Superficial temporal artery-to-middle cerebral artery side-to-side microvascular anastomosis and cranioplasty in a single-stage procedure: Technical nuances and hemodynamic outcomes

Cranioplasty following decompressive craniectomy in patients requiring concurrent cerebral revascularization presents a surgical challenge. While traditional end-to-side bypass may compromise scalp perfusion, a combined single-stage procedure integrating extracranial-to-intracranial (EC-IC) bypass with cranioplasty offers a potential strategy for consolidating treatment, reducing cumulative procedural risks, and optimizing recovery. To assess the feasibility of a single-stage procedure integrating superficial temporal artery (STA)-middle cerebral artery (MCA) side-to-side (S–S) anastomosis with cranioplasty and analyze the postoperative hemodynamic flow distribution. Two patients successfully underwent single-stage STA-MCA S–S microvascular anastomosis with cranioplasty. Good patency of the STA-MCA S–S anastomosis was confirmed by both intraoperative indocyanine green videoangiography (ICG-VA) and postoperative digital subtraction angiography (DSA). On the postoperative DSA, a similar hemodynamic blood flow pattern was observed in both patients, and the proximal STA provided antegrade blood flow to the recipient MCA and the distal STA. No postoperative complications, including cerebral infarction, cerebral hyperperfusion syndrome, or wound healing issues, were observed. A single-stage combined S–S EC-IC anastomosis and cranioplasty procedure offers a viable, safe, and effective surgical strategy for patients requiring EC-IC revascularization and cranioplasty after craniectomy.