Preop

Revascularization patients are extremely susceptible to intraoperative strokes. The following guidelines are absolute: 

• No mannitol or diuretics
• No local
• Maintain normocapnia: PaCO2 40-45
• SBP 140-180

Preinduction a line, know pre induction SBP and keep in that range intra op.

Definitely need Foley

Monitoring

SSEPs and EEG for Moya-Moya STA-MCA bypass. If bypass is planned to a more proximal MCA branch (e.g. M2), then motors may be used. 

Setup

Use Doppler probe to mark course of STA.

Suture

9-0 Ethicon Nylon suture on a BV100-4 needle or 10-0 Ethicon Nylon suture on a BV75-3 needle. 

Positioning

Turn the bed 180. Pull the patient north until the shoulders are at the break in the bed. Place a pink foam bump longitudinally under the shoulder. Place thin purple foams between the arm and torso on both sides then pull the sheet up and wrap the patient with 3-inch tape like a burrito. 

Place the Layla bar holder on the contralateral side to the pathology. 

Pinning

Double pins are posterior, in the axial plane, just off midline towards the contralateral side to the pathology. Single pin is preferably in the hairline but okay to do in the forehead, at the mid-pupillary line, on the side opposite the pathology. 

Attach the Mayfield on the inner side, away from the operator. 

Once draped, the Layla bar goes on the side opposite the pathology. The distal arm of the Layla bar is oriented directly towards the operator such that it is parallel with the floor and with the side of the bed. It should be at about the level of the incision. 

The Greenburg retractor is attached on the side of the pathology with the clamp turned such that the short bar is pointed away from the operator. 

Head positioning

1. Turn the head such that it is in the same plane as the floor
2. Laterally flex slightly towards the ground.
3. No flexion or extension, maintain neutrality in that plane. 

Marking

Frontal division of STA

Parietal division of STA

Closure

Dura is reapproximated with several interrupted 4-0 Nurolon sutures. Not watertight. Place no sutures at the bottom of the exposure, near where the STA enters intracranially. 

Cut a piece of Nu-Knit to the shape of the bone graft then cut a large slit at the bottom to accommodate the STA. 

Use Leksell rongeurs to clip the sharp bone edges at the large burr hole at the bottom of the bone flap. 

Bring the temporalis anteriorly, towards the orbit, during closure of the muscle. Sew to the cuff of muscle you left behind on the bone flap. Use 2-0 Polysorb suture. 

Close the galea with 2-0 Polysorb. Be very cautious at the bottom of the incision not to injure the STA with a needle. The galeal closure is often tenuous due to the extensive soft tissue dissection required for the STA harvest. If any part of the galeal closure is questionable, don't hesitate to reinforce with 3-0 nylon vertical mattress, except for at the bottom of the incision near the STA.

Close skin with staples. Dress with bacitracin ointment, Telfa (not stapled to the head), and a Stockinette. 

Postop

CTA head immediately. Call Lang with scan. If there is no hemorrhage and the graft is patent, send to the ICU and have them given 300 mg of aspirin per rectum. 

Minocycline protocol: 200 mg PO daily for 1 week.

Ask Lang re: systolic BP parameters. He may ask for SBP 100-140.