Abstract：Objective To observe the anatomical characteristics of the wing muscle segment of the maxillary artery and explore the feasibility of exposing the maxillary artery in cerebral vascular bypass grafting. Methods Twelve fresh adult cadaver head specimens, including 3 females and 9 males aged 50-80 years with an average age of 64 years, were collected. After latex was infused, the zygomatic arch was resected, and the pterygoid muscle segment of the maxillary artery was exposed by pterygoid approach. The running characteristics of the maxillary artery and its relationship with the external wing muscle were observed and recorded. The distance from the pterygoid segment of the maxillary artery to the infratemporal crest was measured. The clinical data of two patients, one male and one female, with cerebrovascular bypass graft treated in the Department of Neurosurgery of the First Affiliated Hospital of Zhengzhou University from October 2020 to April 2021 were retrospectively analyzed. The male and female patients were aged 62 and 38 years, respectively. One of the patients was diagnosed with basilar artery dilatation and aneurysm, which were treated by the interventional occlusion of the dominant vertebral artery in the first stage and then by maxillary artery-radial artery-superior cerebellar artery bypass in the second stage. The other case was diagnosed with cerebral infarction, anterior clinoid meningioma, and severe stenosis of the left internal carotid artery. Maxillary artery-radial artery-middle cerebral artery bypass graft and meningioma resection were performed. The maxillary artery was exposed by pterional approach combined with zygomatic arch resection in the two patients. The patency of the bridging vessels and the postoperative neurological function were observed. Results (1) In all specimens, the pterygoid and pterygopalatine segments of the maxillary artery were exposed successfully, and no cranial nerve injury occurred. The pterygoid maxillary artery ran laterally to the LPM in 17 sides. The length from the end of the maxillary artery to the infratemporal crest was 8.2-18.4 (13.2±4.2) mm in lateral variation. The maxillary artery passes through the medial side of the external pterygoid muscle on seven sides, and the pterygopalatine fossa segment is short and cannot be lifted up to the inferior temporal crest; therefore, its free length was not recorded. (2) The pterygoid muscle segment of the maxillary artery was successfully exposed in both patients, and cerebral vascular bypass was successfully completed. Case one's neurological function was stable after surgery. Three months after the operation, computed tomography angiography(CTA) of the head showed that the bridge vessels were unobstructed and the basilar artery aneurysm size had no significant change. In case 2, the muscle strength of left upper limb decreased from preoperative grade 2 to grade 0. There was no new cerebral infarction in telephone follow-up 3 months after the operation, muscle strength of the affected limb recovered to level 4, and CTA showed bridge vessel occlusion. Conclusion The pterygoid muscle segment of the maxillary artery can be safely and effectively exposed by pterygoid approach combined with zygomatic arch resection. The maxillary artery running on the lateral side of the extra pterygoid muscle is relatively long and superficial and is a good donor vessel for vascular bypass surgery.
陈鑫璞, 白亚辉, 刘建新, 王凯. 上颌动脉显露技术在脑血管搭桥术中的应用[J]. 中华解剖与临床杂志, 2022, 27(6): 385-390.
Chen Xinpu, Bai Yahui, Liu Jianxin, Wang Kai. Microsurgical techniques for exposing maxillary artery in cerebral revascularization surgery. Chinese Journal of Anatomy and Clinics, 2022, 27(6): 385-390.
Chiluwal AK, Nouri M, Knobel D, et al.Surgical trapping of a large complex middle cerebral artery aneurysm with double-barrel bypass: 3-dimensional operative video[J]. Oper Neurosurg (Hagerstown), 2021, 20(6): E444-E445. DOI: 10.1093/ons/opab028.
[2]
Doherty RJ, Moneley D, Brennan P, et al.Internal maxillary artery to middle cerebral artery bypass for a complex recurrent middle cerebral artery aneurysm: case report and technical considerations[J]. Br J Neurosurg, 2020:1-4. DOI: 10.1080/02688697.2020.1849545.
[3]
Patel NV, Ligas B, Gandhi S, et al.Internal maxillary to middle cerebral artery bypass using an anterior tibial artery graft, performed using a 3-dimensional exoscope: 2-dimensional operative video[J]. Oper Neurosurg (Hagerstown), 2020, 19(2):E187. DOI: 10.1093/ons/opz379.
