Superficial temporal artery–middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia

Clinical article

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Object

Superficial temporal artery (STA)–middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients.

Methods

The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway.

Results

Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation.

Conclusions

This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.

Abbreviations used in this paper:BP = blood pressure; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; CVR = cerebrovascular reserve; FEV1 = forced expiratory volume in 1 second; ICA = internal carotid artery; 123I-IMP = N-isopropyl-p-[123I]iodoamphetamine; MCA = middle cerebral artery; rCBF = regional cerebral blood flow; STA = superficial temporal artery; TIA = transient ischemic attack.

Article Information

Address correspondence to: Yasuhiko Kaku, M.D., Department of Neurosurgery, Asahi University Murakami Memorial Hospital, Hashimoto-cho 3-23, Gifu, Japan 500-8523. email: kaku@murakami.asahi-u.ac.jp.

Please include this information when citing this paper: published online May 25, 2012; DOI: 10.3171/2012.4.JNS111958.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 4. Upper: The 3D CT angiogram demonstrates a parietal branch of the STA within the scalp and a cortical artery on the brain surface. The most suitable segment of both the artery provided as the donor (arrow) and the recipient (arrowhead) arteries for extracranial-intracranial bypass is demonstrated. The distance between the previously noted segment of the donor artery and the superior border of the helix can be calculated. Lower: The image of the craniotomy is shown superimposed on the skull image of the preoperative 3D CT angiogram. The star indicates the previously noted segment of the donor artery as the center of the craniotomy. The arrow indicates the distance between the segment of the donor artery and the rostral attachment of the ear.

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    Case 4. Intraoperative photographs of the anesthesia procedure. Left: The head of the patient is fixed with an adjustable pillow, and the airway is left unsecured. Right: A sufficient amount of local anesthesia (35–40 ml of a combined solution of 2% lidocaine and 0.25% bupivacaine) is first infiltrated to the superficial layer of the preselected scalp incision line on the STA, then as a circular scalp block around the scalp incision line throughout the entire thickness of the scalp, and finally to the temporal muscle.

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    Case 4. Intraoperative photographs of the surgical procedure. A: A 5-cm linear skin incision is made over the parietal branch of the STA, the center of which was the point that was measured on the preoperative 3D CT angiogram. B: The donor artery, which is the parietal branch of the STA (arrow), is dissected. C: The recipient artery (single arrow) can be identified at the center of the craniotomy. The double arrow indicates the donor artery. D: The end-to-side anastomosis is completed using interrupted sutures.

  • View in gallery

    Case 4. A: Preoperative MR angiogram demonstrating the right ICA occlusion with stenosis of the right proximal A1 segment of the anterior cerebral artery (arrow). B: Magnetic resonance angiography demonstrating moderate stenosis of the left proximal ICA (arrow). C: 123I-IMP SPECT demonstrating a resting rCBF decreased to 80% of the normal value (left) and a CVR capacity decreased to 10% in the right MCA territory (right). D: Postoperative MR angiography confirming the patency of the STA-MCA bypass. The arrow indicates the anastomotic site.

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