Cerebral Revascularization

The purpose of cerebral revascularization is to bring more blood to areas of brain ischemia. Ischemia is a condition where the flow of oxygen-rich blood to a part of the body is restricted. The types of revascularization are “therapeutic revascularization” for emergent cases, and “preventive revascularization” which are elective cases. 

Indications for revascularization are:

• Cerebral ischemia, chronic and intractable
• Cerebral ischemia, progressive
• Moya moya disease
• Inoperable (surgical-endovascular) aneurysms
• Skull base tumors

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Case #1 - Giant Mid-Basilar Aneurysm

The image above shows a 49-year old man with a giant aneurysm in the mid-basilar artery (MCA). Procedure involved a middle cerebral artery (MCA-M2) to proximal cerebral artery (PCA-P2) bypass with a radial artery graft (RAG) and trapping of the aneurysm.

The above images were taken during the operation. The arrows point out the bypass graft and the trapping of the aneurysm.



A post-operative angiogram (above) shows good filling of the graft and proximal cerebral artery vessels (PCAs). The patient made a complete recovery with no neurological deficit.  

Case  #2

 A 53-year old female with long standing history of a lack of coordination, imbalance, double vision (diplopia) and dizziness, presented with sudden severe headaches for 24 hours and recurrent Transient Ischemic Attacks (TIA). A cerebral angiogram revealed bilateral aneurysms of the Vertebral Artery (VA) and Basilar Artery (BA).



 Treatment included:

• Testing of failed right Vertebral Artery (VA) for occlusion (blockage/obstruction).
• Radial Artery Bypass of the left External Carotid Artery (ECA) to the Proximal Cerebral Artery (PCA)
• Endovascular coil occlusion of aneurysm to the right (VA)
• Treatment of aneurysm to the Basilar Artery (BA)

The patient did well. She was discharged home with a prescription for Plavix.

Case #3 - Bilateral Carotid Ophthalmic Aneurysm

 
In the case of a 55-year old woman with bilateral carotid-ophthalmic aneurysms, a 3-D CT angiograph best demonstrates the form and structure of the aneurysm.

Aneurysm can be seen in each of the following 3 images:

Operations were performed on both aneurysms; one in the right carotid artery and a giant aneurysm located in the left Internal Carotid Artery (ICA).

Figure 1, below, illustrates aneurysm before surgery



Figure 2 below illustrates after surgery 


 
The operative approach included a frontotemporal craniotomy with orbital osteotomy.

A postoperative angiogram (following two images) show complete occlusion of the aneurysms. Patient did extremely well with good recovery.

Case #4 Right Internal Carotid Artery (ICA), Stenosis with Pseudoaneurysm

 A 56-year old woman with a long history of headaches and multiple left-sided Transient Ischemic Attacks (TIAs) was not responding to medical management. An angiogram showed stenosis (constriction) with a pseudoaneurysm to the right Internal Carotid Artery (ICA). A pseudoaneurysm, or false aneurysm, is a continual leakage of blood from an artery into the surrounding tissue.

The patient underwent double ECA–ICA bypass, using both radial arteries (see images below).