[4]
White TG, Klironomos G, Langer DJ, et al.Combined internal maxillary artery to middle cerebral artery and in situ middle cerebral to middle cerebral artery bypass for complex middle cerebral artery aneurysm: 3-dimensional operative video[J]. Oper Neurosurg (Hagerstown), 2020,18(4):E121-E122. DOI: 10.1093/ons/opz166.
[5]
Zaki Ghali MG, Srinivasan VM, Britz GW.Maxillary artery to intracranial bypass[J]. World Neurosurg, 2019, 128: 532-540. DOI: 10.1016/j.wneu.2019.03.015.
[6]
Wang L, Cai L, Lu S, et al.The history and evolution of internal maxillary artery bypass[J]. World Neurosurg, 2018, 113: 320-332. DOI: 10.1016/j.wneu.2018.02.158.
[7]
Büyükmumcu M, Ustün ME, Seker M, et al.Maxillary-to-petrous internal carotid artery bypass: an anatomical feasibility study[J]. Surg Radiol Anat, 2003,25(5-6):368-371. DOI: 10.1007/s00276-003-0150-x.
[8]
Eller JL, Sasaki-Adams D, Sweeney JM, et al.Localization of the internal maxillary artery for extracranial-to-intracranial bypass through the middle cranial fossa: a cadaveric study[J]. J Neurol Surg B Skull Base, 2012, 73(1):48-53. DOI: 10.1055/s-0032-1304556.
[9]
Feng X, Lawton MT, Rincon-Torroella J, et al.The lateral triangle of the middle fossa: surgical anatomy and a novel technique for transcranial exposure of the internal maxillary artery[J]. Oper Neurosurg (Hagerstown), 2016,12(2):106-111. DOI: 10.1227/NEU.0000000000001099.
[10]
Arbag H, Cicekcibasi AE, Uysal II, et al.Superficial temporal artery graft for bypass of the maxillary to proximal middle cerebral artery using a transantral approach: an anatomical and technical study[J]. Acta Otolaryngol, 2005,125(9):999-1003. DOI: 10.1080/00016480510037933.
[11]
Abdulrauf SI, Sweeney JM, Mohan YS, et al.Short segment internal maxillary artery to middle cerebral artery bypass: a novel technique for extracranial-to-intracranial bypass[J]. Neurosurgery, 2011, 68(3): 804-809. DOI: 10.1227/NEU.0b013e3182093355.
[12]
Shi X, Qian H, K C KI, et al. Bypass of the maxillary to proximal middle cerebral artery or proximal posterior cerebral artery with radial artery graft[J]. Acta Neurochir (Wien), 2011, 153(8):1649-1655. DOI: 10.1007/s00701-011-1070-x.
[13]
Nossek E, Costantino PD, Eisenberg M, et al.Internal maxillary artery-middle cerebral artery bypass: infratemporal approach for subcranial-intracranial (SC-IC) bypass[J]. Neurosurgery, 2014, 75(1): 87-95. DOI: 10.1227/NEU.0000000000000340.
[14]
石祥恩, 张永力, 刘方军, 等. 上颌动脉搭桥治疗颅内巨大动脉瘤[J]. 中华神经外科杂志, 2013, 29(1): 37-40. DOI: 10.3760/cma.j.issn.1001-2346.2013.01.010.Shi XE, Zhang YL, Liu FJ.et al.Radial artery graft for bypass of internal maxillary artery to intracranial artery: a wise choice for complex intracranial aneurysms[J]. Chin J Neurosurg, 2013, 29(1): 37-40. DOI: 10.3760/cma.j.issn.1001-2346.2013.01.010.
Alvernia JE, Hidalgo J, Sindou MP, et al.The maxillary artery and its variants: an anatomical study with neurosurgical applications[J]. Acta Neurochir (Wien), 2017,159(4): 655-664. DOI: 10.1007/s00701-017-3092-5.
[17]
Vrionis FD, Cano WG, Heilman CB.Microsurgical anatomy of the infratemporal fossa as viewed laterally and superiorly[J]. Neurosurgery, 1996, 39(4): 777-786. DOI: 10.1097/00006123-199610000-00027.
2022, Vol. 27 
