Giant Middle Cerebral Artery Aneurysm Research Articles

Giant unruptured middle cerebral artery aneurysm revealed by intracranial hypertension: is a systematic decompressive hemicraniotomy mandatory?

Our study aimed to evaluate the postoperative outcome of patients with unruptured giant middle cerebral artery (MCA) aneurysm revealed by intracranial hypertension associated to midline brain shift. From 2012 to 2022, among the 954 patients treated by a microsurgical procedure for an intracranial aneurysm, our study included 9 consecutive patients with giant MCA aneurysm associated to intracranial hypertension with a midline brain shift. Deep hypothermic circulatory flow reduction (DHCFR) with vascular reconstruction was performed in 4 patients and cerebral revascularization with aneurysm trapping was the therapeutic strategy in 5 patients. Early (< 7 days) and long term clinical and radiological monitoring was done. Good functional outcome was considered as mRS score ≤ 2 at 3 months. The mean age at treatment was 44 yo (ranged from 17 to 70 yo). The mean maximal diameter of the aneurysm was 49 mm (ranged from 33 to 70 mm). The mean midline brain shift was 8.6 mm (ranged from 5 to 13 mm). Distal MCA territory hypoperfusion was noted in 6 patients. Diffuse postoperative cerebral edema occurred in the 9 patients with a mean delay of 59 h and conducted to a postoperative neurological deterioration in 7 of them. Postoperative death was noted in 3 patients. Among the 6 survivors, early postoperative decompressive hemicraniotomy was required in 4 patients. Good functional outcome was noted in 4 patients. Complete aneurysm occlusion was noted in each patient at last follow-up. We suggest to discuss a systematic decompressive hemicraniotomy at the end of the surgical procedure and/or a partial temporal lobe resection at its beginning to reduce the consequences of the edema reaction and to improve the postoperative outcome of this specific subgroup of patients. A better intraoperative assessment of the blood flow might also reduce the occurrence of the reperfusion syndrome.

Giant aneurysm of the middle cerebral artery treated by effective embolization

Giant aneurysms (GA) of middle cerebral artery (MCA) are rare and account for approximately 0.5-4.8% of intracranial artery aneurysms. Early diagnosis of brain GA is critical. Classic digital subtraction angiography (DSA) with the option of three-dimensional rotational angiography remains the “gold standard” in the diagnosis of intracranial aneurysms, including GA. The primary goal of brain GA treatment is to permanently exclude the aneurysm from the circulation while preserving the flow in the candelabra. The secondary goal is to stop the growth of the aneurysm and reduce the ‘mass effect’ symptoms it causes. Despite new endovascular techniques and advances in microsurgery, the treatment of GA MCA is still a therapeutic challenge. There are only a few reports in the literature describing cases of patients diagnosed with GAs of MCA and evaluating various treatment methods. In this article, we present the case of a 78-year-old patient with GA of the right MCA, who underwent effective embolization of the active part of the aneurysm.

‘Peacock tail’ Clipping Technique for a Giant Middle Cerebral Artery Aneurysm: A Technical Note

Background: Giant middle cerebral artery (MCA) aneurysms are surgically challenging lesions. Because of the complexity and variability of these aneurysms, a customized surgical technique is often needed for each case. In this article, we present a modified clip reconstruction technique of a ruptured complex giant partially thrombosed middle cerebral artery aneurysm. Case description: The aneurysm was exposed using the pterional approach. Following proximal control, the aneurysm sac was decompressed. Then, we applied permanent clips to reconstruct the aneurysm neck. The configuration of the aneurysm mandated a tailored clipping pattern to account for residual aneurysm sac sagging beyond the confinement of the single inflow and the two outflow channels. As a result, clipping in a fanning pattern was done to obliterate the lateral extensions while retaining a smooth curvature of the reconstructed neck. This final clipping pattern mirrored the arrangement of the peacock tail feathers. The 'peacock tail’ clipping technique can be thought of as a variation of the traditional straight tandem clipping, also known as 'picket-fence,' applied to less complicated aneurysm configurations. Conclusion: Giant MCA aneurysms may demand an adaptive clipping technique to account for the unique geometry of each aneurysm. In this paper, we described the 'peacock tail’ clipping technique for clip reconstruction of a giant complex partially thrombosed M2 MCA aneurysm as a modification of the conventional tandem clipping technique.

