Management of complex intracranial aneurysms with bypass surgery: a technique application and experience in 93 patients

Abstract

Despite advances in microsurgery and the development of new endovascular techniques, the treatment of complex intracranial aneurysms remains a daunting challenge for neurosurgeons. In the present study, we retrospectively reviewed our experience of bypass surgery in the treatment of 93 cases of complex intracranial aneurysms. A series of 93 consecutive cases of complex intracranial aneurysms were treated with bypass surgery between April 2004 and July 2013. Radial artery (RA) grafts were used in 58 cases, saphenous vein (SV) grafts in 16 cases, and occipital artery (OA) grafts in 6 cases, while the remaining 13 cases were managed with superficial temporal artery (STA) grafts. In this series, the aneurysms were excised after trapping in 32 cases with mass effect and neural compression. Proximal occlusion of the parent artery was performed in 22 cases of fusiform or giant dissecting aneurysms with subsequent retrograde flow to avoid compromise of the perforators nearby. Trapping was performed after bypass surgery in the remaining 39 cases. Postoperative angiographies were performed in 91 patients and patency of the bypass graft and obliteration of the aneurysms were confirmed in 89 patients. Patency of the bypass could not be confirmed in the remaining two patients, of which one presented with cerebral infarction due to graft occlusion, and the other remained asymptomatic. Within 1 month after surgery, 88 patients had good outcome, four patients needed assistance for daily living, and one death occurred due to brainstem infarction. In 77 patients with a mean follow-up of 3.0 years, 72 patients had good outcome, 4 patients needed assistance for daily living, and 1 death occurred unrelated to surgery. Complex intracranial aneurysms present unique therapeutic challenges that require thorough surgical planning, individualized treatment strategies, and refined neurovascular techniques for successful outcome. Proper use of bypass surgery is imperative in preserving the parent artery and its major perforators. The internal maxillary artery, used as a donor in a bypass, is an effective method due to its shorter distance from the recipient vessels and relatively large diameter with resulting higher flow rate.

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms

“…The techniques of performing IMA bypass have been described in our previous articles. 24,25,29,[32][33][34]36 Briefly, we approached the aneurysms using a frontotemporal craniotomy with zygomatic osteotomy. The radial artery (RA) was harvested and prepared before being anastomosed in an end-to-end fashion to the pterygoid segment of the IMA (I 2 ) by using 9-0 prolene.…”

“…As for the interposition graft of IMA bypass, the RA 24,25,[32][33][34]36 and forearm cephalic vein 12,13 have been used in clinical settings. Recently, preclinical studies focusing on STA trunk grafts have been comprehensively reported in the literature.…”

“…Recently, the internal maxillary artery (IMA) bypass, the only substantive modification of cerebral revascularization techniques, has gained momentum. 24,25,[32][33][34]36 This technique was heralded as a new "workhorse" in the field of high-flow bypass to replace conventional cervical artery bypass. 14,29 However, very limited data exist regarding the experiences with using this novel extracranial artery as a donor, especially in the territory of the MCA.…”

Bypass surgery to treat symptomatic fusiform dilation of the internal carotid artery following craniopharyngioma resection: report of 2 cases

“…A decision was made to treat both lesions in one operation. An IMA bypass, which we have described in previous reports, 11,12 was performed via an end-to-end anastomosis (IMA to proximal radial artery), followed by an end-toside anastomosis (distal radial artery to M 2 segment). Then, the FDICA was clipped after aneurysmorrhaphy to expose the tumor.…”

Treatment of Complex Internal Carotid Aneurysms

“…Introduction. Despite new endovascular and surgical treatment options, complex intracranial aneurysms are still a big challenge [1][2][3][4][5]. Complex aneurysms recognized as big or giant size, with broad calcified neck, fusiform shape, intraluminal thrombus, branches arising from the aneurysm, atherosclerotic wall of the aneurysms, absence of collateral blood flow [1,2,4,[6][7][8][9].…”