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T he superficial temporal artery–middlecerebralartery (STA-MCA)bypasswas introduced more than 50 years ago, and the craft involved inbypasssurgery remains simple, with surgeons relying on suturing and basic instruments, three different types of anastomoses, minimal technology, and manual dexterity. Nonetheless, creative neurosurgeons have advancedbypasssurgery into a complex surgical art by developing an array ofbypassesthat include standard extracranial-to-intracranial (EC-IC)bypassusing scalp arteries, EC-IC with interpositional grafts, and

C erebralbypasssurgery has undergone near constant evolution since its introduction in 1969. 34 , 35 A number of innovative microsurgical techniques have been described and tailored to treat a diverse array of disease entities, including moyamoya disease, atherosclerotic vascular occlusive disease, and complexcerebralaneurysms, or to facilitate vessel sacrifice with the resection of skull base tumors. 18 However, evidence-based guidelines have been comparatively slower to evolve. The results of randomized controlled trials, such as the Carotid Occlusion

C erebralbypasssurgery indications have undergone significant modifications. Despite the revolution in endovascular neurosurgery,cerebralbypasssurgery remains an essential component in the management of some skull base lesions. In this paper, we describe ourcerebralbypasssurgery techniques, incorporating lessons learned over 2 decades. Clinical Materials and Methods Between 1986 and 2006, the senior author treated 100 skull base lesions with adjunctivebypasssurgery. Saphenous vein grafts were used in all cases. During thebypassprocedures

) partially occluded by proximal or distal occlusion of the parent artery. Abypassprocedure was performed whenever a parent artery was deliberately sacrificed to re-perfuse the involved territory and preventcerebralischemia or infarction. Although we use preoperative balloon-test occlusion and routinely monitor patients intraoperatively with somatosensory and motor evoked potentials, these tests result in significant false-negative rates and inconsistencies, and we prefer not to rely on them when deciding on the type ofbypassto use. 15 , 17 , 25 , 48 Results

applications of microvascular surgery. His interest was further stimulated when he was asked to perform an embolectomy of a cortical artery, a technique he had not yet mastered. 133 Dr. Senning, a cardiovascular surgeon, encouraged him to pursue a technique that would enable such a procedure to be performed. His enthusiasm to learn techniques ofcerebralrevascularization increased after the report of an EC–ICbypassin a patient who had an occluded ICA at the neck. 131 Professor Yaşargil then began looking for a position in which he could train in microvascular techniques