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.     

Rupture of previously unruptured giant carotid aneurysm after superficial temporal-middle cerebral artery bypass and internal carotid occlusion

A 51-year-old woman with an unruptured giant aneurysm of the internal carotid artery was treated by gradual occlusion of the internal carotid artery in the neck combined with a superficial temporal artery to middle cerebral artery bypass graft. Visual field defects improved after the operation, and thrombosis of the aneurysm was confirmed by angiography and computed tomography. Nevertheless, a fatal hemorrhage occurred 34 days after the final turn of the Selverstone clamp. The possible mechanism of rupture of the apparently thrombosed aneurysm is discussed. There is a risk of rupture of the aneurysm as long as the aneurysmal lumen remains after proximal ligation, no matter how small it may be.     

Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft

Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery.     

“Reverse” superficial temporal artery-middle cerebral artery bypass

A new technical variant on the superficial temporal artery-middle cerebral artery anastomosis was performed in a patient with occlusions of both the left internal and external carotid arteries and persistent ischemic symptomatology. Instead of anastomosing the proximal segment of the superficial temporal artery to the middle cerebral artery as is conventionally done, the distal segment of the superficial temporal artery was anastomosed to a cortical branch of the left middle cerebral artery. Reconstituted flow of the left superficial temporal artery via right superficial temporal artey collateral branches proved adequate to relieve the patient's ischemic episodes. “Reverse” superficial temporal artery-middle cerebral artery anastomosis should be considered in those cases where occlusive disease of the external carotid circulation renders conventional bypass procedures ineffective in the treatment of ischemic symptomatology.     

Combined surgical and intraoperative endovascular approach for a giant internal carotid artery aneurysm in the high cervical region.

For the obliteration of a large aneurysm located at the cranial base or high cervical region, several therapeutic strategies including a parent vessel ligation, and endovascular occlusion have been reported, because it is difficult to access the aneurysm itself. We used a combined surgical and endovascular approach for the treatment of a large internal carotid artery aneurysm in the high cervical region. In the present case, we performed superficial temporal artery to middle cerebral artery bypass, then obliterated the aneurysm with distal coil embolization and proximal ligation in one session, using portable digital subtraction angiography. The combined endovascular and surgical approach involves less invasive surgery for complex cerebrovascular lesions.     

A case of persistent trigeminal artery aneurysm treated by proximal obliteration of feeding vessels in both intra- and extracranial compartments

The authors described a case with a saccular aneurysm of the persistent trigeminal artery (PTA) treated with intra- and extracranial proximal obliteration of the feeding arteries. PTA aneurysm is a rare disorder found only 14 cases in the literature. There have been only 4 cases treated by surgical procedure; 2 underwent direct surgery and the remaining 2 had carotid ligation. Both of the cases treated by direct obliteration of the aneurysm sustained diplopia and sensory disturbance around the orbit as postoperative neurological deficits. We thought another choice of treatment to reduce the risk of rupture of the aneurysm avoiding postoperative complications. Clinical presentation of the present case was rt-oculomotor palsy, which disappeared before the operation. Cerebral angiography disclosed an intracavernous sinus aneurysm with a broad neck arising from the rt-internal carotid-PTA junction. Bilateral posterior cerebral arteries were perfused by the rt-internal carotid artery was compressed manually, lt-vertebral angiography showed the aneurysm and the internal carotid artery simultaneously via the PTA as retrograde filling. Because the direct surgery might cause damage to the cranial nerves passing through the cavernous sinus, we employed proximal obliteration of the feeding vessels. The operation was done by the following steps: ligation of the cervical portion of the rt-internal carotid artery, rt-superficial temporal artery-middle cerebral artery anastomosis, clipping of the PTA at the basilar side.(ABSTRACT TRUNCATED AT 250 WORDS)     

Trauma to the high cervical carotid artery

An alternative approach to the treatment of distal extracranial nonoccluding internal carotid artery penetrating injuries is described in which internal carotid artery ligation is followed expectantly. A warning transient neurologic deficit prompted an unsuccessful attempt at revascularization via a superficial temporal artery to middle cerebral artery anastomosis. The failure of the anastomosis was thought to be secondary to a postinjury hypercoagulable state and a diminished demand for intracranial blood flow secondary to an unexpected, impressive development of collateral blood supply.     

