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Background: The cutdown procedure in cerebrovascular bypass requires incising the scalp along the preoperative marking identifying the arteries. We present two patients in whom preoperative marking on the scalp misidentified veins as arteries and thus complicated the surgical procedure. Case description: A 46-year-old male with Moyamoya disease (Case 1) and a 73-year-old male with atherosclerotic occlusion of the internal carotid artery (Case 2) were scheduled for bypass surgery using a scalp artery, the superficial temporal artery and the posterior auricular artery, respectively. The candidate scalp arteries were preoperatively marked using a handheld Doppler ultrasonic flowmeter. Cutdowns were made along the markings, however, the arteries were not found. In Case 1 the superficial temporal vein was exposed at the cutdown site; posterior extension of the incision revealed the donor artery. In Case 2 we were unable to identify the intended donor artery and a thin branch of the superficial temporal artery was used instead. Although the donor vessels were successfully anastomosed in both patients they developed partial alopecia. Postoperative radiological review revealed that the cutdowns were made on scalp veins, i.e. the veins were misidentified as donor arteries by the Doppler ultrasonic flowmeter. Conclusion: As such misidentification hampers the success of the cutdown method for preventing cutaneous ischemia and complicates the operation, preoperative marking of the donor arteries must consider the possibility of their misidentification.

Background: Giant dolichoectatic basilar trunk aneurysms have an unfavorable natural history and are associated with high morbidity, but their neurosurgical treatment is complex and challenging. Methods: Flow reversal reconstruction with fourth-generation bypass and proximal vertebral artery clip occlusion is performed via orbitozygomatic craniotomy with the Kawase approach under rapid ventricular pacing. Conclusion: Fourth-generation bypass is an innovative, technically challenging, and clinically effective tool in the treatment armamentarium for giant dolichoectatic basilar trunk aneurysms. [ABSTRACT FROM AUTHOR]

Objective: Deep learning enables precise hand tracking without the need for physical sensors, allowing for unsupervised quantitative evaluation of surgical motion and tasks. We quantitatively assessed the hand motions of experienced cerebrovascular neurosurgeons during simulated microvascular anastomosis using deep learning. We explored the extent to which surgical motion data differed among experts., Methods: A deep learning detection system tracked 21 landmarks corresponding to digit joints and the wrist on each hand of 5 expert cerebrovascular neurosurgeons. Tracking data for each surgeon were analyzed over long and short time intervals to examine gross movements and micromovements, respectively. Quantitative algorithms assessed the economy and flow of motion by calculating mean movement distances from the baseline median landmark coordinates and median times between sutures, respectively., Results: Tracking data correlated with specific surgical actions observed in microanastomosis video analysis. Economy of motion during suturing was calculated as 19, 26, 29, 27, and 28 pixels for surgeons 1, 2, 3, 4, and 5, respectively. Flow of motion during microanastomosis was 31.96, 29.40, 28.90, 7.37, and 47.21 seconds for surgeons 1, 2, 3, 4, and 5, respectively., Conclusions: Hand tracking data showed similarities among experts, with low movements from baseline, minimal excess motion, and rhythmic suturing patterns. The data revealed unique patterns related to each expert's habits and techniques. The results showed that surgical motion can be correlated with hand motion and assessed using mathematical algorithms. We also demonstrated the feasibility and potential of deep learning-based motion detection to enhance surgical training., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Mutations in the smooth muscle-specific isoform of alpha actin (ACTA2) cause smooth muscle dysfunction in arteries. This rare loss-of-function mutation may cause a diffuse occlusive cerebral arteriopathy, resulting in stroke. While ACTA2 arteriopathy is often described as moyamoya-like, it has a distinct phenotype characterized by dilation of the proximal internal carotid artery (ICA) and occlusion of the terminal ICA and proximal middle cerebral artery. Intracranial arteries have an abnormally straight course, often with small aneurysms. There is limited experience with revascularization procedures for ACTA2 arteriopathy, and the safety and efficacy of these procedures are unknown. In this paper the authors present a symptomatic 6-year-old patient with ACTA2 cerebral arteriopathy who underwent both indirect revascularization and direct cerebrovascular bypass. Postoperatively, the patient suffered an ischemic infarct in a neighboring vascular territory. While direct cerebrovascular bypass is technically feasible, patients with ACTA2 arteriopathy may be at increased risk for perioperative stroke compared with patients with moyamoya disease.

