Giant middle cerebral artery aneurysm

Giant middle cerebral artery aneurysm

Giant middle cerebral artery aneurysm (size > 2.5 cm)

Case reports

Bendok et al. presented the case of a 61-year-old female who was brought to the emergency room after she had partial complex seizures. CT and MRI of the brain revealed a right temporal lobe mass which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. A CT angiography was performed followed by a diagnostic conventional cerebral angiogram and confirmed the presence of a giant thrombosed aneurysm 1).


A video case illustrates key surgical steps required in safe management of a giant recurrent previously coiled MCA aneurysm. The patient described in this case was a 68-year old male who presented with a sudden onset severe headache and dizziness. The patient had a history of a prior coil embolization of a 12 mm left middle cerebral artery aneurysm at an outside hospital. Imaging demonstrated recurrence of now a giant left middle cerebral artery aneurysm with coil compaction and left temporal lobe edema. MRI further demonstrated thrombus in the aneurysm and aneurysm wall enhancement concerning for impending rupture. Given the aneurysm size, imaging features and mass effect, the aneurysm was treated with microsurgical clipping. This case is valuable to the literature with a clear video case illustration of aneurysm dome excision, aneurysm endarterectomy and picket fence aneurysm neck reconstruction. Aneurysm dome excision is critical for treatment of giant aneurysms causing mass effect and was only used in this case as thrombus and coil mass did not allow for direct clipping across the neck without compromise of the MCA M2 branch. Hence, this video highlights key technical tenets, such as safe thrombus removal and adequate cleaning of the endoluminal surface and preparedness for bypass in challenging cases 2).


A 64-year-old woman who suffered subarachnoid hemorrhage in 2005. She was treated with coiling of the aneurysm at an outside institution. She presented to the clinic with headaches and was found on angiography to have giant recurrence of the aneurysm. To allow adequate exposure for clipping, Arko et al. performed the surgery through a cranio-orbito-zygomatic (COZ) skull base approach, which is demonstrated. The surgery was performed in an operating room/angiography hybrid suite allowing for high quality intraoperative angiography. The technique and room flow are also demonstrated. The video can be found here: http://youtu.be/eePcyOMi85M 3).

Videos

Left pterional craniotomy for thrombectomy and clipping of ruptured left MCA giant aneurysm

Cranio-orbito-zygomatic approach of a giant MCA aneurysm in a hybrid angio/OR suite

References

1)

Bendok BR, Abi-Aad KR, Rahme R, Turcotte EL, Welz ME, Patra DP, Hess R, Kalen B, Krishna C, Batjer HH. Tulip Giant Aneurysm Amputation and “Shingle Clip Cut Clip” Technique for Microsurgical Reconstruction of a Giant Thrombosed Middle Cerebral Artery Aneurysm. World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32108-4. doi: 10.1016/j.wneu.2019.07.192. [Epub ahead of print] PubMed PMID: 31377441.
2)

Glauser G, Piazza M, Choudhri O. Aneurysm Dome Excision and Picket Fence Clip Reconstruction of a Previously Coiled Recurrent Giant MCA Aneurysm: Technical Nuances. World Neurosurg. 2019 Apr 1. pii: S1878-8750(19)30913-1. doi: 10.1016/j.wneu.2019.03.233. [Epub ahead of print] PubMed PMID: 30947002.
3)

Arko L, Quach E, Sukul V, Desai A, Gassie K, Erkmen K. Cranio-orbito-zygomatic approach for a previously coiled/recurrent giant MCA aneurysm in a hybrid angio/OR suite. Neurosurg Focus. 2015 Jul;39(VideoSuppl1):V8. PubMed PMID: 26132625.

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