title: Internal maxillary artery-middle cerebral artery bypass: infratemporal approach for subcranial-intracranial (SC-IC) bypass.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: *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.
authors.forename: Erez
authors.initials: E
authors.lastname: Nossek
authors.forename: Peter D
authors.initials: PD
authors.lastname: Costantino
authors.forename: Mark
authors.initials: M
authors.lastname: Eisenberg
authors.forename: Amir R
authors.initials: AR
authors.lastname: Dehdashti
authors.forename: Avi
authors.initials: A
authors.lastname: Setton
authors.forename: David J
authors.initials: DJ
authors.lastname: Chalif
authors.forename: Rafael A
authors.initials: RA
authors.lastname: Ortiz
authors.forename: David J
authors.initials: DJ
authors.lastname: Langer
mesh_terms: D000368:Aged; D002548:Cerebral Revascularization / Q000379:methods*; D002561:Cerebrovascular Disorders / Q000601:surgery*; D003399:Craniotomy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008438:Maxillary Artery / Q000601:surgery; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery; D038361:Neuronavigation; D019635:Neurosurgical Procedures / Q000379:methods*