Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree

Clinical article

Restricted access

Object

The object of this study was to describe the authors' institutional experience in the treatment of complex middle cerebral artery (MCA) aneurysms necessitating bypass and vessel sacrifice.

Methods

Cases in which patients with MCA aneurysms were treated with a combination of bypass and parent artery sacrifice were reviewed retrospectively.

Results

The authors identified 24 patients (mean age 46 years) who were treated with bypass and parent artery sacrifice. The aneurysms were located in the M1 segment in 7 patients, MCA bifurcation in 8, and more distally in 9. The mean aneurysm diameter was 30 mm (range 7–60 mm, median 26 mm). There were 8 saccular and 16 fusiform aneurysms.

Twenty-one extracranial-intracranial and 4 intracranial-intracranial bypasses were performed. Partial or total trapping (only) of the parent artery was performed in 17 cases, trapping with resection of aneurysm in 3, and aneurysm clipping with sacrifice of an M2 branch in 4.

The mean follow-up period was 27 months. The aneurysm obliteration rate was 100%. No recanalization of the aneurysms was detected during follow-up.

There was 1 perioperative death (4% mortality rate) and 6 cerebrovascular accidents, causing permanent morbidity in 5 patients. The median modified Rankin Scale score of patients with an M1 aneurysm increased from 0 preoperatively to 2 at latest follow-up, while the score was unchanged in other patients. Most of the permanent deficits were associated with M1 aneurysms. Twenty-one patients (88%) had good outcome as defined by a Glasgow Outcome Scale score of 4 or 5.

Conclusions

Bypass in combination with parent vessel occlusion is a useful technique with acceptable frequencies of morbidity and mortality for complex MCA aneurysms when conventional surgical or endovascular techniques are not feasible. The location of the aneurysm should be considered when planning the type of bypass and the site of vessel occlusion. Flow alteration by partial trapping may be preferable to total trapping for the M1 aneurysms.

Abbreviations used in this paper:ASA = acetylsalicylic acid; CTA = CT angiography; DS = digital subtraction; DSA = DS angiography; ECA = external carotid artery; EC-IC = extracranialintracranial; ELANA = excimer laser-assisted nonocclusive anastomosis; GOS = Glasgow Outcome Scale; ICA = internal carotid artery; IC-IC = intracranial-intracranial; MCA = middle cerebral artery; mRS = modified Rankin Scale; OA = occipital artery; SAH = subarachnoid hemorrhage; STA = superficial temporal artery.
Article Information

Contributor Notes

Address correspondence to: Leena Kivipelto, M.D., Ph.D., Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland. email: leena.kivipelto@hus.fi.Please include this information when citing this paper: published online November 29, 2013; DOI: 10.3171/2013.10.JNS13738.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Amin-Hanjani SAlaraj ACharbel FT: Flow replacement bypass for aneurysms: decision-making using intraoperative blood flow measurements. Acta Neurochir (Wien) 152:102110322010

    • Search Google Scholar
    • Export Citation
  • 2

    Anson JALawton MTSpetzler RF: Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms. J Neurosurg 84:1851931996

    • Search Google Scholar
    • Export Citation
  • 3

    Ausman JIDiaz FGSadasivan BGonzeles-Portillo M JrMalik GMDeopujari CE: Giant intracranial aneurysm surgery: the role of microvascular reconstruction. Surg Neurol 34:8151990

    • Search Google Scholar
    • Export Citation
  • 4

    Barrow DLAlleyne C: Natural history of giant intracranial aneurysms and indications for intervention. Clin Neurosurg 42:2142441995

    • Search Google Scholar
    • Export Citation
  • 5

    Brozici Mvan der Zwan AHillen B: Anatomy and functionality of leptomeningeal anastomoses: a review. Stroke 34:275027622003

  • 6

    Charbel FTMeglio GAmin-Hanjani S: Superficial temporal artery-to-middle cerebral artery bypass. Neurosurgery 56:1 Suppl1861902005

    • Search Google Scholar
    • Export Citation
  • 7

    Choudhari KA: Wrapping and coating of cerebral aneurysms: history, evolution and surgical management after a re-bleed. Br J Neurosurg 18:2592672004

    • Search Google Scholar
    • Export Citation
  • 8

    Cognard CWeill ASpelle LPiotin MCastaings LRey A: Long-term angiographic follow-up of 169 intracranial berry aneurysms occluded with detachable coils. Radiology 212:3483561999

    • Search Google Scholar
    • Export Citation
  • 9

    Dashti RHernesniemi JNiemelä MRinne JLehecka MShen H: Microneurosurgical management of distal middle cerebral artery aneurysms. Surg Neurol 67:5535632007

