Surgical treatment of middle cerebral artery aneurysms

Restricted access

✓ The authors report their experience with the surgical therapy of middle cerebral artery (MCA) aneurysms in 413 cases, and describe their technique. After the M1 portion of the MCA is identified, the Sylvian fissure is opened. During the administration of 20% mannitol, temporary occluding clips are applied to the feeding and draining vessels of the aneurysm. The aneurysm is freed from all surrounding tissue, and the aneurysm neck is treated by ligation, clipping, or wrapping. Analysis of surgical results in 91 cases operated on after the surgical approach had become standardized indicates that more than 94% of patients have returned to useful social lives by the time of follow-up evaluation. Twenty-four percent of these patients were operated on within 48 hours after subarachnoid hemorrhage.

Article Information

Address reprint requests to: Jiro Suzuki, M.D., Division of Neurosurgery, Tohoku University School of Medicine, 5-13-1, Nagamachi, Sendai 982, Japan.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Diagram showing the location of craniotomy for a middle cerebral artery aneurysm. The patient is in a neutral position with the chin up. SI = skin incision; ST = superior temporal line of the frontal bone; DI = dural incision.

  • View in gallery

    After temporary occlusion of the proximal (M1) portion of the middle cerebral artery, the Sylvian fissure is opened distally to expose the aneurysm. A1 = the A1 portion of the anterior cerebral artery; C1 = the C1 portion of the internal carotid artery.

  • View in gallery

    A temporary clip is placed on the proximal (M1) portion of the middle cerebral artery, as proximally as possible. Before treatment of the aneurysm (An), the efferent artery (that is, the M2 portion) is also clipped temporarily.

  • View in gallery

    A daughter aneurysm and small branch of the middle cerebral artery (MCA) are sometimes hidden behind the aneurysm (left), therefore the entire aneurysm should be dissected, not just the aneurysm neck (right). M1 and M2 = branches of the MCA.

  • View in gallery

    Ligation of the aneurysm neck should be carried out to confirm that there is no kink or stenosis of the arteries. The aneurysm neck is then clipped.

  • View in gallery

    Correlation between surgical results and occlusion time of the middle cerebral artery treated under hypothermia (closed circles), normothermia (crosses), and normothermia with 20% mannitol (open circles). Results: Ex = excellent; G = good; F = fair; P = poor; and D = died in hospital.

References

1.

Endo SSuzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Development and degree of vasospasm. Stroke 8:7027071977Endo S Suzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Development and degree of vasospasm. Stroke 8:702–707 1977

2.

Endo SSuzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Participation of adrenergic nerves in cerebral vessel wall. Stroke 10:7037111979Endo S Suzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Participation of adrenergic nerves in cerebral vessel wall. Stroke 10:703–711 1979

3.

Heros RCOjemann RGCrowell RM: Superior temporal gyrus approach to middle cerebral artery aneurysms: technique and results. Neurosurgery 10:3083131982Heros RC Ojemann RG Crowell RM: Superior temporal gyrus approach to middle cerebral artery aneurysms: technique and results. Neurosurgery 10:308–313 1982

4.

Kagawa SKoshu KYoshimoto Tet al: The protective effect of mannitol and perfluorochemicals on hemorrhagic infarction: an experimental study. Surg Neurol 17:66701982Kagawa S Koshu K Yoshimoto T et al: The protective effect of mannitol and perfluorochemicals on hemorrhagic infarction: an experimental study. Surg Neurol 17:66–70 1982

5.

Kempe LG: Cranial Cerebral and Intracranial Vascular Disease. Operative Neurosurgery Vol 1. Berlin/Heidelberg/New York: Springer-Verlag1968 pp 4554Kempe LG: Cranial Cerebral and Intracranial Vascular Disease. Operative Neurosurgery Vol 1. Berlin/Heidelberg/New York: Springer-Verlag 1968 pp 45–54

6.

Kodama NHori SKamiyama Ket al: Cervical sympathectomy for cerebral vasospasm after aneurysm rupture in Wilkins RH (ed): Cerebral Arterial Spasm. Baltimore: Williams & Wilkins1980 pp 680684Kodama N Hori S Kamiyama K et al: Cervical sympathectomy for cerebral vasospasm after aneurysm rupture in Wilkins RH (ed): Cerebral Arterial Spasm. Baltimore: Williams & Wilkins 1980 pp 680–684

7.

Mizoi KYoshimoto TSuzuki J: Experimental study of new cerebral protective substances — functional recovery of severe, incomplete ischaemic brain lesions pretreated with mannitol and fluorocarbon emulsion. Acta Neurochir 56:1571661981Mizoi K Yoshimoto T Suzuki J: Experimental study of new cerebral protective substances — functional recovery of severe incomplete ischaemic brain lesions pretreated with mannitol and fluorocarbon emulsion. Acta Neurochir 56:157–166 1981

8.