The M2-M1 middle cerebral artery reimplantation bypass with protective superficial temporal artery to middle cerebral artery bypass for giant partially thrombosed middle cerebral artery aneurysm in the hybrid operating suite.

Giant middle cerebral artery (MCA) aneurysms are complex and challenging. Revascularization is frequently required in addition to trapping or clip reconstruction, and the MCA reimplantation bypass is ultimately needed when aneurysm excision is planned. The operation was conducted in the hybrid operating suite, where an intraoperative cerebral angiography revealed a compromised MCA after multiple attempts of clip reconstruction. Therefore, we decided to perform an M2-M1 reimplantation bypass in conjunction with trapping and aneurysmectomy. Reimplantation bypass can be a rescue procedure for revascularization in complex aneurysms. The angioarchitecture varies among individuals; therefore, the optimal bypass technique should be tailored.

The results of surgery for giant aneurysms of the middle cerebral arteries: a retrospective study

Background: Surgical treatment of middle cerebral artery (MCA) giant aneurysms is a challenging task. The information on its current principles is rather limited, with the publications based on isolated case reports and small series.&#x0D; Aim: To identify the types of procedures and evaluate the results of surgery in patients with giant MCA aneurysms.&#x0D; Materials and methods: We retrospectively analyzed the data on 55 patients who had undergone surgery for MCA giant aneurysms in the Burdenko Neurosurgery Center from 2010 to 2021. Thereafter 52 patients were followed up for 6 to 120 months (for 53.1 33.7 months on average).&#x0D; Results: The giant MCA aneurysms were located at the M1 segment bifurcation in 33 (60%) patients, within the M1 segment, in 11 (20%), M2 in 7 (12.7%), and M3 and M4 in 4 (7.3%) patients. There were 32 (58.2%) saccular and 23 (41.8%) fusiform aneurysms. Surgical interventions for MCA giant aneurysms included their neck clipping (50.9%, n = 28), clipping with formation of the arterial lumen (3.6%, n = 2), bypass procedures (34.5%, n = 19), wrapping (3.6%, n = 2), and endovascular procedures (7.3%, n = 4). Perioperative worsening of the neurologic status (The Modified Rankin Scale, mRS) was observed in 50.9% (n = 28) of the patients, and the death rate was 1.8% (n = 1). The complete closure of giant aneurysms was achieved in 78.2% (n = 43) of the cases. The long-term outcome was favorable in 76.9% of the patients (40 from 52 available for the follow up).&#x0D; Conclusion: Microsurgical clipping and bypass types of surgery were the most common surgical procedures for the treatment of MCA giant aneurysms. These procedures are technically complex and are associated with a relatively high number of complications. The main directions of future studies could be in the search for new and more precise diagnostic assessment of the collateral circulation in the cortical MCA branches, improvement of the algorithm for the bypass selection, as well as an investigation of the long-term results of endovascular and combined treatments. A thorough long-term postoperative patient follow-up and the possibility of high quality control angiography are of major importance.

Microsurgical Clipping of Giant Saccular Middle Cerebral Artery Aneurysm: A Case Report

Giant saccular middle cerebral artery aneurysm is rare vascular lesion and few cases have been reported in the literature. Microsurgical clipping is applied to treat a giant middle cerebral artery aneurysm .A 26 year-male presented with complain severe headache, multiple episodes of vomiting and one episode of sudden loss conscious since few hours prior to admission at emergency department. Cerebral Angiography showed a giant saccular middle cerebral artery (MCA) aneurysm. A standard right pterional approach applied to expose MCA and microsurgical clipping was performed. No any serious neurological complication was noted after surgery except right facial palsy. Patient was discharged at the 12th day of surgery.Endovascular therapy as well as STA-MCA bypass surgery plus clipping are usually applied to manage the giant MCA aneurysm. However, alone microsurgical clipping is also effective and has better result.

