Elective Sonolucent Cranioplasty for Real-Time Ultrasound Monitoring of Flow and Patency of an Extra- to Intracranial Bypass

Caroline Hadley, Robert North, Visish Srinivasan, Peter Kan, Jan Karl Burkhardt

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


AbstractCross-sectional imaging studies or catheter angiogram are the imaging modalities of choice to evaluate bypass patency after extra- to intracranial (EC-IC) bypass surgery. Although providing accurate results, these imaging modalities are time-consuming and/or present radiation risk for the patient. Ultrasound imaging is a fast and widely available imaging modality, but is limited in this setting due to the non-sonolucent autologous bone flap covering the bypass after surgery. The recently FDA approved clear polymethyl methacrylate (PMMA) cranioplasty implant overcomes this limitation by its sonolucent characteristic, but has not yet been used in the setting of EC-IC bypass surgery. Here, the authors describe for the first time the feasibility of an elective sonolucent cranioplasty to monitor flow and patency of an EC-IC bypass in real time using ultrasound. This moyamoya patient underwent a direct superficial temporal artery to middle cerebral artery (STA-MCA) bypass, after which a PMMA implant was used to close the craniotomy defect, instead of reimplanting the autologous bone flap. Immediate postoperative bedside transcranioplasty ultrasound confirmed bypass patency and allowed for quantitative flow measurements as well as for exclusion of postoperative hemorrhage. Postoperative CTA and catheter angiogram confirmed patency of the bypass without complications. This report shows for the first time that this technique is feasible and permits bedside transcranioplasty ultrasound assessment of bypass flow in real time, confirmed with angiography. This technique may permit easy comparison of baseline findings with follow up assessments and facilitate less invasive monitoring of bypass patency.

Original languageEnglish (US)
Pages (from-to)622-624
Number of pages3
JournalJournal of Craniofacial Surgery
Issue number3
StatePublished - May 1 2020
Externally publishedYes


  • Extra- to intracranial bypass
  • real-time ultrasound monitoring
  • sonolucent cranioplasty

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology


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