Middle Cerebral Aneurysm Research Articles

Application of a Three-dimensional Printed Anatomical Model in Presurgical Planning of Surgical Treatment of Brain Aneurysms

Three dimensional (3D) printed models represent innovative tools in anatomy teaching and surgical planning. The present study aimed at generating 3D skull models incorporating middle cerebral artery (MCA) aneurysms and in assessing their anatomical accuracy and utility as training and preoperative planning tools. Two aneurysm models were generated. Initially, a full skull (model A) and subsequently a half skull (model B) using white polyactic acid (PLA) filament incorporating two arterial networks with hard black PLA filament (in model A) and a softer semitransparent filament (in model B). The models were based on computed tomographic angiography (CTA) of a female patient suffering from bilateral unruptured middle cerebral aneurysms. Model A, a high contrast model, was designed for anatomical illustration purposes. Model B was designed to allow for clipping simulations. The anatomical accuracy of the two models compared to CTA was assessed by measuring their dimensions at the neck, proximal, distal branches and fundus, using an electronic micrometer. The utility of the models for the comprehension of the underlying anatomy, pathology and preoperative planning was evaluated by means of online questionnaires following clipping simulations conducted by neurosurgery residents and specialized neurosurgeons. Of the two 3D printed models generated, model B (clipping model) showed the highest degree of anatomical accuracy. The results of the online survey on the utility of the proposed models indicate that the majority of participants accepted the innovation with positive responses and approve the use of 3D printed aneurysm models for preoperative planning and resident training.

Surgical treatment and perioperative management of intracranial aneurysms in Chinese patients with ischemic cerebrovascular diseases: a case series

BackgroundPatients with ischemic cerebrovascular diseases are more likely to suffer from intracranial aneurysms, and their surgical treatment has a growing controversy in this condition. The current case series was aimed at exploring surgical treatment and perioperative management of intracranial aneurysms in Chinese patients with ischemic cerebrovascular diseases.MethodsMinimally invasive surgical approach through small pterion or inferolateral forehead was applied in 31 patients. Anti-platelet drugs were withdrawn 1 week before surgical operation. Systolic blood pressure was controlled to be more than 110 mmHg and increased by 20% after the clipping of intracranial aneurysms. Branches of external carotid artery were spared to ensure collateral circulation. Temporary blocking was minimized and ischemic time was shortened during surgical operation.ResultsPatients had an average age of 66 (46–78) years, and proportion of males was 39% (12 males). There were 35 unruptured intracranial aneurysms with a diameter more than 5 mm. There were 20 posterior communicating and anterior choroidal aneurysms (57%), seveb middle cerebral aneurysms (20%), and eight anterior communicating aneurysms (23%), with 21 lobular aneurysms (60%). Twenty-nine patients had normal neurological function (Glasgow Outcome Scale [GOS] 5), one patient with mild neurological defect (GOS 4), and one patient with severe neurological defect (GOS 3) at discharge. Meanwhile, there were 26 patients with modified Rankin Scale (MRS) 0–1, 4 patient with MRS 2, and one patient with MRS 3 at discharge. There were four patients lost during the follow-up. During the follow-up, 26 patients had normal neurological function (GOS 5), and one patient with severe neurological defect (GOS 3). Meanwhile, there were 25 patients with MRS 0–1, one patient with MRS 2, and one patient with MRS 3. All patients had no recurrence of intracranial aneurysms after operation.ConclusionsThe current case series found that minimally invasive surgical approach and intraoperative monitoring, supplemented by effective management of cerebrovascular perfusion, circulation and coagulation, can promote the treatment of intracranial aneurysms and prevent the development of cerebral ischemia and aneurysm rupture in Chinese patients with ischemic cerebrovascular diseases. Future studies with large sample size will be needed to confirm the results from the current case series.

