Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series

Abstract

Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.

Navigating Complexity: A Comprehensive Approach to Middle Cerebral Artery Aneurysms

“…The Identification of the Specific Complexity Profile [ 2 , 19 , 30 ] is determined by the combination of major and minor complexity criteria. Major criteria include fusiform shape, large/giant size, vessel originating from the sac, intrasaccular thrombi [ 3 ], and previous treatments [ 6 , 7 , 8 ]. Minor criteria encompass wide neck, proximal vessel tortuosity, and wall calcification.…”

“…The unruptured intracranial aneurysm score (UIATS) defines the aneurysmal complexity given the presence of a neck wider than the diameter of the parent vessel, calcified dome or proximal vessel tortuosity/stenosis, aneurysm thrombosis, or sac smaller than 3 mm [ 3 , 4 , 5 ]. Giant aneurysms and cases with a previous endovascular or surgical treatment can be likewise considered complex [ 4 , 6 , 7 , 8 ]. The Berlin classification emphasizes this concept in MCA aneurysms, driving best management practices in thrombosed aneurysms [ 4 ].…”

External Carotid Artery-Saphenous Vein Graft-M2/M2 Triple-Vessel Anastomosis and Trapping of Complex Middle Cerebral Artery Aneurysm: 360° Virtual Reality–Enhanced Operative Video

“…Complex cerebral revascularization techniques may be required for certain middle cerebral artery (MCA) aneurysms not amenable to conventional microsurgical clipping or endovascular techniques. 1-8 Bypass with various trapping strategies may be used depending on the anatomy of perforating, parent, and daughter vessels. We describe the case of a 60-year-old woman who presented with a large unruptured, wide-necked MCA aneurysm with both frontal and temporal M2 branches incorporated in the aneurysm neck.…”

Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

“…7-29 When a high-flow bypass is required for this purpose, radial artery grafts are especially effective. 30-38 We present a case of a 57-year-old woman who presented with acute left-sided hemiparesis after redo coiling of a recurrent giant right internal carotid artery terminus aneurysm that had previously undergone Atlas stent-assisted coiling. She underwent mechanical thrombectomy with TICI2b revascularization, but despite this intervention, she progressed to complete hemiplegia the following morning.…”