J Cerebrovasc Endovasc Neurosurg.  2018 Sep;20(3):191-197. 10.7461/jcen.2018.20.3.191.

STA-Distal ACA Bypass Using a Contralateral STA Interposition Graft for Symptomatic ACA Stenosis

• Hwang YH
• Kwon YS
• Lee YH

• KMID: 2422772
• DOI: http://doi.org/10.7461/jcen.2018.20.3.191

Abstract

Intracranial arterial stenosis usually occurs due to atherosclerosis and is considered the most common cause of stroke worldwide. Although the effectiveness of bypass surgery for ischemic stroke is controversial, the superficial temporal artery to the middle cerebral artery bypass for ischemic stroke is a common procedure. In our report, a 50-year-old man presented with sudden-onset left side weakness and dysarthria. An angiogram showed significant stenosis in the junction of the right cavernous-supraclinoid internal carotid artery and right pericallosal artery. Symptoms altered between improvement and deterioration. Magnetic resonance imaging showed a repeated progression of anterior cerebral artery (ACA) infarction despite maximal medical therapy. We performed a STA-ACA bypass with contralateral STA interposition. Postoperative course was uneventful with no further progression of symptoms. Thus, bypass surgery may be considered in patients with symptomatic stenosis or occlusion of the ACA, especially when patients present progressive symptoms despite maximal medical therapy.

Keyword

Anterior cerebral artery; Cerebral revascularization; Infarction; Temporal arteries

MeSH Terms

Anterior Cerebral Artery
Arteries
Atherosclerosis
Carotid Artery, Internal
Cerebral Revascularization
Constriction, Pathologic*
Dysarthria
Humans
Infarction
Magnetic Resonance Imaging
Middle Aged
Middle Cerebral Artery
Stroke
Temporal Arteries
Transplants*

Figure

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  Fig. 1 Preoperative MRI, cerebral angiography, and SPECT. (A) Initial MRI shows acute infarction on the territory of right ACA. (B) 1-month follow up MRI shows further progression of the ACA infarction. (C) Cerebral angiography reveals right supraclinoid cavernous stenosis and right distal ACA (white arrow). (D) Basal and (E) Diamox SPECT shows decreased vascular reserve function in the ACA territory. MRI = magnetic resonance imaging; SPECT = single-photon emission computed tomography; ACA = anterior cerebral artery.

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  Fig. 2 Intraoperative photograph and ICG angiography. (A) Contralateral STA to ipsilateral STA end to end fashioned anastomosis and (B) distal ACA to STA bypass end to side fashioned anastomosis were performed. (C) Intraoperative ICG angiography. ICG = indocyanine green; STA = superficial temporal artery; ACA = anterior cerebral artery.

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  Fig. 3 Cerebral angiography obtained 4 days after surgery and perfusion MRI at 6 months after surgery. (A, B) Blood flows to the right ACA region from right ECA. (C) Basal and (D) Diamox SPECT show improved perfusion status, compared to previous SPECT. MRI = magnetic resonance imaging; ACA = anterior cerebral artery; SPECT = single-photon emission computed tomography.

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