Analysis of the therapeutic effect of stent-assisted embolization and surgical clipping for the treatment of middle cerebral artery bifurcation aneurysms

Objective: To compare the clinical effects of stent-assisted embolization and surgical clipping in the treatment of middle cerebral artery bifurcation wide-necked aneurysms. Methods: From July 2014 to March 2017, the clinical and imaging data of 45 patients with Hunt-Hess 0-Ⅲ grade middle cerebral artery bifurcation wide-necked aneurysms were divided into stent-assisted embolization group (20 patients from PLA Rocktet Army Hospital) and surgical clipping group (25 patients from Peking University International Hospital). The total occlusion rates of aneurysm, operation-related adverse events, clinical outcomes, and results of follow-up imaging from the two groups were compared. Results: The total occlusion rates in the stent-assisted embolization group and surgical clipping group were 90.0% (18/20) and 92.0% (23/25), respectively, and the difference was not statistically significant (P=0.815). The favorable six-month postoperative outcomes defined as the modified Rankin Scale ≤2 were 94.7% (18/19) in the stent-assisted embolization group and 91.3% (21/23) in the surgical clipping group (P=0.667). Fewer patients experienced the operation-related adverse events in the stent-assisted embolization group (15.0%, 3/20), as compared to that of the surgical clipping group (24.0%, 6/25), but the difference were not significant (P=0.453). After 2-24 months (median 7 months) of the operation, the follow-up imaging indicated that in the stent-assisted embolization group, 2 out of the 19 patients had residual or recurrent aneurysms.While in the surgical clipping group, residual or recurrent aneurysms were identified in 2 out of the 23 patients 2-14 months (median 3 months) after the surgery; the frequency was not statistically different between the two groups (P=0.841). Conclusion: Stent assisted embolization is a safe and effective treatment for the low grade middle cerebral artery bifurcation wide-necked aneurysms.

Prejuízos neurocognitivos na hemorragia subaracnóide aneurismática no pré e pós operatório

Os prejuízos neurocognitivos após uma hemorragia subaracnóide (HSA) aneurismática, bem como as classificações de resultados neurocirúrgicos, vêm em processo de reavaliação. O tratamento endovascular dos aneurismas intracranianos, que inicialmente foi introduzido para a oclusão dos aneurismas mais difíceis, vem se tornando um método de escolha por ser menos invasivo, porem não se conhece o impacto neurocognitivo do tratamento da HSA aneurismática seja ele cirúrgico ou endovascular. Sabe-se que a HSA isoladamente também está associada com alterações cognitivas a longo prazo. Alguns fatores clínicos associados, como vasoespasmo, ressangramento, hidrocefalia, ruptura intra-operatória também podem agravar essas alterações cognitivas. Os estudos correlacionando essas variáveis foram iniciados há pouco tempo e não existe consenso a partir de estudo controlado na literatura. O objetivo deste relato visa demonstrar a aplicação clínica e neuropsicológica direcionada para analisar o estado cognitivo pré e pós-operatório em uma paciente que foi internada após duas hemorragias subaracnóideas (HSA) aneurismáticas, cujo aneurisma da artéria cerebral média esquerda foi clipado. São analisados o estado pré e pós-operatório tentado-se delimitar a disfunção dentro de padrão de comportamento individual, os distúrbios pré-operatórios e a seqüelas pós-operatórias quando ela foi averiguada mais tarde, analisando-se o impacto de ambas, hemorragia e cirurgia sobre o funcionamento cognitivo e funções afetivas.

Ruptured distal middle cerebral artery mycotic aneurysm: A rare, first presentation of infective endocarditis

Mycotic cerebral aneurysms are rare inflammatory aneurysms associated with high mortality and morbidity reaching up to 80% after rupture. We report a case of incidentally diagnosed infective endocarditis presenting with rupture of distal middle cerebral artery mycotic aneurysm and intracerebral hematoma. Aneurysmectomy with clip ligation of the terminal cortical branch and hematoma evacuation was done with good surgical outcome.

Rare case of a ruptured distal middle cerebral artery fusiform aneurysm: a neurosurgical challenge.

Distal ruptured fusiform middle cerebral artery (MCA) M4 segment aneurysms are rare and their management is a challenge to the neurosurgeon. Fusiform aneurysm of M4 part of is even rarer. Patient usually presents with headache or neurological deficit. Computed tomographic angiography helps to confirm diagnosis. Treatment involves micro-neurosurgical clipping or trapping and excision of aneurysm. Early surgical intervention of distal middle cerebral artery aneurysms favours better outcome. We report a case of 20 year old female patient who presented with complaint of severe headache. Neuroimaging was suggestive of right M4 middle cerebral artery fusiform aneurysm with intracerebral haemorrhage. Patient was managed by trapping and excision of aneurysm and recovered well.

