Surgical management of complex middle cerebral artery aneurysms: An institutional review

Anuj Bhide; Yashuhiro Yamada; Yoko Kato; Tsukasa Kawase; Riki Tanaka; Kyosuke Miyatani; Daijiro Kojima; Ahmed Sayah

doi:10.4103/ajns.AJNS_5_20

Asian Journal of Neurosurgery, Table of Contents

CC BY-NC-ND 4.0 · Asian J Neurosurg 2020; 15(04): 959-965
DOI: 10.4103/ajns.AJNS_5_20

Original Article

Surgical management of complex middle cerebral artery aneurysms: An institutional review

Authors

Anuj Bhide

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan

²Department of Neurosurgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
Yashuhiro Yamada

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Yoko Kato

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Tsukasa Kawase

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Riki Tanaka

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Kyosuke Miyatani

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Daijiro Kojima

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan
Ahmed Sayah

¹Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan

Abstract

Background: Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators. Objectives: The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management. Methods: Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed. Results: The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings. Conclusions: MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.

Key-words:

Complex aneurysms - computational flow dynamics - FLOW 800 - giant aneurysms - middle cerebral aneurysms

Full Text

References

References
1 Park W, Chung J, Ahn JS, Park JC, Kwun BD. Treatment of large and giant middle cerebral artery aneurysms: Risk factors for unfavorable outcomes. World Neurosurg 2017;102:301-12.
2 Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561 patients with 690 middle cerebral artery aneurysms: Anatomic and clinical features as correlated to management outcome. Neurosurgery 1996;38:2-11.
3 Diaz OM, Rangel-Castilla L, Barber S, Mayo RC, Klucznik R, Zhang YJ. Middle cerebral artery aneurysms: A single-center series comparing endovascular and surgical treatment. World Neurosurg 2014;81:322-9.
4 Zhu W, Liu P, Tian Y, Gu Y, Xu B, Chen L, et al. Complex middle cerebral artery aneurysms: A new classification based on the angioarchitecture and surgical strategies. Acta Neurochir (Wien) 2013;155:1481-91.
5 Choi IS, David C. Giant intracranial aneurysms: Development, clinical presentation and treatment. Eur J Radiol 2003;46:178-94.
6 Drake CG, Peerless SJ. Giant fusiform intracranial aneurysms: Review of 120 patients treated surgically from 1965 to 1992. J Neurosurg 1997;87:141-62.
7 Gomes F, Dujovny M, Umansky F, Ausman JI, Diaz FG, Ray WJ, et al. Microsurgical anatomy of the recurrent artery of Heubner. J Neurosurg 1984;60:130-9.
8 Gomes FB, Dujovny M, Umansky F, Berman SK, Diaz FG, Ausman JI, et al. Microanatomy of the anterior cerebral artery. Surg Neurol 1986;26:129-41.
9 Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr., Piepgras DG, et al. Unruptured intracranial aneurysms: Natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103-10.
10 UCAS Japan Investigators, Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012;366:2474-82.
11 Regli L, Uske A, de Tribolet N. Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: A consecutive series. J Neurosurg 1999;90:1025-30.
12 Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005;366:809-17.
13 Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, et al. The barrow ruptured aneurysm trial: 6-year results. J Neurosurg 2015;123:609-17.
14 Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, et al. Coiling versus microsurgical clipping in the treatment of unruptured middle cerebral artery aneurysms: A meta-analysis. Neurosurgery 2018;83:879-89.
15 Raftopoulos C, Goffette P, Vaz G, Ramzi N, Scholtes JL, Wittebole X, et al. Surgical clipping may lead to better results than coil embolization: Results from a series of 101 consecutive unruptured intracranial aneurysms. Neurosurgery 2003;52:1280-7.
16 Xu F, Xu B, Huang L, Xiong J, Gu Y, Lawton MT. Surgical treatment of large or giant fusiform middle cerebral artery aneurysms: A case series. World Neurosurg 2018;115:e252-62.
17 Huang L, Cao W, Ge L, Lu G, Wan J, Zhang L, et al. Endovascular management of giant middle cerebral artery aneurysms. Int J Clin Exp Med 2015;8:7517-25.
18 Mantilla CD, Lefevre PH, Dargazanli C, Gascou G, Costalat V. Treatment of middle cerebral artery aneurysms with flow-diverter stents: A systematic review and meta-analysis F. Am J Neuroradiol 2017;1-6. [doi: 10.3174/ajnr.A5388].
19 Davies JM, Lawton MT. “Picket Fence” clipping technique for large and complex aneurysms. Neurosurg Focus 2015;39 Video Suppl 1:V17.
20 Gomez-Paz S, Enriquez-Marulanda A, Ascanio LC, Foreman P, Thomas AJ, Ogilvy CS. Suction decompression assisted clipping of a large middle cerebral artery aneurysm: 2-Dimensional operative video. World Neurosurg X 2019;2:100014.
21 Takeda R, Kurita H. “Mass reduction” clipping technique for large and complex intracranial middle cerebral artery aneurysm. World Neurosurg 2019;125:150-5.
22 Tayebi Meybodi A, Huang W, Benet A, Kola O, Lawton MT. Bypass surgery for complex middle cerebral artery aneurysms: An algorithmic approach to revascularization. J Neurosurg 2017;127:463-79.