Cerebral Artery Aneurysm:
Surgical repair by a mixed
Boris Zurita –Cueva M.D.
and Jaime Velasquez MD.
Hospital de la Policia
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Abstract: The key
for treatment of giant intracranial aneurysms
is its exclusion from the circulation and restoration of the normal
report describes the technique of the middle
cerebral artery bifurcation reconstruction using
microsuture aneurysmorraphy and clipping.
Key –Words: Giant aneurysm, Middle
cerebral artery, aneurysmorrhaphy.
Case report and
A 67 year-
old right handed woman presented with complaints of headache and
fever fifteen days before admission. She was diagnosed of
paludism, but during her stance at the hospital she suddenly presented
decreased of level of consciousness that evolves to coma.
On admission the
patient was comatose , with a score of 10 in
Glasgow coma scale, and a right hemiparesis.
Computerized tomography (CT)
revealed a 4cm mass in the left insular region with
perilesional oedema and subaracnoid
haemorrhage at this site.
Cerebral angiography confirmed the
presence of a partially trombosed
giant aneurysm at the left MCA bifurcation.
The patient’s level of
consciousness evolves to Glasgow 14 , two weeks
after admission , time when we decided to operate.
pterional approach was performed ,with
extensive drilling of orbitary fissure and anterior
clinoid process, in order to give space in front and
below de aneurysm and expose de M1 segment of the right middle cerebral artery.
The we opened the sylvian
fissure in a distal to medial manner. We took care not to close the M1 segment
until subpial dissection of the aneurysm was completed. We observed that both M2
segments were incorporated in its wall and originate from the aneurysm dome
making impossible the normal clipping procedure of the aneurysm. We tried many
times to reconstruct the anatomy of middle cerebral artery with a 20mm clip but
the pulse of the dome slipped out the clip. We proceed then to open the aneurysm
dome with a Nº11 knife, clipping previously the M1
segment. A microendarterectomy and blood clots
evacuation was performed. We proceed with resection of the aneurysm dome and
reconstruction with 8-0 micro suture of the
parent artery. A small neck rest of the aneurysm was created and this was
occluded conventionally with the 20mm clip. All the procedure lasted 30
minutes , with two periods of 15 minutes of temporal
clipping, protected with barbiturate and manitol
administration . At the end of the reconstruction
we observed surprisingly the increased flow and diameter in both M2.
The patient experienced an
uneventful postoperative course. The patient´s
neurological examination improved slowly ten days after.
The patient returned to her
previous activity and now is neurologically intact. The magnetic resonance
angiography showed disappearance of the aneurysm and preservation of
the vascular anatomy of the region.
Giant intracranial aneurysms,
defined as greater than 2.5 cm in diameter, represent about 5 % of all
intracranial aneurysms and usually originate from carotid artery.
Middle cerebral artery aneurysms
represent 13 % of this group. They produce
symptoms exerting mass effect, but some debute with
subaracnoid haemorrhage) (5,11).
Occasionally, they may present with ischemic symptoms related to distal emboli.
The surgical treatment is a real
challenge because the efferent vessels are incorporated at the aneurysm wall.
intraluminal clots and their big size make them impossible to clip.
Indirect surgical treatment do not
warrant cure and have high degree of
complications. Carotid cervical occlusion has a 27 % of ischemic
bypass and clipping the parent artery is
another alternative. Unfortunately ischemic complications
been reported even when the vascular bypasses were patent (3,4,6,14,15).
Wrapping the aneurysms
dome with muscle or muslin does not exclude a
new bleeding episode and distal embolization (7).
Definitive the ideal treatment is
aneurysms exclusion of circulation and reconstruction of the normal anatomy of
reconstructed giant aneurysmatic lesions performing
and clipping (8,18,19).
We have done a variant of this
technique :First we performed de
endarterectomy ,then we resect part of
the aneurysm dome , leaving part of it to form later a new artery by
microsuture and a standart
clip. This technique avoids the use of booster
clips and secures the correct reconstruction of the typical middle
cerebral artery anatomy .
This technique is reported like a
viable option in the management of difficult giant aneurysms of the MCA. We
recommended direct microsurgical approach and
reconstruction of this kind of lesion.
J. Spetzler R: Anastomosis
of the anterior temporal artery to a secondary trunk of the middle cerebral
artery for treatment of a giant M1 segment aneurysm. J
W, Spetzler RF, Carter LP: Reconstruction of
the MCA Bifurcation after excision of a giant
aneurysm. J Neurosurg 68: 974-977,1988.
Chang HS, Fukushima T,
Miyazaki S: Fusiform
posterior cerebral artery aneurysms treated with exicision
and end to end anastomosis.
JNeurosurg. 64 : 501-504,
Umansky F, Mehta B: Cerebral revascularitation
to a main limb of the middle cerebral artery in the sylvian
anastomosis. JNeurosurg 63: 21-29,1985.
Giant intracraneal aneurysms.
surgical treatment in
174 patients.CLIN Neurosurg
Fuji K ,Fujui
M, Nagata S. : Microsurgical procedures for management of giant middle cerebral
artery aneurysm causing increased intracranial pressure.
Surg neurol: 32:366-71,1989.
Suematsu K, Nakamura J : Transient ischemic
attacks caused by unrupture intracranial aneurysms.
Neurol. 17: 464-467,1982.
BR, Sundt TM Jr.:
Treatment of intracavernous and giant carotid
aneurysms by combined carotid ligation and extra to
intracranial bypass. JNeurosurg 52:1-10,1980.
Y: Giant intracranial aneurysms. JNeurosurg.51:743-756,1979.
Y: Giant intracranial aneurysms. In Wilkins R,Rengachary
Mc Graw-Hill.1985,Vol.2 ,p: 1404-1414.
HermanJM,Marciano F, and
Spetzler R: Rupture giant aneurysm of an occluded middle cerebral artery
in a severe –grade patient: Case report. Neurosurg.
Juhasz J., Coth S,
Horvath M.: The surgery of Middle cerebral artery aneurysms.
Acta Neurochirg (Wien)
Peerless S, Drake SJ: Treatment of
giant cerebral aneurysms of the anterior circulation.
Neurosurg Rev 5: 149-154,1982.
R, Arruda W, Prestes A:
Arterial graft reconstruction in an aneurysms of the
middle cerebral artery. Neurosurg 26:327-329,1990.
Neuwelt EA, Beyer CW: Failure of
extra-intracranial bypass in acute middle cerebral artery occlusion: Case
report. Neurosurgery 6: 185-188,1980.
R, Rina HA, Lemole M
Jr. : Giant aneurysms.
Neurosurg 49 : 902. 2001.
L, and Vadja J: Surgical
with giant intracranial aneurysms. JNeurosurg 61:
T, Piepgras DG: Surgical approach to giant
intracranial aneurysms . Operative experience with 80
. 51: 731-742,1979.
T , Piepgras DG: Booster
clips for giant and thick based aneurysms. JNeurosurg
60: 157-162, 1984.
shows a giant aneurysm of the left middle cerebral artery
Intraoperative view of the aneurysm. (A transitory clip is in the right
Complete reconstruction of the middle cerebral artery anatomy. (Observe both M2
segments TS, Ti)
Posoperative MRI angiography showing
patency of both M2 segments and reconstruction of
normal anatomy of middle cerebral artery bifurcation (yellow arrow).