Large Middle Cerebral Artery Aneurysm Research Articles

Predictors of recurrence and complications for the endovascular treatment of unruptured middle cerebral artery aneurysm: A high-volume center experience over 12 years

ObjectTo assess the safety and efficacy of endovascular treatment (EVT) of unruptured middle cerebral artery (MCA) aneurysms in a retrospective cohort in a high-volume center. Predictors of complications and recurrence were determined. MethodsRetrospectively reviewed our database of prospectively collected information for all patients with unruptured MCA aneurysms that were treated by endovascular approach from March 2008 to December 2020. A multivariate analysis was conducted to identify predictors of complications and recurrence. ResultsThree hundred and fifty-one patients with 370 unruptured MCA aneurysms underwent EVT were included in this study. Seventy-three aneurysms (19.7%) were treated by coiling without stent, 297 (80.3%) with stent-assisted coiling. The procedures were performed with a technical success rate of 100%. Procedure-related neurological complications occurred in 15 patients (4.1%), including 1 patient died from post-procedural stent thrombosis. Age ≥ 65 years (P = 0.039; OR = 3.400; 95% CI, 1.065–10.860) and aneurysm size ≥ 5 mm (P = 0.009; OR = 15.524; 95% CI, 1.988–121.228) were significantly associated with ischemic complications of EVT. Three hundred and six aneurysms were (87.2%) completed image follow-up (235 DSA and 71 CE-MRA). The median angiographic follow-up time were 7.0 ± 4.3 months (range from 1 to 88 months). Follow-up angiograms showed that 249 aneurysms (81.4%) were completed occluded, 29 aneurysms (9.5%) were improved, 17 aneurysms (5.6%) were stable, and 11 aneurysms (3.6%) were recanalized and 10 of them accepted retreatments. Aneurysm size ≥ 10 mm was a predictor of recanalization (P = 0.004; OR = 11.213; 95% CI, 2.127–59.098) and stent-assisted coiling can significantly reduce recanalization (P = 0.004; OR = 0.105; 95% CI, 0.023–0.479). ConclusionsEVT is a safe and effective therapeutics for unruptured MCA aneurysms management, and provides durable aneurysm occlusion rate during follow-up. Large MCA aneurysms have higher recurrence and ischemic complications risk after EVT. Stent-assisted coiling can significantly reduce the recurrence rate without increasing the risk of complications.

Staged Hybrid Techniques With Straightforward Bypass Surgery Followed by Flow Diverter Deployment for Complex Recurrent Middle Cerebral Artery Aneurysms.

BackgroundRecurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm.Illustrative CaseA 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment.ConclusionsStaged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms.

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.

The Usefulness of a Hybrid Operating Room for the Surgical Flow Alteration Treatment of a Large Middle Cerebral Artery Aneurysm: A Case Report

The Usefulness of a Hybrid Operating Room for the Surgical Flow Alteration Treatment of a Large Middle Cerebral Artery Aneurysm: A Case Report

A case of unruptured aneurysm of the internal carotid artery presenting as olfactory hallucinations

Background:Olfactory hallucination, a symptom of medial temporal lobe epilepsy, is rarely associated with unruptured intracranial aneurysms.Case Description:We encountered this situation in a 70-year-old woman with an unruptured aneurysm at the bifurcation of the internal carotid and posterior communicating artery. We were able to achieve epileptic control by craniotomy clipping and medial temporal lesionectomy.Conclusion:According to our knowledge, previous reports are limited to cases of large middle cerebral artery aneurysms compressing the lateral orbitofrontal cortex, and this is apparently the first report of a case where olfactory hallucinations occurred from direct stimulation of the entorhinal cortex by an internal carotid and posterior communicating artery bifurcation aneurysm. We examined the pathophysiology underlying the development of olfactory hallucinations. We found craniotomy clipping and focal resection to be useful from the standpoint of seizure control. Whether seizure control can also be obtained with intracranial aneurysm coiling should be investigated in the future.

Thrombosed large middle cerebral artery aneurysm mimicking an intra-axial brain tumor: case report and review of literature.

This case report presents a fully thrombosed large aneurysm of middle cerebral artery mimicking an intra-axial brain tumor in a 54-year-old male patient. A small mass like lesion was found incidentally in right frontal area. Brain magnetic resonance image showed dark signal intensity on T2-weighted images and peripheral high signal intensity on T1-weighted images with peripheral rim enhancement. We considered intra-axial tumors such as glioma or metastatic tumor as a differential diagnosis. The lesion was approached transcortically, and intraoperatively, the lesion was found to be a large thrombosed aneurysm originating from the lateral lenticulostriate artery of right middle cerebral artery. One vascular clip was applied at the parent artery, and the thrombosed aneurysm was totally removed. There have been many reports of other intracranial lesions wrongly diagnosed as intracranial neoplasms. And thrombosed aneurysms mimicking intracranial neoplasm have been reported in 4 cases previously. According to those case reports, there were no efficient imaging tools to differentiate between these thrombosed aneurysms and intracranial neoplasms. We reviewed those reports and considered about the efficient method to diagnosed accurately before surgery. To sum up, when a patient presents with an intracranial lesion lying on the course of major or distal cerebral arteries, the surgeon should have thrombosed aneurysm in mind as one of the differential diagnosis and be prepared when surgically treating such lesions.

