Nossek Erez, Costantino Peter D, Eisenberg Mark, Dehdashti Amir R, Setton Avi, Chalif David J, Ortiz Rafael A, Langer David J
*Department of Neurosurgery, North Shore - Long Island Jewish/Hofstra School of Medicine North Shore University Hospital, Manhasset, NY; ‡Department of Neurosurgery, North Shore - Long Island Jewish/Hofstra School of Medicine North Shore University Hospital Lenox Hill Hospital; New York, NY; §The New York Head & Neck Institute, North Shore- Long Island Jewish/Hofstra School of Medicine Lenox Hill Hospital, New York, NY.
Neurosurgery. 2014 Jul;75(1):87-95. doi: 10.1227/NEU.0000000000000340.
Internal maxillary artery (IMax)-middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a "keyhole" craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis.
To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass.
Orbitozygomatic osteotomy is used followed by frontotemporal craniotomy and subsequently laterotemporal fossa craniectomy, reaching its medial border at a virtual line connecting the foramen rotundum and foramen ovale. The IMax was identified by using established anatomic landmarks, neuronavigation, and micro Doppler probe (Mizuho Inc. Tokyo, Japan). Additionally, we studied the approach in a cadaveric specimen in preparation for microsurgical bypass.
There were 4 cases in which the technique was used. One bypass was performed for flow augmentation in a hypoperfused hemisphere. The other 3 were performed as part of treatment paradigms for giant middle cerebral artery aneurysms. Vein grafts were used in all patients. The proximal anastomosis was performed in an end-to-side fashion in 1 patient and end-to-end in 3 patients. Intraoperative graft flow measured with the Transonic flow probe ranged from 20 to 60 mL/min. Postoperative angiography demonstrated good filling of the graft with robust distal flow in all cases. All patients tolerated the procedure well.
IMax to middle cerebral artery subcranial-intracranial bypass is safe and efficacious. The laterotemporal fossa craniectomy technique resulted in reliable identification and wide exposure of the IMax, facilitating the proximal anastomosis.
上颌内动脉（IMax）-大脑中动脉（MCA）搭桥术最近被描述为一种替代颈外-颅内搭桥术的方法。该技术在颞窝使用“锁孔”开颅术，需要进行技术要求较高的端侧吻合。
描述一种中颅窝底外侧颞下开颅术，以利于充分暴露IMax从而便于搭桥。
采用眶颧截骨术，随后行额颞开颅术，接着行颞下窝开颅术，其内侧边界位于连接圆孔和卵圆孔的虚拟线上。通过既定的解剖标志、神经导航和微型多普勒探头（日本东京瑞穗公司）来识别IMax。此外，我们在尸体标本上研究了该入路，为显微外科搭桥做准备。
有4例使用了该技术。1例为在灌注不足的半球进行血流增加的搭桥手术。另外3例作为巨大大脑中动脉瘤治疗方案的一部分进行。所有患者均使用静脉移植物。1例患者近端吻合采用端侧方式，3例采用端端方式。术中使用Transonic血流探头测得的移植物血流范围为20至60 mL/分钟。术后血管造影显示所有病例移植物充盈良好，远端血流强劲。所有患者对手术耐受性良好。
IMax至大脑中动脉的颅外-颅内搭桥术安全有效。颞下窝开颅术能可靠地识别并充分暴露IMax，便于近端吻合。