Objective To investigate the method, treatment technology and curative effect of microsurgical treatment of giant aneurysms in the bifurcation of middle cerebral artery (MCA). Methods The clinical data of 11 patients with MCA bifurcation giant aneurysms were analyzed retrospectively. All patients were single aneurysms with an average diameter of (22.0 ± 10.9) mm. At admission, hunt Hess classification showed grade I in 5, grade II in 2, grade III in 2 and grade N in 2. All patients underwent craniotomy and microsurgery. The prognosis of patients was evaluated by Glasgow prognosis scale (GOS). Results In this group, 6 patients underwent plastic clipping of aneurysms, and the other 5 were treated with combined extracranial-intracranial or intracranial -intracranial vascular bypass, of which 3 underwent plastic clipping of moving aneurysms combined with superficial temporal artery middle cerebral artery bypass, 1 patient underwent superficial temporal artery middle cerebral artery double bypass, and 1 underwent moving aneurysmectomy combined with end-to-end anastomosis of tumor carrying artery. Postoperative CTA or I and DSA showed that the aneurysms disappeared completely, and the bridging vessels were unobstructed in 4 cases of intracranial extracranial vascular bypass and 1 case of intracranial intracranial vascular anastomosis. The postoperative follow-up of 6 - 84 months showed 9 patients had a good prognosis and no neurological dysfunction, with GOS score of 4 - 5, and 2 patients had mild disability. Conclusions Microsurgery is the main method for the treatment of giant aneurysms in the bifurcation of MCA. According to the characteristics of aneurysm morphology, anatomical location and whether there are branch vessels, plastic clipping and aneurysm isolation or proximal occlusion of tumor carrying artery combined with vascular bypass can be selected for treatment. [ABSTRACT FROM AUTHOR]

Background: Extracranial-intracranial (EC-IC) arterial bypass has been used in the treatment of various cerebrovascular ischemic disease due to atherosclerosis or Moyamoya disease, skull base tumors encasing large IC artery or complex IC aneurysms. Aim: The aim is to analyze surgical technique (EC-IC bypass) and its outcome with intraoperative use of dual image video angiography (DIVA) and Doppler ultrasound. Materials and Methods: We studied in this article a series of 23 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a superficial temporal artery-middle cerebral artery anastomosis was done for steno-occlusive disease, giant IC aneurysm or Moyamoya disease. The study was conducted between 2018 and 2020. We used dual-image video angiography (DIVA) and Doppler ultrasound to assess the luminal patency of anastomosis during the procedure. Results: In this study, three patients presented with Moyamoya disease, 4 had aneurysm, whereas 16 patients presented with the vascular steno-occlusive disease. The patients were divided into three categories (steno-occlusive disease, Moyamoya, and flow replacement for giant aneurysm). Dual image video angiography, along with intraoperative Doppler, helped us in the assessment of luminal patency of the anastomosis. Conclusion: Hemodynamic recovery after cerebrovascular bypass brings about a better outcome in ischemic stroke. The result of surgery improves with proper selection of patients with hemodynamic impairment (in Stage 2). With various modalities such as intraoperative Doppler, DIVA (Dual-image Video Angiography) and improved surgical techniques may aid in the reduction of complications and improve clinical outcome. [ABSTRACT FROM AUTHOR]