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...

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.

急性期破裂脳動脈瘤に対するEnterprise VRDを用いた瘤内塞栓術におけるオザグレルの有用性

We evaluate the safety and efficacy of ozagrel sodium (ozagrel) in stent-assisted coil embolization (SACE) of acutely (＜72 hours) ruptured wide-necked intracranial aneurysms, including primary success rates and short-term follow-up results. Approval by an institutional review board was obtained for this retrospective study. Results in 20 consecutive patients (6 men, 14 women; mean age, 68.2 years; range, 45–89 years) who were treated with SACE for acutely ruptured wide-necked intracranial aneurysms were evaluated. All patients were treated with Enterprise VRD stents (Johnson & Johnson Codman, Miami, FL, USA). Patients were treated with systemic heparinization and treated intraoperatively with an intravenous bolus infusion of 40 mg of ozagrel followed by intravenous drip infusion of 40 mg of ozagrel for 30 minutes. Single or dual oral antiplatelet agents were administrated immediately after the procedures. The modified Rankin Scale (mRS) was recorded at discharge. The indications for use of stent-assist were failure of the balloon remodeling technique (n＝10), coil tail protrusion (n＝1), coil instability (n＝5), and intentional (n＝4). All aneurysms were treated successfully with SACE. Complete occlusion was achieved in 13 cases (65%), nearly complete occlusion in six (30%), and partial occlusion in one (5%). One patient (5%) with a large middle cerebral artery aneurysm that resulted in partial occlusion developed embolic complications three days after the procedure, but she recovered and was discharged with an mRS score of 1. Perioperatively, ventricular drainage was performed in four patients (20%), spinal drainage in 11 (55%), and ventriculo-peritoneal shunt in two (10%). None presented with hemorrhagic complications. At the time of discharge, 15 patients (75%) had recovered in good condition (mRS 0–2), four were moderately or severely disabled (mRS 3–5), and one (5%) died (mRS 6) from primary brain damage. The remaining 19 patients developed no ischemic or hemorrhagic complications during the mean follow-up duration of 6.7 months. Our results indicate that ozagrel is a safe and effective antiplatelet agent in Enterprise VRD-assisted coiling in acutely ruptured intracranial aneurysms.

Advantage of Microscope Integrated for Both Indocyanine Green and Fluorescein Videoangiography on Aneurysmal Surgery: Case Report

Neck clipping of a large middle cerebral artery aneurysm was performed using a newly developed surgical microscope integrated with modules for both indocyanine green (ICG) and fluorescein videoangiography. During surgery, ICG and fluorescein videoangiography by intra-arterial or intravenous injection were safely carried out without interrupting the surgical procedure. Based on the findings obtained from the case, we evaluated the differences between the dyes and the injection routes. With intra-arterial injection, fluorescein offered sharper contrast images and was better at depicting fine arteries than ICG. Patchy staining of vessel walls was observed in intravenous fluorescein videoangiography, while it was not evident in ICG. Intra-arterial injection method had a great advantage in the rapid clearance of the dyes, which allowed us to perform repeated videoangiography within a short period, and was useful in detecting incomplete clipping in this case; however, catheter insertion requires additional work and carries a potential risk. Use of a microscope integrated for both ICG and fluorescein videoangiography would be another method for repeated evaluation. Namely, alternate use of the dyes enables us to perform videoangiography in a short time even via intravenous injection.

Unusual angiographic images of unruptured, large, kissing middle cerebral artery aneurysms

