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

Clinical article

View More View Less
  • Department of Neurosurgery, Asahi University Murakami Memorial Hospital, Gifu, Japan
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

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.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Abou-Chebl A, , Lin R, , Hussain MS, , Jovin TG, , Levy EI, & Liebeskind DS, et al.: Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study. Stroke 41:11751179, 2010

    • Search Google Scholar
    • Export Citation
  • 2

    Bilotta F, & Rosa G: ‘Anesthesia’ for awake neurosurgery. Curr Opin Anaesthesiol 22:560565, 2009

  • 3

    Coppens JR, , Cantando JD, & Abdulrauf SI: Minimally invasive superficial temporal artery to middle cerebral artery bypass through an enlarged bur hole: the use of computed tomography angiography neuronavigation in surgical planning. Technical note. J Neurosurg 109:553558, 2008

    • Search Google Scholar
    • Export Citation
  • 4

    Fischer G, , Stadie A, , Schwandt E, , Gawehn J, , Boor S, & Marx J, et al.: Minimally invasive superficial temporal artery to middle cerebral artery bypass through a minicraniotomy: benefit of three-dimensional virtual reality planning using magnetic resonance angiography. Neurosurg Focus 26:5 E20, 2009

    • Search Google Scholar
    • Export Citation
  • 5

    Gough MJ, , Bodenham A, , Horrocks M, , Colam B, , Lewis SC, & Rothwell PM, et al.: GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery. Trials 9:28, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Hunt SA, , Abraham WT, , Chin MH, , Feldman AM, , Francis GS, & Ganiats TG, et al.: ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 112:e154e235, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Jumaa MA, , Zhang F, , Ruiz-Ares G, , Gelzinis T, , Malik AM, & Aleu A, et al.: Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke 41:11801184, 2010

    • Search Google Scholar
    • Export Citation
  • 8

    Kaku Y, , Watarai H, , Kokuzawa J, , Tanaka T, & Andoh T: Less invasive technique for EC-IC bypass. 13th European Congress of Neurosurgery Glasgow, MEDIMOND International Proceedings, 2007. 527532

    • Search Google Scholar
    • Export Citation
  • 9

    Kaku Y, , Watarai H, , Kokuzawa J, , Tanaka T, & Andoh T: Less invasive technique for EC-IC bypass. Acta Neurochir Suppl 103:8386, 2008

  • 10

    Karagöz HY, , Sönmez B, , Bakkaloglu B, , Kurtoglu M, , Erdinç M, & Türkeli A, et al.: Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 70:9196, 2000

    • Search Google Scholar
    • Export Citation
  • 11

    Kessler P, , Neidhart G, , Bremerich DH, , Aybek T, , Dogan S, & Lischke V, et al.: High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients. Anesth Analg 95:791797, 2002

    • Search Google Scholar
    • Export Citation
  • 12

    Khu KJ, , Doglietto F, , Radovanovic I, , Taleb F, , Mendelsohn D, & Zadeh G, et al.: Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. Clinical article. J Neurosurg 112:10561060, 2010

    • Search Google Scholar
    • Export Citation
  • 13

    Kikuta K, , Takagi Y, , Fushimi Y, , Ishizu K, , Okada T, & Hanakawa T, et al.: “Target Bypass”: a method for preoperative targeting of a recipient artery in superficial temporal artery-to-middle cerebral artery anastomoses. Neurosurgery 62:6 Suppl 3 14341441, 2008

    • Search Google Scholar
    • Export Citation
  • 14

    Kurtoğlu M, , Ateş S, , Bakkaloğlu B, , Beşbaş S, , Duvan I, & Akdaş H, et al.: Epidural anesthesia versus general anesthesia in patients undergoing minimally invasive direct coronary artery bypass surgery. Anadolu Kardiyol Derg 9:5458, 2009

    • Search Google Scholar
    • Export Citation
  • 15

    Lee EJ, , Lee MY, , Shyr MH, , Cheng JT, , Toung TJK, & Mirski MA, et al.: Adjuvant bupivacaine scalp block facilitates stabilization of hemodynamics in patients undergoing craniotomy with general anesthesia: a preliminary report. J Clin Anesth 18:490494, 2006

    • Search Google Scholar
    • Export Citation
  • 16

    Lucchetti V, , Moscariello C, , Catapano D, & Angelini GD: Coronary artery bypass grafting in the awake patient: combined thoracic epidural and lumbar subarachnoid block. Eur J Cardiothorac Surg 26:658659, 2004

    • Search Google Scholar
    • Export Citation
  • 17

    Noiseux N, , Prieto I, , Bracco D, , Basile F, & Hemmerling T: Coronary artery bypass grafting in the awake patient combining high thoracic epidural and femoral nerve block: first series of 15 patients. Br J Anaesth 100:184189, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Pauwels RA, , Buist AS, , Calverley PM, , Jenkins CR, & Hurd SS: GOLD Scientific Committee: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 163:12561276, 2001

    • Search Google Scholar
    • Export Citation
  • 19

    Rodgers A, , Walker N, , Schug S, , McKee A, , Kehlet H, & van Zundert A, et al.: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. A review BMJ 321:1493, 2000

    • Search Google Scholar
    • Export Citation
  • 20

    Skucas AP, & Artru AA: Anesthetic complications of awake craniotomies for epilepsy surgery. Anesth Analg 102:882887, 2006

  • 21

    Souter MJ, , Rozet I, , Ojemann JG, , Souter KJ, , Holmes MD, & Lee L, et al.: Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography. J Neurosurg Anesthesiol 19:3844, 2007

    • Search Google Scholar
    • Export Citation
  • 22

    Triltsch AE, , Welte M, , von Homeyer P, , Grosse J, , Genähr A, & Moshirzadeh M, et al.: Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med 30:10071014, 2002

    • Search Google Scholar
    • Export Citation
  • 23

    Watanabe G, , Yamaguchi S, , Tomiya S, & Ohtake H: Awake subxyphoid minimally invasive direct coronary artery bypass grafting yielded minimum invasive cardiac surgery for high risk patients. Interact Cardiovasc Thorac Surg 7:910912, 2008

    • Search Google Scholar
    • Export Citation
  • 24

    Yaşargil MG: Microsurgery Applied to Neurosurgery Stuttgart, Georg Thieme, 1969. 105115

Metrics

All Time Past Year Past 30 Days
Abstract Views 559 82 5
Full Text Views 163 16 2
PDF Downloads 145 15 2
EPUB Downloads 0 0 0