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How we do it? Performing a protective superficial temporal artery-middle cerebral artery bypass with endoscopic transnasal cavernous sinus lesion operation

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Abstract

Background

To describe the concept of a protective superficial temporal artery-middle cerebral artery (STA-MCA) bypass performed prior to endoscopic transnasal cavernous sinus (CS) lesion resection in order to reduce the risk of perioperative cerebral ischemia due to internal carotid artery (ICA) vasospasm, occlusion, and even injury.

Method

We illustrated the procedure of a 14-year-old female accepting a protective STA-MCA bypass with endoscopic transnasal CS lesion resection.

Conclusion

A protective bypass may be a prophylactic strategy in selected endoscopic transnasal CS surgery cases, particularly where the diagnosis is uncertain, or the risk of ICA injury or occlusion is high.

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Acknowledgements

This study was sponsored by the CAMS Innovation Fund for Medical Sciences (CIFMS, 2019-I2M-5-008), the National Natural Science Foundation of China (No. 82201461), the Shanghai Sailing Program (No. 22YF1404500), and the Fujian Province Science and Technology Innovation Joint Fund (No. 2021Y9135)

Author information

Author notes

  1. Zhicheng Wang, Changzhen Jiang, and Zixiao Yang contributed equally to the work.

Authors and Affiliations

  1. Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350004, Fujian, China

    Zhicheng Wang & Changzhen Jiang

  2. Department of Neurosurgery, National Regional Medical Center, The First Affiliated Hospital Binhai Campus, Fujian Medical University, Fuzhou, 350209, Fujian, China

    Zhicheng Wang & Changzhen Jiang

  3. Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  4. National Center for Neurological Disorders, Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  5. Neurosurgical Institute of Fudan University, Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  6. Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  7. Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  8. Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China

    Zixiao Yang & Jianping Song

  9. Department of Neurosurgery, National Regional Medical Center, Huashan Hospital Fujian Campus, Fudan University, Fuzhou, Fuzhou, 350209, Fujian, China

    Jianping Song

Authors
  1. Zhicheng Wang
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  2. Changzhen Jiang
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  3. Zixiao Yang
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  4. Jianping Song
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Corresponding author

Correspondence to Jianping Song.

Ethics declarations

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by Huashan Hospital Institutional Review Board (HIRB), Fudan University, Shanghai, China.

Informed consent

It represents a video of a surgical case. The patient gave approval for this publication.

Conflict of interest

The authors declare no competing interests.

Additional information

Key points

1. The CSs contain the ICA and several cranial nerves, making it a vital area to consider during surgery.

2. The ICA travels superomedially to the abducens nerve and medially to the ophthalmic and maxillary divisions of the trigeminal nerve within the CS.

3. Despite advances in microneurosurgery, ICA injury during endoscopic endonasal surgery remains a significant concern.

4. The techniques for repairing ICA injury, including manual compression, balloon tamponade, covered stent placement, or rescuing cerebral revascularization, remain low success rates due to unpredictable consequences in a time-crunched situation

5. During endoscopic transnasal surgery for CS lesions, prophylactic measures, such as the use of a protective EC-IC bypass prior to surgery, can be considered to be developed to manage ICA injuries.

6. Preoperative hemodynamic evaluation using the balloon occlusion test (BOT) can assess collateral perfusion in case of ICA occlusion during surgery.

7. The low-flow EC-IC bypass procedure involves the anastomosis of the STA to the MCA through a small craniotomy, allowing for blood flow diversion.

8. A keyhole surgery approach can reduce the length of the bypass procedure.

9. ICGVA can confirm the patency of the bypass.

10. The combined protective STA-MCA bypass and endoscopic transnasal surgery for CS lesions is complex and requires careful planning, monitoring, and execution, but it can be performed safely and effectively by experienced hands.

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Supplementary information

This video illustrates a protective STA-MCA bypass combined with transnasal endoscopic right CS lesion resection (MP4 99150 kb)

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Wang, Z., Jiang, C., Yang, Z. et al. How we do it? Performing a protective superficial temporal artery-middle cerebral artery bypass with endoscopic transnasal cavernous sinus lesion operation. Acta Neurochir 165, 3729–3735 (2023). https://doi.org/10.1007/s00701-023-05657-9

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  • DOI: https://doi.org/10.1007/s00701-023-05657-9

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