intracranial-extracranial arterial anastomosis

This operation was first used by Donaphy and Yasargil in 1967 to treat ischemic cerebrovascular disease and achieved good results. Treatment of diseases: brain tumor transient ischemic attack Indication 1. Occlusive cerebrovascular disease, repeated transient ischemic attack, this operation can prevent or reduce its onset. Reversible ischemic neurological damage, complete stroke, more than 3 weeks, less than 1 year, stable condition, hemiplegia, aphasia, etc. recovered, but slow progress or stop. 2. Intracranial giant aneurysms, brain tumors, etc. It is estimated that the surgery may damage the carotid artery and the main branches of the trunk, and the anastomosis before or after surgery. 3. Carotid artery injury after trauma can not be restored, leading to insufficient blood supply to the brain. 4. Other reasons for the lack of blood supply to the carotid artery and its branches. Contraindications 1. Acute phase of a complete stroke and progressive stroke. 2. There are no blood vessels in the skull and outside. 3. There are general signs of cerebral arteriosclerosis, dementia, and hemiplegia. 4. Suffering from severe heart, lung and kidney disorders, high blood pressure, diabetes, etc. Preoperative preparation 1. Before the operation, cerebral angiography should be performed to confirm the diagnosis and cerebrovascular condition, and the anastomotic artery to be used should be selected. 2. If there are conditions, measure regional cerebral blood flow and understand the local blood supply. 3. Trial of hyperbaric oxygen therapy. If effective, predict the surgical outcome. 4. Perform a CT scan to understand the extent of cerebral infarction. Surgical procedure (a) superficial temporal artery - middle cerebral artery anastomosis 1. Position: lateral position. 2. Incision: First, use the gentian violet to draw the direction of the superficial temporal artery on the scalp, making an arc-shaped incision. The forelimb of the incision is located between the anterior and posterior branches of the superficial temporal artery, and the posterior limb of the incision is inside the occipital artery. Open the flap and clamp the distal end of the superficial temporal artery. The diaphragm was cut over the auricle, the skull was drilled, and the bone window was enlarged to a diameter of 4 cm. Or as a small bone flap, cut the dura mater, choose a cortical artery, the outer diameter should be no less than 1mm. Common angle gyrus, can also choose the posterior tibial artery, posterior apical artery and forehead ascending branch. The cerebral cortex is covered with a saline pad. 3. Separation of blood vessels: The superficial temporal artery is separated from the flap under the operating microscope, and the posterior branch is usually used. At the time of separation, the artery was separated from the artery by 3 to 4 mm, and the small branch was cut by a bipolar coagulation burn and detached to a length of about 6 to 7 cm. After checking the blood flow of the superficial temporal artery, the artery was clamped at 2 to 3 cm from the broken end. After the cortical arteries were selected, the arachnoid membrane was dissected under a surgical microscope, and a segment of arteries 1 cm long was isolated, and the small branches were chopped by bipolar coagulation and then cut. A small piece of rubber film is placed under the artery to protect the cerebral cortex and facilitate anastomosis. 4. Arterial anastomosis: The superficial temporal artery is pulled through the hole and bone hole in the diaphragm to the bloody artery. An outer membrane of 0.5 cm length at the end was peeled off, clamped with a temporary arterial clip on the proximal side, and the end was trimmed into a neat new opening. The hemorrhage in the lumen was flushed with heparin saline for use. Clip the two arterial clips at the ends of the exposed cortical artery. Cut a 2 to 3 mm incision in the wall of the cortical artery or cut it into an elliptical opening with scissors. Heparin saline was used to flush out the blood in the lumen. The superficial temporal artery was anastomosed to the cortical branch of the middle cerebral artery. Sutures were interrupted with a 10-0 single-strand nylon thread and a non-invasive needle. The two opposite corners are sutured first, and then 3 to 4 needles are sutured in the anterior wall and the posterior wall. When the ligation is performed, the anastomotic margin is everted, so that the two intima are intima to the intima, and a total of 8 to 10 stitches are sutured. Never sew the front and rear walls together. In order to avoid this shortcoming, a shallow superficial artery can be sutured at the midpoint of the anterior wall of the cortical artery incision, and the other corner is sutured at the midpoint of the posterior wall. The anterior wall of the superficial temporal artery corresponds to the side of the cortical artery, and the posterior wall and the other Corresponding to the side angles, the front and rear walls of the two arteries are separated and sutured. Before ligation of the last needle, loosen the arterial clips of the two arteries, allowing the blood to rush out of the air and small blood clots in the lumen, and then quickly ligature. After the anastomosis is completed, the arterial clip on the distal side of the cortex is loosened, then the proximal arterial clip is released, and the arterial clip of the superficial temporal artery is finally released. If there is a small leak in the anastomosis, it can be stopped by lightly pressing the cotton sheet for a while (not to block the blood flow by heavy pressure). If there is arterial spasm, it can be removed by immersing in 3% papaverine or 1% lidocaine cotton for a while. 5. Stitching: When the dura mater is sutured, a small hole is allowed to pass through the superficial artery. If the bone flap is used, the bone piece is restored, and a bone hole is bitten through the superficial temporal artery, so that the superficial temporal artery is not twisted. The rest is stitched layer by layer. (B) occipital artery - posterior inferior cerebellar anastomosis The patient is lying or sitting on the side, making a midline incision in the posterior fossa, and the upper end is folded behind the mastoid. Open the flap, the peeling pillow clearly shows the occipital bone, and the skull opens the window. Cut the dura mater, find and select the posterior inferior cerebellar anastomosis near the cerebellar tonsil. The occipital artery is inserted from the deep to the shallow layer and parallel to the occipital nerve at the midpoint of the mastoid tip and the extra-occipital protuberance line. The artery was found to be stripped about 8 to 9 cm long, and the small branches on both sides were separated from the artery by a few mm and separated by bipolar coagulation. The arterial clip was used to clamp the free arterial root and the lumen was flushed with heparin saline. The occipital muscle is made into a fissure, and the occipital artery is introduced into the skull through the fissure, so that the artery is not oppressed. The occipital artery-the posterior inferior cerebellar artery was anastomosed in the same way as before. After the anastomosis is completed, the wound is sutured layer by layer without drainage. complication Intracranial hematoma.