A Step-by-Step Dissection of Cerebral Pathologies for Neurosurgical Trainees: The Middle Cerebral Artery Bifurcation Aneurysm

Abstract

Background Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases.

Methods After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees.

Results Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed.

Conclusion Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold.

Keywords

vascular neurosurgery - aneurysm - educational

^* LW Sannwald and ML Moskopp are considered joined first co-authors.

Publication History

Received: 26 June 2022

Accepted: 14 October 2022

Article published online:
20 March 2023

• References

• 1 Morais Filho AB, Rego TLH, Mendonça LL. et al. Theysiopathology of spontaneous hemorrhagic stroke: a systematic review. Rev Neurosci 2021; 32 (06) 631-658
• 2 Lawton MT, Vates GE. Subarachnoid hemorrhage. N Engl J Med 2017; 377 (03) 257-266
• 3 Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet 2017; 389 (10069): 655-666
• 4 Molyneux A, Kerr R, Stratton I. et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360 (9342): 1267-1274
• 5 Molyneux AJ, Kerr RS, Yu LM. et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. 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 (9488): 809-817
• 6 Pflaeging M, Kabbasch C, Schlamann M. et al. Microsurgical clipping versus advanced endovascular treatment of unruptured middle cerebral artery bifurcation aneurysms after a “coil-first” policy. World Neurosurg 2021; 149: e336-e344
• 7 Smith TR, Cote DJ, Dasenbrock HH. et al. Comparison of the efficacy and safety of endovascular coiling versus microsurgical clipping for unruptured middle cerebral artery aneurysms: a systematic review and meta-analysis. World Neurosurg 2015; 84 (04) 942-953
• 8 Rhoton Jr AL. Rhoton Cranial Anatomy & Surgical Approaches. New York, NY: Oxford University Press; 2020
• 9 Lang J. Skull Base and Related Structures. Stuttgart: Schattauer GmbH; 2001
• 10 Agarwal N, White MD, Cohen J, Lunsford LD, Hamilton DK. Longitudinal survey of cranial case log entries during neurological surgery residency training. J Neurosurg 2018; 130 (06) 2025-2031
• 11 Stienen MN, Bartek Jr J, Czabanka MA. et al; EANS Young Neurosurgeons and EANS Training Committee. Neurosurgical procedures performed during residency in Europe-preliminary numbers and time trends. Acta Neurochir (Wien) 2019; 161 (05) 843-853
• 12 Andrews RJ, Bringas JR. A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 1993; 33 (06) 1052-1063 , discussion 1063–1064
• 13 Moskopp D, Wassmann H. Zerebroprotektive Massnahmen bei Energiekrisen des Gehirns: Behandlungsstrategien bei Erkrankungen des ZNS mit akuter Mangeldurchblutung. Zülpich: Biermann Verlag GmbH; 1994
• 14 Michenfelder JD, Milde JH, Sundt Jr TM. Cerebral protection by barbiturate anesthesia. Use after middle cerebral artery occlusion in Java monkeys. Arch Neurol 1976; 33 (05) 345-350
• 15 Selman WR, Spetzler RF, Roski RA, Roessmann U, Crumrine R, Macko R. Barbiturate coma in focal cerebral ischemia. Relationship of protection to timing of therapy. J Neurosurg 1982; 56 (05) 685-690
• 16 Tanabe J, Ishikawa T, Moroi J. Safe time duration for temporary middle cerebral artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2017; 8: 79
• 17 Tanabe J, Ishikawa T, Moroi J, Suzuki A. Preliminary study on safe thresholds for temporary internal carotid artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2014; 5: 47
• 18 Maekawa H, Hadeishi H. Venous-preserving sylvian dissection. World Neurosurg 2015; 84 (06) 2043-2052