P.155 Giant aneurysm, tiny patient: flow diversion stenting of a giant MCA aneurysm in a young child

Background: A 3-year-old girl presented with a 6-day history of severe headaches. On examination, upper motor neuron signs were noted in the left upper and lower extremities with increased tone, reflexes, and a positive Babinski sign. MRI of the brain revealed a giant right middle cerebral artery (MCA) aneurysm with significant mass effect, associated with cerebral edema and ventricular effacement. CT and CT angiogram showed evidence of aneurysmal wall calcification and lamellar thrombosis within the aneurysmal sac. In addition, there was a smaller right MCA aneurysm in close proximity to the giant aneurysm. Methods: After a balloon occlusion test to assess collateral blood flow to the MCA territory, it was decided to treat both aneurysms with a flow diverting stent. Dual antiplatelet loading was done with aspirin and clopidogrel. The smallest available diameter of Pipeline Shield stent was deployed. Results: The patient remained neurologically unchanged. Early follow-up imaging demonstrated stent patency, reduced size and mass effect of the large aneurysm, reduced cerebral edema, and no flow into the smaller aneurysm. Conclusions: Flow diversion stenting may be employed successfully in pediatric patients, though has unique technical considerations including small size vessels and limited evidence for antiplatelet agent choice and dosing.

Placement of interlocking fenestrated clips for a large broad-based middle cerebral artery aneurysm with atherosclerosis: Technical case report

IntroductionClip ligation of a large or giant middle cerebral artery (MCA) aneurysm is sometimes challenging, since these aneurysms commonly involve the efferent arteries and often show atherosclerotic changes in the aneurysm wall. We present herein a surgical case of large MCA aneurysm with atherosclerosis, and demonstrate a technique that enables adjustment of the patency of efferent arteries and the dog-eared remnant of the complex bifurcation aneurysm by placement of interlocking fenestrated clips. Case illustrationA 63-year-old woman was referred to our hospital for treatment of a relatively large unruptured left MCA saccular aneurysm (dome height × neck width: 9.5 mm × 7.6 mm). She underwent microsurgical clip ligation of the aneurysm. Due to the atherosclerotic changes in the aneurysm neck and efferent arteries, a large amount of dog-eared remnant of the aneurysm neck or clip slippage was likely to occur following single clip ligation. The interlocking clip application technique was thus considered using fenestrated clips with high closure force at the tips, resulting in successful aneurysm obliteration without complicated replacement of the clips. ConclusionAlthough complex clip application techniques for large MCA aneurysms with atherosclerosis have been reported, the present technique could provide an alternative.

Sequential approach of internal maxillary-to-middle cerebral artery bypass and endovascular occlusion for giant middle cerebral artery aneurysm: a case report

BackgroundThe combined approach to complex brain МСА aneurysm seems to be generally considered viable. Although it is fairly common, the combinations of modalities, which are suggested in different case reports, vary significantly. This case discusses a sequential approach of reconstructive microsurgery with internal maxillary-to-middle cerebral artery bypass followed by the balloon test occlusion and endovascular embolization of the aneurysm and the MCA. The combined approach together with use of maxillary artery helped minimize the intraoperative and postoperative complications.Case presentationA 62-year-old female with rare episodes of headache and depression revealed giant middle cerebral artery aneurysm. The patient underwent a combined operation in a hybrid operating room with no serious neurologic deficit after surgery.ConclusionsMultimodality management in a hybrid operating room should be considered in case of complex fusiform aneurysm of MCA, which is associated with high risks of clipping. Thus, the sequential procedures will improve patient outcomes in treatment of complex МСА aneurysms.

How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm.

