Combined microsurgical and endovascular treatment of a giant left middle cerebral artery aneurysm

Giant fusiform aneurysms of the middle cerebral artery (MCA) bifurcation pose significant treatment challenges. A giant fusiform aneurysm of the left MCA in a pediatric patient, which persisted despite Hunterian ligation of the M1 and double barrel superficial temporal artery (STA) to M2 bypasses, is reported. The aneurysm was trapped by endovascular coiling of the feeding M2 trunk through the STA anastamosis. Hunterian ligation combined with extracranial-intracranial bypass is an effective technique for treating giant fusiform aneurysms of the MCA bifurcation for patients who fail balloon test occlusions. However, in certain cases, flow reversal may not eliminate the aneurysm and continued aneurysm filling may occur through retrograde filling from the bypass recipient vessels. In these cases, endovascular trapping of the aneurysm may be undertaken through the bypass graft. The feasibility of this management scheme is demonstrated.     

STA-ACA bypass using the contralateral STA as an interposition graft for the treatment of complex ACA aneurysms: report of two cases and a review of the literature

Bypass surgery has been used as a remedy for the complex cerebral aneurysm, which was unsolved with the clipping method. However, little has been reported about bypass options for anterior cerebral artery (ACA) aneurysms. The authors experienced two patients with complex ACA aneurysms, large fusiform and large thrombosed aneurysms involving the distal A1 and proximal A2 segments, respectively. To achieve complete obliteration of the aneurysm, we performed a superficial temporal artery (STA)-ACA bypass using contralateral STA as interposition grafts with endovascular trapping without any ischemic events. These cases show that STA-ACA bypass using contralateral STA interposition graft is a feasible option to maintain blood supply to the ACA territory if a proximal ACA lesion requires trapping.     

Reflow into a thrombosed giant middle cerebral artery aneurysm after extracranial-intracranial bypass

This report graphically illustrates the consequences of flow augmentation through extracranial-intracranial bypass grafts. Propagation of clot from a thrombosed middle cerebral artery aneurysm into the middle cerebral artery produced transient ischemic attacks. Superficial temporal artery-middle cerebral artery bypass was performed to augment cerebral blood flow. Postoperative angiography demonstrated filling of the aneurysm through improved collateral channels. The role of bypass operation in the presence of an aneurysm and its contribution to collateral blood flow and clot lysis are discussed.     

Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note

It is difficult to treat large internal carotid aneurysms with simple surgical clipping. Here, we present a retrograde suction decompression (RSD) procedure for large internal carotid aneurysms using a balloon guide catheter combined with a blood-returning circuit and a superficial temporal artery to middle cerebral artery (STA-MCA) bypass.All patients underwent an STA-MCA bypass before the temporary occlusion of the internal carotid artery (ICA). A 6-French sheath was inserted into the common carotid artery (CCA), and a 6-French Patrive balloon catheter was placed into the ICA 5 cm past the bifurcation. Aneurysm exposure was obtained; temporary clips were placed on the proximal M1, A1, and posterior communicating (Pcom) segments; and an extension tube was then connected to the balloon catheter. A three-way stopcock was placed, and aspiration was performed through the device to collapse the aneurysm. The aspirated blood was returned to a venous line with an added heparin to prevent anemia after aspiration. During the decompression, the blood flow to the cortical area was supplied through the STA-MCA bypass. After the aneurysm collapse, the surgeon carefully dissected the perforating artery from the aneurysm dome or neck, and permanent clips were then placed on the aneurysm neck. Our procedure has several advantages, such as STA-MCA bypass without external carotid artery occlusion for preventing ischemic complications of the cortical area, anemia may be avoided because of the return of the aspirated blood, and a hybrid operation room is not required to perform this method.     

