Bypass graft in the management of the giant serpentine aneurysms

Abstract

Objective The purpose of this study was to use graft bypass for giant serpentine aneurysms. Method 21 patients with giant serpentine aneurysms were treated with the use of graft bypass. Out of 14 patients with unruptured aneurysms, 4 patients presented with headache, 3 with reversible ischemic neurologic deficit( RIND), 5 patients had neck stiffness and features of lower cranial nerve palsy and out of the remaining two each had epilepsy and visual fields deficits respectively. 7 patients compromised ruptured aneurysms, inclusive of six patients with Hunt - Hess grade Ⅰ and Ⅱ1 , and one grade Ⅲ. Their suffering course ranged from 20 days to 3.5 years(mean, 7. 3 months). Cerebral angiography disclosed the M1 segment aneurysms of the middle cerebral artery in 6 patients and M2 segment in 4 patients, AI segment aneurysms of the anterior cerebral artery in 1 patients and A2 segment in 1 patient, P1 segment aneurysm of the posterior cerebral artery in 2 patients, basilar trunk in 2 patients, and the vertebral aneurysms in 5 patients. The aneurysm size in diameter from 0. 3 to 2. 5 cm(mean diameter, 1.2 cm), 13 aneurysms had length of more than 3. 0 cm and 8 patients with serpentine aneurysms had more than 5.0 cm. We used radial artery graft in 7 patients, superficial artery graft(STA) in 6 patients, occipital artery(OA) in 6 patients and greater saphenous vein ( GSV ) in remaining 2 patients. We underwent extra - intracranial bypass in 12 patients which includes external carotid artery to intracranial artery bypass in 5 cases, occipital artery to intracranial artery bypass in 4 cases and internal maxillary artery to intracranial artery bypass in 3 cases. The recipient intracranial vessel were anastomosed to the middle cerebral arteries in five patients, to the inferiopostrior cerebellar arteries in three patients, to P2 segment of the posterior cerebral arteries in three patients, and to anterioposterior cerebellar artery in one patient. The interposed grafts were performed between the arteries proximal and distal to the aneurysms in 9 patients, which includes interposition graft between M1 and M2 segment of the middle cerebral arteries(MCA) in three patients, M1 trunk of the MCA in two patients, the distal Al segment and proxmial A2 segment of the anterior cerebral arteries in two patients, and the extra - intracranial vertebral arteries in 2 patients. The aneurysms were trapped in 11 cases, the aneurysms were excised in 7 cases after isolating them, and the clip was places at the proximal end of the aneurysm in three cases with perforating arteries arising from the body of the aneurysm after performing the reverse flow bypass to the aneurysm sac securing the perforators. Results 20 patients returned to their normal life, they were free of headaches, seizure, visual acuity and visual field were improved and hemiparesis was recovered. One patient needed assist for his daily life. The postoperative angiographies demonstrated satisfactory patency of the bypass graft and elimination of the aneurysms in 19 patients though the patency of bypass graft in one patient was unidentifiable instead the patient was without neurological deficits clinically. One patient had developed postoperative hematoma in the ipsilateral sylvian fissure 2 days after the surgery. The hematoma was evacuated immediately but got neurological deficit on the contralateral lower limb with the power of grade Ⅳ. Conclusions Bypass graft should be an effective management for surgical treatment of giant serpentine aneurysms. Key words: Intracranial aneurysm; Cerebral revascularization; Vessel graft; Bypass