Giant middle cerebral artery aneurysms are frequently anatomically complicated. Trapping may yield poor outcome, and bypass revascularization is often necessary as an adjunctive treatment to preserve flow. The technical nuances of superficial temporal artery to middle cerebral artery bypass are described in the setting of clip reconstruction of giant middle cerebral artery (MCA) aneurysm. In addition to an operative video, the anatomy and surgical technique are demonstrated in virtual reality to enhance the didactic clarity. Meticulous technique is paramount for successful superficial temporal artery MCA bypass. Along with clip reconstruction, it is a critical part of the treatment of complex, giant MCA aneurysms.

Microsurgical Management of a Previously Coiled Giant Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Microsurgical Management of a Previously Coiled Giant Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series

Management of large or giant fusiform middle cerebral artery (MCA) aneurysms represents a significant challenge. To describe the authors' experience in the treatment of large or giant fusiform MCA aneurysm by using various surgical techniques. We retrospectively reviewed a database of aneurysms treated at our division between 2015 and2017. Overall, 20 patients (11 males, 9 females) were identified, with a mean age of 40.7 years (range, 13-65 years; median, 43 years). Six patients (30%) had ruptured aneurysms and 14 (70%) had unruptured aneurysms. The mean aneurysm size was 19 mm (range, 10-35 mm). The aneurysms involved the prebifurcation in 5 cases, bifurcation in 4 cases, and postbifurcation in 11 cases. The aneurysms were treated by clip reconstruction (n= 5), clip wrapping (n= 1), proximal occlusion or trapping (n= 4), and bypass revascularization (n= 10). Bypasses included 7 low-flow superficial temporal artery-MCA bypasses, 2 high-flow extracranial-intracranial bypasses, and 1 intracranial-intracranial bypass (reanastomosis). Bypass patency was 90%. Nineteen aneurysms (95%) were completely obliterated, and no rehemorrhage occurred during follow-up. There was no procedural-related mortality. Clinical outcomes were good (modified Rankin Scale score ≤2) in 18 of 20 patients (90%) at the last follow-up. Surgical treatment strategy for large or giant fusiform MCA aneurysms should be determined on an individual basis, based on aneurysm morphology, location, size, and clinical status. Favorable outcomes can be achieved by various surgical techniques, including clip reconstruction, wrap clipping, aneurysm trapping, aneurysm excision followed by reanastomosis, and partial trapping with bypass revascularization.

Fluorescein videoangiography during extracranial-to-intracranial bypass surgery: preliminary results.

Over the last years, intraoperative use of fluorescein is gaining ground in the field of neurosurgery, due to development of a microscope-integrated YELLOW 560 module, with reported experiences in brain malignancies, aneurysms, and arteriovenous malformation surgery. The aim of this study is to determine the feasibility and value of fluorescein videoangiography during bypass procedures. The authors enrolled 11 patients who underwent extracranial-to-intracranial bypass for moyamoya disease, atherosclerotic steno-occlusive cerebrovascular disease, and flow replacement during a giant middle cerebral artery (MCA) aneurysm treatment. Patients underwent fluorescein videoangiography using microscope-integrated fluorescence module. In all 11 cases, good bypass patency was intraoperatively demonstrated through fluorescein videoangiography and confirmed by post-operative digital subtraction angiography or computed tomographic angiography. The technique seems to be less sensible than standard indocyanine green videoangiography in terms of flow velocity assessment during first pass and does not benefit from a dedicated software to perform hemodynamic parameter analysis (i.e., FLOW 800). Fluorescein videoangiography was able to show a higher number of vesselsthanindocyanine green videoangiography, providing an extremely well-defined view of cortical vascular network, also in deeper cortical areas. In case of deep-seated anastomosis, it allowed real-time manipulation of neurovascular structures, making it possible a safe analysis of vessels in deep surgical field during videoangiography observation. Fluorescein videoangiography is a cost-effective, easy-to-use, fast and safe intraoperative tool and is useful to assess graft patency and extent of cortical vascular network also in deeper cortical areas. In case of deep-seated anastomosis, it provides the great advantage of performing real-time manipulation of neurovascular structures during videoangiography observation. It could represent a valuable complementary or alternative technique to assess intraoperative bypass function.

