Superficial Temporal Artery to Middle Cerebral Artery (STA–MCA) Bypass for Symptomatic Cerebrovascular Occlusive Disease: Surgical Video.

Introduction: Cerebrovascular occlusive disease remains a major cause of ischemic stroke worldwide. Approximately 10-15% of ischemic strokes involving the carotid territory are associated with complete carotid artery occlusion. Although extracranial-to-intracranial (EC-IC) bypass is not routinely indicated for all patients with ischemic cerebrovascular disease, advances in cerebral hemodynamic assessment have allowed identification of a subgroup of patients with recurrent ischemic symptoms, impaired cerebral perfusion, and exhausted vascular reserve who may benefit from surgical revascularization. We present the microsurgical technique of superficial temporal artery to middle cerebral artery (STA–MCA) bypass in a patient with medically refractory cerebrovascular insufficiency. Case Report: A 53-year-old man presented with recurrent transient ischemic attacks despite optimal medical therapy. Over a two-year period, he experienced approximately twenty episodes of transient neurological deficits, significantly affecting his quality of life. Cerebral angiography demonstrated severe stenosis involving the M2 segment of the middle cerebral artery with reduced distal perfusion. Functional cerebral perfusion studies confirmed hemodynamic compromise, supporting the indication for surgical revascularization. A microsurgical end-to-side STA–MCA bypass was performed using the parietal branch of the superficial temporal artery as the donor vessel and an M4 cortical branch of the middle cerebral artery as the recipient artery. After careful preparation of the recipient vessel and temporary arterial control, the arteriotomy was performed and the microvascular anastomosis was completed under high magnification using standard microsurgical techniques. Temporary occlusion time was minimized to reduce ischemic risk. Following completion of the bypass, graft patency and adequate blood flow were confirmed using intraoperative Doppler ultrasonography and indocyanine green videoangiography. The bypass demonstrated satisfactory flow, with preservation of the surrounding cortical vessels and no intraoperative complications. Results: The postoperative course was uneventful. The patient was discharged three days after surgery without new neurological deficits. During two years of clinical follow-up, he remained free of transient ischemic attacks and ischemic stroke events. Follow-up vascular imaging confirmed long-term bypass patency and maintained cerebral revascularization. Conclusion: STA–MCA bypass remains an effective treatment option for carefully selected patients with symptomatic cerebrovascular occlusive disease and documented cerebral hypoperfusion who continue to experience ischemic events despite optimal medical management. Modern cerebral hemodynamic assessment allows better identification of patients who may benefit from revascularization. Careful patient selection, precise microsurgical technique, and intraoperative confirmation of graft function can provide durable cerebral blood flow improvement and excellent long-term clinical outcomes.