STA-MCA procedue

so this is what I am having done in a week and 2 days and i find myself not so scared anymore but worried because I won't be here for my children while i am in Jacksonville for surgery and such...... i guess I should be scared of surgery and worried and terrified right?! but i am not... I am more concerned with how will my daughter be feeling while i am away and what will my 19 mo old be thinking when mama and papa are gone for so long.....these are the things that bother me... also, what bothers me also is my husband being alone down there through this...... what is he going to do.. what will he be thinking and i just can't imagine him being alone during this you know... i really really worries me to no end..... he is a strong person but he's got so much on him and to be going through this by himself with NOONE there just kills me to think about...

so here is the procedure they will be doing:
STA-MCA Bypass
History and general surgical techniques. The first STA-MCA bypass for moyamoya disease was performed by Yasargil in 1972, and since then several small series have been reported. Karasawa et al. reported on 12 moyamoya patients under going bypass, with 10 patients (83%) having good to excellent results. Quest and Carrol reported a similar outcome in 11 of 13 patients (85%). Ishikawa et al. compared STA-MCA bypass (48 procedures) with indirect revascularization methods (16 procedures), such as encephaloduroarteriomyosynangiosis, in pediatric moyamoya patients and showed that the incidence of postoperative ischemic events was significantly reduced in the direct bypass group (10%) compared to the indirect group (56%, p < 0.01 ). They concluded that direct revascularization is the procedure of choice over indirect revascularization whenever possible. Matsushima et al. have shown a similar advantage of direct revascularization over indirect methods, although with a smaller group of patients.
Since 1991 (as of May 2000), we have performed 60 STA-MCA grafts (Figs. 2, 3, 4) in moyamoya patients ages 5 to 63 years, with excellent clinical results overall. Six patients had temporary minor worsening postoperatively, which resolved with volume expansion, and one patient had a postoperative hemorrhage into a previously ischemic region. Mean follow-up was 43 months (range, 1 month to 7 years), and 95% of patients were neurologically stable or improved. One patient developed persistent TIAs after occlusion of a STA-MCA bypass with short vein interposition. Follow-up angiography showed that 97% of grafts were patent, and there was improved hemodynamic reserve on cerebral blood flow studies in most patients. There were no perioperative deaths, but one adult died of a myocardial infarction 72 months after bypass, and another adult died 18 months following an external carotid to MCA bypass using a vein interposition (from hemorrhage into ischemic brain). Of 13 pediatric moyamoya patients (21 hemispheres) treated with STA-MCA bypasses (9 following strokes, and 6 with refractory TIAs), none have developed new strokes (mean follow-up 45 months, range 2-84 months). Postoperative angiograms showed 100% graft patency and successful revascularization of the MCA distribution in over 90% of the cases, and postoperative xenon CT scans showed increased augmentation with acetazolamide as compared to the preoperative study.
Several operative generalities are applicable to STA-MCA revascularization procedures. Patients are positioned with the head above the heart to reduce venous cerebral congestion. Hyperventilation and alpha-adrenergic agents are not recommended because of their vasoconstrictive effects, but mild hypothermia (32-34°C) and barbiturates are used routinely to provide a cerebral protective effect during occlusion times. The mean arterial pressure should be kept in the normal to high range, and patients should be volume expanded to prevent ischemic events. Vasoconstrictive agents such as epinephrine should not be used during scalp infiltration. Intraoperative monitoring with EEG and somatosensory evoked potentials provides early detection of ischemic changes, and thiopental may be administered during the MCA occlusion for the anastomosis.
Microinstruments and the operating neurosurgical microscope are routinely used for revascularization procedures. Donor vessels should be selected with an outer diameter ³ 1 mm, because smaller vessels have higher occlusion rates, provide less blood flow, and are more difficult to anastomose. Vein interpositions may be used, and they provide immediate dilatation to increase blood flow to the recipient vessel. Papaverine is useful in preventing vascular spasm.
If venous interposition is needed, the superficial temporal vein or saphenous vein can be used. The vein segments are meticulouslv harvested, and side branches are carefully ligated while avoiding any laceration to the vein itself. The vein is then irrigated with heparinized saline and inspected for any lacerations that would require surgical repair prior to use. The vein is stored in heparinized saline until needed.
