Safety, Feasibility, and Patient-Rated Outcome of Sonolucent Cranioplasty in Extracranial-Intracranial Bypass Surgery to Allow for Transcranioplasty Ultrasound Assessment

Alex R Flores, Visish M Srinivasan, Jill Seeley, Charity Huggins, Peter Kan, Jan-Karl Burkhardt, Alex R Flores, Visish M Srinivasan, Jill Seeley, Charity Huggins, Peter Kan, Jan-Karl Burkhardt

Abstract

Objective: We sought to analyze the safety and feasibility of elective sonolucent cranioplasty in the setting of extracranial-to-intracranial (EC-IC) bypass surgery to monitor bypass patency using ultrasound.

Methods: Patients who underwent direct EC-IC bypass surgery agreed to sonolucent cranioplasty at the time of surgery and received a sonolucent polymethyl methacrylate (PMMA) implant. Besides monitoring clinical outcome, all patients received transcranioplasty ultrasound (TCUS) on postoperative day 1 and at last follow-up. In addition, bypass patency was confirmed using catheter angiogram and fit of implant using computed tomography. Patient-rated outcome was assessed through phone questionnaire.

Results: EC-IC bypass surgery with PMMA cranioplasty was successful in all 7 patients with patent bypasses on postoperative angiogram. Direct TCUS was feasible in all patients, and bypass patency was monitored. There were no complications such as postoperative hemorrhagic/ischemic complications related to the bypass procedure in this patient population, as well as no complications related to the PMMA implant. Postoperative computed tomography showed favorable cosmetic results of the PMMA implant in both the pterional area for superficial temporal artery-middle cerebral artery bypasses and parietooccipital area for occipital artery-middle cerebral artery bypasses as confirmed by high-rated overall patient satisfaction with favorable cosmetic, pain, and sensory patient-rated outcomes.

Conclusions: In this study we were able to show that this novel technique is safe, allows for patency assessment of the EC-IC bypass using bedside TCUS technique, and is cosmetically satisfying for patients.

Keywords: Extracranial-to-intracranial bypass; Real-time ultrasound monitoring; Sonolucent cranioplasty; Transcranioplasty ultrasound.

Copyright © 2020 Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Overview of evolution of different sonolucent polymethyl methacrylate (PMMA) implants used in this patient cohort. (A) Large, slightly curved piece used as raw material for cutting of a specific cranioplasty after outlining the size (top) and after cut out (bottom). (B) Similar to A, a large PMMA implant was cut to a specific size as needed to cover a cranial defect of a recraniotomy defect with additional craniotomy. A piece of telfa (white) was used to outline the size needed. (C and D) Small, disk-shaped implant curved (C) or flat (D) depending on the needs that could be used with minimal to no additional cutting or shaping.
Figure 2
Figure 2
A 41-year-old female patient with moyamoya disease presented with repeated transient ischemic attacks, and catheter angiogram (A) showed severe internal carotid artery narrowing with classic moyamoya disease vessel appearance (asterisk). She underwent left double-barrel superficial temporal artery−middle cerebral artery (MCA) bypass; intraoperative images are shown before (B), after the 2 anastomoses (C), and after indocyanine green angiography (D). (E−G) After the size of the PMMA cranioplasty was outlined, the implant was cut out using a craniotomy (E) and fixated using titanium plates and screws (G). Postoperative catheter angiogram (H) confirmed bypass patency (asterisk), and postoperative CTA in coronal reconstruction showed the PMMA implant and the patent bypass graft (I). Transcranioplasty Doppler ultrasound confirmed flow and bypass patency as well (J and K). 1 asterisk, frontal M4 MCA branch, 2 asterisks, temporal M4 MCA branch; c, PMMA implant; fSTA, frontal STA branch; pSTA, parietal STA branch.
Figure 3
Figure 3
This 42-year-old patient with moyamoya disease had a previous superficial temporal artery−middle cerebral artery (MCA) bypass and presented with new transient ischemic attacks despite previous surgery. The patient underwent an occipital artery (OA)-to-MCA bypass (A) using 1 of the distal OA branches for a direct bypass anastomosis (1 asterisk) and the second branch as an encephaloduroarteriosynangiosis (EDAS) (2 asterisks), as well as the dura for dural inversion technique (D). (B−D) A large, slightly curved polymethyl methacrylate implant was used as raw material for cutting of a specific cranioplasty after outlining the size. In this case the top and bottom portion of the implant were left open to allow enough space for the inflow and outflow artery of the direct bypass and EDAS (E) and was then fixated with titanium screws and plates (F) After only Duragen (Integra Lifesciences, Plainsboro Township, New Jersey, USA) was used to close the dura without compressing the graft. Postoperative transcranioplasty Doppler ultrasound (G), as well as computed tomography angiography in coronal reconstruction (H and I), confirmed bypass patency with inflow OA bypass graft (1 asterisk) exiting the distal EDAS branch (2 asterisks).

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