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Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies

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      Abstract

      Background

      Because of the diversity of aneurysm morphology, complicated arterial anatomy and hemodynamic characteristics, tailored surgical treatments are required for cases of individual complex middle cerebral artery (MCA) aneurysms.

      Methods

      During an 8-year period, 59 complex MCA aneurysms in 58 patients were treated microsurgically in our department. Complex aneurysms were defined as having large (10–24 mm in diameter) or giant (diameter ≥ 25 mm) size or non-saccular morphology (fusiform, dissecting or serpentine).

      Results

      Direct clipping of the aneurysmal necks was achieved in eight patients, while reconstructive clipping was performed in 25 patients. Indirect aneurysm occlusion was performed in 25 cases, including trapping or resecting the aneurysm in four cases, trapping or resecting the aneurysm with extra-intracranial (EC) or intra-intracranial (IC) bypass in 21 cases and internal carotid artery (ICA) sacrifice with EC-IC bypass in one case. Forty-eight aneurysms (81.4 %) were completely obliterated. Graft patency was confirmed in 20 of 21 cases (95.2 %) with bypass. A recurrent aneurysm was detected in one case and a re-operation was performed. Two patients with Hunt-Hess grade IV aneurysms died during the perioperative period. Overall, 52 cases (88.1 %) had good outcomes (Glasgow Outcome Scale ≥ 4) during the late follow-up period.

      Conclusion

      The surgical modality and strategy for treating complex MCA aneurysm are decided according to the morphology of the aneurysm, vascular anatomy and the hemodynamic characteristics of each case. Thus, we developed a new classification based on the angioarchitecture. Favorable outcomes can be achieved by treating complex MCA aneurysms with appropriate surgical modalities, strategies and techniques.

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      Most cited references 21

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      Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992.

      The paucity of information about giant fusiform intracranial aneurysms prompted this review of 120 surgically treated patients. Twenty-five aneurysms were located in the anterior and 95 in the posterior circulation. Six patients suffered from atherosclerosis and only three others had a known arteriopathy. The remaining 111 patients presented with aneurysms resulting from an unknown arterial disorder; these patients were much younger than those harboring atherosclerotic aneurysms. Mass effect occurred in only 50% of cases and hemorrhage in 20%. Eight aneurysms caused transient ischemic attacks. Hunterian proximal occlusion or trapping were dominant among the treatment methods. In contrast to the management of giant saccular aneurysms, the usual thrombotic occlusion of a giant fusiform aneurysm after proximal parent artery occlusion requires the presence of two collateral circulations to prevent infarction, one for the end vessels and another for the perforating vessels that arise from the aneurysm. Although there was some reliance on the circle of Willis and on collateral vessels manufactured at surgery, the extent of natural leptomeningeal and perforating collateral, thalamic, lenticulostriate, and brainstem vessels was astonishing and formerly unknown to the authors. Good outcome occurred in 76% of patients with aneurysms in the anterior circulation; two of the six cases with poor results included patients who were already hemiplegic. Ninety percent of patients with posterior cerebral aneurysms fared well. Only 67% of patients with basilar or vertebral aneurysms had good outcomes, although more (17%) of these patients were in poor condition preoperatively because of brainstem compression.
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        Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy.

        One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a "coil first" policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy.
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          Microanatomy of the anterior cerebral artery.

          The microanatomic features of the anterior cerebral artery were studied in 30 unfixed human brains which were injected with tinted polyester resin via cannulation of the internal carotid arteries under microscopic dissection. The outer diameter, length, and number of perforating branches were measured for each of the following vessels: anterior cerebral artery (proximal A1 segment, distal A2 segment), anterior communicating artery, and recurrent artery of Heubner. The perforating branches of the proximal segment of the anterior cerebral artery penetrated the brain at the anterior perforated substance, lateral chiasm, and optic tracts. The perforating branches of the anterior communicating artery penetrated the brain at the lamina terminalis, anterior perforated substance, and medial chiasm. The first 5 mm of the distal anterior cerebral artery (A2) had perforating branches penetrating the brain at the gyrus rectus and olfactory sulcus. The recurrent artery of Heubner originated from the A2 segment of the anterior cerebral artery in 57% of the cases, from the anterior cerebral artery-anterior communicating artery junction in 35%, and from the A1 segment in 8%. The depth of the interhemispheric fissure at the genu was 36.0 +/- 0.5 mm and at the midbody of the corpus callosum, 35.0 +/- 0.5 mm. Extension of the dissection to approach the anterior communicating artery from the genu of the corpus callosum using the anterior interhemispheric route was an additional 31.7 +/- 0.7 mm. The callosal arterial supply from the anterior cerebral artery showed short callosal branches in all brain specimens and long callosal vessels in 10% of the specimens.
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            Author and article information

            Affiliations
            Department of Neurosurgery, Huashan Hospital of Fudan University, 12 Wulumuqi zhong Road, Shanghai, 200040 China
            Contributors
            +86-21-52888771 , +86-21-62492884 , lfzhouc@online.sh.cn
            +86-21-52887670 , +86-21-62492884 , maoying@fudan.edu.cn
            Journal
            Acta Neurochir (Wien)
            Acta Neurochir (Wien)
            Acta Neurochirurgica
            Springer Vienna (Vienna )
            0001-6268
            0942-0940
            30 May 2013
            30 May 2013
            August 2013
            : 155
            : 8
            : 1481-1491
            23715946
            3718994
            1751
            10.1007/s00701-013-1751-8
            © The Author(s) 2013

            Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

            Categories
            Clinical Article -Neurosurgical Techniques
            Custom metadata
            © Springer-Verlag Wien 2013

            Surgery

            complex aneurysm, middle cerebral artery, bypass surgery, clipping

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