The combination of STA-MCA anastomosis with another operation for the occlusive cerebrovascular disease (author's transl)

Case 1. A 65 year old male had left hemiparesis with sudden onset since 8 years ago, which gradually aggravated for these 2 years. On Sept. 27, 1973, he was admitted to the Department of Neurosurgery, Kitano Hospital. There was left spastic hemiparesis with hemisensory disturbance and he could not walk without help for the maked spasticity. Left carotid angiogram revealed the complete occlusion of the internal carotid artery and marked stenosis of the external carotid artery at the common carotid bifurcation. External carotid endarterectomy was performed on Nov. 19, 1973, which was followed by STA-MCA anastomosis 2 months later. The spasticity of extremities and left hemisparesis were gradually improved and he was able to walk without help. Case 2. On Apr. 14, 1974, a 63 year old female developed complete stroke with right hemiparesis and speech disturbance after transient ischemic attacks of 5 days duration. On Aug. 9, he was admitted and had emotional incontinence, right hemiparesis, Gerstmann's syndrome and motor aphasia. Left carotid angiogram revealed a saccular aneurysm of the middle cerebral artery and the occlusion of the distal middle cerebral arterys. These findings suggested that the occlusion was caused by embolus from the middle cerebral aneurysm, and the combined surgery with STA-MCA anastomosis and operation for the aneurysm was planned. On Aug. 30, 1974, under left frontotemporal craniotomy, aneurysmal neck clipping and aneurysmectomy were performed and thereafter, STA-MCA double anastomosis was done. One week after operation, the gradual improvement of pre-operative symptomes was noted. Recently, STA-MCA anatomosis is well known to be one of the effective operative methods for the occlusive methods for the occlusive cerebrovascular diseases and in addition, we found that the combination of STA-MCA anastomosis with other operations was effective for unusual cases presenting in this report. Furthermore, except for the occlusive cerebrovascular diseases, we usually plan STA-MCA anastomosis for the cases of 1) carotid ligation or trapping for carotid-cavernous sinus fistula and some internal carotid aneurysms, 2) some intracranial tumors with the danger involving the main cerebral arteries by operation to protect the cerebrovascular insufficiency.     

"Giant pneumoaneurysm" after combined internal carotid artery occlusion and extracranial-intracranial anastomosis

A patient with a giant aneurysm of the internal carotid artery (ICA) was treated by combined ICA occlusion in the neck and superficial temporal artery to middle cerebral artery anastomosis. Six months after complete closure of the ICA, the patient had episodes of nasal discharge mixed with dark red, old blood. Computed tomographic scan demonstrated that the lumen of the giant aneurysm was filled with a large amount of air, which communicated with the nasal cavity. Not finding a similar case in the literature, we named this entity "giant pneumoaneurysm." After direct operation, the giant pneumoaneurysm collapsed. This unusual complication may be due to a decrease of blood supply to the aneurysmal wall through the vasa vasorum.     

Treatment of unruptured duplicated middle cerebral artery aneurysm: case report

BACKGROUND: Duplication of the middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery (ICA). The origin of the DMCA lies between the anterior choroidal artery and the distal end of the ICA. The association of cerebral aneurysm and DMCA is rare. CASE DESCRIPTION: In this 63-year-old woman, preoperative angiography and 3-dimensional computed tomography angiography revealed an aneurysm at the origin of the DMCA. The aneurysm was clipped and superficial temporal artery-DMCA anastomosis was performed. She was discharged with no neurologic deficits. Duplication of the middle cerebral artery can be divided into 2 types based on whether the site of separation from the ICA is at the top of the ICA (type A) or between the ICA top and the anterior choroidal artery (type B). The diameter of type A DMCA is comparable with that of the main middle cerebral artery trunk; in type B, it is smaller. In all 18 previously reported cases, the aneurysm was associated with type B DMCA. CONCLUSION: For appropriate treatment planning, it is necessary to determine the DMCA type and the anatomic relationship between the aneurysm and the DMCA. In patients with type B DMCA, the possibility of aneurysm formation should be considered.     

Direct surgery for giant aneurysm exhibiting progressive enlargement after intraaneurysmal balloon embolization.