Distal intracranial arterial aneurysms. Apropos of a case of giant aneurysm of the right angular gyrus artery

A 57 year old man presented with a giant, fusiform, partially thrombosed aneurysm, located distally to the right angular gyrus artery, and revealed by a subarachno?d hemorrhage. There was no history of head trauma, endocarditis or systemic infection, and physical examination was normal. The treatment consisted in simple trapping of the aneurysm, responsible for a transient ischemic parietal syndrome. After a short review of the pathogenesis of peripheral aneurysm of the C.N.S., and previously reported cases of distally located aneurysms of the middle cerebral artery, only one similar case was found concerning a posterior temporal artery aneurysm involving to a giant serpentine aneurysm. The case presented is believed to be a segmentary form of cerebral arterial dolicho ectasia; relations between arterial ectasia or fusiform aneurysms and serpentine aneurysms are discussed.     

Intraoperative Measurement of Arterial Blood Flow Using a Transit Time Flowmeter: Monitoring of Hemodynamic Changes During Cerebrovascular Surgery

Summary  Background. The purpose of this study was to examine the utility and reliability of arterial flow measurements made with a transit time ultrasonic flowmeter for monitoring blood flow changes during intracranial and carotid surgery.  Method. A total of 25 patients underwent intra-operative arterial blood flow measurements. The pulsatile flow curve and mean flow values were obtained using 1- to 6-mm transit time probes with a dual channel flowmeter. Four cases underwent aneurysm clipping, 11 cases superficial temporal artery (STA) – middle cerebral artery (MCA) bypass, 2 cases external carotid artery (ECA) – radial artery – MCA bypass for aneurysm trapping, and 8 cases carotid endarterectomy. In aneurysm clipping, blood flow in the branches distal to the aneurysm was measured before and after clipping. Blood flow in the STA was measured before and after STA-MCA anastomosis, and blood flow in the internal carotid artery (ICA) cervical portion was measured during carotid endarterectomy. Blood flow in the MCA and STA was monitored during radial artery grafting.  Findings. Blood flow in the STA was elevated after STA-MCA anastomosis. However, post-operative hyperperfusion syndrome was found in some cases whose flow elevation was over 50 ml/min. Also in one case of carotid stenosis, of which blood flow of ICA was elevated to 400 ml/min after carotid endarterectomy, hyperperfusion syndrome was found after surgery. In the cases of MCA aneurysm clipping, decreasing of M2 flow was detected when clipping caused bifurcation stenosis.  Interpretation. We found transit time flow measurement useful for management of cerebrovascular surgery: the technique was simple to use and provided stable, reliable results. The method was able to reveal distal branch flow diminution in aneurysm clipping, or residual flow during temporary clipping in aneurysm surgery, and has the potential to predict post-operative complications such as hyperperfusion by signalling over-elevation of donor artery flow in bypass surgery or ICA flow in carotid surgery.     

Successful obliteration of a ruptured partially thrombosed giant m1 fusiform aneurysm with coil embolization at distal m1 after extracranial-intracranial bypass.

Proximal occlusion or trapping combined with EC-IC bypass is usually employed as a definite treatment for a giant fusiform aneurysm in cases where it is impossible to apply clips and do vascular reconstruction. Endovascular treatment is very important as an alternative or combined technique if direct surgery is impossible. The authors report a young male who presented with a 2 nd episode of intracranial bleeding in basal ganglion and subarachnoid hemorrhage with mild right hemiparesis. His 3D-CT scan revealed left ruptured partially thrombosed giant M1 fusiform aneurysm and left unruptured C3 saccular aneurysm. He underwent STA-MCA bypass with attempted M1 reconstruction and a week later attempted total occlusion of the M1 aneurysm with coils. But only a ruptured point at the distal M1 was occluded which, however, resulted in temporary mild right hemiparesis and aphasia. A month later when he was supposed to have his 2 nd coiling procedure his angiogram demonstrated spontaneous and complete obliteration of both the M1 and C3 aneurysms without any new neurological deficit, so no further endovascular procedure was attempted. The discussion is based on this case and previous reports regarding difficult giant M1 fusiform aneurysms, its treatment and spontaneous thrombosis of aneurysmal sac after bypass and distal occlusion. Conclusions are drawn that 1) spontaneous thrombosis of M1 and C3 aneurysms should be the result of hemodynamic alteration in both aneurysms due to a lower flow velocity induced by distal bypass and distal occlusion of M1, 2) combined distal bypass and endovascular obliteration of the aneurysmal sac with coils is a good alternative if vascular reconstruction is difficult or impossible.     

