title: Superficial Temporal Artery to Middle Cerebral Artery Bypass via a Minimized Approach: Operative Nuances and Problem-Solving Aspects.
abstract: BACKGROUND
  The minimized approach for superficial temporal to middle cerebral artery (STA-MCA) bypass surgery is frequently associated with unfamiliar situations and technical problems.
  
  
  OBJECTIVE
  Description of operative nuances and evaluation of problem-solving aspects to facilitate potential limitations related with a limited exposure approach.
  
  
  METHODS
  In patients who underwent STA-MCA bypass surgery between February 2012 and August 2014, a preoperative high-resolution computed tomography-angiography 3-dimensional dataset was obtained to select the optimal vessels for anastomosis. Intraoperative exposure was assessed under standard neuronavigation. Anastomoses were performed with specific instruments developed by the authors. Intraoperative video documentation and follow-up records were analyzed retrospectively.
  
  
  RESULTS
  Seventeen STA-MCA minimally invasive bypass procedures were performed on 12 patients. In all cases, the procedure could be performed through planned craniotomy (mean diameter 2.5 cm). All cases of the procedures dealt with the limitation of surgical field during bypass surgery. The described applications facilitated microsurgical handling in the environment of a limited exposure in all procedures. Follow-up showed all bypasses remained open.
  
  
  CONCLUSIONS
  The surgical applications, operative techniques, problem-solving aspects, and development of new instruments are described. Potentially, these suggestions may enhance the surgical confidence and convenience to perform STA-MCA bypass surgery with a minimized approach.
authors.affiliation: Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany. Electronic address: gerrit.fischer@gmx.de.
authors.forename: Gerrit
authors.initials: G
authors.lastname: Fischer
authors.affiliation: Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Senger
authors.affiliation: Department of Neurosurgery, Liaquat National Hospital & Medical College, Karachi, Pakistan.
authors.forename: Salman
authors.initials: S
authors.lastname: Sharif
authors.affiliation: Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Oertel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods*; D002533:Cerebral Angiography / Q000379:methods; D002548:Cerebral Revascularization / Q000379:methods*; D002561:Cerebrovascular Disorders / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D000066491:Clinical Decision-Making / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D011340:Problem Solving; D025321:Surgery, Computer-Assisted / Q000379:methods; D013699:Temporal Arteries / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Arteriotomy scissors; Bypass clips; Minimally invasive neurosurgery; STA-MCA bypass