Background: Missense mutations in the gene that codes for smooth muscle actin, ACTA2, cause diffuse smooth muscle dysfunction and a distinct cerebral arteriopathy collectively known as multisystemic smooth muscle dysfunction syndrome (MSMDS). Until recently, ACTA2 cerebral arteriopathy was considered to be a variant of moyamoya disease. However, recent basic science and clinical data have demonstrated that the cerebral arteriopathy caused by mutant ACTA2 exhibits genetic loci, histopathology, neurological sequelae, and radiographic findings unique from moyamoya disease. We conducted a literature review to provide insight into the history, clinical significance, and neurosurgical management of this recently described novel cerebral arteriopathy. Summary: We performed a literature search using PubMed with the key words "ACTA2 mutation," "ACTA2 cerebral arteriopathy," and "multisystemic smooth muscle dysfunction syndrome." Case reports with confirmed ACTA2 mutations and cerebral arteriopathy were included in our review. Our literature search revealed 15 articles (58 cases) of confirmed ACTA2 cerebral arteriopathy. Distinctive features of this arteriopathy included an aberrant internal carotid circulation with dilatation of the proximal segments, occlusive disease at the distal segments, and dolichoectasia. As such, mutant ACTA2 predisposed patients to ischemic strokes as children. Direct and indirect cerebral revascularization procedures are the mainstay treatment options with varying degrees of success. Key Messages:ACTA2 cerebral arteriopathy is a recently described novel cerebrovascular disease seen in patients with MSMDS. Patients currently diagnosed with moyamoya disease who also have dysfunction of smooth muscle organs may benefit from reevaluation by a medical geneticist and ACTA2 genotyping. [ABSTRACT FROM AUTHOR]

Background: Giant intracranial aneurysms (GIA) are often not eligible for direct clip occlusion. Surgical alternatives include partial clip occlusion or the placement of a cerebrovascular bypass or the combination of both. These alternative indirect strategies are expected to lead to a decrease in GIA volume over time rather than instantaneously. To examine whether this is the case, we analyzed follow-up imaging results 1 year after surgery. Methods: We retrospectively screened the prospective GIA Registry's imaging database for anterior circulation GIA treated by surgical strategies other than direct clipping. We measured pre- and 1-year post-treatment GIA volume, lateral ventricle volume (LVV), and mid-line shift (MLS) in 19 cases. Results: After a mean follow-up of 466 days (standard deviation ±171) GIA volumes decreased from 9.6 cm (interquartile range (IQR) 6.1-14.1) to 4.3 cm (IQR 2.9-5.7; p < 0.01). Ipsilateral LVV increased from 8.6 cm (IQR 6.4-24.9) to 16.0 cm (IQR 9.1-27.2; p < 0.01) while contralateral LVV increased from 10.3 cm (IQR 7.3-20.1) to 11.7 cm (IQR 8.2-19.4; p = 0.02). MLS changed from 0.1 mm (IQR −1.9 to 2.0) to −0.9 mm (IQR −1.8 to 0.4; p = 0.03). The decrease in GIA volume correlated with the increase in ipsilateral LVV (r = 0.60; p = 0.01) but not with the changes in MLS (r = 0.41; p = 0.08). Conclusions: In our patient cohort, surgical strategies other that direct clipping for the treatment of anterior circulation GIA lead to a significant decrease in GIA volume over time. The resulting decrease in mass effect was more sensitively monitored by the measurement of changes in ipsilateral LVV than changes in MLS. Clinical Trial Registration-URL: . Unique identifier: NCT02066493. [ABSTRACT FROM AUTHOR]

Mycotic brain aneurysms are rare and unusual cerebrovascular lesions arising from septic emboli that degrade the elastic lamina and vessel wall of intracranial arteries, which results in pathologic dilatation. Mycotic aneurysms are nonsaccular lesions that are not often suitable for clipping and instead require bypass, trapping, and flow reversal. This case demonstrates the use of indocyanine green "flash fluorescence" to identify the cortical distribution supplied by an aneurysm's outflow, facilitating safe treatment with a double-barrel extracranial-intracranial bypass and partial trapping and conversion of a deep bypass to a superficial one. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21163., Competing Interests: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication., (© 2022, The Authors.)