April 29, 2016
Revascularization may be an effective strategy for management of hemorrhagic dissection with critical stenosis. Let's review the events around the care of a 52 year-old male who presented with acute right-sided subarachnoid hemorrhage and crescendo left- sided weakness. Imaging demonstrated small amount of subarachnoid hemorrhage over the right front temporal convexity, and angiogram also diagnosed critical stenosis at the level of the frontal trunk of the MCA. MRI confirmed very similar findings. Due to progressive TIA symptoms of this patient and evidence of acute subarachnoid hemorrhage, my strategy involved trapping and clip ligation of the effected segment of the frontal trunk, But prior performing such a procedure, an revascularization technique for the distal M2 trunk would be necessary. Therefore, STA revascularization of the distal trunk was planned. Let's go ahead and review the head positioning and planning of the incision in this case. A right frontal temporal craniotomy was planned. However, the STA had to be harvested for revascularization. Here's the path of the STA based on micro-Doppler mapping. The incision was extended more anteriorly so that the area of the dissection at the anterior aspect of the Sylvian fissure can also be exposed. Here's the mapping of the pathway of the STA. I dissect this scalp just superior to the vessel or superficial to the vessel. The STA is generously dissected. A small amount of soft tissue cuff is left around the parietal branch of the ICA. It's perforating arteries are coagulated and cut. Here's the torturous route of the proximal STA. Vessel loops are used to mobilize the vessel so further dissection can be completed underneath the vessel. Next, a front temporal craniotomy was completed. Sylvian fissure was widely dissected. You can see the area of the dissection along the frontal M2 trunk. Before trapping this section of the frontal trunk, the revascularization procedure was completed. During the craniotomy, I wrap the STA in a piece of glove so that the vessel is protected from the drill. The distal end of the donor vessel is prepared. Here's the M2 trunk just distal to the dissection site. The soft tissue around the distal end of the donor site is removed. It looks relatively clear. A distal M2 is prepared for the arteriotomy and the anastomosis. 9-0 running suture was used for completion of the anastomosis. The toe and the heel of the anastomosis were completed first. Initially, the heel and next the toe. The fish-mouthing technique of the distal donor vessel increases the surface of the anastomosis. In this case, actually the inter-optic technique was used. The inter-optic technique avoids any stenosis at the level of the anastomosis. However, the running method can potentially carry an increased risk of stenosis at the anastomotic site. Due to the larger caliber of the anastomosis, a running suture is quite acceptable in this case, and may decrease the occlusion time during the performance of the anastomosis. The redundant part of the distal donor site was also removed. The other side of the anastomosis is being completed. Here are the final stitches for the completion of the anastomosis. Ample amount of heparin irrigation is used. The flow is restored. Hemostasis is obtained using a piece of cotton. Next straight permanent clips are used to trap and exclude the part of the M2 that was dissected and involved the area of the critical stenosis, micro- Doppler ultrasonography confirmed adequate flow within the bypassed area. You can see evidence of distal flow through the STA donor. The affected side is excluded. Postoperative angiography demonstrated excellent reconstitution of flow distal to the M2 trunk by the STA. Here you can see the STA branch and the distal flow within the M2 trunk. The affected segment of the funnel trunk was also excluded and this patient recovered from his surgery without any neurologic sequelae. Thank you.
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