PREOPERATIVE DIAGNOSIS: Moyamoya disease with bilateral supraclinoid
internal carotid artery occlusion status post bilateral TIAs.
POSTOPERATIVE DIAGNOSIS: Moyamoya disease with bilateral supraclinoid
internal carotid artery occlusion status post bilateral TIAs.
OPERATION: Right frontal temporal craniotomy with microscopic
extracranial-to-intracranial revascularization anastomosis under mild
hypothermia using intraoperative electrophysiological monitoring.
SURGEONS:
ANESTHESIA:
Gary Steinberg, M.D., Justin Massengale, M.D.
General endotracheal anesthesia.
ANESTHESIOLOGIST:
Rebecca Claure, M.D.
ELECTROPHYSIOLOGIST:
SURGICAL NURSES:
EEG TECHNOLOGIST:
Jaime Lopez, M.D.
Sarah Yahn, S.T., Paul Dunning, S.T., Patsy Tew, R.N.
Dru Sigmon.
INDICATIONS: This 8-year-old female first presented with headaches in
08/2005 that were associated with nausea and vomiting. These were
diagnosed as possible migraines. In 02/006 she had a period of
confusion followed by the migraine, and in 03/2006 and 11/2006 had 5
episodes of migraine headache. Then, in November 2006, she had
recurrent confusion with associated headaches and recurrent episodes of
unsteadiness on her feet as well as intermittent dilated pupils. She
also experienced a tingling in her left and right upper extremities,
sometimes associated with difficulty expressing words. MR head scan
disclosed bilateral watershed infarcts, worse on the right side, and an
angiogram demonstrated moyamoya disease with occlusion of the bilateral
supraclinoid internal carotid arteries and extensive moyamoya vessels.
First SPECT cerebral blood flow study was reported to show impaired
hemodynamic reserve on the right side. Prior to surgery the patient
was neuro-electrically normal.
FINDINGS: A 1.0-mm-diameter parietal branch of the superficial
temporal artery was found to be donor. A 1.3-mm-diameter in fore
branch of the middle cerebral artery emergent from the sylvian fissure
on the frontal side was found as the recipient.
PROCEDURE: The patient was brought to the operating room with an IV in
place. She was intubated. General endotracheal anesthesia was
instituted. An arterial line, central venous line and Foley catheter
were placed. She was positioned supine on the operating room table and
her head placed into 3-point pin fixation. The head was elevated above
the heart and turned to the left side, bringing the right frontal
temporal region uppermost in the field. Stimulating recording
electrodes were placed for monitoring the bilateral somatosensory
evoked potentials and bilateral EEG. A cooling blanket was used to the
patient to a core body temperature of 34.1 degrees Centigrade. The
right frontal temporal region was shaved and the course of the
superficial temporal artery parietal branch mapped out with the
Doppler. This region was prepped and draped sterilely.
An incision was made anterior to the right ear and the superficial
temporal artery dissected free. The operative microscope was
positioned and used for harvesting of the superficial temporal artery.
This was essential in order to protect the artery during dissection. A
length of approximately 7 cm of superficial temporal artery parietal
branch was harvested with a generous cuff of soft tissue to protect it.
However, at the underlying temporalis fascia and muscle were split and
dissected from the frontal temporal bone. Burr holes were placed and a
craniotomy bone flap removed overlying the sylvian fissure on the right
side. The dura was tacked up and hemostasis obtained. Then, the
superficial temporal artery was dissected of soft tissue proximally and
distally. It measured 1.0 mm in its distal extent. The dura was
opened in a cruciate manner. The underlying brain was relaxed.
The operating microscope was positioned and used for the remainder of
the case and subdural closure. The operating microscope was absolutely
essential for this case in order to perform the microscopic anastomosis
between the superficial temporal artery parietal branch and the middle
cerebral artery and fore branch using 10-0 suture. A 1.3-mm-diameter
and fore branch of the middle cerebral artery emergent from the sylvian
fissure on the frontal side was identified. The arachnoid overlying a
7-mm segment of this vessel was microscopically opened. Two tiny
branches originating from this segment were coagulated and divided. A
high-visibility background was placed under the M4 segment.
Then, the temporal artery was temporarily occluded proximally and
distally. It was truncated distally. The distal superficial temporal
artery stump was coagulated and the temporary clip removed. Release of
the proximal superficial temporal artery clip revealed good flow. The
artery was irrigated with heparinized saline, truncated to the proper
length for anastomosis and fish-mouthed.
The patient was administered IV thiopental to induce slowing in the
EEG. The mean arterial pressure was raised up to 80-90, and the M4
middle cerebral artery branch was temporarily occluded with temporary
Sugita aneurysm clips. An arteriotomy was made of the M4 branch,
removing an elliptical portion of the superior wall. It was irrigated
with heparinized saline, then an end-to-side anastomosis between the
superficial temporal artery parietal branch and the middle cerebral
artery and fore branch was performed using 10-0 interrupted suture. An
excellent anastomosis was achieved. The temporary clips were removed
from the M4 branch, restoring flow. Total occlusion time was 17
minutes. There were no leaks in the anastomosis. The clip on the
proximal superficial temporal artery was removed, establishing flow
from this vessel into the M4 branch. Good flow was confirmed with the
microvascular Doppler. Surgicel was placed around the anastomosis
site. The brain remained nicely relaxed. The superficial temporal
artery graft was laid on the cortical surface to induce an indirect
bypass as well as the direct one.
The dura was closed with 4-0 suture followed by DuraGen, leaving an
opening for the graft to enter without compromise. The bone was
replaced using the Synthes plating system, leaving a hole for the graft
to enter unimpeded. The temporalis muscle and scalp were closed
__________ in the usual fashion. A sterile dressing was applied. The
patient was rewarmed, extubated and taken to the pediatric intensive
care unit in satisfactory condition.
There were no complications of the procedure and no changes in the
electrophysiological monitoring parameters during part of the case with
the exception of temporary slowing in the EEG after thiopental was
given.
I was present and directly participated in the key portion of the
procedure, which included final dissection of the superficial temporal
artery in the scalp, microscopic exposure of the M4 branch, placement
of temporary clips, microscopic arteriotomy of the M4 branch,
microscopic anastomosis between the superficial temporal artery and
middle cerebral artery branch, removal of temporary clips, confirming
good blood flow in all vessels, obtaining hemostasis.
During the non-key portions of the case I was either present and
directly participating or immediately available to return to the
operating room if necessary.