Predictive anatomical factors for rupture in middle cerebral artery mirror bifurcation aneurysms

OBJECTIVE The aim of this study was to define predictive factors for rupture of middle cerebral artery (MCA) mirror bifurcation aneurysms. METHODS The authors retrospectively analyzed the data in patients with ruptured MCA bifurcation aneurysms with simultaneous presence of an unruptured MCA bifurcation mirror aneurysm treated in two neurosurgical centers. The following parameters were measured and analyzed with the statistical software R: neck, dome, and width of both MCA aneurysms-including neck/dome and width/neck ratios, shape of the aneurysms (regular vs irregular), inflow angle of both MCA aneurysms, and the diameters of the bilateral A1 and M1 segments and the frontal and temporal M2 trunks, as well as the bilateral diameter of the internal carotid artery (ICA). RESULTS The authors analyzed the data of 44 patients (15 male and 29 female, mean age 50.1 years). Starting from the usual significance level of 0.05, the Sidak-corrected significance level is 0.0039. The diameter of the measured vessels was statistically not significant, nor was the inflow angle. The size of the dome was highly significant (p = 0.0000069). The size of the neck (p = 0.0047940) and the width of the aneurysms (p = 0.0056902) were slightly nonsignificant at the stated significance level of 0.0039. The shape of the aneurysms was bilaterally identical in 22 cases (50%). In cases of asymmetrical presentation of the aneurysm shape, 19 (86.4%) ruptured aneurysms were irregular and 3 (13.6%) had a regular shape (p = 0.001). CONCLUSIONS In this study the authors show that the extraaneurysmal flow dynamics in mirror aneurysms are nonsignificant, and the aneurysmal geometry also does not seem to play a role as a predictor for rupture. The only predictors for rupture were size and shape of the aneurysms. It seems as though under the same conditions, one of the two aneurysms suffers changes in its wall and starts growing in a more or less stochastic manner. Newer imaging methods should enable practitioners to see which aneurysm has an unstable wall, to predict the rupture risk. At the moment one can only conclude that in cases of MCA mirror aneurysms the larger one, with or without shape irregularities, is the unstable aneurysm and that this is the one that needs to be treated.

内頸動脈瘤・中大脳動脈瘤のみられた肝動脈瘤破裂の一救命例

内頸動脈瘤・中大脳動脈瘤のみられた肝動脈瘤破裂の一救命例

Clipping versus Coiling for Intracranial Aneurysms: Recent Trends

Background: Cerebral aneurysms are relevant conditions, and the best therapeutic approach in a patient with Ruptured and Unruptured Intracranial Aneurysm has been debated in the last decades. Coil Embolization therapy has increasingly gained popularity over Surgical Clipping. Objectives: The aim of this analysis was to review the surgical and endovascular strategies for intracranial aneurysms, and to find out if one intervention is more suitable than other. Methods: A literature review was carried out identifying studies published from 2002-2017 through Pubmed using the keywords listed below. 75 articles were selected to write this review. Results: The International Subarachnoid Aneurysm Trial contributed to a change in practice of Intracranial Aneurysms. Endovascular Coiling reduced in 7,4% the proportion of patients who died or became dependent, even if the incidence of late rebleeding was higher at 1 year compared to Neurosurgery (2,9% vs. 0,9%). At 18 years the excess risk of rebleeding has not resulted in a significant worse outcome. Endovascular treatment is usually suitable for anterior and posterior circulating aneurysms. Middle cerebral aneurysms are generally treated through clipping. Asymptomatic Unruptured Intracranial Aneurysms smaller than 7 mm usually benefit from simple observation. Despite its benign natural history the number of Unruptured Intracranial Aneurysms treated has increased overtime. Higher mortality is associated with Neurosurgery compared to Endovascular strategy. Anaesthesia applied in surgical clipping is similar to the one applied in endovascular. The most common approaches are general anaesthesia and conscious sedation. Conclusions: There is strong evidence to indicate that Endovascular Coil embolization is associated with better outcomes compared to Neurosurgical Clipping in patients amenable to either strategy. Despite the major technical advances in imaging and endovascular treatment of intracranial aneurysms, surgical clipping is still the most efficient treatment for medial cerebral artery aneurysms.

