Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review.

BACKGROUND: The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases. METHODS: The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration. RESULTS: Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P = 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P = 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P = 0.001). CONCLUSIONS: In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Immersive Surgical Anatomy of the Far-Lateral Approach.

The far-lateral (FL) approach is a classic neurosurgical technique that enables access to the craniocervical junction, which includes the lower clivus, the anterior foramen magnum, and the first two cervical vertebrae. The FL approach also provides access to the inferior cranial nerves (i.e., CN IX, CN X, CN XI, and CN XII), distal portions of the vertebral artery (VA), and inferior basilar trunk. Recent advances in three-dimensional (3D) technology as well as dissections allow for a better understanding of the spatial relationships between anatomical landmarks and neurovascular structures encountered during neurosurgical procedures. This study aims to create a collection of volumetric models (VMs) obtained from cadaveric dissections that depict the FL approach's relevant anatomy and surgical techniques. We describe the relevant multilayer anatomy involved in the FL approach and discuss modifications of this approach as well. Five embalmed heads and two dry skulls were used to record and simulate the FL approach. Relevant steps and anatomy of the FL approach were recorded using 3D scanning technology (e.g., photogrammetry and structured light scanning) to construct high-resolution VMs. Images and VMs were generated to demonstrate major anatomical landmarks for the FL approach. The interactive models allow for clear visualization of the surgical anatomy and windows in 3D and extended reality, rendering a closer look at the nuances of the topography experienced in the laboratory. VMs can be valuable resources for surgical planning and anatomical education by accurately depicting important landmarks.

Peptoids advance multidisciplinary research and undergraduate education in parallel: Sequence effects on conformation and lipid interactions.

Peptoids are versatile peptidomimetic molecules with wide-ranging applications from drug discovery to materials science. An understanding of peptoid sequence features that contribute to both their three-dimensional structures and their interactions with lipids will expand functions of peptoids in varied fields. Furthermore, these topics capture the enthusiasm of undergraduate students who prepare and study diverse peptoids in laboratory coursework and/or in faculty led research. Here, we present the synthesis and study of 21 peptoids with varied functionality, including 19 tripeptoids and 2 longer oligomers. We observed differences in fluorescence spectral features for 10 of the tripeptoids that correlated with peptoid flexibility and relative positioning of chromophores. Interactions of representative peptoids with sonicated glycerophospholipid vesicles were also evaluated using fluorescence spectroscopy. We observed evidence of conformational changes effected by lipids for select peptoids. We also summarize our experiences engaging students in peptoid-based projects to advance both research and undergraduate educational objectives in parallel.

Revascularization of the upper posterior circulation with the anterior temporal artery: an anatomical feasibility study.

OBJECTIVE In various disease processes, including unclippable aneurysms, a bypass to the upper posterior circulation (UPC) including the superior cerebellar artery (SCA) and posterior cerebral artery (PCA) may be needed. Various revascularization options exist, but the role of intracranial (IC) donors has not been scrutinized. The objective of this study was to evaluate the anatomical feasibility of utilizing the anterior temporal artery (ATA) for revascularization of the UPC. METHODS ATA-SCA and ATA-PCA bypasses were performed on 14 cadaver specimens. After performing an orbitozygomatic craniotomy and opening the basal cisterns, the ATA was divided at the M3-M4 junction and mobilized to the crural cistern to complete an end-to-side bypass to the SCA and PCA. The length of the recipient artery between the anastomosis and origin was measured. RESULTS Seventeen ATAs were found. Successful anastomosis was performed in 14 (82%) of the ATAs. The anastomosis point on the PCA was 14.2 mm from its origin on the basilar artery. The SCA anastomosis point was 10.1 mm from its origin. Three ATAs did not reach the UPC region due to a common opercular origin with the middle temporal artery. The ATA-SCA bypass was also applied to the management of an incompletely coiled SCA aneurysm. CONCLUSIONS The ATA is a promising IC donor for UPC revascularization. The ATA is exposed en route to the proximal SCA and PCA through the pterional-orbitozygomatic approach. Also, the end-to-side anastomosis provides an efficient and straightforward bypass without the need to harvest a graft or perform multiple or difficult anastomoses.