Dear Editor, Kissing aneurysms, defined as two adjacent aneurysms of the same or different arteries with separate origins and partially adherent walls, are rare findings with an incidence of less than 1 % [3, 8]. The most uncommon site of their occurrence is a middle cerebral artery (MCA). An extensive literature search revealed only two cases reported in this location [1, 7]. We present a case of kissing, unruptured, large MCA aneurysms with unusual angiographic images that resulted in substantial diagnostic difficulties. A 45-year-old female was referred to magnetic resonance imaging (MRI) because of hemifacial pain. MRI revealed a well-defined, regular mass in the location of the first right MCA (rMCA) bifurcation with a diameter of 33 mm. The lesion had a mixed signal in both T1- and T2-weighted images with a presence of methemoglobin and irregular, flow-void regions inside with vascular type of contrast enhancement (Fig. 1a), which suggested a giant, multilobed MCA aneurysm. On admission to our department, the patient was asymptomatic, with the hemifacial pain resolving spontaneously. The cerebral digital subtraction angiogram (DSA) with three-dimension (3D) rotational acquisition showed a saccular aneurysm (0.6 × 0.7 cm) of rMCA bifurcation. Additionally, a network of tortuous, segmentally ectatic vessels, replacing proximal 2 cm of the angular artery was seen. The angiographic findings were interpreted as segmental agenesis of right angular artery and a rete mirabile type of network, with ectatic and aneurysmal changes (Fig. 1b). Taking into account the patient’s relatively young age, the size and location of aneurysm and the presence of a rete mirabile type of network, the multidisciplinary team’s consensus was to proceed with a surgical treatment. We decided to use intraoperative monitoring of somatosensory and motor evoked potentials. Our plan for surgery was to clip the aneurysm that was more superficial and then after placing a temporal clip on a feeding vessel of the pathological network, without detectable changes in evoked potentials, to close it. We proceeded with the right pterional craniotomy. After exposing the Sylvian fissure, the large partially thrombosed aneurysm was demonstrated. It was arising from the M2 segment, right behind the first MCA bifurcation with a diameter significantly greater than that estimated by DSA (more than 20 mm). More profoundly, there was another aneurysm, similarly partially thrombosed, and smaller than the first one (more than 10 mm). It originated from the second M2 segment and was misinterpreted preoperatively as a rete mirabile type of network (Fig. 1c). The aneurysms had partially adherent walls that were separated in the first stage. Next, under the temporary occlusion of the main MCA branch (7 min, 35 s), the sacks of both aneurysms were opened and cleaned from thrombi to enable appropriate clip placement (two clips for each one). During the procedure, no changes were observed in the evoked potentials. The patient had an uneventful recovery. Control DSA performed 1 month after surgery revealed a small (3 mm) residual aneurysm with restoration of anatomic lumen of the right angular artery as well as complete occlusion of proximal aneurysm located in the first rMCA bifurcation with preservation of normal blood flow through rMCA and all of its branches (Fig. 1d). Fig. 1 a Preoperative T2-weighted MR image showing a pathological mass in the location of the first right MCA bifurcation. b Right internal carotid artery rotational 3D DSA showing saccular aneurysm (arrow) with network of tortuous, segmentally ectatic vessels ... The preoperative diagnosis of multiple or kissing aneurysms is often difficult. They can easily be misinterpreted as a single multilobed aneurysm or a vessel’s wall irregularity due to atherosclerotic arterial changes and result in an unpredictable finding during surgery [5]. According to Harada et al., 57 % of kissing aneurysms were not recognized preoperatively [1]. Special angiographic projections and 3D DSA, which are nowadays widely used, are thought to reduce these problems [2]. However, in our case, DSA results were misleading and an intraoperative finding of kissing aneurysms, instead of one aneurysm with coexisting pathological network, was unexpected. Our treatment was reviewed by the multidisciplinary team which concluded that if the preoperative correct diagnosis would have been established, the treatment method would have been the same, although there are some reports about successfully endovascular treatment of kissing aneurysms [4, 6]. The authors thank Anna Usowicz MD from the Children’s Hospital Oakland and Research Institute for her cooperation and assistance in editing the article.

Paradoxical Association of Moyamoya Syndrome With Large Middle Cerebral Artery Aneurysm and Subarachnoid Hemorrhage -Case Report-

A 69-year-old woman was admitted to our hospital because of fluctuating dysarthria during the past 2 months. Magnetic resonance imaging revealed old cerebral infarction of the left cerebral hemisphere with acute subarachnoid hemorrhage in the left sylvian fissure. Cerebral angiography showed a large saccular aneurysm, 14 mm in diameter, at the bifurcation of the left middle cerebral artery (MCA) in association with moyamoya vasculopathy with atherosclerosis, including steno-occlusive changes at the bilateral terminal internal carotid arteries and abnormal net-like vessels at the base of the brain. She underwent microsurgical neck clipping of the large aneurysm followed by superficial temporal artery-MCA anastomosis without complication. Intraoperative findings showed no evidence of aneurysm rupture, suggesting that the subarachnoid hemorrhage was due to the intrinsic pathology of moyamoya vasculopathy. The postoperative course was uneventful, and the patient was discharged without neurological deficit. Association of moyamoya syndrome with large MCA aneurysm is extremely rare, and formation of large aneurysm at the vascular territory of an occluded vessel is apparently unique.