Hemodynamic control is the primary goal of postoperative management. Hypertension may result in excessive bleeding at the anastomotic site. Hemorrhages, from increased perfusion of the brain as well as possible leaks in the anastomotic site, are other complications. Conversely, hypotension may cause graft occlusion resulting in clinical ischemia. In such cases, an emergent angiogram and graft revision may be necessary. Aspirin is started on the first postoperative day. Cerebrospinal fluid (CSF) leak is a potential complication, due to the non-water-tight dural closure, but this is extremely rare.
Operative Technique
The patient is positioned with the head turned to the contralateral side and the temporal bone parallel to the floor and placed in three-point pin fixation. After the scalp is shaved, a handheld standard Doppler ultrasound probe and the preoperative angiograms are used to identify the location of the STA, which is then marked out with a marking pen. There usually are two main branches, the frontal and parietal STA branches; both should be marked out to allow a choice of vessel during the procedure. Following sterile preparation, an incision is made, beginning over the zygoma, with a #15 blade. The STA is identified and skeletonized using sharp dissection with a combination of scissors and a #15 blade. When necessary, a sterile Doppler probe can be used to confirm the course of the STA. Either the frontal or parietal STA branch may be used, depending on diameter and suitable length. Our preference is to use the larger diameter artery, with the exception being a frontal STA branch, which is larger but passes low over the forehead. It is desirable to leave a cuff of tissue around the artery itself. This reduces direct trauma to the artery, decreases vasospasm of the vessel, and allows the surgeon to grasp the donor segment without injuring the vessel. Smaller branches of the artery are bipolar coagulated; larger branches are isolated and tied off. The length of the artery required depends on the distance from the artery to the graft site. A craniotomy is performed in the superior, midtemporal bone overlying the Sylvian fissure, with care taken to avoid injury of the STA vessel during the bone opening. The dura is then opened, and the neurologic microscope is used to identify the recipient vessels. Optimal recipient middle cerebral artery (MCA) branches have outer luminal diameters ³1 mm. Other variables influencing the choice of recipient vessel include the orientation of the vessel and the location of the MCA branch relative to the Sylvian fissure (closer usually is better, because this allows improved backflow down to the ICA bifurcation). An M3 or M4 MCA branch is preferred. Dissection of the arachnoid layer over a 6- to 10-mm segment exposes this vessel. Tiny branches originating from this segment are coagulated and divided. A small piece of sterile plastic is placed beneath the segment of the MCA at the anastomosis site as a "high visibility" backfield. A temporary aneurysm clip is placed on the proximal STA, and the distal tip of the exposed vessel is ligated and cut. Blood flow through the STA can be tested by transiently removing the proximal temporary aneurysm clip. The lumen of the STA then is irrigated out with heparinized saline to minimize clot formation within the donor vessel. The distal portion of the STA vessel is trimmed to the appropriate length, based on location of the recipient vessel, and the soft tissue cuff is removed from the distal 3 to 5 mm as preparation for the anastomosis. The distal end of the donor vessel is cut in an oblique fashion. Small microvascular clamps then are placed on each side of the recipient vessel to prevent bleeding during the anastomosis. The recipient vessel is cut in a diamond-shaped fashion using a microscissors. Carmine indigo dye may be used to improve visualization of the vessel lumens. The anastomosis is performed under the neuromicroscope using 10-0 monofilament suture. Corner stitches are placed first, followed by the far wall and then the near wall. The intimal layer must be included with each interrupted stitch, but significant narrowing of the anastomotic site should be avoided. We prefer interrupted sutures, but a continuous suture can also be used. Temporary clips are then removed, first from the MCA branch, and then from the proximal STA. Total MCA branch occlusion times typically are 20 to 30 minutes. Significant bleeding may indicate the need for an additional stitch, whereas small amounts of bleeding may be treated with Gelfoam or Surgicel. Once the anastomosis is complete, a Doppler ultrasound may be used to test patency. We use a quantitative and directional ultrasound to asses flow both pre- and post-bypass.
The dura is carefully closed to avoid compromising the STA. The bone flap also is trimmed to minimize any pressure on the donor vessel. Temporalis and scalp closure then proceeds in the usual fashion.