Extracorporeal femoral to carotid artery perfusion in selective brain cooling for a giant aneurysm

Case report

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✓ Giant partially thrombosed intracranial aneurysms are a challenge to treat surgically, and they are also unsuitable for coil embolization. The current options for treatment include extracranial—intracranial bypass followed by parent artery occlusion or direct surgical occlusion in which deep hypothermic circulatory arrest is used.

The authors report the use of another approach in the treatment of a giant anterior circulation aneurysm: selective brain cooling accomplished by extracorporeal perfusion. This facilitated direct surgery on a 4.2-cm, partially thrombosed aneurysm of the middle cerebral artery (MCA). A brain temperature of 22°C was achieved after 20 minutes of perfusion with blood cooled using an extracorporeal technique of femoral—common carotid artery perfusion. This was followed by a 20-minute period of surgical trapping of the MCA, then evacuation and clip occlusion of the aneurysm. During the period of selective brain cooling the patient's core body temperature was maintained above 35°C.

This technique of selective brain cooling may be a useful alternative to currently available surgical and endovascular methods of treatment for giant aneurysms.

Article Information

Address reprint requests to: Stephen P. Lownie, M.D., Division of Neurosurgery, London Health Sciences Centre—University Campus, 339 Windermere Road, London, Ontario, Canada N6A 5A5. email: lownies@lhsc.on.ca.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Left: Contrast-enhanced axial CT scan revealing a 2.7-cm-diameter centrally enhancing mass in the right temporal lobe with mild surrounding edema. Right: Axial T2-weighted magnetic resonance image obtained 10 months later, demonstrating enlargement of the mass to a 4.2-cm diameter, with marked increase in surrounding edema and compression of the right cerebral peduncle.

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    Left: Right CCA angiogram, anteroposterior Towne projection, demonstrating filling of the central lumen of the MCA bifurcation aneurysm and displacement of M2 and M3 branches away from the lumen by the thrombosed portion of the aneurysm mass. Right: Postoperative right CCA angiogram, same projection, demonstrating satisfactory clip occlusion of the aneurysm with preservation of both divisions of the MCA.

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    Intraoperative photograph showing the aneurysm, which is demarcated by arrows. The arrowhead designates the right optic nerve.

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    Graphs depicting extracorporeal flow rate (upper) and temperature (Temp; lower) at four points of measurement (brain, rectum, nasopharynx, and pulmonary artery) compared with time.

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