    • Search Google Scholar
    • Export Citation
  • 10

    Dashti RHernesniemi JNiemelä MRinne JPorras MLehecka M: Microneurosurgical management of middle cerebral artery bifurcation aneurysms. Surg Neurol 67:4414562007

    • Search Google Scholar
    • Export Citation
  • 11

    Dashti RRinne JHernesniemi JNiemelä MKivipelto LLehecka M: Microneurosurgical management of proximal middle cerebral artery aneurysms. Surg Neurol 67:6142007

    • Search Google Scholar
    • Export Citation
  • 12

    Day ALGaposchkin CGYu CJRivet DJDacey RG Jr: Spontaneous fusiform middle cerebral artery aneurysms: characteristics and a proposed mechanism of formation. J Neurosurg 99:2282402003

    • Search Google Scholar
    • Export Citation
  • 13

    Deshmukh VRKakarla UKFigueiredo EGZabramski JMSpetzler RF: Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. Neurosurgery 58:4344422006

    • Search Google Scholar
    • Export Citation
  • 14

    Drake CGPeerless SJ: Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992. J Neurosurg 87:1411621997

    • Search Google Scholar
    • Export Citation
  • 15

    Drake CGPeerless SJHernesniemi JA: Surgery of Vertebrobasilar Aneurysms: London Ontario Experience on 1767 Patients ViennaSpringer-Verlag1996

    • Search Google Scholar
    • Export Citation
  • 16

    Fields JDBrambrink LDogan AHelseth EKLiu KCLee DS: Stent assisted coil embolization of unruptured middle cerebral artery aneurysms. J Neurointerv Surg 5:15192013

    • Search Google Scholar
    • Export Citation
  • 17

    Gonzalez NRDuckwiler GJahan RMurayama YViñuela F: Challenges in the endovascular treatment of giant intracranial aneurysms. Neurosurgery 62:6 Suppl 3132413352008

    • Search Google Scholar
    • Export Citation
  • 18

    Gruber AKiller MBavinzski GRichling B: Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience. Neurosurgery 45:7938041999

    • Search Google Scholar
    • Export Citation
  • 19

    Hoh BLPutman CMBudzik RFCarter BSOgilvy CS: Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization. J Neurosurg 95:24352001

    • Search Google Scholar
    • Export Citation
  • 20

    Isla AAlvarez FRoda JMMuñoz JMorales CGarcia Blazquez M: Serpentine aneurysm: regrowth after a superficial temporal artery-middle cerebral artery bypass and internal carotid artery ligation: case report. Neurosurgery 34:107210741994

    • Search Google Scholar
    • Export Citation
  • 21

    Jafar JJRussell SMWoo HH: Treatment of giant intracranial aneurysms with saphenous vein extracranial-to-intracranial bypass grafting: indications, operative technique, and results in 29 patients. Neurosurgery 51:1381462002

    • Search Google Scholar
    • Export Citation
  • 22

    Jahromi BSMocco JBang JAGologorsky YSiddiqui AHHorowitz MB: Clinical and angiographic outcome after endovascular management of giant intracranial aneurysms. Neurosurgery 63:6626752008

    • Search Google Scholar
    • Export Citation
  • 23

    Kalani MYZabramski JMHu YCSpetzler RF: Extracranialintracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery 72:4284362013

    • Search Google Scholar
    • Export Citation
  • 24

    Lawton MTHamilton MGMorcos JJSpetzler RF: Revascularization and aneurysm surgery: current techniques, indications, and outcome. Neurosurgery 38:83941996

    • Search Google Scholar
    • Export Citation
  • 25

    Lawton MTQuiñones-Hinojosa AChang EFYu T: Thrombotic intracranial aneurysms: classification scheme and management strategies in 68 patients. Neurosurgery 56:4414542005

    • Search Google Scholar
    • Export Citation
  • 26

    Lawton MTSpetzler RF: Surgical management of giant intracranial aneurysms: experience with 171 patients. Clin Neurosurg 42:2452661995

    • Search Google Scholar
    • Export Citation
  • 27

    Murayama YNien YLDuckwiler GGobin YPJahan RFrazee J: Guglielmi detachable coil embolization of cerebral aneurysms: 11 years' experience. J Neurosurg 98:9599662003

    • Search Google Scholar
    • Export Citation
  • 28

    Navratil OLehecka MLehto HDashti RKivisaari RNiemelä M: Vascular clamp-assisted clipping of thick-walled giant aneurysms. Neurosurgery 64:3 Supplons113ons1212009

    • Search Google Scholar
    • Export Citation
  • 29

    Newell DWVilela MD: Superficial temporal artery to middle cerebral artery bypass. Neurosurgery 54:144114492004

