Middle cerebral artery aneurysm case series

Middle cerebral artery aneurysm case series

A study of Gou et al. from the Beijing Neurosurgical Institute, included 285 cases of middle cerebral artery aneurysm surgery with MEP monitoring. The effects of MEP changes on postoperative motor function were assessed, and the key time point for minimizing the incidence of postoperative motor dysfunction was found through receiver operating characteristic (ROC) curve analysis. Motor dysfunction was significantly associated with the occurrence of MEP changes, and patients with irreversible changes were more likely to suffer motor dysfunction than were those with reversible changes. The critical duration of MEP changes that minimized the risk of postoperative motor dysfunction was 8.5 min. This study revealed that MEP monitoring is an effective method for preventing ischemic brain injury during surgical treatment of MCA aneurysm and proposes a critical cutoff for the duration of MEP deterioration of 8.5 min for predicting postoperative motor dysfunction 1).

2018

Esposito et al. from the Department of Neurosurgery, Clinical Neuroscience Center Zurich, report on a consecutive case-series of 50 patients who received clipping of 54 ruptured/unruptured middle cerebral artery aneurysm (MCA-aneurysms) by means of lateral supraorbital approach (LS) or minipterional craniotomy. The distance between MCA (M1)-origin and the aneurysmal neck is key to select the approach: LS was used for MCA-aneurysm located <15mm of the M1-origin and MP for MCA-aneurysms located ≥15mm of the M1-origin.

11 out of 50 patients presented with subarachnoid hemorrhage (10 ruptured MCA aneurysms). Overall, 59 aneurysms were successfully clipped (54 of the MCA). The mean distance between the M1-origin and the aneurysmal neck was 10.1-mm (range: 4-17mm) for patients treated by LS and 20-mm (range: 15-30mm) for MP. All but one MCA aneurysms were successfully treated. At last follow-up (mean 14 months), no reperfusion of the clipped aneurysms was observed.

The strategy for selecting the keyhole approach based on the depth of the aneurysm within the Sylvian fissure is efficient and safe. They suggest the use of LS approach when the aneurysm is located <15mm from the M1-origin and MP approach when the aneurysm is located ≥15mm from the M1-origin 2).

2015

Eighteen intracranial aneurysms, including 13 unruptured and 5 ruptured aneurysms, were treated with LVIS Jr stent-assisted coil embolization.

A total of 18 stents were successfully delivered to the target aneurysms, and the technical success rate was 100%. There was complete occlusion in 8 (44.4%) of 18 cases, neck remnants in 7 (38.9%) cases, and partial occlusion in 3 (16.7%) cases. In-stent thrombosis occurred in 1 case, and the symptoms disappeared after transvenous tirofiban injection. The modified Rankin Scale score at discharge was 0 in 14 patients, 1 in 3 patients, and 2 in 1 patient.

The LVIS Jr stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked MCA aneurysms with tortuous and smaller parent vessels 3).

2014

Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5-year period were analyzed in endovascular (n = 16) and microsurgical (n = 87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or “near complete” aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A “complex” aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series 4).

2013

Five hundred forty-three patients with 631 MCA aneurysms were managed with a “clip first” policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management.

Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001).

At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms 5).

1995

Ogilvy et al., reviewed 65 middle cerebral aneurysms in 62 patients operated on over a 5-year interval where a choice of operative approach was made based on preoperative evaluation of available radiological studies.

The superior temporal gyrus was used when intraparenchymal hematoma was present in the temporal lobe or when the length of the middle cerebral artery trunk was long (average length 2.44 +/- 0.41 SE cm). This approach was used in 20 operations on 22 aneurysms. The sylvian fissure approach was used in cases where the middle cerebral artery main trunk was short (1.32 +/- 0.41 SE cm) or the direction of the aneurysm was favorable. This approach was used in 38 operations. In 4 operations (5 aneurysms) we combined the two approaches to remove clot, obtain adequate exposure, and secure control of the proximal MCA.

In most cases of MCA aneurysms the decision as to which surgical approach to use is made preoperatively depending on the presence of intraparenchymal clot, size of aneurysm, direction of aneurysm, and length of the proximal middle cerebral artery 6).

References

1)

Guo D, Fan X, You H, Tao X, Qi L, Ling M, Li Z, Liu J, Qiao H. Prediction of postoperative motor deficits using intraoperative motor-evoked potentials in middle cerebral artery aneurysm. Neurosurg Rev. 2020 Jan 22. doi: 10.1007/s10143-020-01235-0. [Epub ahead of print] PubMed PMID: 31965363.
2)

Esposito G, Dias SF, Burkhardt JK, Fierstra J, Serra C, Bozinov O, Regli L. Selection strategy for optimal keyhole approaches for MCA aneurysms: lateral supraorbital versus minipterional craniotomy. World Neurosurg. 2018 Oct 13. pii: S1878-8750(18)32344-1. doi: 10.1016/j.wneu.2018.09.238. [Epub ahead of print] PubMed PMID: 30326308.
3)