The ELANA technique: Constructing a high flow bypass using a non-occlusive anastomosis on the ICA and a conventional anastomosis on the SCA in the treatment of a fusiform giant basilar trunk aneurysm

Summary A patient with a partially thrombosed fusiform giant basilar trunk aneurysm presented with devastating headache and symptoms of progressive brain stem compression. Having an aneurysm inaccessible for endovascular treatment, and after failing a vertebral artery balloon occlusion test, he was offered bypass surgery in order to exclude the aneurysm from the cerebral circulation and relieve his symptoms. A connection between the intracranial internal carotid artery and the superior cerebellar artery was created whereupon the basilar artery was ligated just distally to the aneurysm. The proximal anastomosis on the internal carotid artery was made using the excimer laser-assisted non-occlusive anastomosis (ELANA) technique, while a conventional end-to-side anastomosis was used for the distal anastomosis on the superior cerebellar artery. Intra-operative flowmetry showed a flow through the bypass of 40ml/min after ligation of the basilar artery. An angiogram 24 hours later showed normal filling of the bypass and the vessels supplied by it, but also disclosed a subtotal occlusion of the proximal ipsilateral middle cerebral artery with delayed filling distally. The patient, who had a known thrombogenic coagulopathy, died the following day. Autopsy showed no signs of ischemia in the territories supplied by the bypass, but a thrombus in the proximal middle cerebral artery and massive acute hemorrhagic infarction with swelling in its territory and uncal herniation. Multiple fresh thrombi were found in the lungs. The ELANA anastomosis showed re-endothelialisation without thrombus formation on the inside.     

Short-segment Internal Trapping for Symptomatic Thrombosed Large Fusiform Vertebral Artery Aneurysms (Bird’s Nest Trapping): A Technical Note

Internal trapping with coils is an established treatment of symptomatic large non-branching thrombosed fusiform vertebral artery aneurysms (VAA). However, when perforators arise near the aneurysm neck, parent artery occlusion has a high risk of causing medullary infarction. As an alternative treatment, we performed short-segment internal trapping of the artery using n-butyl-2-cyanoacrylate (NBCA) and coils (bird’s nest trapping). Before treatment, perianeurysmal perforators are carefully detected using high-resolution three-dimensional rotational angiography (3DRA). Double microcatheters are advanced to the distal portion of the aneurysm through a balloon guiding catheter where coils are deployed without tight packing. Then, NBCA is injected into the coil mass, taking care to preserve perforators and significant branches. The same maneuver is repeated in the proximal portion of the aneurysm. Coil placement is avoided within the middle of the aneurysm; however, if necessary, only a small number of coils are placed to prevent worsening of mass effect. Two quinquagenarian males presented with a large thrombosed fusiform VAA that caused symptoms due to mass effect. In each case, perforators arose from the parent artery and short-segment internal trapping with NBCA and coils was performed. Symptoms improved after treatment and follow-up imaging confirmed aneurysm shrinkage with no long-time recurrence. In symptomatic large fusiform VAAs where the distance from the lesion to important perforators is extremely short, internal trapping using a combination of NBCA and coils can be more useful than conventional internal trapping.     

