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      Aneurysms of The Middle Cerebral Artery Proximal Segment (M1) · Anatomical and Therapeutic Considerations · Revision of A Series. Analysis of a series of the pre bifurcation segment aneurysms

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          Abstract

          Aneurysms of the middle cerebral artery represent almost a third of all the aneurysms of the circle of Willis anterior sector. Among them, those located at its so-called M1 segment (from its origin up to the bifurcation) range between 2% and 7% of all the aneurysms. It is highly important to know the anatomy of the M1 segment, as well as of the arterial branches that arise from it, since causing its damage during dissection or occlusion of an aneurysm may determine the neurological sequelae.

          The authors of the present work, based on a recent anatomical analysis carried out by one of them (FM), have performed a study of the aneurysms of the M1 segment in a series of 1059 aneurysms treated with surgery along 25 years. At the mentioned location 23 aneurysms were found, which represented 2.2% of the total operated aneurysms. The cases, location of the aneurysms and their relation with the early branches of the middle cerebral artery were studied, as well as the surgical difficulties that they pose.

          A review of the scanty bibliography referring specifically to the aneurysms in this topography has been carried out.

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          International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients.

          Andrew J. Molyneux, Per Enblad, Ligia Kerr … (2008)
          It is often thought that elderly patients in particular would benefit from endovascular aneurysm treatment. The aim of this analysis was therefore to compare the efficacy and safety of endovascular coiling (EVT) with neurosurgical clipping (NST) in the subgroup of elderly SAH patients in the International Subarachnoid Aneurysm Trial (ISAT). In the ISAT cohort 278 SAH patients, 65 years or older, were enrolled. The patients were randomly allocated EVT (n=138) or NST (n=140). The primary outcome was the proportion of patients with a modified Rankin scale score of 0 to 2 (independent survival) at 1 year after the SAH. The rates of procedural complications and adverse events were also recorded. 83 of 138 (60.1%) patients allocated EVT were independent compared to 78 of 140 (56.1%) allocated NST (N.S.). 36 of 50 (72.0%) patients with internal carotid and posterior communicating artery aneurysms allocated EVT were independent compared to 26 of 50 (52.0%) allocated NST (P<0.05). 10 of 22 (45.5%) patients with middle cerebral artery aneurysms allocated EVT were independent compared to 13 of 15 (86.7%) allocated NST (P<0.05). The epilepsy frequency was 0.7% in the EVT group compared to 12.9% in the NST group (P<0.001). In good grade elderly SAH patients with small anterior circulation aneurysms, EVT should probably be the favored treatment for ruptured internal carotid and posterior communicating artery aneurysms, whereas elderly patients with ruptured middle cerebral artery aneurysms appear to benefit from NST. EVT resulted in a lower epilepsy frequency than NST.
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            Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture.

            D Bérubé, Daniel Roy, Minh Nguyen … (2008)
            Procedure-related rupture during endovascular therapy of intracranial aneurysms is associated with a mortality rate of more than one third. Previously ruptured aneurysms are a known risk factor for procedure-related rupture. The objective of this study was to evaluate whether very small, ruptured aneurysms are associated with more frequent intraprocedural ruptures. This was a retrospective cohort study in which the investigators examined consecutive ruptured aneurysms treated with coil embolization at a single institution. The study was approved by the institutional review board. Very small aneurysms were defined as 3 mm (relative risk 5.2, 95% confidence interval 2.2-12.8; p or = 4) compared with patients treated without balloon assistance (5 of 5 compared with 7 of 16; p = 0.05). Death resulting from procedure-related rupture occurred in 8 (38%) of 21 patients, and a vegetative state occurred in 1 patient. Clinical outcome was good in the other 12 patients (57%). Endovascular coil embolization of very small (< or = 3 mm) ruptured cerebral aneurysms is 5 times more likely to result in procedure-related rupture compared with larger aneurysms. Balloon inflation for hemostasis may be associated with better outcome in the event of intraprocedural rupture and merits further study.
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              Spontaneous fusiform middle cerebral artery aneurysms: characteristics and a proposed mechanism of formation.

              C. Ron Yu, C Gaposchkin, R G Dacey … (2003)
              The goal of this study was to identify the origins of spontaneous fusiform middle cerebral artery (MCA) aneurysms. One hundred two cases of spontaneous fusiform MCA aneurysms were reviewed, including 40 from the authors' institutions and 62 identified from the literature. The mean age at symptom onset was 38 years, and the male/female ratio was 1.4:1. At presentation, the MCA lumen was stenosed or occluded in 12 patients, focally dilated in 57, and appeared "serpentine" in 33. Most lesions originated from the M1 or M2 segments, and most (80%) presented with nonhemorrhagic symptoms or were discovered incidentally. The presenting clinical features correlated with morphological findings in the aneurysms, which could be observed to progress from a small focal dilation or vessel narrowing to a serpentine channel. Hemorrhage was the most common presentation in small lesions; the incidence of bleeding progressively diminished with larger lesions. Patients with stenoses or occluded vessels most often presented with ischemic symptoms, and occasionally with hemorrhage. Giant focal dilations or serpentine aneurysms were rarely associated with acute bleeding; clinical presentation was most often prompted by mass effect or thromboembolic stroke. Analysis of results after various treatments indicates that for symptomatic lesions, therapies that reverse intraaneurysmal blood flow and augment distal cerebral perfusion are associated with better outcomes than other strategies, including conservative management. Based on the spectrum of clinical, pathological, neuroimaging, and intraoperative findings, dissection is proposed as the underlying cause of these lesions.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Asian J Neurosurg
                Journal ID (publisher-id): AJNS
                Title: Asian Journal of Neurosurgery
                Publisher: Medknow Publications Pvt Ltd (India )
                ISSN (Print): 1793-5482
                ISSN (Electronic): 2248-9614
                Publication date (Print): Jul-Dec 2010
                Volume: 5
                Issue: 2
                Pages: 57-63
                Affiliations
                [] Neurosurgical Unit Docent Unit Department of Surgery. Hospital Maciel (ASSE-MSP). Graduated School. School of Medicine (Republic University. UDELAR) Montevideo, Uruguay
                [1 ] Neurosurgery Resident, Department of Anatomy, CLAEH Medical School, Punta del Este, Maldonado, Uruguay
                [2 ] Chief of Neurosurgical Department, Hospital Maciel, Department of Anatomy, CLAEH Medical School, Punta del Este, Maldonado, Uruguay
                [3 ] Neurosurgeon, Hospital Maciel, Department of Anatomy, CLAEH Medical School, Punta del Este, Maldonado, Uruguay
                [4 ] Neurosurgeon, Hospital Maciel, Department of Anatomy, CLAEH Medical School, Punta del Este, Maldonado, Uruguay
                Author notes
                Correspondence: Edgardo Spagnuolo, Neurosurgical Department, Hospital Maciel (ASSE), 25 de Mayo, s/n. Montevideo, CP:11.000, E-mail address: spagjohn@ 123456yahoo.com
                Article
                Publisher ID: AJNS-5-57
                PMC ID: 3201075
                PubMed ID: 22028759
                SO-VID: b9a7a18c-200e-4172-a87c-d319a70c19a1
                Copyright © © Asian Journal of Neurosurgery
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Surgery
                Keywords: cerebral aneurysms. aneurysms of the middle cerebral artery,m1 segment
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: cerebral aneurysms. aneurysms of the middle cerebral artery, m1 segment

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