M2/M2 side-to-side rescue anastomosis for accidental M2 trunk occlusion during middle cerebral artery aneurysm clipping: technical note.

Abstract

A technically feasible and rapid technique for revascularizing the main branches of the middle cerebral artery (MCA) is described. This technique is applied mainly when clipping of an MCA aneurysm is complicated and occlusion of the origin of an MCA main branch results. M2/M2 side-to-side anastomosis was applied in two patients in whom unplanned M2 occlusion occurred during the course of complicated MCA aneurysm clipping. The first patient underwent an emergency procedure after temporoparietal intracerebral hemorrhage. Unilateral mydriasis precluded preoperative angiographic workup, and a complex large MCA aneurysm was found as the source of hemorrhage. Shaping of the aneurysm neck by bipolar coagulation and clipping resulted in accidental occlusion of the superior trunk, and patency could not be regained despite multiple clip corrections. The second patient had an unruptured multilobulated aneurysm 8 mm in maximum diameter. Continuity of the inferior trunk was lost during clipping because of a tear at the origin. In both instances, side-to-side anastomosis was placed approximately 15 mm from the bifurcation, where the MCA main trunks ran side by side for a length of approximately 5 mm. After intracerebral hemorrhage, the first patient recovered to a level of moderate disability within 2 months. Substantial hemiparesis and expressive dysphasia remained as sequelae of the intracerebral hemorrhage. Digital subtraction angiography 2 months after the emergency procedure confirmed patency of the side-to-side anastomosis. The second patient was neurologically intact after recovery from anesthesia. Before discharge from the hospital on postoperative Day 8, digital subtraction angiography confirmed patency of the anastomosis. The MCA main branches usually run in close proximity for a short segment at the bottleneck entrance to the insular cistern. M2/M2 side-to-side anastomosis at this site is a rapid and feasible mode of revascularization of an M2 trunk accidentally occluded during complicated MCA aneurysm clipping.