-flow extracranial-intracranial (EC-IC) bypass, including an IMA-RA-MCA bypass.

A comparison of haemodynamics between subcranial-intracranial bypass and the traditional extracranial-intracranial bypass.

BACKGROUND: Ischemic cerebrovascular diseases are traditionally treated using an extracranial-intracranial (EC-IC) bypass. The use of the internal maxillary artery (IMA) in the subcranial-intracranial (SC-IC) bypass was recently described as an alternative treatment. However, the haemodynamics of this new approach have not been defined. METHODS: The haemodynamic parameters (flow volume [FV], internal diameter [ID], time-averaged mean velocity [TAM], pulsatility index [PI] and resistance index [RI]) of the IMA-radial artery graft (RAG)-middle cerebral artery (MCA) (n = 12) bypass and superficial temporal artery (STA)-MCA bypass (n = 18) were measured using intraoperative duplex ultrasonography and compared. RESULTS: The FV was 81.36 ± 30.41 (62.05-100.70) ml/min for the IMA-RAG-MCA bypass. This was significantly higher than that of the STA-MCA bypass (27.25 ± 9.32 (22.62-31.88) ml/min; P < .01). The ID and TAM in the IMA-RAG-MCA bypass were higher than in the STA-MCA bypass (P < .01; P < .01). No significant differences were observed in PI (P ≈ .21) and RI (P ≈ .08). The early patency rate (one month after the operation) was 100% for the IMA-RAG-MCA bypass and 94% for the STA-MCA bypass. CONCLUSIONS: The IMA-RAG-MCA bypass provides moderate to high blood flow to the revascularized territory and blood flow was higher by this method than the STA-MCA bypass.

Bypass surgery to treat symptomatic fusiform dilation of the internal carotid artery following craniopharyngioma resection: report of 2 cases.

Fusiform dilation of the internal carotid artery (FDICA) is an infrequent vascular complication following resection of suprasellar lesions in the pediatric population, and its course appears to be benign without apparent clinical symptoms. However, data correlating symptomatic FDICA with bypass surgery are scarce. The authors here report 2 symptomatic cases that were treated using internal maxillary artery bypass more than 5 years after total removal of a craniopharyngioma at an outside institution. Both cases of FDICA were resected to relieve the mass effect and to expose the craniopharyngioma. The postoperative course was uneventful, and radiological imaging revealed graft conduit patency. To the authors' knowledge, this is the first reported use of extracranial to intracranial bypass to treat FDICA following removal of a suprasellar lesion. Their findings suggest that bypass surgery is a useful therapeutic approach for symptomatic cases of FDICA and total removal of recurrent craniopharyngioma. Moreover, the indications for surgical intervention and treatment modalities are discussed in the context of previous relevant cases.

Management of complex intracranial aneurysms with bypass surgery: a technique application and experience in 93 patients.

Despite advances in microsurgery and the development of new endovascular techniques, the treatment of complex intracranial aneurysms remains a daunting challenge for neurosurgeons. In the present study, we retrospectively reviewed our experience of bypass surgery in the treatment of 93 cases of complex intracranial aneurysms. A series of 93 consecutive cases of complex intracranial aneurysms were treated with bypass surgery between April 2004 and July 2013. Radial artery (RA) grafts were used in 58 cases, saphenous vein (SV) grafts in 16 cases, and occipital artery (OA) grafts in 6 cases, while the remaining 13 cases were managed with superficial temporal artery (STA) grafts. In this series, the aneurysms were excised after trapping in 32 cases with mass effect and neural compression. Proximal occlusion of the parent artery was performed in 22 cases of fusiform or giant dissecting aneurysms with subsequent retrograde flow to avoid compromise of the perforators nearby. Trapping was performed after bypass surgery in the remaining 39 cases. Postoperative angiographies were performed in 91 patients and patency of the bypass graft and obliteration of the aneurysms were confirmed in 89 patients. Patency of the bypass could not be confirmed in the remaining two patients, of which one presented with cerebral infarction due to graft occlusion, and the other remained asymptomatic. Within 1 month after surgery, 88 patients had good outcome, four patients needed assistance for daily living, and one death occurred due to brainstem infarction. In 77 patients with a mean follow-up of 3.0 years, 72 patients had good outcome, 4 patients needed assistance for daily living, and 1 death occurred unrelated to surgery. Complex intracranial aneurysms present unique therapeutic challenges that require thorough surgical planning, individualized treatment strategies, and refined neurovascular techniques for successful outcome. Proper use of bypass surgery is imperative in preserving the parent artery and its major perforators. The internal maxillary artery, used as a donor in a bypass, is an effective method due to its shorter distance from the recipient vessels and relatively large diameter with resulting higher flow rate.

