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  • A Quantitative Analysis of Extracranial-Intracranial Bypass Using Pedicled External Carotid Artery Donors

    Final Number:

    Michael Adam Cohen MD; Alexander I Evins MD; Philip E. Stieg MD, PhD; Antonio Bernardo MD

    Study Design:
    Laboratory Investigation

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Cerebral revascularization techniques are essential components of cerebrovascular neurosurgery. External carotid artery (ECA) arterial pedicled donors are faster and safer than dual-anastomosis bypasses in patients with adequate flow. Several recent studies using intraoperative flow measurements have indicated that large diameter grafts are not always necessary to provide adequate flow to high-demand areas. The superficial temporal artery (STA), middle meningeal artery (MMA), and occipital artery (OA) are easily available ECA donors that can augment or replace flow to the anterior or posterior circulation.

    Methods: The STA, MMA, and OA were dissected in 5 cadaveric specimens (10 sides). Frontotemporal, middle fossa, subtemporal, retrosigmoid, far-lateral, suboccipital, supracerebellar infratentorial, and occipital transtentorial approaches were performed on all sides. Depth of field, usable length, angle of exposure, diameter, proximal control, and maneuverability were quantified for all recipient vessels in each possible anastomotic configuration, as well as donor required length and diameter at the site of anastomosis.

    Results: The internal carotid artery was exposed at the petrous and supraclinoid segments and STA and MMA anastomoses were analyzed. The middle cerebral artery was exposed in the sylvian fissure and STA and MMA anastomoses were analyzed. All segments of the posterior cerebral artery were exposed using multiple approaches, and STA, MMA, and OA anastomoses were analyzed. The superior cerebellar artery was exposed by a combination of approaches and STA, MMA, and OA anastomoses were analyzed. The posterior inferior cerebellar artery was exposed using multiple approaches and OA anastomoses were analyzed. The vertebral artery was exposed with a far-lateral approach and OA anastomoses were analyzed.

    Conclusions: Although the STA is the most popular donor for cerebral bypass, the MMA and OA should not be overlooked as potential donors.

    Patient Care: By providing new information on bypass donor and recipient vessel selection which can help reduce bypass failure.

    Learning Objectives: By the conclusion of this session, participants should be able to understanding the factors donor and recipient vessel selection in extracranial-intracranial bypass surgery and our new approach for selection.


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