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The artery is progressively isolated and its collaterals clipped or coagulated and divided (Fig. 2b). Arterial vasospasm is avoided by leaving a conjunctive cuff around the artery and regularly irrigating it with papaverin Selleck Veliparib saline. The proximal bifurcation should be exposed to allow full mobilization of the donor artery or to interrupt the frontal branch and improve flow into the donor parietal branch. The continuity of the frontal branch could initially be preserved in order to keep the proximal trunk of the STA patent during temporary clipping of the parietal branch or to retrogradely flush the anastomosis. The superior surface of the donor vessel should be colored to detect any secondary twisting. The donor artery is then left intact until final anastomosis (Fig. 2c). The skin incision can be prolonged anteriorly to perform a larger skin flap and if necessary a conventional fronto-pterional bone flap. The temporal muscle is sectioned vertically along the projection of the STA and then retracted on both sides (Fig. 2d). A large craniotomy is performed in the fronto-pterional region (giant aneurysm) or above the sylvian fissure (Fig. 2e), the hypoperfused area diagnosed on PET or SPECT or a recipient vessel detected on preoperative MRI in the cases of Moyamoya disease or carotid/MCA occlusion patients. The dura is tacked to the bone flap margins and usually opened in a cross fashion to allow wide exposure of the cortical arteries (Fig. 2f). In the particular case of Moyamoya patients, attention RRAD should be paid not to interrupt pre-existing meningo-cortical feeders detected Fulvestrant on preoperative external carotid angiography. The arachnoid is often thick (i.e. Moyamoya disease patients) and it is recommended to open it widely above the sulci to optimize secondary development of neovascularization. This stage is also useful to identify the most appropriate cortical vessel (Fig. 3a). The recipient artery is usually a distal branch of the MCA (M3 or M4). Its selection relies on several parameters: accessibility, caliber, proximal and distal vascular bed. The opercular or cortical branch is most frequently chosen with a diameter of at least 1?mm (in general?>?0.5?mm) (Fig. 3b). According to Kawashima et al. [20], the caliber of cortical arteries decreases as follows: frontal branch 1.19?mm (��?0.32)?