Superficial temporal artery to middle cerebral artery bypass: past, present, and future

Abstract

Object The aim of this study was to review the historical developments and current status of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. Method A literature review was performed to review the origins and current uses of the STA bypass procedure in neurosurgery. Results The idea of providing additional blood supply to the brain to prevent stroke and maintain neurological function has been present in the mind of neurosurgeons for many decades. In 1967 the first STA–MCA bypass was done by M. G. Yaşargil, and an enormous step was made into the field of microneurosurgery and cerebral revascularization. During the decades that followed, this technique was used as an adjuvant or a definitive surgical treatment for occlusive disease of the extracranial and intracranial cerebral vessels, skull base tumors, aneurysms, carotid–cavernous fistulas, cerebral vasospasm, acute cerebral ischemia, and moyamoya disease. With the results of the first randomized extracranial–intracranial (EC–IC) bypass trial and the development of endovascular techniques such as angioplasty for intracranial atherosclerotic disease and cerebral vasospasm, the indications for STA–MCA bypass became limited. Neurosurgeons continued to perform EC–IC bypasses as an adjuvant to clipping of aneurysms and in the treatment of skull base tumors and moyamoya disease; the procedure is less commonly used for atherosclerotic carotid artery occlusion (CAO) with definite evidence of hemodynamic insufficiency. The evidence that patients with symptomatic CAO and “misery perfusion” have an increased stroke risk has prompted a second trial for evaluating EC–IC bypass for stroke prevention. The Carotid Occlusion Surgery Study is a new trial designed to determine whether STA–MCA bypass can reduce the incidence of stroke in these patients. New trials will also reveal the role of the STA–MCA bypass in the prevention of hemorrhages in moyamoya disease. Conclusions The role of STA–MCA bypass in the management of cerebrovascular disease continues to be refined and evaluated using advanced imaging techniques and by performing randomized trials for specific purposes, including symptomatic CAO.