Treatment of a Giant Thrombotic M1 Segment Middle Cerebral Artery Aneurysm With Radial Artery Bypass and Distal Occlusion to Create a “Blind Sac” Following Endovascular Failure: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Sheila R Eshraghi ◽  
Daniel L Barrow
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Cerebral Angiogram ◽  
Lenticulostriate Arteries ◽  
Thrombosed Aneurysm

Abstract The case is of a 36-yr-old male with a previously coiled aneurysm arising from the proximal M1 segment of the middle cerebral artery (MCA) just beyond the internal carotid artery (ICA) bifurcation who presented to our institution with subjective left hemiparesis, headache, and vomiting. Physical exam revealed a left facial droop, but neurological exam was otherwise normal, including full motor strength. Neuroimaging showed a large partially thrombosed aneurysm recurrence, measuring 5.2 cm, with obstructive hydrocephalus. Cerebral angiogram showed filling within a small portion of the aneurysm and marked stenosis of the MCA beyond the neck. A ventriculostomy was placed, and he underwent a pterional craniotomy for high-flow radial artery bypass from the common carotid artery to an M2 branch of the MCA and clip placement. This case demonstrates the creation of a blind sac by placing a clip on the MCA distal to the aneurysm and proximal to the lenticulostriate arteries for the treatment of a giant proximal M1 segment aneurysm. Postoperative digital subtraction angiography shows the MCA distribution, including the lenticulostriate arteries, filling through the radial artery bypass, and anterograde flow through the ICA, which perfuses up to and including the anterior choroidal artery. There is no residual filling of the aneurysm. The patient remained at his neurological baseline postoperatively and required ventriculoperitoneal shunt placement for hydrocephalus. At outpatient follow-up, computed tomography imaging showed decreased size of the thrombosed aneurysm, measuring 4.5 cm, and he had no neurological deficits. The patient gave informed consent for surgery and deidentified video recording of this case.

Creation of a Middle Communicating Artery With External Carotid Artery-Radial Artery Graft-M2 Middle Cerebral Artery Interpositional Bypass and M2 Middle Cerebral Artery-M2 Middle Cerebral Artery Reimplantation for a Recurrent Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 20 (1) ◽  
pp. E44-E45
Author(s):  
Fabio A Frisoli ◽  
Joshua S Catapano ◽  
Dimitri Benner ◽  
Michael T Lawton
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Radial Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
External Carotid Artery ◽  
External Carotid ◽  
Radial Artery Graft ◽  
Lenticulostriate Arteries ◽  
Artery Graft

Abstract Dolichoectatic aneurysms of the middle cerebral artery (MCA) bifurcation pose unique treatment challenges.1 One treatment consists of an extracranial-intracranial (EC-IC) interpositional bypass and double-reimplantation of the M2 divisions.2-8 We present a variation of this construct in which an M2 MCA-M2 MCA end-to-side reimplantation was performed, creating a middle communicating artery (MCoA). The patient, a 61-yr-old woman, had previously undergone a “picket fence” clip reconstruction of an unruptured, giant left MCA bifurcation aneurysm in 2014.9 After the patient provided informed written consent for treatment, a 5-yr surveillance angiogram revealed substantial aneurysm regrowth opposite the clips.  A pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. Proximal external carotid artery-radial artery graft (ECA-RAG) anastomosis was performed to arterialize the graft. The distal RAG was anastomosed end-to-side to the temporal division of the M2 segment, and the vessel proximal to the bypass inflow was transected from the aneurysm. We repurposed this “dead-end” as an MCoA by end-to-side reimplantation onto a branch of the frontal M2 trunk. The superior trunk was then clip occluded at its origin at the aneurysm. The aneurysm could not be proximally occluded due to lenticulostriate arteries arising from the back of the bifurcation.  Postoperative angiography confirmed patency of the MCoA and its donor bypasses. The aneurysm no longer filled, and the lenticulostriate arteries were preserved. The patient was discharged on postoperative day 3 and made an excellent recovery (3-mo modified Rankin Scale [mRS] = 1). The MCoA is a novel construct that redistributed flow from the interpositional graft into the superior trunk, without the need for additional ischemia time while working with the inferior trunk. Used with permission from Barrow Neurological Institute.

External Carotid Artery-to-Middle Cerebral Artery Bypass Using a Saphenous Vein Graft With 3-Vessel Anastomosis for the Treatment of a Large, Ruptured Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kristine Ravina ◽  
Joshua Bakhsheshian ◽  
Joseph N Carey ◽  
Jonathan J Russin
Keyword(s):  
Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Saphenous Vein ◽  
Saphenous Vein Graft ◽  
Artery Bypass ◽  
Artery Aneurysm ◽  
External Carotid Artery ◽  
External Carotid ◽  
Bifurcation Aneurysm