Treatment of ruptured spontaneous saccular aneurysm in the central artery of the middle cerebral artery using bypass surgery combined with trapping - case report -

A 54-year-old man presented with a rare ruptured distal middle cerebral artery (MCA) aneurysm manifesting as subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm in the central artery of the left MCA. The patient underwent anastomosis between the superficial temporal artery and the central artery distal to the lesion followed by trapping and excision of the lesion. The postoperative course was uneventful. Histological examination of the excised specimen revealed a saccular aneurysm and absence of bacteria, inflammation, or neoplasm. The present case shows that a spontaneous saccular aneurysm can develop at the cortical segment of the MCA, and can be successfully treated with bypass surgery combined with trapping.     

STA-MCA anastomosis in patients with skull base tumours involving the internal carotid artery—Haemodynamic assessment by ultrasonic Doppler flowmeter

Summary The role of superficial temporal artery -middle cerebral artery (STA-MCA) anastomosis was investigated with an ultrasonic Doppler flowmeter in 3 patients with sphenoid ridge meningiomas and one with a parasellar malignant teratoma, all of which involved the intracranial internal carotid artery. The intraoperative Doppler flow study revealed a remarkable increase in flow volume of the STA after trial occlusion of the middle cerebral artery in one case and permanent occlusion in two cases. These results substantiate the effectiveness of STA-MCA anastomosis. We also discuss surgical and other contrivances for obtaining sufficient blood supply from this bypass to prevent cerebral ischaemia in the acute phase after elective or accidental occlusion of a major cerebral artery. This is the first report of STA-MCA anastomosis in cases with brain tumour.     

Extracorporeal femoral to carotid artery perfusion in selective brain cooling for a giant aneurysm. Case report

Giant partially thrombosed intracranial aneurysms are a challenge to treat surgically, and they are also unsuitable for coil embolization. The current options for treatment include extracranial-intracranial bypass followed by parent artery occlusion or direct surgical occlusion in which deep hypothermic circulatory arrest is used. The authors report the use of another approach in the treatment of a giant anterior circulation aneurysm: selective brain cooling accomplished by extracorporeal perfusion. This facilitated direct surgery on a 4.2-cm, partially thrombosed aneurysm of the middle cerebral artery (MCA). A brain temperature of 22 degrees C was achieved after 20 minutes of perfusion with blood cooled using an extracorporeal technique of femoral-common carotid artery perfusion. This was followed by a 20-minute period of surgical trapping of the MCA, then evacuation and clip occlusion of the aneurysm. During the period of selective brain cooling the patient's core body temperature was maintained above 35 degrees C. This technique of selective brain cooling may be a useful alternative to currently available surgical and endovascular methods of treatment for giant aneurysms.     

Cerebral Hyperperfusion Syndrome following the Excision of a Mycotic Aneurysm with Superficial Temporal Artery-to-Middle Cerebral Artery Bypass: Case Report

The authors report a rare case of cerebral hyperperfusion syndrome (HPS) following the excision of a mycotic aneurysm with superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass. A 74-year-old woman with infective endocarditis presented with progressive cerebral infarction and subarachnoid hemorrhage due to a mycotic aneurysm, which was excised with a STA-MCA bypass. Postoperatively, the patient developed HPS that was considered to be exacerbated by a previous ischemic event. Therefore, cerebral hemodynamics should be evaluated before bypass surgery to prevent subsequent hyperperfusion.     

Trapping and vascular reconstruction for ruptured fusiform aneurysm in the proximal A1 segment of the anterior cerebral artery

A 65-year-old woman presented with subarachnoid hemorrhage (SAH). Angiography detected a small bulge in the A1 segment of the right anterior cerebral artery (ACA). The patient was managed conservatively. Ten days after the initial SAH, the patient suffered a second SAH. Cerebral angiography demonstrated a fusiform aneurysm in the right A1 segment and vasospasm in the left A1 segment. The aneurysm of the right A1 segment was trapped and the right superficial temporal artery (STA) was end-to-end anastomosed to the distal portion of the right A1 segment. The patient had no postoperative cerebral ischemic events. Postoperative cerebral angiography revealed that the bypass flow through the right STA perfused the right ACA territories. STA-A1 end-to-end anastomosis can prevent cerebral ischemic events following parent vessel occlusion or microsurgical trapping for fusiform cerebral aneurysms in the A1 segment without sufficient collateral flow to the ipsilateral ACA territory from the contralateral ACA.     

