Minimally invasive superficial temporal artery to middle cerebral artery bypass through a minicraniotomy: benefit of three-dimensional virtual reality planning using magnetic resonance angiography.
OBJECT
The aim of the authors in this study was to introduce a minimally invasive superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery by the preselection of appropriate donor and recipient branches in a 3D virtual reality setting based on 3-T MR angiography data.


METHODS
An STA-MCA anastomosis was performed in each of 5 patients. Before surgery, 3-T MR imaging was performed with 3D magnetization-prepared rapid acquisition gradient echo sequences, and a high-resolution CT 3D dataset was obtained. Image fusion and the construction of a 3D virtual reality model of each patient were completed.


RESULTS
In the 3D virtual reality setting, the skin surface, skull surface, and extra- and intracranial arteries as well as the cortical brain surface could be displayed in detail. The surgical approach was successfully visualized in virtual reality. The anatomical relationship of structures of interest could be evaluated based on different values of translucency in all cases. The closest point of the appropriate donor branch of the STA and the most suitable recipient M(3) or M(4) segment could be calculated with high accuracy preoperatively and determined as the center point of the following minicraniotomy. Localization of the craniotomy and the skin incision on top of the STA branch was calculated with the system, and these data were transferred onto the patient's skin before surgery. In all cases the preselected arteries could be found intraoperatively in exact agreement with the preoperative planning data. Successful extracranial-intracranial bypass surgery was achieved without stereotactic neuronavigation via a preselected minimally invasive approach in all cases. Subsequent enlargement of the craniotomy was not necessary. Perioperative complications were not observed. All bypasses remained patent on follow-up.


CONCLUSIONS
With the application of a 3D virtual reality planning system, the extent of skin incision and tissue trauma as well as the size of the bone flap was minimal. The closest point of the appropriate donor branch of the STA and the most suitable recipient M(3) or M(4) segment could be preoperatively determined with high accuracy so that the STA-MCA bypass could be safely and effectively performed through an optimally located minicraniotomy with a mean diameter of 22 mm without the need for stereotactic guidance.