Feng Z, Li Q, Zhao R, Zhang P, Chen L, Xu Y, Hong B, Zhao W, Liu J, Huang Q. Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent. J Stroke Cerebrovasc Dis. 2015 Jun;24(6):1357-62. doi: 10.1016/j.jstrokecerebrovasdis.2015.02.016. Epub 2015 Apr 4. PubMed PMID: 25851343.
4)

Dammann P, Schoemberg T, Müller O, Özkan N, Schlamann M, Wanke I, Sandalcioglu IE, Forsting M, Sure U. Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center. Neurosurg Rev. 2014 Oct;37(4):643-51. doi: 10.1007/s10143-014-0563-5. Epub 2014 Jul 9. PubMed PMID: 25005630.
5)

Rodríguez-Hernández A, Sughrue ME, Akhavan S, Habdank-Kolaczkowski J, Lawton MT. Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy. Neurosurgery. 2013 Mar;72(3):415-27. doi: 10.1227/NEU.0b013e3182804aa2. PubMed PMID: 23208060.
6)

Ogilvy CS, Crowell RM, Heros RC. Surgical management of middle cerebral artery aneurysms: experience with transsylvian and superior temporal gyrus approaches. Surg Neurol. 1995 Jan;43(1):15-22; discussion 22-4. PubMed PMID: 7701417.

Scalp cirsoid aneurysm treatment

Scalp cirsoid aneurysm treatment

In a systematic review, a total of 58.5% of cases scalp cirsoid aneurysm were managed with surgical excision only, 21.6% with endovascular embolization only, and 14.5% with a combination of both methods. 1).


The commonest artery involved in the scalp cirsoid aneurysm is the superficial temporal artery, due to its long and twisted course. The different methods of treatment include ‘en bloc’ resection and primary closure of the lesion, and sclerotherapy in which sodium tetradecyl sulfate is injected into the unwanted vessels with carbon dioxide gas, and the vessel is made to undergo sclerosis. The latter is associated with complications such as thromboembolismallergy and skin necrosis. Direct puncture endovascular embolization, using either chemical NBCA, absolute alcohol or mechanical coils, is another effective method widely used for AVM correction and an old method of ligation of feeding arteries, which is associated with the formation of collaterals and recurrence 2).


Heiferman published a case of a patient who underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in a operative video. Care was taken to identify, cauterize, and transect feeding vessels from the superficial temporal, supratrochlear, and supraorbital arteries circumferentially to completely devascularize and resect the galeal nidus from overlying scalp tissue and underlying pericranium. Previously unreported in the literature, transosseous emissary veins partially draining the lesion was noted on angiography and were waxed thoroughly during surgery 3).


Although most SAVMs can be operated by traditional method of excision, use of temporary clipping of feeding arteries (like Superficial temporal artery[STA], External carotid artery[ECA]) enables total excision of giant SAVMs with minimal blood loss for a definitive cure. This novel technique obviates the need for preoperative embolization 4).


Munakomi et al. presented one case where staged embolization, excision, and subsequent grafting was done 5).


Percutaneous injection of sotradecol can be considered as one of the treatment options for arteriovenous fistula of the scalp. Further experience is needed to compare the safety and effectiveness of sotradecol with other agents currently used in the treatment of scalp arteriovenous fistulae 6).


Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding 7).


Well-planned surgery of cirsoid aneurysm of the scalp without preoperative interventions could achieve complete excision of the lesion without any residual masses or recurrence and with a low incidence of complications 8)9).

References

1)

Sofela A, Osunronbi T, Hettige S. Scalp Cirsoid Aneurysms: Case Illustration and Systematic Review of Literature. Neurosurgery. 2020 Feb 1;86(2):E98-E107. doi: 10.1093/neuros/nyz303. Erratum in: Neurosurgery. 2019 Dec 1;85(6):861. PubMed PMID: 31384940.
2)

Elkin DC. Cirsoid aneurysm of the scalp with the report of an advanced case. Ann Surg 1924; 80:332-40.
3)

Heiferman DM, Syed HR, Li D, Rothstein BD, Shaibani A, Tomita T. Resection of an Embolized Cirsoid Aneurysm With Intracranial Venous Drainage: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2019 Mar 1;16(3):E94. doi: 10.1093/ons/opy303. PubMed PMID: 30295882.
4)

Gangadharaswamy SB, Maulyavantham Nagaraj N, Pai BS. Surgical management of scalp arteriovenous malformations using a novel surgical technique-Case series. Int J Surg Case Rep. 2017;37:250-253. doi: 10.1016/j.ijscr.2017.06.057. Epub 2017 Jul 8. PubMed PMID: 28715722; PubMed Central PMCID: PMC5514622.
5)

Munakomi S, Bhattarai B, Cherian I. Conquering the odds: Cirsoid aneurysm with holocranial feeders-staged embolization, excision and grafting. Asian J Neurosurg. 2015 Jul-Sep;10(3):259-61. doi: 10.4103/1793-5482.161167. PubMed PMID: 26396624; PubMed Central PMCID: PMC4553749.
6)