The Association among Polycystic Kidney Disease, Brain Aneurysms and Cerebral Cavernous Malformations

Polycystic kidney disease (PKD) is commonly associated to cerebral aneurysms. We describe a young man with PKD and a middle cerebral aneurysm associated also to two temporal cavernous malformations. This association has been never reported. We suggest that CMs may belong to the phenotype of PKD and that may should be screened in PKD patients with cerebral haemorrhage.

Three-Dimensional Angiographic Evaluation of Middle Cerebral Artery Trunk Aneurysms: Demonstration of the Close Relationship Between the Early Frontal Cortical Branches and Lateral Lenticulostriate Arteries

For the treatment planning of a patient with a middle cerebral artery (MCA) trunk aneurysm, understanding the anatomic relationship among the aneurysm, branching vessels, and lenticulostriate arteries (LSAs) is important. We aimed to demonstrate the branching-vessel anatomy related to an MCA trunk aneurysm using 3-dimensional (3D) angiography. We retrospectively reviewed 3D angiographic findings of 64 cases of MCA trunk aneurysms using a 3D workstation with various postprocessing conditions. We classified the aneurysms into 4 groups (early frontal cortical branch [EFCB], early temporal cortical branch [ETCB], LSA, and nonbranching aneurysms) and analyzed the relationship between the branching vessels and the LSAs. There were 30 EFCB aneurysms, 25 ETCB aneurysms, 7 LSA aneurysms, and 2 nonbranching aneurysms. Twenty-six (86.7%) of the 30 EFCB aneurysms shared common origins and were associated with the LSAs, but none of the 25 ETCB aneurysms were. Three of 24 patients who received clipping for an EFCB aneurysm experienced a postoperative infarction in the LSA territory. In these 3patients, the LSA originated from the EFCB and was closely related with the aneurysm. We have identified a clinically important anatomic relationship between the MCA trunk aneurysm and branching vessels, including the LSAs. EFCB aneurysms show a close relationship with the LSAs. Pretreatment identification of the origin of the LSAs is important to obviate any perforator injury in EFCB aneurysms.

Clipping Surgery for Unruptured Middle Cerebral Artery Aneurysms.

Clipping surgeries for 139 consecutive unruptured middle cerebral aneurysms were performed between April 1991 and March 2014. Left hemiparesis occurred in one case (0.7 %). Transient symptoms arose in six patients due to perforator injury, arterial branch occlusion, damage to the venous system, or chronic subdural hematoma. Neither mortality nor decline in cognitive function was noted in this study. Clipping surgery for unruptured middle cerebral artery aneurysms can be done with minimal morbidity. However, meticulous management during the perioperative period as well as the use of modern technologies during the surgery, such as MEP monitoring and ICG videoangiography, are needed for safe and secure clipping surgery.

Metalloproteinase-9 and neutrophil gelatinase-associated lipocalin plasma and tissue levels evaluation in middle cerebral artery aneurysms

Background. Cerebral aneurysms are relatively common in adults, with a prevalence ranging between 1% and 5%. Subarachnoid hemorrhage, following aneurismal rupture, is a major cause of death and disability in these patients. Matrix Metalloproteinases (MMPs) and Neutrophil Gelatinase-Associated Lipocalin (NGAL) seem to be involved in the pathogenesis and in the clinical course of aneurysms. In this study, we evaluated the relationship between tissue and plasma levels of MMP-9 and NGAL in patient with ruptured and unruptured middle cerebral artery aneurysms. Methods. An open label study was conducted on 7 patients with middle cerebral aneurysms. Three patients had ruptured aneurysms (Group I) and four patients had unruptured aneurysms (Group II). All patients underwent aneurysm clipping. Plasma levels of MMP-9 and NGAL were evaluated through ELISA Test. During the surgery, biopsies of the aneurysmatic arteries were taken and frozen (− 80°C) for Western blot evaluation of MMPs and NGAL expression. Four healthy volunteers (Group III) represented the control group for ELISA testing. Results. Both plasma MMP-9 and NGAL levels were significantly high in aneurysmatic patients respect to those of control patients, and these levels were higher (P < 0.01) in patients with ruptured aneurysms respect to patients with unruptured aneurysms (P < 0.01). The latest findings were similarly evident in tissue evaluation of MMP-9 and NGAL between ruptured and unruptured aneurysms. Conclusion. This study suggests that MMP-9 and NGAL plasma levels may be useful to predict the clinical course of a cerebral aneurysms in order to evaluate the progression of the disease and the tendency of an aneurysm to rupture.