  • 30

    Pumar JMLete IPardo MIVázquez-Herrero FBlanco M: LEO stent monotherapy for the endovascular reconstruction of fusiform aneurysms of the middle cerebral artery. AJNR Am J Neuroradiol 29:177517762008

    • Search Google Scholar
    • Export Citation
  • 31

    Quiñones-Hinojosa ALawton MT: In situ bypass in the management of complex intracranial aneurysms: technique application in 13 patients. Neurosurgery 57:1 Suppl1401452005

    • Search Google Scholar
    • Export Citation
  • 32

    Randell TNiemelä MKyttä JTanskanen PMäättänen MKaratas A: Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage: the Helsinki experience. Surg Neurol 66:3823882006

    • Search Google Scholar
    • Export Citation
  • 33

    Rodríguez-Hernández ASughrue MEAkhavan SHabdank-Kolaczkowski JLawton MT: Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy. Neurosurgery 72:4154272013

    • Search Google Scholar
    • Export Citation
  • 34

    Sanai NZador ZLawton MT: Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass. Neurosurgery 65:6706832009

    • Search Google Scholar
    • Export Citation
  • 35

    Scott RMLiu HCYuan RAdelman L: Rupture of a previously unruptured giant middle cerebral artery aneurysm after extracranial-intracranial bypass surgery. Neurosurgery 10:6006031982

    • Search Google Scholar
    • Export Citation
  • 36

    Sekhar LNStimac DBakir ARak R: Reconstruction options for complex middle cerebral artery aneurysms. Neurosurgery 56:1 Suppl66742005

    • Search Google Scholar
    • Export Citation
  • 37

    Seo BRKim TSJoo SPLee JMJang JWLee JK: Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms. Clin Neurol Neurosurg 111:6706752009

    • Search Google Scholar
    • Export Citation
  • 38

    Shi ZSZiegler JDuckwiler GRJahan RFrazee JAusman JI: Management of giant middle cerebral artery aneurysms with incorporated branches: partial endovascular coiling or combined extracranial-intracranial bypass—a team approach. Neurosurgery 65:6 Suppl1211312009

    • Search Google Scholar
    • Export Citation
  • 39

    Steinberg GKDrake CGPeerless SJ: Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 79:1611731993

    • Search Google Scholar
    • Export Citation
  • 40

    Sughrue MESaloner DRayz VLLawton MT: Giant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery 69:126112712011

    • Search Google Scholar
    • Export Citation
  • 41

    Sundt TM IIISundt TM Jr: Principles of preparation of vein bypass grafts to maximize patency. J Neurosurg 66:1721801987

  • 42

    Tulleken CAVerdaasdonk RM: First clinical experience with Excimer assisted high flow bypass surgery of the brain. Acta Neurochir (Wien) 134:66701995

    • Search Google Scholar
    • Export Citation
  • 43

    Tulleken CAVerdaasdonk RMBeck RJMali WP: The modified excimer laser-assisted high-flow bypass operation. Surg Neurol 46:4244291996

    • Search Google Scholar
    • Export Citation
  • 44

    Tulleken CAVerdaasdonk RMMansvelt Beck HJ: Nonocclusive excimer laser-assisted end-to-side anastomosis. Ann Thorac Surg 63:6 SupplS138S1421997

    • Search Google Scholar
    • Export Citation
  • 45

    van der Zwan AHillen BTulleken CADujovny MDragovic L: Variability of the territories of the major cerebral arteries. J Neurosurg 77:9279401992

    • Search Google Scholar
    • Export Citation
  • 46

    van Doormaal TPvan der Zwan AVerweij BHHan KSLanger DJTulleken CA: Treatment of giant middle cerebral artery aneurysms with a flow replacement bypass using the excimer laser-assisted nonocclusive anastomosis technique. Neurosurgery 63:12222008

    • Search Google Scholar
    • Export Citation
  • 47

    Vendrell JFCostalat VBrunel HRiquelme CBonafe A: Stent-assisted coiling of complex middle cerebral artery aneurysms: initial and midterm results. AJNR Am J Neuroradiol 32:2592632011

    • Search Google Scholar
    • Export Citation
  • 48

    Wiebers DOWhisnant JPHuston J IIIMeissner IBrown RD JrPiepgras DG: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:1031102003

    • Search Google Scholar
    • Export Citation
  • 49

    Yaşargil MG: Microsurgery Applied to Neurosurgery StuttgartGeorg Thieme1969

TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 480 367 28
PDF Downloads 271 201 13
EPUB Downloads 0 0 0
PubMed
Google Scholar