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Neurosurgery:
doi: 10.1227/NEU.0b013e318285b587
Operative Technique

Double-Barrel Bypass for Cerebral Ischemia: Technique, Rationale, and Preliminary Experience With 10 Consecutive Cases

Duckworth, Edward A.M. MD, MS; Rao, Vikas Y. MD; Patel, Akash J. MD

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Abstract

BACKGROUND: In selected patients, extracranial-intracranial bypass remains an important treatment for the prevention of stroke. Traditionally, superficial temporal artery–middle cerebral artery (STA-MCA) bypass uses 1 STA branch. We have adopted a “double-barrel” technique in which both branches are joined with MCA recipients in distinct vascular territories.

OBJECTIVE: To assess the feasibility of routinely using both branches of the STA for cerebral revascularization.

METHODS: Ten consecutive patients underwent double-barrel bypass. Patients were selected if they demonstrated symptomatic MCA hypoperfusion resistant to medical therapy or had symptomatic moyamoya disease. Flow-directed bypass was performed to augment flow to the territories most at risk in each case, based on preoperative and intraoperative data. Computed tomography perfusion was routinely performed to evaluate baseline deficits and postoperative augmentation. Clinical data were analyzed to assess patient demographics and outcomes.

RESULTS: The double-barrel bypass was no more difficult technically than the traditional approach, with the second branch harvested through a small satellite incision. By isolating temporary occlusion to each territory, there was no additional ischemia to each brain region. No intraoperative complications or wound-healing issues occurred. Postoperative computed tomography perfusion studies all showed improvement, and delayed vascular imaging demonstrated universal graft patency. Nine of 10 patients have been asymptomatic since surgery, whereas 1 patient demonstrated symptoms in a separate vascular distribution.

CONCLUSION: Double-barrel STA-MCA bypass is both feasible and potentially advantageous. In our series, both bypass branches remained patent, augmenting flow to the territories most at need.

ABBREVIATIONS: CTP, computed tomography perfusion

ICA, internal carotid artery

ICG, indocyanine green

MMA, middle meningeal artery

STA-MCA, superficial temporal artery–middle cerebral artery

TIA, transient ischemic attack

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