Transfer of Learning from Practicing Microvascular Anastomosis on Silastic Tubes to Rat Abdominal Aorta.

OBJECTIVE: Learning to perform microvascular anastomosis is difficult. Laboratory practice models using artificial vessels are frequently used for this purpose. However, the efficacy of such practice models has not been objectively assessed for the performance of microvascular anastomosis during live surgical settings. This study was conducted to assess the transfer of learning from practicing microvascular anastomosis on tubes to anastomosing rat abdominal aorta. METHODS: Ten surgeons without any experience in microvascular anastomosis were randomly assigned to an experimental or a control group. Both groups received didactic and visual training on end-to-end microvascular anastomosis. The experimental group received 24 sessions of hands-on training on microanastomosis using Silastic tubes. Next, both groups underwent recall tests on weeks 1, 2, and 8 after training. The recall test consisted of completing an end-to-end anastomosis on the rat's abdominal aorta. Anastomosis score, the time to complete the anastomosis, and the average time to place 1 stitch on the vessel perimeter were compared between the 2 groups. RESULTS: Compared with the control group, the experimental group did significantly better in terms of anastomosis score, total time, and per-stitch time. The measured variables showed stability and did not change significantly between the 3 recall tests. CONCLUSION: The skill of microvascular anastomosis is transferred from practicing on Silastic tubes to rat's abdominal aorta. Considering the relative advantages of Silastic tubes to live rodent surgeries, such as lower cost and absence of ethical issues, our results support the widespread use of Silastic tubes in training programs for microvascular anastomosis.

Assessment of the Temporopolar Artery as a Donor Artery for Intracranial-Intracranial Bypass to the Middle Cerebral Artery: Anatomic Feasibility Study.

BACKGROUND: Intracranial-intracranial bypass is a valuable cerebral revascularization option. Despite several advantages, one of the main shortcomings of the intracranial-intracranial bypass is the possibility of ischemic complications of the donor artery. However, when sacrificed, the temporopolar artery (TPA) is not associated with major neurologic deficits. We sought to define the role of TPA as a donor for revascularization of the middle cerebral artery (MCA). METHODS: Pterional craniotomy was performed on 14 specimens. The TPA was released from arachnoid trabecula, and the small twigs to the temporal lobe were cut. The feasibility of side-to-side and end-to-side bypass to the farthest arterial targets on insular, opercular, and cortical MCA branches was assessed. The distance of the bypass point was measured in reference to limen insulae. RESULTS: A total of 15 TPAs were assessed (1 specimen had 2 TPAs). The average cisternal length of the TPA was 37.3 mm. For side-to-side bypass, the TPA was a poor candidate as an intracranial donor, except for the cortical orbitofrontal artery, which was reached in 87% of cases. However, the end-to-side bypass was successfully completed for most arteries (87%-100%) on the anterior frontal operculum and more than 50% of the cortical or opercular middle and posterior temporal arteries. There was no correlation between the TPA's cisternal length and maximum bypass reach. CONCLUSIONS: When of favorable diameter, the TPA is a competent donor for intracranial-intracranial bypass to MCA branches at the anterior insula, and anterior frontal and middle temporal opercula (arteries anterior to the precentral gyrus coronal plane).

Anterior Temporal Artery-to-Anterior Cerebral Artery Bypass: Anatomic Feasibility of a Novel Intracranial-Intracranial Revascularization Technique.

BACKGROUND: Complex aneurysms of the anterior cerebral artery (ACA) may require a bypass procedure as part of their surgical management. Most current bypass paradigms recommend technically demanding side-to-side anastomosis of pericallosal arteries or use of interposition grafts, which involve longer ischemia times. The purpose of this study is to assess the feasibility of an anterior temporal artery (ATA) to ACA end-to-side bypass. METHODS: Fourteen cadaveric specimens (17 ATAs) were prepared for surgical simulation. The cisternal course of the ATA was freed from perforating branches and arachnoid. The M3-M4 junction of the ATA was cut, and the artery was mobilized to the interhemispheric fissure. The feasibility of ATA bypass to the precommunicating and postcommunicating ACA was assessed in relation to the cisternal length and branching pattern of the middle cerebral artery. RESULTS: Successful anastomosis was feasible in 14 ATAs (82%). Three ATAs did not reach the ACA. These ATAs were branching distally and originated from the M3 (opercular) middle cerebral artery. In specimens where bypass was not feasible, the average cisternal length of the ATA was significantly shorter than the rest. CONCLUSIONS: ATA-ACA bypass is anatomically feasible and may be a useful alternative to other revascularization techniques in selected patients. It is technically simpler than A3-A3 in situ bypass. ATA-ACA bypass can be performed through the same pterional exposure used for the ACA aneurysms, sparing the patient an additional interhemispheric approach, required for the A3-A3 anastomosis.

