Cleveland Clinic, Cerebrovascular Center, Cleveland, Ohio, USA.
Neurosurgery. 2010 Dec;67(2 Suppl Operative):527-31. doi: 10.1227/NEU.0b013e3181f8889e.
Early origin of the middle cerebral artery M2 segment is a normal variant. When such a vessel is occluded proximally, the parenchyma distal to the vessel may become ischemic. Targeted extracranial to intracranial bypass to such a specific branch may preserve perfusion to the end organ. We describe the use of intra-aneurysmal injection of indocyanine green to identify a target middle cerebral artery branch (MCA) for bypass, immediately followed by proximal parent vessel sacrifice via endovascular embolization.
A 45-year-old woman presented to an outside hospital with headaches. Magnetic resonance imaging revealed a giant aneurysm of the right MCA. The aneurysm gave rise to an M2 branch that supplied the right anterior frontal operculum, as well as the anterolateral portion of the superior temporal gyri. Balloon test occlusion was nondiagnostic because of the territory involved, and the risk of sizable infarction after vessel sacrifice was thought to be high. Craniotomy and targeted extracranial to intracranial bypass to an M4 opercular branch was performed with intra-aneurysmal injection of indocyanine green. In our combined endovascular/open cerebrovascular suite, an opercular MCA branch that fluoresced during the first-pass arterial circulation of indocyanine green was identified, and a superficial temporal artery to MCA bypass was performed. Angiographic verification of bypass patency was confirmed, followed by embolic occlusion of the giant aneurysm with preservation of flow to the parenchyma at risk through the bypass.
Targeted bypass to distal branches is feasible with intra-arterial and intra-aneurysmal injection of indocyanine green, allowing confident preservation of blood supply to areas distal to the sacrificed vessel.
大脑中动脉 M2 段的早期起源是一种正常变异。当近端的血管闭塞时，血管远端的实质可能会发生缺血。针对特定分支的颅外-颅内旁路术可能会保留终末器官的灌注。我们描述了使用血管内吲哚菁绿注射来识别特定的大脑中动脉分支（MCA）进行旁路，然后立即通过血管内栓塞牺牲近端母血管。
一名 45 岁女性因头痛到一家外院就诊。磁共振成像显示右侧 MCA 巨大动脉瘤。该动脉瘤起源于一个 M2 分支，供应右侧额前盖部以及上颞叶的前外侧部分。由于受累范围广，球囊测试闭塞无诊断价值，而且认为在血管牺牲后发生大面积梗塞的风险很高。在我们的联合血管内/开放脑血管套件中，进行了经皮颅内-颅内旁路手术，同时对动脉瘤内注射吲哚菁绿。在初次通过吲哚菁绿的动脉循环时，荧光显影识别出一个 MCA 盖分支，进行了颞浅动脉到 MCA 的旁路手术。通过旁路术保留了受风险影响的实质的血流，通过血管造影术确认了旁路术的通畅性。