Ogawa KSato HSakurai Yet al: [Treatment for cerebral vasospasm with mannitol and angiotensin II — induced hypertension] in Iwabuchi T (ed): Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke. Tokyo: Neuron1982 pp 253258 (Jpn)Ogawa K Sato H Sakurai Y et al: [Treatment for cerebral vasospasm with mannitol and angiotensin II — induced hypertension] in Iwabuchi T (ed): Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke. Tokyo: Neuron 1982 pp 253–258 (Jpn)

9.

Owada KHori SSuzuki J: Results of cervical sympathectomy for cerebral vasospasm following aneurysm rupture in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979 pp 435441Owada K Hori S Suzuki J: Results of cervical sympathectomy for cerebral vasospasm following aneurysm rupture in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron 1979 pp 435–441

10.

Sato SSuzuki J: Anatomical mapping of the cerebral nervi vasorum in the human brain. J Neurosurg 43:5595681975Sato S Suzuki J: Anatomical mapping of the cerebral nervi vasorum in the human brain. J Neurosurg 43:559–568 1975

11.

Seki HYoshimoto TOgawa Aet al: Effect of mannitol on rCBF in canine thalamic ischemia — an experimental study. Stroke 14:46501983Seki H Yoshimoto T Ogawa A et al: Effect of mannitol on rCBF in canine thalamic ischemia — an experimental study. Stroke 14:46–50 1983

12.

Shephard RH: Operation for aneurysms of the middle cerebral artery in Symon L (ed): Operative Surgery. Fundamental International Techniquesed 3. London/Boston: Butterworths1979 pp 252257Shephard RH: Operation for aneurysms of the middle cerebral artery in Symon L (ed): Operative Surgery. Fundamental International Techniques ed 3. London/Boston: Butterworths 1979 pp 252–257

13.

Sonobe MSuzuki J: Vasospasmogenic substance produced following subarachnoid haemorrhage, and its fate. Acta Neurochir 44:971061978Sonobe M Suzuki J: Vasospasmogenic substance produced following subarachnoid haemorrhage and its fate. Acta Neurochir 44:97–106 1978

14.

Suzuki J: Cerebral vasospasm: prediction, prevention and protection in Pia HWLangmaid CZierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag1979 pp 155162Suzuki J: Cerebral vasospasm: prediction prevention and protection in Pia HW Langmaid C Zierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag 1979 pp 155–162

15.

Suzuki J: Prognosis of 1000 pure saccular aneurysms operated upon in Pia HWLangmaid CZierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag1979 pp 413418Suzuki J: Prognosis of 1000 pure saccular aneurysms operated upon in Pia HW Langmaid C Zierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag 1979 pp 413–418

16.

Suzuki JFujimoto SMizoi Ket al: The protective effect of combined administration of anti-oxidants and perfluorochemicals on cerebral ischemia. Stroke 15 (In press 1984)Suzuki J Fujimoto S Mizoi K et al: The protective effect of combined administration of anti-oxidants and perfluorochemicals on cerebral ischemia. Stroke 15 (In press 1984)

17.

Suzuki JHori S: Prediction of reattacks following rupture of intracranial aneurysms in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979 pp 6772Suzuki J Hori S: Prediction of reattacks following rupture of intracranial aneurysms in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron 1979 pp 67–72

18.

Suzuki JIwabuchi THori S: Cervical sympathectomy for cerebral vasospasm after aneurysm rupture. Neurol Med Chir 15:41501975Suzuki J Iwabuchi T Hori S: Cervical sympathectomy for cerebral vasospasm after aneurysm rupture. Neurol Med Chir 15:41–50 1975

19.

Suzuki JKodama NFujiwara Set al: Surgical treatment of middle cerebral artery aneurysms: from the experiences of 174 cases in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979 pp 278283Suzuki J Kodama N Fujiwara S et al: Surgical treatment of middle cerebral artery aneurysms: from the experiences of 174 cases in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron 1979 pp 278–283

20.

Suzuki JKodama NHomma M: New clip and flexible clip forceps for neurosurgery in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979 pp 386388Suzuki J Kodama N Homma M: New clip and flexible clip forceps for neurosurgery in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron 1979 pp 386–388

21.

Suzuki JKodama NYoshimoto Tet al: Ultra-early surgery of intracranial aneurysms. Acta Neurochir 63:1851911982Suzuki J Kodama N Yoshimoto T et al: Ultra-early surgery of intracranial aneurysms. Acta Neurochir 63:185–191 1982

22.