Extracranial-intracranial vein graft bypass for giant intracranial aneurysm surgery for pediatric patients: two technical case reports

OBJECTIVE AND IMPORTANCE: Herein we describe two cases of extracranial-intracranial vein graft bypasses for the treatment of giant intracranial aneurysms in prepubertal pediatric patients. One patient is, we think, the youngest patient reported in the literature to have been successfully treated in such a manner, with a good long-term outcome. Such grafts seem to enlarge longitudinally during the growth spurt, making such techniques reasonable long-term therapeutic options for the management of complex intracranial aneurysms in pediatric patients. CLINICAL PRESENTATION: Patient 1, a 13-year-old boy, presented with headaches and rapidly progressive right cavernous sinus syndrome. Computed tomography and cerebral angiography revealed a giant, fusiform, right intracavernous internal carotid artery aneurysm. Patient 2, a 23-month-old girl, was discovered to harbor an asymptomatic, recurrent, giant, fusiform, left M1 middle cerebral artery aneurysm 1 year after presenting with seizures related to subarachnoid hemorrhage from the aneurysm, for which she had been treated with clipping and an M2-M2 anastomosis. INTERVENTION: Both patients underwent craniotomies, with sacrifice of the proximal parent vessel (the distal cervical internal carotid artery and the proximal middle cerebral artery, respectively), combined with cerebral revascularization through extracranial-intracranial saphenous vein bypass grafts. Both patients experienced excellent long-term clinical outcomes, have undergone significant growth, and exhibit excellent long-term graft patency and aneurysm obliteration. CONCLUSION: These two cases highlight the safety and efficacy of extracranial-intracranial vein graft bypasses among prepubertal pediatric patients. The indications for bypass procedures to treat giant intracranial aneurysms are discussed, and the technical aspects of maximizing vein bypass graft patency are reviewed.     

Microsurgical neurovascular anastomosis: The example of superficial temporal artery to middle cerebral artery bypass. Technical principles

The superficial temporal artery to the middle cerebral artery (STA-MCA) bypass is a good example of cerebrovascular anastomosis. In this article, we describe the different stages of the procedure: patient installation, superficial temporal artery harvesting, recipient artery exposure, microsurgical anastomosis, and closure of the craniotomy. When meticulously performed, with the observance of important details at each stage, this technique offers a high rate of technical success (patency > 90%) with a very low morbi-mortality (respectively 3% and 1%). Some anesthetic parameters have to be considered to insure perioperative technical and clinical success. STA-MCA bypass is a very useful technique for the management of complex or giant aneurysms where surgical treatment sometimes requires the sacrifice and revascularization of a main arterial trunk. It is also a valuable option for the treatment of chronic and symptomatic hemispheric hypoperfusion (Moyamoya disease, carotid or middle cerebral artery occlusion).     

Surgical treatment and radiological consideration of supergiant cerebral aneurysms

We have collected four cases of supergiant cerebral aneurysm, each greater than 6.0 cm in diameter. Two of these cases were saccular aneurysms of the anterior communicating artery and middle cerebral artery, of which the necks were clipped with resection of the aneurysms. Another patient had a fusiform aneurysm of the middle cerebral artery, which was resected accompanied by a reconstructive procedure of cerebral blood flow. The last patient had a fusiform aneurysm of the internal carotid artery. Following internal carotid artery occlusion surgery with superficial temporal artery-middle cerebral artery anastomosis, the aneurysm completely disappeared radiologically within several months.     