A case of giant intracranial carotid artery aneurysm exhibiting progressive enlargement after incomplete intraaneurysmal balloon embolization is presented. The patient was successfully treated by the trapping and decompression of the aneurysm with a superficial temporal artery-middle cerebral artery anastomosis. The thrombus surrounding the intraluminal balloons was very soft and poorly organized. Either direct surgery with extracranial-intracranial arterial bypass or complete intravascular surgery should be performed for giant aneurysms when direct clipping is impossible.     

Maxillary artery to middle cerebral artery anastomosis in dog-- a new experimental model (author's transl)]

End-to-side anastomosis between the maxillary artery and a branch of the middle cerebral artery was performed in the dog. The technique was devised as a new experimental model for extracranial-intracranial arterial shunt operation. The middle cerebral artery was ligated at the origin through a subtemporal small burr hole under the operating microscope in 13 dogs. Then, the shunt operation was carried out in 8 dogs 4 hours after the ligation(acute state), and in 5 dogs 3 weeks after(chronic stage). The patency of the anastomotic site was evaluated by the selective external carotid angiography 2 weeks after the shunt operation. In the acute stage of 8 dogs, 7 cases showed patency of anastomosis (88%), and in the chronic stage of 5 dogs, arteriogram revealed 4 patent anastomosis (80%). In successful cases, arteriogram showed excellent filling of the entire territory of the middle cerebral artery through the shunts (Fig. 4, 5). Various types of experimental shunt operation were attempted in our review of the literature. Among them, the anastomosis between the superficial temporal artery and a branch of the middle cerebral artery by Yasargil (1967) is rather popular and this procedure has been used by some investigators including us to investigate the effect of the extracranial-intracranial shunt on experimental acute stroke. So far as dog's experiment is concerned, the superficial temporal artery appeared to be not suitable for a donor artery, because the superficial temporal artery runs far from the middle cerebral artery and its distal part is extremely small in caliber. Therefore, the superficial temporal artery was often obstructed by compression, kinking or narrowing by surrounding tissues and by adhesion to the bone edge of the burr hole. On the other hand, the maxillary artery of the dog, which is the largest terminal branch of the external carotid artery, has plenty of blood flow and suitable size for end-to-side anastomosis to the middle cerebral artery. In addition, maxillary artery is located very close to the proximal part of the middle cerebral artery. These anatomical and spatial advantage of the maxillary artery seemed to be favorable donor artery to the middle cerebral artery and have brought hight patency rate in our series of anastomosis than that of the other previous experimental extracranial-intracranial shunts. To our knowledge, this is the first report on successful patent shunt formation after long-term occlusion of the middle cerebral artery in animals. Now, it is in our mind that progress of the study can be expected in the field of extracranial-intracranial shunt operation for cerebral infarction by this experimental procedure.     

Giant fusiform middle cerebral aneurysm: successful treatment utilizing microvascular bypass.

A case of giant middle cerebral fusiform aneurysm is presented. The aneurysm was treated by superficial temporal-middle cerebral artery anastomosis and obliteration of the aneurysm by trapping. The application of extracranial to intracranial anastomosis to the problem is discussed.     

Cerebral revascularization to a main limb of the middle cerebral artery in the Sylvian fissure. An alternative approach to conventional anastomosis

Thirteen patients underwent an anastomosis of the superficial temporal artery (STA) or a saphenous vein graft to one of the secondary trunks of the middle cerebral artery (MCA). They included five patients with giant MCA trifurcation aneurysms, four patients in whom an earlier conventional STA-MCA anastomosis had become occluded, two patients who had stenosis of one of the secondary limbs of the MCA, and one patient who had a carotid-cavernous fistula. One patient had a saphenous vein graft from the common carotid artery to a secondary trunk of the MCA to bypass an occluded internal carotid artery and severely stenosed external carotid artery. The primary advantages of this procedure are that a large-caliber anastomosis to one of the secondary limbs of the MCA immediately restores flow into the MCA tree with a larger amount of vessel filling than with a standard cortical bypass, and large vessels can be used for the anastomosis. The disadvantages are that one of the secondary branches of the MCA must be occluded, the cerebral hemisphere around the Sylvian fissure must be retracted, a lumbar subarachnoid drain is needed, and the anastomosis must be performed deep within the Sylvian fissure. The procedure is a satisfactory alternative in cases in which a conventional STA-MCA anastomosis has either failed or would be less likely to succeed.     

