Superficial temporal artery to middle cerebral artery bypass: past, present, and future

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The aim of this study was to review the historical developments and current status of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass.</jats:p></jats:sec> <jats:sec> <jats:title>Method</jats:title> <jats:p>A literature review was performed to review the origins and current uses of the STA bypass procedure in neurosurgery.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The idea of providing additional blood supply to the brain to prevent stroke and maintain neurological function has been present in the mind of neurosurgeons for many decades. In 1967 the first STA–MCA bypass was done by M. G. Yaşargil, and an enormous step was made into the field of microneurosurgery and cerebral revascularization. During the decades that followed, this technique was used as an adjuvant or a definitive surgical treatment for occlusive disease of the extracranial and intracranial cerebral vessels, skull base tumors, aneurysms, carotid–cavernous fistulas, cerebral vasospasm, acute cerebral ischemia, and moyamoya disease. With the results of the first randomized extracranial–intracranial (EC–IC) bypass trial and the development of endovascular techniques such as angioplasty for intracranial atherosclerotic disease and cerebral vasospasm, the indications for STA–MCA bypass became limited. Neurosurgeons continued to perform EC–IC bypasses as an adjuvant to clipping of aneurysms and in the treatment of skull base tumors and moyamoya disease; the procedure is less commonly used for atherosclerotic carotid artery occlusion (CAO) with definite evidence of hemodynamic insufficiency. The evidence that patients with symptomatic CAO and “misery perfusion” have an increased stroke risk has prompted a second trial for evaluating EC–IC bypass for stroke prevention. The Carotid Occlusion Surgery Study is a new trial designed to determine whether STA–MCA bypass can reduce the incidence of stroke in these patients. New trials will also reveal the role of the STA–MCA bypass in the prevention of hemorrhages in moyamoya disease.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The role of STA–MCA bypass in the management of cerebrovascular disease continues to be refined and evaluated using advanced imaging techniques and by performing randomized trials for specific purposes, including symptomatic CAO.</jats:p></jats:sec>

Indocyanine Green Videoangiography for Confirmation of Bypass Graft Patency

“…The role of intracranial bypasses grew after the introduction of microsurgical techniques in the 1960s and 1970s 25) . In 1967, Yasargil performed the first STA-MCA bypass in a patient with complete occlusion of the MCA 28,29) .…”

“…In 1967, Yasargil performed the first STA-MCA bypass in a patient with complete occlusion of the MCA 28,29) . Subsequently, the indications for EC-IC bypasses expanded to include inaccessible extracranial carotid stenosis or occlusion, occlusive intracranial disease, complex aneurysms not amenable to simple clip ligation, skull base tumors, cerebral vasospasm, carotid dissection, carotid-cavernous fistulas, and moya-moya disease 7,20,25) . The EC-IC bypass trial in 1985 failed to show surgical benefit over medical therapy leading to a decrease in the performance of the procedure 23) .…”

“…Since the original description of the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass by Donagy and Yasargil in 1967 a number of extracranial to intracranial (EC-IC) and intracranial to intracranial (IC-IC) bypasses have been used to augment cerebral blood flow in a variety of conditions 25) . Adherence to meticulous microsurgical techniques is essential for high short-term and long-term patency rates 28) .…”

Moyamoya disease: a summary

“…Most cases (77%) are treated surgically because this has been shown to be more effective than nonsurgical treatment. 15,42,67 Medical treatments that have been proposed include vasodilators, antiplatelet agents, antifibrolytic agents, and fibrinolytic agents. 68 However, the efficacy of medical treatments has yet to be proven in clinical trials.…”

“…43,49 In children with MMD, direct and indirect extracranial-intracranial bypass has been shown to improve symptoms, reverse neurological deficits, prevent further ischemic episodes, allow normal intelligence development, decrease seizure activity, and result in the disappearance of involuntary movements. 67 In adults, these procedures have resulted in the prevention of ischemic episodes and improvement in symptoms and cerebral hemodynamics.…”