J Cerebrovasc Endovasc Neurosurg.  2024 Mar;26(1):51-57. 10.7461/jcen.2023.E2022.11.003.

Internal maxillary artery (IMax) – middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report

• Degollado-García J
• Casas-Martínez MR
• Mejia BRF
• Balcázar-Padrón JC
• Rodríguez-Rubio HA
• Nathal E

• KMID: 2554046
• DOI: http://doi.org/10.7461/jcen.2023.E2022.11.003

Abstract

Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft’s free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.

Keyword

Cerebral revascularization; Maxillary artery; Brain ischemia; Carotid artery stenoses; Carotid atherosclerosis; IMax bypass

Figure

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  Fig. 1. Imaging studies. (A-C) Preoperative time to peak (TTP), mean transit time (MTT), and regional cerebral blood volume (rCBV) perfusion MRI shows low perfusion in the right hemisphere. (D) MRI shows an area of a previous infarction in the right opercular area. (E-G) Postoperative TTP, MTT, and rCBV perfusion image without areas of hypoperfusion. (H) CT-angio shows the IMax-radial artery graft (RAG) end-to-end anastomosis (yellow arrow) and the end-to-side M2 anastomosis (white arrow). CT-angio, computed tomography angiography; IMax, internal maxillary artery

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  Fig. 2. Illustrative case. (A) Surgical planning for a pterional and transzygomatic approach. (B and C) Incision and dissection of the radial artery. (D) IMax to radial artery graft end-to-end anastomosis. (E) Radial artery to M2 end-to-side anastomosis. (F) Intraoperative fluorescein video angiography shows the IMax-M2 anastomosis with radial artery graft (white arrows) with adequate perfusion of the cerebral hemisphere. IMax, internal maxillary artery

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  Fig. 3. Sagittal view shows the IMax-radial artery graft (RAG) end-to-end anastomosis (yellow arrow) and the end-to-side M2 anastomosis (white arrow). IMax, internal maxillary artery

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