Suzuki JKomatsu SSato Tet al: Correlation between CT findings and subsequent development of cerebral infarction due to vasospasm in subarachnoid haemorrhage. Acta Neurochir 55:63701980Suzuki J Komatsu S Sato T et al: Correlation between CT findings and subsequent development of cerebral infarction due to vasospasm in subarachnoid haemorrhage. Acta Neurochir 55:63–70 1980

23.

Suzuki JKwak ROkudaira Y: The safe time limit of temporary clamping of cerebral arteries in the direct surgical treatment of intracranial aneurysm under moderate hypothermia. Tohoku J Exp Med 127:171979Suzuki J Kwak R Okudaira Y: The safe time limit of temporary clamping of cerebral arteries in the direct surgical treatment of intracranial aneurysm under moderate hypothermia. Tohoku J Exp Med 127:1–7 1979

24.

Suzuki JOnuma TYoshimoto T: Results of early operations on cerebral aneurysms. Surg Neurol 11:4074121979Suzuki J Onuma T Yoshimoto T: Results of early operations on cerebral aneurysms. Surg Neurol 11:407–412 1979

25.

Suzuki JTanaka SYoshimoto T: Recirculation in the acute period of cerebral infarction: brain swelling and its suppression using mannitol. Surg Neurol 14:4674721980Suzuki J Tanaka S Yoshimoto T: Recirculation in the acute period of cerebral infarction: brain swelling and its suppression using mannitol. Surg Neurol 14:467–472 1980

26.

Suzuki JYoshimoto T: The effect of mannitol in prolongation of permissible occlusion time of cerebral artery — clinical data of aneurysm surgery. Neurosurg Rev 1:13191979Suzuki J Yoshimoto T: The effect of mannitol in prolongation of permissible occlusion time of cerebral artery — clinical data of aneurysm surgery. Neurosurg Rev 1:13–19 1979

27.

Suzuki JYoshimoto T: Indication and timing in the surgery of ruptured cerebral aneurysm. Phronesis 36:34481978Suzuki J Yoshimoto T: Indication and timing in the surgery of ruptured cerebral aneurysm. Phronesis 36:34–48 1978

28.

Suzuki JYoshimoto THori S: Continuous ventricular drainage to lessen surgical risk in ruptured intracranial aneurysm. Surg Neurol 2:87901974Suzuki J Yoshimoto T Hori S: Continuous ventricular drainage to lessen surgical risk in ruptured intracranial aneurysm. Surg Neurol 2:87–90 1974

29.

Suzuki JYoshimoto TKodama Net al: A new therapeutic method for acute brain infarction: revascularization following the administration of mannitol and perfluorochemicals — a preliminary report. Surg Neurol 17:3253321982Suzuki J Yoshimoto T Kodama N et al: A new therapeutic method for acute brain infarction: revascularization following the administration of mannitol and perfluorochemicals — a preliminary report. Surg Neurol 17:325–332 1982

30.

Watanabe TYoshimoto TSuzuki J: The effect of mannitol in preventing the development of cerebral infarction: an electron microscopical investigation in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979 pp 359365Watanabe T Yoshimoto T Suzuki J: The effect of mannitol in preventing the development of cerebral infarction: an electron microscopical investigation in Suzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron 1979 pp 359–365

31.

Yaşargil MGFox JLRay MW: The operative approach to aneurysms of the anterior communicating artery in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag1975 Vol 2 pp 113168 (see pp 115–128)Yaşargil MG Fox JL Ray MW: The operative approach to aneurysms of the anterior communicating artery in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag 1975 Vol 2 pp 113–168 (see pp 115–128)

32.

Yoshimoto TSakamoto TWatanabe Tet al: Experimental cerebral infarction. Part 3: Protective effect of mannitol in thalamic infarction in dogs. Stroke 9:2172181978Yoshimoto T Sakamoto T Watanabe T et al: Experimental cerebral infarction. Part 3: Protective effect of mannitol in thalamic infarction in dogs. Stroke 9:217–218 1978

33.

Yoshimoto TSuzuki J: Temporary clipping — prolongation of the time of occlusion by mannitol in Pia HWLangmaid CZierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag1979 pp 388392Yoshimoto T Suzuki J: Temporary clipping — prolongation of the time of occlusion by mannitol in Pia HW Langmaid C Zierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag 1979 pp 388–392

34.

Yoshimoto TUchida KKaneko Uet al: An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment. J Neurosurg 50:1521571979Yoshimoto T Uchida K Kaneko U et al: An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment. J Neurosurg 50:152–157 1979

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 135 135 41
Full Text Views 188 188 18
PDF Downloads 104 104 5
EPUB Downloads 0 0 0

PubMed

Google Scholar