Hendrix LE, Meyer GA, Erickson SJ. Cirsoid aneurysm treatment by percutaneous injection of sodium tetradecyl sulfate. Surg Neurol. 1996 Dec;46(6):557-60; discussion 560-1. PubMed PMID: 8956889.
7)

Kumar A, Ahuja CK, Khandelwal N, Bakshi JB. Cirsoid aneurysm of the right pre-auricular region: an unusual cause of tinnitus managed by endovascular glue embolisation. J Laryngol Otol. 2012 Sep;126(9):923-7. doi: 10.1017/S0022215112001466. Epub 2012 Jul 5. PubMed PMID: 22874530.
8)

El Shazly AA, Saoud KM. Results of surgical excision of cirsoid aneurysm of the scalp without preoperative interventions. Asian J Neurosurg. 2012 Oct;7(4):191-6. doi: 10.4103/1793-5482.106651. PubMed PMID: 23559986; PubMed Central PMCID: PMC3613641.
9)

Chowdhury FH, Haque MR, Kawsar KA, Sarker MH, Momtazul Haque AF. Surgical management of scalp arterio-venous malformation and scalp venous malformation: An experience of eleven cases. Indian J Plast Surg. 2013 Jan;46(1):98-107. doi: 10.4103/0970-0358.113723. PubMed PMID: 23960313; PubMed Central PMCID: PMC3745130.

Basilar trunk aneurysm

Basilar trunk aneurysm

Basilar trunk aneurysms (BTAs), are basilar artery aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery.

Most aneurysms of the basilar trunk are fusiform in morphology. Surgical access for these is extremely difficult.

Classification

Case series

52 patients. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8-86) months, and imaging follow-up was 26 (interquartile range, 2-80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population (P=0.021). There was preponderance of segmental ectasia or mural bleeding ectasia (P=0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled.

BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage 1).

Case reports

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher’s Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient’s sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms 2).


A 37-year-old woman with basilar artery fenestration malformation and an aneurysm at the mid-distal junction; her symptoms included sudden headaches with nausea and vomiting.

Head digital subtraction angiography showed fenestration at the junction of the middle and upper portions of the basilar artery associated with an aneurysm, and spontaneous pseudoaneurysm formation could not be excluded.

The patient underwent stent-assisted fenestration and channel occlusion.

Five months later, no abnormalities were found by head magnetic resonance imaging. The stents were well positioned, and no occluded branches or aneurysms were present.

For mid-distal basilar artery fenestration malformation with an aneurysm, occlusion of the lesion channel is relatively safe when there are no perforating vessels in the fenestration channel and the lesion channel is a nondominant channel. Overall, more attention should be paid to the possibility of pseudoaneurysm formation in the diagnosis and treatment of this type of aneurysm 3).


A 61-year-old man presented with dysarthria and left hemiparesis attributable to a basilar trunk dissecting aneurysm. Antiplatelet therapy was instituted, and the patient’s clinical condition markedly improved. However, he developed severe headache, dysarthria, and left hemiparesis 35 days later. Angiography revealed significant enlargement of the aneurysm, and stent-assisted coiling was then uneventfully performed. The patient remained clinically stable with only mild left-sided hemiparesis at the 2-year clinical follow-up 4).

References

1)

Saliou G, Sacho RH, Power S, Kostynskyy A, Willinsky RA, Tymianski M, terBrugge KG, Rawal S, Krings T. Natural history and management of basilar trunk artery aneurysms. Stroke. 2015 Apr;46(4):948-53. doi: 10.1161/STROKEAHA.114.006909. Epub 2015 Feb 24. PubMed PMID: 25712945.
2)

Sai Kiran NA, Kiran Kumar VA, Kumar VA, Agrawal A. Microsurgical Clipping of Distal Basilar Trunk Aneurysm during Adenosine-Induced Profound Hypotension. Asian J Neurosurg. 2019 Nov 25;14(4):1214-1217. doi: 10.4103/ajns.AJNS_157_19. eCollection 2019 Oct-Dec. PubMed PMID: 31903365; PubMed Central PMCID: PMC6896639.
3)

Zhang D, Wang H, Feng Y, Xu N. Fenestration deformity of the basilar artery trunk with an aneurysm: A case report. Medicine (Baltimore). 2019 Jul;98(28):e16393. doi: 10.1097/MD.0000000000016393. PubMed PMID: 31305446; PubMed Central PMCID: PMC6641678.
4)

Fu C, Zhao C, Zhao H, Li D, Yu W. Growing dissecting aneurysm of basilar trunk treated with stent-assisted coiling. J Stroke Cerebrovasc Dis. 2015 Jan;24(1):e5-9. doi: 10.1016/j.jstrokecerebrovasdis.2014.07.033. Epub 2014 Sep 27. PubMed PMID: 25270634.

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