A Review of Computational Hemodynamics in Middle Cerebral Aneurysms and Rheological Models for Blood Flow

Cerebrovascular accidents are the third most common cause of death in developed countries. Over recent years, CFD simulations using medical image-based anatomical vascular geometries have been shown to have great potential as a tool for diagnostic and treatment of brain aneurysms, in particular to help advise on the best treatment options. This work aims to present a state of the art review of the different models used in CFD, focusing in particular on modeling blood as a viscoelastic non-Newtonian fluid in order to help understand the role of the complex rheological nature of blood upon the dynamics of middle cerebral aneurysms. Moreover, since the mechanical properties of the vessel walls also play an important role in the cardiovascular system, different models for the arterial structure are reviewed in order to couple CFD and computational solid dynamics to allow the study of the fluid–structure interaction (FSI).

Long-Term MRI Findings of Muslin-Induced Foreign Body Granulomas after Aneurysm Wrapping

Muslin-induced foreign body granulomas are rare delayed complications after wrapping of intracranial aneurysms. Few small case series have been reported, with a paucity of documented MRI findings. In addition, there are no reports on long-term radiological appearances or temporal evolution of conservatively managed patients. We thus report on the long-term radiological and clinical follow-up of two patients with asymptomatic muslin-induced foreign body granulomas after wrapping of recurrent middle cerebral arterial aneurysms. Both patients were successfully managed conservatively and remain asymptomatic three and six years after diagnosis of their granulomas. A literature review confirms that MRI features of muslin-induced foreign body granuloma are typical. Features include focal areas of elevated T2 signal with increased diffusion-weighted signal and thin rim enhancement. To the best of our knowledge, this is the first report to confirm that there is a corresponding reduction in apparent diffusion coefficient, as typical in an intracranial abscess. Thus a history of aneurysm wrapping is critical for diagnosis. Accurate clinical recognition of this exuberant inflammatory response will avoid misdiagnosis as pyogenic abscess or tumor and prevent unnecessary or invasive treatment.

Intra-aneurysmal superselective pharmacologic testing in a child

Treatment options for complex intracranial aneurysms with branch vessels originating from the fundus or neck are limited, because these arteries frequently supply eloquent brain territory. A 9-year-old boy presented with a recurrent proximal middle cerebral artery intracranial aneurysm. Sodium amobarbital was slowly injected through a microcatheter directly into the aneurysm fundus and an incorporated prominent lenticulostriate vessel for provocative functional testing. Serial neurologic examinations identified no new neurologic deficit. We proceeded with endovascular coiling of the aneurysm and inevitable sacrifice of the perforator vessel. The patient remained free of new neurologic symptoms with no angiographic evidence of aneurysm recurrence. To our knowledge, this is the youngest patient with a proximal intracranial aneurysm who has undergone superselective intra-aneurysmal provocative testing and subsequent successful endovascular treatment.

Double waffle-cone technique using twin Solitaire detachable stents for treatment of an ultra-wide necked aneurysm

Several stent-supported coiling techniques have been devised for treating wide-necked bifurcation aneurysms including the Y-stent and waffle-cone constructs. The Y-stent technique is not technically possible with obtusely oriented daughter vessels, and the waffle-cone method is inadequate for aneurysms with necks exceeding the stent’s maximal expansion diameter. We describe here the novel use of the Solitaire electrolytically detachable slotted stent (Solitaire, ev3, Irvine, CA, USA) featuring large-sized cells to fashion a concentric “double waffle-cone” construct. This method enabled the doubling of the neck coverage to treat an ultra-wide necked middle cerebral aneurysm with obtusely oriented daughter branches. The technique relies on the intra-cell crossing of the first stent using the second stent delivery microcatheter and fine tuning the relative position with the aid of cross-sectional cone-beam computed tomographic angiography to achieve optimal coverage of the neck prior to detachment of the stents in position. A retrievable stent with large cells such as the Solitaire device is optimal for this application given the need for relative adjustment of the deployment before final stent release to avoid under- or over-penetration of the distal stent struts into the aneurysm dome. An additional advantage of this approach over the kissing-stent technique is the absence of intraluminal stent struts, which was confirmed here by down-the-barrel cross-sectional imaging. The double waffle-cone construct enabled the successful coiling of the aneurysm with no post-procedural ischemic events detected on diffusion-weighted MRI and with stable complete embolization and no residual filling or in-stent stenosis at 6month follow-up.