Abstract Cerebral revascularization is the treatment of choice for select complex intracranial aneurysms unamenable to traditional approaches.1 Complex middle cerebral artery (MCA) bifurcation aneurysms can include the origins of 1 or both M2 branches and may benefit from a revascularization strategy.2,3 A novel 3-vessel anastomosis technique combining side-to-side and end-to-side anastomoses, allowing for bihemispheric anterior cerebral artery revascularization, was recently reported.4  This 2-dimensional operative video presents the case of a 73-yr-old woman who presented as a Hunt-Hess grade 4 subarachnoid hemorrhage due to the rupture of a large right MCA bifurcation aneurysm. The aneurysm incorporated the origins of the frontal and temporal M2 branches and was deemed unfavorable for endovascular treatment. A strategy using a high-flow bypass from the external carotid artery to the MCA with a saphenous vein (SV) graft was planned to revascularize both M2 branches simultaneously, followed by clip-trapping of the aneurysm. Intraoperatively, the back walls of both M2 segments distal to the aneurysm were connected with a standard running suture, and the SV graft was then attached to the side-to-side construct in an end-to-side fashion. Catheter angiograms on postoperative days 1 and 6 demonstrated sustained patency of the anastomosis and good filling through the bypass. The patient's clinical course was complicated by vasospasm-related right MCA territory strokes, resulting in left-sided weakness, which significantly improved upon 3-mo follow-up with no new ischemia.  The patient consented for inclusion in a prospective Institutional Review Board (IRB)-approved database from which this IRB-approved retrospective report was created.

scholarly journals Excision of a Large Complex Left Middle Cerebral Artery Aneurysm With a Middle Cerebral Artery—Middle Cerebral Artery and Superficial Temporal Artery—Middle Cerebral Artery Bypass: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (2) ◽  
pp. E147-E148
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Temporal Artery ◽  
Left Middle Cerebral Artery ◽  
Bifurcation Aneurysm ◽  
Orbitozygomatic Approach

Abstract Revascularization techniques for microsurgical manage-ment of middle cerebral artery (MCA) bifurcation aneurysms are often necessary for treatment of fusiform or giant aneurysms. Augmentation of the standard pterional approach to include an extended orbitozygomatic or modified orbitozygomatic approach provides a wider and more favorable approach to the MCA when attempting revascularization. Direct excision of a giant aneurysm (aneurysmectomy) with mobilization and reanastomosis of the MCA afterward has been reported. This patient had a giant MCA bifurcation aneurysm for which aneurysmectomy and distal reanastomosis were performed between the M1 and two M2 branches via a modified orbitozygomatic craniotomy. A second bypass between a third M2 branch at the ipsilateral superficial temporal artery was performed. Postoperative angiography confirmed patency of the bypasses. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Internal Carotid Artery to Posterior Cerebral Artery Bypass for Fusiform Basilar Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E1-E1
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Posterior Cerebral Artery ◽  
Artery Bypass ◽  
Management Strategies ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Interposition Graft

Abstract Fusiform dolichoectatic basilar trunk aneurysms pose an immense surgical challenge because of the extremely eloquent tissue at risk during the procedure and the complex management strategies required to relieve mass effect on the brainstem. The patient presented in this case experienced progressive brainstem deterioration with quadraparesis and multiple cranial neuropathies. The patient underwent a modified orbitozygomatic craniotomy for visualization, and an end-to-side anastomosis between a radial artery interposition graft and the posterior cerebral artery was performed, followed by an end-to-side anastomosis of the interposition graft to the intracranial internal carotid artery. A permanent clip was applied to the top of the basilar trunk to obliterate distal flow. Postoperative imaging demonstrated progressive thrombosis of the fusiform aneurysm. Basilar aneurysms represent challenging lesions for both microsurgical and endovascular treatments. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Blister Aneurysms of the Internal Carotid Artery: Microsurgical Results and Management Strategy

Neurosurgery ◽  
2017 ◽  
Vol 80 (2) ◽  
pp. 235-247 ◽  
Author(s):  
Christopher M. Owen ◽  
Nicola Montemurro ◽  
Michael T. Lawton
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Treatment Strategy ◽  
Internal Carotid ◽  
Artery Bypass ◽  
External Carotid ◽  
Parent Artery ◽  
Intraoperative Rupture

Abstract BACKGROUND: Blister aneurysms of the supraclinoid internal carotid artery (ICA) are challenging lesions with high intraoperative rupture rates and significant morbidity. An optimal treatment strategy for these aneurysms has not been established. OBJECTIVE: To analyze treatment strategy, operative techniques, and outcomes in a consecutive 17-year series of ICA blister aneurysms treated microsurgically. METHODS: Seventeen patients underwent blister aneurysm treatment with direct clipping, bypass and trapping, or clip-reinforced wrapping. RESULTS: Twelve aneurysms (71%) were treated with direct surgical clipping. Three patients required bypass: 1 superficial temporal artery to middle cerebral artery bypass, 1 external carotid artery to middle cerebral artery bypass, and 1 ICA to middle cerebral artery bypass. One patient was treated with clip-reinforced wrapping. Initial treatment strategy was enacted 71% of the time. Intraoperative rupture occurred in 7 patients (41%), doubling the rate of a poor outcome (57% vs 30% for patients with and without intraoperative rupture, respectively). Severe vasospasm developed in 9 of 16 patients (56%). Twelve patients (65%) were improved or unchanged after treatment, and 10 patients (59%) had good outcomes (modified Rankin Scale scores of 1 or 2). CONCLUSION: ICA blister aneurysms can be cautiously explored and treated with direct clipping as the first-line technique in the majority of cases. Complete trapping of the parent artery with temporary clips and placing permanent clip blades along normal arterial walls enables clipping that avoids intraoperative aneurysm rupture. Trapping/bypass is used as the second-line treatment, maintaining a low threshold for bypass with extensive or friable pathology of the carotid wall and in patients with incomplete circles of Willis.

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