Botulinum toxin to improve vessel graft patency in cerebral revascularization surgery: report of 3 cases

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Surgical revascularization continues to play an important role in the management of complex intracranial aneurysms and ischemic cerebrovascular disease. Graft spasm is a common complication of bypass procedures and can result in ischemia or graft thrombosis. The authors here report on the first clinical use of botulinum toxin to prevent graft spasm following extracranial-intracranial (EC-IC) bypass. This technique was used in 3 EC-IC bypass surgeries, 2 for symptomatic carotid artery occlusions and 1 for a ruptured basilar tip aneurysm. In all 3 cases, the harvested graft was treated ex vivo with botulinum toxin before the anastomosis was performed. Post-bypass vascular imaging demonstrated patency and the absence of spasm in all grafts. Histopathological analyses of treated vessels did not show any immediate endothelial or vessel wall damage. Postoperative angiograms were without graft spasm in all cases. Botulinum toxin may be a reasonable option for preventing graft spasm and maintaining patency in cerebral revascularization procedures.

ABBREVIATIONS BTX = botulinum toxin; DLCFA = descending branch of the lateral circumflex femoral artery; EC-IC = extracranial-intracranial; ICA = internal carotid artery; MCA = middle cerebral artery; RA = radial artery; SAH = subarachnoid hemorrhage; STA = superficial temporal artery.

Article Information

Correspondence Ben A. Strickland: Keck School of Medicine of the University of Southern California, Los Angeles, CA.

INCLUDE WHEN CITING Published online March 2, 2018; DOI: 10.3171/2017.9.JNS171292.

Disclosures The authors have no conflicts of interest.

© AANS, except where prohibited by US copyright law.



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    Case 1. Preoperative workup demonstrated left ICA occlusion with significant penumbral tissue. Lateral (A) and oblique (B) angiograms obtained in a 57-year-old man presenting with acute aphasia and hemiparesis, demonstrating a cervical left ICA occlusion. A CT angiography study (not shown) demonstrated vessel reconstitution beyond the ophthalmic segment. Axial diffusion-weighted (left, C) and perfusion-weighted (right, C) MRI studies demonstrated scattered anterior cerebral artery and MCA infarcts with a large ischemic penumbra in the left MCA distribution, as seen by (from left to right) increased mean transit times, decreased cerebral blood flow, and preserved cerebral blood volumes. Figure is available in color online only.

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    Case 1. Postoperative imaging and histology demonstrated EC-IC graft health and the absence of spasm following ex vivo BTX treatment. Postoperative day 2 anteroposterior (A) and lateral (B) angiograms demonstrating a patent STA-MCA interposition graft (arrows) without evidence of spasm. Intrinsic left ICA flow is improved in these images because of partial endovascular treatment of the occlusion. A photomicrograph (C) of a portion of the DLCFA graft following BTX treatment demonstrated an intact endothelium and vessel muscular walls, with no structural deformities. H & E, original magnification ×100. Figure is available in color online only.

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    Case 2. Preoperative vessel imaging demonstrated a large basilar tip aneurysm. CT angiography study obtained in a 45-year-old man following an SAH, demonstrating a broad-based, bilobed basilar tip aneurysm, with the patient’s anterior circulation entirely dependent on the posterior communicating arteries. He was treated with an STA-MCA bypass with a BTX-treated DLCFA graft for revascularization of the anterior circulation in conjunction with clip ligation of the basilar tip aneurysm. Figure is available in color online only.

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    Case 2. Postoperative angiography and histology demonstrated EC-IC graft health and the absence of spasm following BTX treatment. Postoperative day 11 anteroposterior (A) and lateral (B) angiograms demonstrating a patent STA-MCA with a DLCFA graft (arrows) that had been treated ex vivo with BTX. *Site of spasm on untreated distal STA at the clip site. Beginning of graft. A comparison of low-magnification and high-magnification images of untreated (C and D, respectively) and BTX-treated (E and F, respectively) portions of the DLCFA graft demonstrates integrity of the endothelium and vessel wall and no structural deformities after BTX treatment. Vasodilation was also noted in the treated sample. H & E, original magnification ×40 (C and E), ×100 (D and F). Figure is available in color online only.

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    Case 3. Postoperative angiography and histology in a 56-year-old man treated using an STA-MCA bypass with a BTX-treated DLCFA graft for a progressively symptomatic, pressure-dependent right ICA occlusion. Day 4 postoperative anteroposterior (A) and lateral (B) angiograms demonstrated no spasm and graft patency. Arrows indicate the bypass graft. Site of STA-graft anastomosis. Low-magnification (C) and high-magnification (D) images of a portion of the BTX-treated DLCFA demonstrated no evidence of endothelial or vessel wall injury. H & E, original magnification ×40 (C), ×100 (D). Figure is available in color online only.

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    Angiograms (A and B) from previous cerebral bypass cases using DLCFA grafts, which were harvested in a manner similar to that in the featured cases, but without BTX treatment, demonstrating a susceptibility for postoperative vasospasm (arrows). When such vasospasm occurred, multiple rounds of intraarterial verapamil injections were typically needed for management. Figure is available in color online only.



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