Changes in Computed Tomography Perfusion Parameters after Superficial Temporal Artery to Middle Cerebral Artery Bypass: An Analysis of 29 Cases

Introduction Analysis of computed tomography perfusion (CTP) studies before and after superficial temporal artery to middle cerebral artery (STA-MCA) bypass is warranted to better understand cerebral steno-occlusive pathology. Methods Retrospective review was performed of STA-MCA bypass patients with steno-occlusive disease with CTP before and after surgery. CTP parameters were evaluated for change after STA-MCA bypass. Results A total of 29 hemispheres were bypassed in 23 patients. After STA-MCA bypass, mean transit time (MTT) and time to peak (TTP) improved. When analyzed as a ratio to the contralateral hemisphere, MTT, TTP, and cerebral blood flow (CBF) improved. There was no effect of gender, double vessel versus single vessel bypass, or time until postoperative CTP study to changes in CTP parameters after bypass. Conclusions Blood flow augmentation after STA-MCA bypass may best be assessed by CTP using baseline MTT or TTP and ratios of MTT, TTP, or CBF to the contralateral hemisphere. The failure of cerebrovascular reserve to improve after cerebral bypass may indicate irreversible loss of autoregulation with chronic cerebral vasodilation or the inability of CTP to detect these improvements.     

Multiple reimplantation technique for treatment of complex giant aneurysms of the middle cerebral artery: technical note

Background

Giant middle cerebral artery (MCA) aneurysms are among the most challenging neurovascular lesions, especially when the M2 and M3 branches are incorporated into the aneurysm. Here we report on two cases with complex MCA aneurysms, in which double and triple arterial reimplantation of the efferent vessels into a saphenous vein graft (SVG) was applied to reconstruct the MCA tree, allowing final trapping of the aneurysm.

Methods

In the first case, a 41-year-old woman presented with a partially thrombosed giant MCA aneurysm including three efferent branches. Two superior trunks were disconnected and reimplanted onto an SVG fed by the external carotid artery (ECA). Following anastomosis between the SVG and the inferior trunk, the aneurysm was trapped. The second case is a 67-year-old man with recurrent giant MCA aneurysm incorporating two efferent M2 branches. First, the superior trunk was reimplanted onto an SVG, then the SVG was anastomosed to the inferior trunk. Finally the afferent M1 was clipped. Intraoperative indocyanine green (ICG) videoangiography (FLOW 800) was used for studying bypass patency.

Results

In both cases, successful bypass patency was demonstrated by ICG videoangiography. Postoperative digital subtraction angiography (DSA) confirmed bypass patency. The first case was discharged without any neurological deficit. The second case suffered from bleeding due to refilling of the aneurysm via the inferior M2. An additional clip was placed on the inferior M2 in a second step. The patient was discharged with weakness of the left arm.

Conclusion

Reconstructing an MCA bifurcation or trifurcation combining multiple arterial reimplantation is effective for treatment of selective cases of complex MCA aneurysms.     

Giant internal carotid aneurysm at the cavernous portion with abrupt disappearance of N20 100 minutes after carotid occlusion--case report.

A 69-year-old female with bilateral giant internal carotid aneurysms at the cavernous portion was admitted with complaints of diplopia and radiating pain. The aneurysm on the left side was larger and symptomatic, and treated with the internal carotid artery ligation and the superficial temporal artery-middle cerebral artery (STA-MCA) double bypasses. However, intraoperative somatosensory evoked potential (SEP) monitoring revealed the disappearance of N20 100 minutes after the carotid occlusion and rapid recovery of N20 following flow restoration. Therefore, a high-flow bypass using radial artery grafting was installed, and carotid ligation was performed again without any change in SEP. Postoperative angiograms demonstrated complete disappearance of the aneurysm and sufficient blood supply through a patent high-flow bypass. Although both STA-MCA double bypasses were occluded, no change in cerebral blood flow was detected by single photon emission computed tomography. Her neurological deficits improved, and she is being followed as an outpatient with a plan of second surgery for the remaining aneurysm.