4 - Intracranial Aneurysms

The modern history of the management of intracranial aneurysm encompasses little more than a quarter century. These are seen in 5% routine autopsies and those under 2 mm exist in 17% normal adult brain vasculature. One third of strokes are SAH and aneurysms account for 70% of these. Aneurysms rupture at a rate of 12/100.000 population/year, mostly on the 5th, and 6th decades. Given the high morbidity and mortality of these (43% from first haemorrhage if untreated), surgeons can attempt to avoid rebleeding for a week or more until surgery becomes safe and expand the ability to deal safely with most of them regardless of size or position. Early surgery has still an unacceptable morbidity and operation is usually planned between the 6th and 10th day after the first bleed. Early surgery is only indicated when there is a clot and deterioration. Conservative measures are reduction of blood pressure and use of antifibrinolysins and some minor surgical means whose practicality is still unknown. The recognition of warning leaks must be one of the significant factors for future treatment. Several surgical adjuncts are of considerable value, i.e., brain shrinking agents, microsurgical technique, induced hypotension. Aneurisms are classified as: small (less than 12 mm) large or bulbous (12-25 mm) and giant (greater than 25 mm). From 326 of small vertebral-basilar aneurysms the results were excellent in 246, good in 35, poor in 26 and 19 died. From 71 basilar aneurysms only 6 died, the results being excellent in 42, good in 10 and poor in 13. The management of giant anterior circulation (Table III) and posterior circulation (Table IV) aneurysms, involved various surgical procedures including carotid, middle cerebral, vertebral and basilar artery ligation, neck occlusion, wrapping or coating, as an overall result the outcome was good in 52 out of 63 gicunt anterior circulation giant aneurysms but was bad in 48 out of 91 posterior circulation giant aneurysms. The best results were obtained with 7 carotid-cavernous aneurysms (all good) and the worse results with 17 giant aneurysms of the basilar trunk at the superior cerebellar artery (11 poor, 6 good). A technique for the percutaneous occlusion of the basilar artery with a plastic Rommel type tourniquet is described (Fig 3). This allows the occlusion under local anesthesia. It has been used in 10 cases with 2 deaths STA-MCA by-pass proved to be useful for the progressive occlusion of the MCA in 3 cases of giant middle cerebral aneurysms.

Surgical treatment for middle cerebral artery aneurysmwith intracerebral hematomaaround lateral fissure

Objective To study surgical treatment for middle cerebral aneurysm (MCA) with intracerebral hematoma around the lateral fissure.Methods 31 cases of MCA with intracerebral hematoma (volume of hematoma was more than 20ml) around the lateral fissure were treated surgically in our hospital from January 2005 to February 2012.Their clinical data were colleted and the surgical shortages were studied from the aspects of anatomy and surgical techniques.Results The surgical shortages included:The bone window was too small due to poor preoperational incision design; The incision of anterior temporal cortex was too short when eliminating hematoma; Insufficient attention was paid to the elimination of intracerebral hematoma occurred after successful aneurysm occlusion ; The bleeding wasn1 stopped carefully ; Some early hematomas with hard texture near the aneurysm and important branches were excessively eliminated,thus leading to branch injury.Conclusions The incisions of scalp and temporal cortex should be properly enlarged or extended to the direction of posterior temporal lobe,which is beneficial to the clearance of temporal hematoma.Some organized hematomas adhering to the aneurysm and near the important branches of parent artery should be cleared appropriately. Key words: Middle cerebral artery aneurysm ; Intracerebral hematoma; Surgery

Treatment of Ruptured Middle Cerebral Aneurysms Associated with Intracerebral Hematomas

Treatment of Ruptured Middle Cerebral Aneurysms Associated with Intracerebral Hematomas