Microsurgical clipping of giant thrombosed aneurysm

Abstract Treatment of giant thrombosed aneurysm is still a challenge for most of neurosurgeons. We present our experience of a patient with a thrombosed giant middle cerebral artery aneurysm manifesting as headache that developed over a 15-year period. Magnetic resonance (MR), computed tomographic angiography (CTA), and digital subtraction angiography (DSA) have clarified the vascular lesion and directed the therapeutic protocol. An open craniotomy with direct clipping and thrombectomy was performed successfully with an uneventful postoperative course.

Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes

This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes. This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period. The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment. Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.

A systematic review of pipeline embolization device for giant intracranial aneurysms.

The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using "giant aneurysm" and "pipeline" as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.

Ruptured Giant Middle Cerebral Artery Aneurysm in Infancy (P3.115)

Ruptured Giant Middle Cerebral Artery Aneurysm in Infancy (P3.115)

E-018 Flow-Diversion for Complex Middle Cerebral Artery Aneurysms

ObjectiveTo evaluate the safety and efficacy of flow-diversion for treatment of large and complex middle cerebral artery (MCA) aneurysmsMethodWe conducted a retrospective review of the clinical charts of all patients...

Internal Maxillary Artery-Middle Cerebral Artery Bypass

BACKGROUND:Internal maxillary artery (IMax)–middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a “keyhole” craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis.OBJECTIVE:To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass.METHODS:Orbitozygomatic osteotomy is used followed by frontotemporal craniotomy and subsequently laterotemporal fossa craniectomy, reaching its medial border at a virtual line connecting the foramen rotundum and foramen ovale. The IMax was identified by using established anatomic landmarks, neuronavigation, and micro Doppler probe (Mizuho Inc. Tokyo, Japan). Additionally, we studied the approach in a cadaveric specimen in preparation for microsurgical bypass.RESULTS:There were 4 cases in which the technique was used. One bypass was performed for flow augmentation in a hypoperfused hemisphere. The other 3 were performed as part of treatment paradigms for giant middle cerebral artery aneurysms. Vein grafts were used in all patients. The proximal anastomosis was performed in an end-to-side fashion in 1 patient and end-to-end in 3 patients. Intraoperative graft flow measured with the Transonic flow probe ranged from 20 to 60 mL/min. Postoperative angiography demonstrated good filling of the graft with robust distal flow in all cases. All patients tolerated the procedure well.CONCLUSION:IMax to middle cerebral artery subcranial-intracranial bypass is safe and efficacious. The laterotemporal fossa craniectomy technique resulted in reliable identification and wide exposure of the IMax, facilitating the proximal anastomosis.ABBREVIATIONS:EC-IC, extracranial-intracranialIMax, internal maxillary arteryMCA, middle cerebral arterySC-IC, subcranial-intracranialSTA, superficial temporal artery

Flow diversion for complex middle cerebral artery aneurysms

This study aims to evaluate the safety and efficacy of flow diversion for treatment of large and complex middle cerebral artery (MCA) aneurysms. We conducted a retrospective review of the clinical charts of all patients who underwent Pipeline Embolization Device (PED) placement for aneurysm at our institution from October 2010 to October 2013. We included ten patients, of which five had large MCA aneurysms and three had giant ones. Fusiform unruptured aneurysms represented seven of all ten aneurysms. Angiographic and clinical follow-up were available for all patients mostly between 7 and 12 months. We had no technical complications, one periprocedural morbidity, and no mortality. On follow-up, we had no hemorrhagic complications, no aneurysms rupture, and only one clinically significant thromboembolic event in a patient who discontinued antiplatelet therapy against medical advice. One patient had completely occluded his diseased vessel but remained asymptomatic. The overall complication rate is 3/10. On follow-up, complete occlusion occurred in seven patients (7/9). PED treatment for large, giant, and bifurcation MCA aneurysms was feasible, with satisfying complete occlusion rate, no mortality, and reasonable morbidity rate.