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[High-flow transcranial bypass for prevention of brain ischemia]
C A Tulleken1, A van der Zwan, L J Kappelle
1Kliniek voor Neurochirurgie, Universitair Medisch Centrum, Utrecht.
Insights
A new high-flow transcranial bypass technique safely restores brain blood flow. This advanced method uses laser-assisted connections for patients with internal carotid artery issues, improving circulation effectively.
Area of Science:
- Neurosurgery
- Vascular Surgery
- Cerebrovascular Surgery
Background:
- Internal carotid artery occlusion necessitates alternative cerebral blood supply strategies.
- Traditional low-flow bypasses using superficial temporal artery have limited efficacy due to small vessel size.
- Advancements in surgical techniques are crucial for managing complex cerebrovascular conditions.
Observation:
- Excimer laser-assisted anastomosing technique enables safe creation of high-flow bypasses.
- Donor vessels like the great saphenous vein connect the external carotid artery to the intracranial internal carotid artery.
- This technique facilitates safe internal carotid artery closure in select patient groups.
Findings:
- High-flow transcranial bypass achieved a mean flow of 140 ml/min in approximately 90 patients.
- Successful bypass creation allowed for internal carotid artery occlusion in patients with giant aneurysms, skull base tumors, or brain ischemia.
- Demonstrated efficacy in complex cases, including a patient with progressive ophthalmoplegia due to a giant aneurysm.
Implications:
- Offers a viable solution for patients requiring internal carotid artery sacrifice.
- Enhances treatment options for cerebrovascular diseases and complex cranial pathologies.
- Potential to improve neurological outcomes by ensuring adequate cerebral perfusion.
Abstract:
In patients in whom the internal carotid artery has to be occluded because of the presence of an intracranial giant aneurysm or an infiltrating skull base tumour and in patients with brain ischaemia, whose internal carotid artery has been occluded spontaneously on the basis of atherosclerosis, a transcranial bypass can be created. Since the beginning of the seventies 'low-flow bypasses' are made in which a branch of the superficial temporal artery is connected with a cortical branch of the middle cerebral artery. Because of the small calibre of the blood vessels involved the desired effect on the brain circulation is limited. Thanks to the nonocclusive Excimer laser-assisted anastomosing technique, developed by Tulleken et al. in the last fifteen years, it is now possible to create a high-flow bypass in a safe way. A donor vessel, e.g. the V. saphena magna, is connected at one end to the external carotid artery and at the other to the intracranial part of the internal carotid artery beyond the pathological lesion. The mean flow through the bypass was 140 ml/min in about 90 patients. For example, in three patients, a woman aged 45 with rightsided progressive ophthalmoplegia due to a giant aneurysm, a woman aged 31 years with an aneurysm in the right middle ear and a man with a chemodectoma at the base of the skull, a transcranial high-flow bypass was created nonocclusively, after which the internal carotid artery was closed without any problems.