The anterior temporal artery: an underutilized but robust donor for revascularization of the distal middle cerebral artery.

OBJECTIVE The anterior temporal artery (ATA) supplies an area of the brain that, if sacrificed, does not cause a noticeable loss of function. Therefore, the ATA may be used as a donor in intracranial-intracranial (IC-IC) bypass procedures. The capacities of the ATA as a donor have not been studied previously. In this study, the authors assessed the feasibility of using the ATA as a donor for revascularization of different segments of the distal middle cerebral artery (MCA). METHODS The ATA was studied in 15 cadaveric specimens (8 heads, excluding 1 side). First, the cisternal segment of the artery was untethered from arachnoid adhesions and small branches feeding the anterior temporal lobe and insular cortex, to evaluate its capacity for a side-to-side bypass to insular, opercular, and cortical segments of the MCA. Any branch entering the anterior perforated substance was preserved. Then, the ATA was cut at the opercular-cortical junction and the capacity for an end-to-side bypass was assessed. RESULTS From a total of 17 ATAs, 4 (23.5%) arose as an early MCA branch. The anterior insular zone and the frontal parasylvian cortical arteries were the best targets (in terms of mobility and caliber match) for a side-to-side bypass. Most of the insula was accessible for end-to-side bypass, but anterior zones of the insula were more accessible than posterior zones. End-to-side bypass was feasible for most recipient cortical arteries along the opercula, except for posterior temporal and parietal regions. Early ATAs reached significantly farther on the insular MCA recipients than non-early ATAs for both side-to-side and end-to-side bypasses. CONCLUSIONS The ATA is a robust arterial donor for IC-IC bypass procedures, including side-to-side and end-to-side techniques. The evidence provided in this work supports the use of the ATA as a donor for distal MCA revascularization in well-selected patients.

Topographic Surgical Anatomy of the Parasylvian Anterior Temporal Artery for Intracranial-Intracranial Bypass.

BACKGROUND: The anterior temporal artery (ATA) is an appealing donor artery for intracranial-intracranial bypass procedures. However, its identification may be difficult. Current literature lacks useful landmarks to help identify the ATA at the surface of the sylvian fissure. The objective of this study was to define the topographic anatomy of the cortical segment of the ATA relative to constant landmarks exposed during the pterional approach. METHODS: The temporopolar artery (TPA), ATA, and middle temporal artery (MTA) were examined in 16 cadaveric specimens. The topographic anatomy and key landmarks of the arteries at the sylvian fissure were recorded. The distance between the point of emergence from the sylvian fissure to the lesser sphenoid wing and anterior tip of the temporal lobe was measured. The features of the inferior frontal gyrus relative to each of the arteries at the sylvian fissure were also recorded. RESULTS: The average distances from the lesser sphenoid wing to the TPA, ATA, and MTA were 3.7 mm, 21.2 mm, and 37 mm. The mean distances from the temporal pole were TPA, 14.7 mm; ATA, 32.0 mm; and MTA, 45.4 mm. The differences between the average distances were statistically significant (P < 0.0001). The ATA most frequently faced pars triangularis, whereas the TPA always faced pars orbitalis. The MTA was always found posterior to the junction of pars triangularis and pars opercularis. CONCLUSIONS: This article provides topographic evidence for efficient identification of the ATA in the parasylvian space. The key relationship and landmarks identified in this study may increase efficiency and safety when harvesting the ATA for intracranial-intracranial bypass.