Giant aneurysm at the junction of the left internal carotid and persistent primitive trigeminal arteries--case report.

A 67-year-old female presented with an unruptured giant aneurysm at the junction of the left internal carotid artery (ICA) and the persistent primitive trigeminal artery (PTA), manifesting as progressive left abducens nerve paresis. The PTA was clipped by the left suboccipital approach. The aneurysm was then successfully thrombosed by ligation of the left ICA at the cervical portion following left superficial temporal artery-middle cerebral artery anastomosis. The left abducens nerve paresis improved postoperatively. Magnetic resonance imaging was of considerable value in the pre- and postoperative evaluation of the giant aneurysm.     

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.     

Preoperative construction of an extracranial arterial shunt for resection of an aortic arch aneurysm with occluded left carotid artery

A 68-year-old man with aortic arch aneurysm was referred to our department. Preoperative carotid echography and magnetic resonance angiography revealed occlusion of the left internal carotid artery. Single-photon emission computed tomography scanning indicated that cerebral blood flow was decreased and reactivity to acetazolamide was reduced in the left temporal lobe. A successful superficial temporal artery-middle cerebral artery anastomosis was first made by neurosurgeons. A postoperative single-photon emission computed tomography scan showed that cerebral blood flow and reactivity to acetazolamide were remarkably improved. Two months after the anastomosis, the aortic arch aneurysm was successfully repaired.     

Observations on moyamoya disease: a case treated with superficial temporal-middle cerebral artery anastomosis

A 24-year-old Caucasian woman with Moyamoya disease was treated by a superficial temporal, middle cerebral artery anastomosis. Her pre and postoperative angiograms revealed that the telangiectatic network in the region of the basal ganglion served as a transcerebral collateral circulation from the internal carotid artery proximal to its occlusion to the cortical branches of the middle cerebral artery. The transit through two capillary systems (basal ganglia and cortical) explains the slow circulation time. Prompt venous drainage was seen to occur once a more direct collateral supply was established by the superficial temporal-middle cerebral artery anastomosis.     

Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm: association with transsphenoidal surgery and radiation therapy: case report

A 62-year-old woman presented with simultaneous subarachnoid hemorrhage (SAH) and massive epistaxis. The patient had been treated for pituitary prolactinoma by two transsphenoidal surgeries, gamma knife radiosurgery, and conventional radiation therapy since age 43 years. Cerebral angiography showed left petrous internal carotid artery (ICA) aneurysm with slight stenosis on the adjacent left petrous ICA. She underwent superficial temporal artery-middle cerebral artery (STA-MCA) double anastomosis with endovascular internal trapping without complication the day after onset. Postoperative course was uneventful; the patient did not develop symptomatic vasospasm, recurrent epistaxis, or cerebrospinal fluid rhinorrhea. Postoperative angiography demonstrated complete disappearance of the aneurysm with patent STA-MCA anastomosis. The patient was discharged 2 months after surgery without neurological deficit. The present case is extremely rare with simultaneous onset of SAH and epistaxis caused by ruptured petrous ICA aneurysm. The transsphenoidal surgeries and radiation therapies might have been critical in the formation of the petrous ICA aneurysm.     

Enlargement and rupture of distal basilar artery aneurysm after iatrogenic carotid occlusion

A case of angiographic enlargement and fatal rupture of a previously asymptomatic distal basilar aneurysm in a 12-year-old girl is reported. She had been treated by carotid sacrifice for a giant intracavernous carotid aneurysm. After superficial temporal-middle cerebral artery bypass, this patient underwent a trapping procedure and decompression of her symptomatic giant aneurysm. Despite postoperative patency of her bypass graft, the involved middle cerebral circulation was irrigated substantially by retrograde flow through her posterior communicating artery. An incidental distal basilar aneurysm involving the origin of her superior cerebellar arteries, posterior cerebral arteries, and multiple perforators was treated by a wrapping procedure. Eleven days after carotid ligation, she suffered a fatal subarachnoid hemorrhage from her basilar aneurysm. This catastrophe was undoubtedly produced by our failure to consider the additional hemodynamic stress placed upon the distal basilar artery by carotid sacrifice and may have been preventable by a more aggressive attack on this previously asymptomatic lesion.