Extracranial to Intracranial Flow through Flaps
Beina Azadgoli, MS, Hyuma Leland, MD, Erik Wolfswinkel, MD, Brock Lanier, MD, Jonathan Russin, MD, Joseph Carey, MD.
Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Purpose: Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, intracranial aneurysms requiring bypass, and neurovascular disorders. Soft tissue transfer is indicated for craniofacial trauma and tumors and in cases of indirect cerebral revascularization. Fascial, skin, omental, and muscle flaps have been used for these indications. In this series, we describe early results of flow through flaps for cerebral revascularization in conjunction with soft tissue reconstruction.
Methods: A retrospective review of a prospectively maintained database was performed. Seven patients were identified who required direct arterial bypass in conjunction with a soft tissue procedure for indirect revascularization or soft tissue reconstruction.
Results: Indications for arterial bypass included intracranial aneurysm (n=1) and moyamoya disease (n=6). Indications for soft tissue reconstruction included infected cranioplasty (1) and indirect cerebral revascularization for moyamoya disease (6). Flaps included flow through radial forearm fasciocutaneous flaps (2), a flow through radial forearm fascial flap (1) and flow through pedicled temporoparietal fascial flaps (4). The superficial temporal vessels (6) and facial vessels (1) were used as the recipient site pedicle. Flow through reperfusion was established into the middle cerebral artery (5) and anterior communicating artery (2). There were no intraoperative complications. All flaps survived and there were no donor site complications. Postoperative imaging demonstrated graft patency in 6/7 patients. In one case of flow through TPF flap, the direct graft failed, but the indirect flap remained vascularized.
Conclusions: Flow through flaps can be safely used for conditions where combined arterial bypass and soft tissue procedures are required. Early outcomes have not demonstrated any major complications. Long-term results with direct and indirect re-vascularization are pending.
Figure 1. A. Pre-operative markings B. Superficial temporal fascial flap C. Inset of flap and dural closure
Figure 2. A. Cortical MCA branch dissected out with the prepared distal STA adjacent to it B. STA to M4 completed anastomosis
Figure 3. Flow through radial forearm fascial flap anastomosed to STA and STV and bypass to anterior cerebral artery
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