A 1-Donor 2-Recipient Superficial Temporal Artery-Middle Cerebral Artery Bypass for Moyamoya Syndrome: 2-Dimensional Operative Video

Abstract We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-sided weakness. He was found to have left M1 segment near occlusion on angiography with a large area of uncompensated hypoperfusion. The patient underwent a direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Direct bypass in the acute setting of ischemia has been previously described.1-5 Moyamoya ischemic disease can be treated with either direct or indirect surgical revascularization. There have been several techniques developed for direct bypasses in moyamoya ischemic disease. These include the standard 1-donor 1-recipient (1D1R) end-to-side (ES) bypass, the “double-barrel” 2-donor 2-recipient (2D2R) ES bypass, and the more recently developed 1-donor 2-recipient (1D2R)6,7 utilizing both an ES and a side-to-side (SS) bypass with a 1-donor vessel. The case presentation, surgical anatomy, decision-making, operative nuances, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video

Paramedian Supracerebellar Infratentorial Approach for Pontine Cavernoma: 2-Dimensional Operative Video

We describe the case of a 26-yr-old male who presented with headaches, dizziness, and left hemi-hypoesthesia in addition to being COVID-19 positive. The patient was found to have a large hemorrhage in the right dorsolateral pons that was found to be due to a pontine cavernous malformation. The patient underwent a right-sided paramedian supracerebellar infratentorial approach for resection of this lesion with preservation of the developmental venous anomaly. We present the operative video with a specific focus on approach selection, anatomic illustrations, and technical nuances. The literature on the timing of brainstem cavernoma surgery is reviewed.1-4 The patient's postoperative clinical course and postoperative imaging are reviewed. The patient gave informed consent for the procedure and verbal consent for being part of this submission and the publication of their image

Excision and End-to-End Anastomosis of a Giant Partially Thrombosed Cervical Internal Carotid Artery Aneurysm Mimicking a Neck Tumor: 2-Dimensional Operative Video

Aneurysms of the cervical internal carotid artery (ICA) are a rare entity1,2 accounting for less than 0.2% to 0.5% of all carotid surgeries3 and less than 1% of all arterial aneurysms.4 There are several types of aneurysms, which include dissecting aneurysms, pseudoaneurysms, mycotic aneurysms, and fusiform and saccular aneurysms.5 The causes can include atherosclerosis, trauma, infection, and dysplasia. We present the case of a 70-yr-old otherwise healthy female found to have a neck mass. She was referred from a peripheral vascular surgeon to a head and neck surgeon for potential biopsy. The head and neck surgeon obtained vascular imaging and referred the patient to neurosurgery for definitive management. The patient gave informed consent for the procedure. An excision of the cervical ICA aneurysm and reanastomosis of the cervical ICA was performed. The patient remained neurologically intact postoperatively and imaging demonstrated complete aneurysm occlusion and a patent cervical ICA anastomosis. The patient gave verbal consent for this case to be published

Anterior Petrosal [Kawase] Approach to Meckel's Cave Meningioma: 2-Dimensional Operative Video

Abstract Meningiomas arising from Dorello's canal1-3 are a rare disease entity often resulting in an unclear diagnosis even at the time of surgery.4,5 We present a case of a 63-yr-old man who presented with a sixth nerve palsy. He was found to have a lesion in the region of Meckel's cave on neuroimaging studies. Additionally, there were cutaneous and joint complaints that gave rise to a clinical possibility of sarcoidosis. The differential diagnosis also included meningioma or other inflammatory processes. The patient underwent a right-sided middle fossa approach and partial anterior petrosectomy (Kawase approach). Meckel's cave was opened, the tumor resected, and the petrosphenoid ligament (Gruber's) was identified. It was a meningioma. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video

Microsurgical Clipping and Bypass for Fusiform Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate complex endovascular or microsurgical treatment. We present a case of a 25-yr-old female with an incidentally discovered left 14-mm fusiform MCA aneurysm incorporating the frontal MCA trunk origin in its dome. The location and anatomy were not favorable for endovascular treatment with flow diversion.  The patient was offered continued observation or microsurgical treatment. Direct clipping of this aneurysm was not possible. After a thorough discussion of the risks, benefits, indications, and natural history of the lesion, the patient desired to have the aneurysm treated given her young age, location, size of the aneurysm, and the significant clinical experience of the treating team in bypass surgery.  The patient underwent superficial temporal artery to frontal M2 (STA-FM2) direct bypass for flow replacement followed by microsurgical trapping and clip ligation. The patient was maintained on antiplatelet therapy preoperatively and postoperatively. The patient had a transient aphasia and mild right upper extremity weakness (4/5) in the immediate postoperative period, which fully recovered by the time of patient discharge. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The different strategies for bypass and clip ligation are reviewed with particular focus on the anatomic constraints for each bypass configuration. The outcomes of bypass surgery for MCA aneurysms are reviewed.1-7 The patient gave verbal consent for participating in the procedure, surgical video, and publication of their image