Ectopic recurrence of craniopharyngioma: Reporting three new cases.

Ectopic recurrence of craniopharyngioma is extremely rare following transcranial procedures of primary tumour. Here we describe 3 new cases of ectopic recurrence along the surgical route after transcranial gross total resection of primary tumour. All 3 cases are male adults--2 of them had papillary-type tumour with the other being adamantinomatous. All ectopic tumours were safely resected via repeated craniotomy. Long-term surveillance of patients with resected craniopharyngioma is essential.

Long-term outcomes of trapping vertebral artery-posterior inferior cerebellar artery dissecting aneurysms after revascularization.

OBJECTIVE: This study is designed to evaluate the long-term outcome of trapping vertebral artery-posterior inferior cerebellar artery (VA-PICA) dissecting aneurysms after revascularization. MATERIALS AND METHODS: Five patients with VA-PICA dissecting aneurysms were treated surgically between 2007 and 2010. All the aneurysms were trapped through a far-lateral approach after revascularization of the PICAs by occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. All patients were scheduled for clinical follow-up in the out-patient department at 3 months, 6 months, then annually. Computed tomography (CT) scan and CT angiography, or magnetic resonance (MR) imaging and MR angiography were performed to assess the anastomosis and cerebral blood supply. RESULTS: Among the five patients, two of them did not have any neurological deficit after surgery, the other three had post-operative lower cranial nerve palsy but recovered completely within 6 months. Post-operative cerebral angiography (received by two patients) and CT angiography (received by the other three patients) showed patent bypasses in all patients and there was no reappearance of the aneurysms. After following-up from 47 to 74 months (61 month is the median follow-up period), all patients showed excellent outcomes. CONCLUSION: Trapping the aneurysms after revascularization of PICAs by OA-PICA bypass is a safe method to treat the VA-PICA dissecting aneurysms.

[Application of virtual reality system for individualized preoperative planning of sphenoidal ridge meningioma].

OBJECTIVE: To evaluate the usefulness of virtual reality (VR) technique for individualized preoperative planning of sphenoidal ridge meningioma. METHODS: Multiple imaging data of CTA/MR were acquired from 41 surgical patients with sphenoidal ridge meningioma during the period from July 2009 to June 2013 were transferred into the Dextroscope system. A suite of built-in 3D tools enabled users to obtain measurement and simulated intraoperative viewpoint about the lesion and adjacent anatomic structures. A sophisticated preoperative plan was defined.Operative duration, total resection rate, complication rate and KPS scores were compared with control group undergoing routine operation (n = 27). RESULTS: 3D stereoscopic VR images in accordance with reality were reconstructed for 41 cases. As compared with control group,VR preoperative plan could shorten operative duration and reduce complication rate (P < 0.05). However, there was no improvement in total resection rate or KPS score (P > 0.50). CONCLUSION: VR technique of Dextroscope system offers comprehensive information of sphenoidal ridge and related neurovascular anatomical structure. Thus it may aid surgical planning and facilitate individualized operation.

Successful surgical management of a superior cerebellar artery aneurysm in a patient with Marfan syndrome: illustrative case.

BACKGROUND: Marfan syndrome, a connective tissue disorder, poses unique challenges in neurosurgery, given the fragility of vascular structures. Superior cerebellar artery (SCA) aneurysms in patients with the syndrome are rare and present distinct surgical difficulties, necessitating innovative approaches. OBSERVATIONS: A 29-year-old male with Marfan syndrome presented with a subarachnoid hemorrhage from a ruptured SCA aneurysm. Given the lack of a defined aneurysm neck and the small diameter of the SCA, standard clipping and endovascular therapies were unsuitable. A microsurgical approach using microsutures was successfully employed, effectively managing the aneurysm while preserving the parent artery. LESSONS: This case underscores the efficacy of the microsuture technique in complex neurosurgical scenarios, particularly in patients with connective tissue disorders such as Marfan syndrome. The adaptability of surgical strategies, as demonstrated in this case, is crucial for achieving successful outcomes in patients with unique anatomical challenges.