The anterior temporal artery: an underutilized but robust donor for revascularization of the distal middle cerebral artery

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OBJECTIVE

The anterior temporal artery (ATA) supplies an area of the brain that, if sacrificed, does not cause a noticeable loss of function. Therefore, the ATA may be used as a donor in intracranial-intracranial (IC-IC) bypass procedures. The capacities of the ATA as a donor have not been studied previously. In this study, the authors assessed the feasibility of using the ATA as a donor for revascularization of different segments of the distal middle cerebral artery (MCA).

METHODS

The ATA was studied in 15 cadaveric specimens (8 heads, excluding 1 side). First, the cisternal segment of the artery was untethered from arachnoid adhesions and small branches feeding the anterior temporal lobe and insular cortex, to evaluate its capacity for a side-to-side bypass to insular, opercular, and cortical segments of the MCA. Any branch entering the anterior perforated substance was preserved. Then, the ATA was cut at the opercular-cortical junction and the capacity for an end-to-side bypass was assessed.

RESULTS

From a total of 17 ATAs, 4 (23.5%) arose as an early MCA branch. The anterior insular zone and the frontal parasylvian cortical arteries were the best targets (in terms of mobility and caliber match) for a side-to-side bypass. Most of the insula was accessible for end-to-side bypass, but anterior zones of the insula were more accessible than posterior zones. End-to-side bypass was feasible for most recipient cortical arteries along the opercula, except for posterior temporal and parietal regions. Early ATAs reached significantly farther on the insular MCA recipients than non-early ATAs for both side-to-side and end-to-side bypasses.

CONCLUSIONS

The ATA is a robust arterial donor for IC-IC bypass procedures, including side-to-side and end-to-side techniques. The evidence provided in this work supports the use of the ATA as a donor for distal MCA revascularization in well-selected patients.

ABBREVIATIONS AA = angular artery; AP = anterior parietal; ATA = anterior temporal artery; CA = central artery; EC = extracranial; IC = intracranial; MCA = middle cerebral artery; MT = middle temporal; OF = orbitofrontal; PC = precentral; PF = prefrontal; PP = posterior parietal; PT = posterior temporal; TO = temporooccipital; TP = temporopolar.

Article Information

Correspondence Arnau Benet, Department of Neurosurgery, Rm. M-779, University of California, San Francisco, 505 Parnassus Ave., San Francisco, CA 94143. email: arnau.benet@ucsf.edu.

INCLUDE WHEN CITING Published online November 11, 2016; DOI: 10.3171/2016.8.JNS161225.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Cadaveric dissection photographs. A: Twelve cortical branches of the MCA: TP artery (1), ATA (2), MT artery (3), PT artery (4), TO artery (5), AA (6), PP artery (7), AP artery (8), CA (9), PC artery (10), PF artery (11 and 11′), and OF artery (12). B: Opening the sylvian fissure and exposing the ATA (2 branches, numbered 1 and 2; dashed line). IFG = inferior frontal gyrus; TPA = TP artery. C: Side-to-side double-barrel bypass from the ATAs (numbered as 1 and 2; contoured with yellow lines) to the OF artery (12) and CA (9) (contoured with dashed green lines). The interrupted green lines outline the course of the recipient arteries. The yellow line outlines the course of donor ATAs. Figure is available in color online only.

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    Illustration showing the average farthest anastomosis for different bypass choices from the ATA to recipient branches of the MCA. A: Average maximum reach of the ATA for a side-to-side bypass to the insular segment of the MCA on different insular zones relative to the average length of each insular zone (see Table 2 for detailed results and text for description of insular zones). Yellow triangle represents Zone I of the insula, which is the area anterior to the anterior short gyrus, including the anterior limiting sulcus. B: Percentage of specimens with a successful side-to-side bypass to the M3 segment. C: Percentage of specimens with a successful side-to-side bypass to the M4 segment. D: Average maximum reach of the ATA for an end-to-side bypass to the insular segment of the MCA on different insular zones relative to the average length of each insular zone. Yellow triangle represents Zone I of the insula, which is the area anterior to the anterior short gyrus, including the anterior limiting sulcus. See Table 2 for detailed results. E: Percentage of specimens with a successful end-to-side bypass to the M3 segment. F: Percentage of specimens with a successful end-to-side bypass to the M4 segment. Copyright Arnau Benet. Published with permission. Figure is available in color online only.

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    Illustrative case of mobilization of an early ATA to revascularize an insular branch of the MCA. A–C: Axial CT scan (A), digital subtraction angiogram (B), and 3D digital subtraction angiogram (C). This mycotic aneurysm of the right MCA gave rise to massive intracranial rupture in a 24-year-old man with infective endocarditis and multiple previous septic embolic strokes. An efferent M2 branch originated from the dome of the aneurysm (yellow arrow). The red arrow indicates an early branching ATA. D and E: The aneurysm was exposed via splitting of the sylvian fissure and trapped. F and G: The cisternal course of the ATA was released and mobilized to reach the efferent branch coming off the aneurysm. The MCA branch was reimplanted onto the mobilized ATA. H: Postoperative angiogram showing bypass patency. Red arrow indicates the anastomosis. Figure is available in color online only.

  • View in gallery

    Graph depicting the relative frequency of successful end-to-side and side-to-side bypasses to different M3 and M4 arterial territories. C = central artery; ES = end-to-side bypass; SS = side-to-side bypass. Figure is available in color online only.

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