Intra-aneurysmal hemodynamics in a large middle cerebral artery aneurysm with wall atherosclerosis

Background The remodeling of arterial extra-cellular matrix induced by hemodynamic stimuli is involved in the process of atherosclerosis in the carotid and cerebral arteries. Scarce information is available on the relationship between atherosclerotic changes in brain aneurysms itself and its intra-aneurysmal hemodynamics. Methods Surgical exploration of a large MCA aneurysm depicted extensive atherosclerotic changes in the aneurysm wall. Computational tomographic angiography of this aneurysm was used to create an in vitro aneurysm model. This model was used to perform intra-aneurysmal flow measurement using particle imaging velocimetry and LDV. Intra-aneurysmal hemodynamic pattern with wall shear stress distribution was compared between areas with and without atherosclerotic changes. Results No high oscillation of wall shear stress was observed on the atherosclerotic plaque area. However, the magnitude of wall shear stress tended to be higher in the area without atherosclerotic changes than the area with those changes ( P < .001). There was no atherosclerotic change at the aneurysm inflow zone, where relatively fast flow velocity and higher magnitude of wall shear stress was noted. Conclusions This single case of atherosclerosis in an aneurysm shows some similarity in hemodynamic values observed in cases of carotid atherosclerotic plaques.

石灰化を有する中大脳動脈瘤のクリッピング術

石灰化を有する中大脳動脈瘤のクリッピング術

One-session operation via bilateral craniotomies for multiple aneurysms after subarachnoid haemorrhage

One-session bilateral craniotomies for radical clipping of multiple aneurysms have been performed in 14 patients after subarachnoid haemorrhage. Bilateral small or medium sized aneurysms in pre-operatively good-grade Hunt and Hess (HH)I-III) patients (nine cases) were clipped without mortality or morbidity. Four poor-grade patients (HH IV at admission, improving to HH III pre-operatively) were treated, with unfavourable outcome in one patient. Another poor-grade patient (HH IV at surgery) with bilateral large middle cerebral artery aneurysms, a large intracerebral haematoma and a pontine angle meningioma survived with dysphasia and short-memory dysfunction. A slack brain at surgery and a short operation time justify one-session bilateral craniotomies also in the early post-bleeding period.

Giant aneurysm のクリッピング術に際し注意すべき点について

Surgical treatment of giant aneurysms is difficult and surgical results are not satisfactory. The authors reviewed the results of our surgery (aneurysmal clipping) of 26 giant aneurysms (internal cerebral artery: 13, anterior cerebral artery: 6, middle cerebral artery: 5, basilar artery: 1, vertebral artery: 1). The outcome of our cases is as follows: good (17), fair (2), poor (1), dead (6). Presenting several representative cases, the authors also described technical aspects of aneurysmal clipping: (1) systemic heparinization should be done to prevent cerebral embolism, when a temporary trapping procedure is used before neck clipping. (2) when the aneurysmal dome is punctured and the neck is clipped, additional clips should be applied to prevent slip-out of the clip first applied on the neck; (3) The technique of retrograde suction decompression of the aneurysm is useful in giant para-clinoidal aneurysms. This permits reflow of blood without any trouble, when it takes a long time to dissect the aneurysmal wall and clip the neck. This technique can be used repeatedly. (4) In cases of partially thrombosed giant aneurysms, thrombectomy makes neck clipping easier.In addition, one case of large middle cerebral artery aneurysm, which showed hemorrhagic infarction presumably due to hyperperfusion following aneurysmal clipping, was presented. This phenomenon appeared to be similar to the normal perfusion pressure breakthrough phenomenon, which is well known in patients with large arteriovenous malformations

Temporary clipping during early operation for ruptured aneurysm: preliminary report.

Temporary arterial occlusion was performed in 16 patients undergoing early aneurysm operation. Ten patients had a ruptured middle cerebral artery (MCA) aneurysm, and 6 had a ruptured anterior communicating artery aneurysm. Premature aneurysm rupture during operation necessitated temporary arterial occlusion in 10 patients. In 5 patients, temporary arterial occlusion was performed to facilitate dissection of the aneurysm. In 1 patient with a large MCA aneurysm, temporary occlusion was performed to provoke collapse of the completely exposed aneurysm sac, thus making clipping of the base possible. The results do not indicate that temporary occlusion by the standard aneurysm clips now in general use leads to angiographically detectable arterial wall changes or increased thromboembolic complications. Temporary clipping of the MCA proximal to the perforating arteries may be well tolerated for up to 20 minutes during early aneurysm operation. Temporary occlusion of one or both anterior cerebral arteries or temporary pericallosal clipping need not unconditionally lead to disastrous consequences if rendered necessary during aneurysm operations performed in the acute stage.