Transzygomatic-Subtemporal Approach for Middle Meningeal-to-P2 Segment of the Posterior Cerebral Artery Bypass: An Anatomical and Technical Study

ABSTRACT

We evaluated the use of a bypass between the middle meningeal artery (MMA) and P2 segment of the posterior cerebral artery (PCA) as an alternative to an external carotid artery (ECA-to-PCA) anastomosis. Five adult cadaveric heads (10 sides) were used. After a temporal craniotomy and zygomatic arch osteotomy were performed, the dura of the floor of the middle cranial fossa was separated and elevated. The MMA was dissected away from the dura until the foramen spinosum was reached. Intradurally, the carotid and sylvian cisterns were opened. After the temporal lobe was retracted, the interpeduncular and ambient cisterns were opened and the P2 segment of the PCA was exposed. The MMA trunk was transsected just before the bifurcation of its anterior and posterior branches where it passes inside the dura and over the foramen spinosum. It was anastomosed end to side with the P2 segment of the PCA. The mean caliber of the MMA trunk before its bifurcation was 2.1 ± 0.25 mm, and the mean caliber of the P2 was 2.2 ± 0.2 mm. The mean length of the MMA used to perform the bypass was 32 ± 4.1 mm, and the mean length of the MMA trunk was 39.5 ± 4.4 mm. This bypass procedure is simpler to perform than an ECA-to-P2 revascularization using long grafts. The caliber and length of the MMA trunk are suitable to provide sufficient blood flow. Furthermore, the course of the bypass is straight.

Artery graft - bypass - middle meningeal artery - posterior cerebral artery

REFERENCES

• 1 Ausman J I, Diaz F G, de los Reyes R A et al.. Posterior circulation revascularisation. Superficial temporal artery to superior cerebellar artery anastomosis.  J Neurosurg. 1982;  56 766-776
• 2 Heros R C, Ameri A M. Rupture of a giant basilar aneurysm after saphenous vein interposition graft to the posterior cerebral artery: case report.  J Neurosurg. 1984;  61 387-390
• 3 Sekhar L N, Wright D C, Olding M. Brain revascularization by saphenous vein and radial artery bypass graft. In: Sekhar LN, Olivera ED Cranial Microsurgery. New York, NY; Thieme 1999: 581-600
• 4 Sundt T M, Piepgras D G, Houser O W, Campbell J K. Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation.  J Neurosurg. 1982;  56 205-215
• 5 Sundt T M, Piepgras D G, Marsh W R. Bypass vein grafts for giant aneurysms and severe intracranial occlusive disease in the anterior and posterior circulation. In: Sundt TM Occlusive Cerebrovascular Disease, Diagnosis and Surgical Management. Philadelphia, PA; WB Saunders 1987: 439-464
• 6 Diaz F G, Pearce J E, Ausman J I. Complications of cerebral revascularization with autogenous vein grafts.  Neurosurgery. 1985;  17 271-276
• 7 Ausman J I, Nicoloff D M, Chou S N. Posterior fossa revascularization: anastomosis of vertebral artery to PICA with interposed radial artery graft.  Surg Neurol. 1978;  9 281-286
• 8 Ausman J I, Diaz F G, de los Reyes R A, Pak H, Patel S, Boulos R. Superficial temporal to proximal superior cerebellar artery anastomosis for basilar artery stenosis.  Neurosurgery. 1981;  9 56-60
• 9 Ausman J I, Diaz F G, de los Reyes R A, Pak H, Patel S, Boulos R. Anastomosis of occipital artery to anterior inferior cerebellar artery for vertebrobasilar junction stenosis.  Surg Neurol. 1981;  16 99-102
• 10 Ausman J I, Diaz F G, Dujovny M. Posterior circulation revascularization.  Clin Neurosurg. 1986;  33 331-343
• 11 Hopkins L N, Martin N A, Hadley M N, Spetzler R F, Budny J, Carter L P. Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease.  J Neurosurg. 1987;  66 662-674
• 12 Khodadad G. Occipital artery-posterior inferior cerebellar artery anastomosis.  Surg Neurol. 1976;  5 225-227
• 13 Little J R, Furlan A J, Bryerton B. Short vein grafts of cerebral revascularization.  J Neurosurg. 1983;  59 384-388
• 14 The EC/IC Bypass Study Group . Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial.  N Engl J Med. 1985;  313 1191-1200
• 15 Sekhar L N, Schramm Jr V I, Jones N F et al.. Operative exposure and management of the petrous and upper cervical internal carotid artery.  Neurosurgery. 1986;  19 967-982
• 16 Sen C, Sekhar L N. Direct vein graft reconstruction of the cavernous, petrous, and upper cervical internal carotid artery: lessons learned from 30 cases.  Neurosurgery. 1992;  30 732-743
• 17 Golby A J, Marks M P, Thompson R C, Steinberg G K. Direct and combined revascularization in pediatric moyamoya disease.  Neurosurgery. 1999;  45 50-60
• 18 Miller C F, Spetzler C F, Kopaniky D J. Middle meningeal to middle cerebral arterial bypass for cerebral revascularization. Case report.  J Neurosurg. 1979;  50 802-804
• 19 Nishikawa M, Hashi K, Shiguma M. Middle meningeal-middle cerebral artery anastomosis for cerebral ischemia.  Surg Neurol. 1979;  12 205-208
• 20 Owers N O. Anatomic pathways facilitating middle cerebral artery bypass.  Am Surg. 1987;  53 282-284