Double-barrel STA-MCA bypass for cerebral revascularization: lessons learned from a 10-year experience

Abstract

OBJECTIVE In select patients, extracranial-intracranial (EC-IC) bypass remains an important tool for cerebral revascularization. Traditionally, superficial temporal artery–middle cerebral artery (STA-MCA) bypass was performed using one limb of the STA only. In an attempt to augment flow and to direct flow to different ischemic areas of the brain, the authors adopted a “double-barrel” technique in which both branches of the STA are used to revascularize distinct MCA territories. METHODS A series of consecutive double-barrel STA-MCA bypasses performed between 2010 and 2020 were reviewed. Each anastomosis was directed to augment flow to a territory most at risk based on preoperative perfusion studies, cerebral angiography, and intraoperative indocyanine green data. CT perfusion and CTA were routinely used to evaluate postoperative augmentation and graft patency. Patient perioperative outcomes, surgical complications, and modified Rankin Scale (mRS) scores at the last follow-up were reported. RESULTS Forty-four patients (16 males, 28 females) successfully underwent double-barrel STA-MCA bypass on 54 cerebral hemispheres: 28 operations were for moyamoya disease, 23 for atherosclerotic disease refractory to medical therapy, 2 for complex cerebral aneurysms, and 1 for carotid occlusion as a sequela of cavernous meningioma growth. Ten patients underwent multiple operations, 9 of whom had moyamoya disease/syndrome, with the subsequent operation on the contralateral hemisphere. The average patient age at surgery was 45.1 years (range 14–73 years), with a mean follow-up time of 22.1 months. Intraoperative graft patency was confirmed in 100% of cases, and 101 (98.1%) of the 103 anastomoses with imaging follow-up were patent. Perfusion to the revascularized hemisphere was improved in 88.2% of cases. Perioperative ischemic and hemorrhagic complications occurred in 8 procedures (2 were asymptomatic), whereas remote ischemic and hemorrhagic events occurred in 7 cases. There was no mortality in the series, and the mean patient mRS scores were 1.72 at presentation and 1.15 at the last follow-up. CONCLUSIONS The high rates of intraoperative and postoperative patency support the feasibility of dual-anastomosis STA-MCA bypass for revascularization. The perioperative complication rate is not significantly different from that of single-anastomosis bypass. The functional outcomes at follow-up and perfusion improvement postoperatively support the efficacy and safety of this method as a treatment strategy.

Bibliometric and visual analysis of cerebral revascularization from 1999 to 2022

“…In this study’s keyword analysis, we identified several significant research hot spots in the field of cerebral revascularization over the past two decades, including “cerebral revascularization,” “moyamoya disease,” “surgery,” “extracranial intracranial bypass,” “occlusion,” “revascularization,” “superficial temporal artery,” “aneurysm,” “stroke,” and “internal carotid artery” ( Table 6 ). We subsequently reviewed the relevant literature and discovered that, in recent years ( Gunawardena et al, 2019 ; Kan et al, 2021 ), “extracranial intracranial bypass” or “STA-MCA bypass” is the most important neurosurgical treatment in the field of cerebral revascularization, and the majority of them have significant effects on the treatment and prognosis of moyamoya disease, for instance, the safety of STA-MCA bypass in the treatment of moyamoya disease ( Liu et al, 2017 ), the hemodynamic problems of STA-MCA bypass in the treatment of moyamoya disease ( Jeffree and Stoodley, 2009 ), the significance of Color Doppler monitoring of STA-MCA bypass in the treatment of moyamoya disease ( Kawamata et al, 2011 ; Feghali et al, 2019 ). However, we employed keyword clustering analysis to determine the tight association within the cerebral revascularization research field.…”

“…In this study's keyword analysis, we identified several significant research hot spots in the field of cerebral revascularization over the past two decades, including "cerebral revascularization, " "moyamoya disease, " "surgery, " "extracranial intracranial bypass, " "occlusion, " "revascularization, " "superficial temporal artery, " "aneurysm, " "stroke, " and "internal carotid artery" (Table 6). We subsequently reviewed the relevant literature and discovered that, in recent years (Gunawardena et al, 2019;Kan et al, 2021), "extracranial intracranial bypass"…”

Clinical Management of Moyamoya Patients

“…Surgical techniques can be classified into three groups: direct, indirect, and combined revascularization procedures. Direct revascularization, which has been performed in MMA patients since the 1970s, consists of a direct extracranial-intracranial bypass, which could be an STA to MCA bypass, as performed in most cases, or a middle meningeal artery (MMA) to MCA bypass [99][100][101][102]. Anterior cerebral arteries could also be considered as receiving vessels if severe ischemia is found in the ACA area.…”

Combined Double-Barrel Superficial Temporal Artery to M4 Bypass and Parent Artery Occlusion for the Treatment of Complex Intracranial Aneurysms in Internal Carotid Artery and Middle Cerebral Artery: A Retrospective Case Series

“…Recently, direct double-barrel STA to MCA bypass has been applied in the reconstruction of regional cerebral blood flow for giant intracranial aneurysms and Moyamoya disease. 12 This type of anastomosis allows distal MCA (M4) to be the recipient sites, which improves operability and makes the recipient's vessels easier to obtain. Given that its capacity for blood flow supply has not been well documented, we retrospectively investigated patients with complex intracranial aneurysms who received this procedure in our center during the past 5 years and assessed this bypass' ability to provide blood flow for distal parent artery areas.…”