Distal middle cerebral artery aneurysm: A proposition of microsurgical management

One-Stage Combined Open and Endovascular Treatment Using a Hybrid Operating Room is Safe and Effective for Distal Middle Cerebral Artery Aneurysms

BACKGROUND

Aneurysms located in the distal middle cerebral artery (DMCA) are relatively rare and lack an established treatment strategy. For DMCA aneurysms, we performed a one-stage combined procedure of endovascular parent artery occlusion (PAO) with coils and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in a hybrid operating room (HOR). The aim of this study was to evaluate the safety and efficacy of this procedure.

METHODS

Cases of unruptured DMCA aneurysms treated with the one-stage combined PAO and STA-MCA bypass in HOR were retrospectively examined, and patients' and aneurysmal backgrounds, surgical procedures, and treatment outcomes were analyzed.

RESULTS

Six patients were included in the study. The average maximum diameter of the aneurysms was 14.4 mm. One aneurysm was located at M2 and five at M3. All aneurysms had a fusiform shape. No cases were associated with infection, trauma, or malignant tumors. In all 6 cases, the combined PAO and STA-MCA bypass was successfully completed. No postoperative hemorrhagic complications occurred. A symptomatic ischemic complication occurred in 1 case whose symptom disappeared in a week. Three months after surgery, complete obliteration of the aneurysm and patency of the bypass was confirmed in all cases.

CONCLUSIONS

The one-stage combined PAO and STA-MCA bypass in the HOR is safe and effective for DMCA aneurysms, potentially serving as a treatment option for this complex aneurysm.

Microsurgical treatment of distal middle cerebral artery aneurysm: A single-center review

OBJECTIVE

To review the characteristics of distal middle cerebral artery (MCA) aneurysm treated by microsurgery, the detailed surgical options, and the clinical result.

METHODS

We retrospectively reviewed cerebral aneurysm in the M2 and M3 segments of the MCA surgically treated between January 2015 and December 2022. The demographic data, aneurysm-related findings, type of surgical approach, surgical technique, and clinical outcomes of the enrolled patients were analyzed.

RESULTS

Sixteen distal MCA aneurysms were treated with microneurosurgery (incidence, 1.0%; female, 12; mean age, 58.1 years; ruptured, three). Twelve aneurysms were in the M2 segment (insular segment), two aneurysms at the M2-M3 junction, and two aneurysms in the M3 segment (opercular segment). Twelve aneurysms were saccular (average size, 4.9 mm; multiplicity, 50%; average aneurysms, 3.0; partially thrombosed, 1; sidewall aneurysm, 2). Three aneurysms were fusiform, of which two were ruptured. Of the ruptured aneurysms, one was a ruptured dissecting aneurysm. The trans-sylvian and trans-sulcal approaches were used in fourteen and two patients, respectively. Neck clipping, wrap clipping, and surgical trapping were performed in twelve, one, and one patient, respectively. Proximal occlusion was performed in one patient. Bypass technique was required in two patients (neck clipping and proximal occlusion). The modified Rankin Score was 6 in the two patients with ruptured aneurysms. The remaining patients did not show further neurological deterioration after microneurosurgery.

CONCLUSIONS

Distal MCA aneurysms had a high incidence of being diagnosed with multiple other aneurysms and were relatively non-saccular.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

Ruptured Distal Middle Cerebral Artery Aneurysms-Characteristics and Strategy

BACKGROUND

Distal middle cerebral artery (dMCA) aneurysms are very rare. Most ruptured dMCA aneurysms lead to subarachnoid hemorrhage (SAH) coexisting with intracerebral hematoma (ICH), resulting in a deteriorating state. The risk factors of rupture of dMCA aneurysms remain unknown. To elucidate the risk of rupture, we studied differences between 4 ruptured and eleven unruptured dMCA aneurysms.

METHODS

We retrospectively analyzed patients diagnosed with a dMCA aneurysm according to the maximum size of the aneurysm, aspect ratio, and aneurysm size to vessel size (size ratio).

RESULTS

Four patients presented with SAH coexisting with ICH, resulting in a midline shift, caused by rupture of the dMCA aneurysm. The median aspect ratio of ruptured and unruptured dMCA aneurysms was 2.38 and 1.65, respectively, with no significant difference. The median maximum diameter of ruptured and unruptured dMCA aneurysms was 2.98 and 3.78 mm, respectively, with nonsignificant difference. The median size ratio of ruptured and unruptured dMCA aneurysms was 3.13 and 1.84, respectively, being significant difference (P < 0.02). The outcomes of 4 patients having ruptured dMCA aneurysm were as follows: one patient died due to the initial attack, and the others were severely disabled due to cerebral infarction caused by vasospasm.

CONCLUSIONS

Distal MCA aneurysms, even if they are small, may be likely to rupture leading to SAH complicated by ICH and result in a poor neurological state and unfavorable outcomes. We recommend aggressive treatment for dMCA aneurysms considering morphological factors such as the size ratio even if they are small and unruptured.

Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms

BACKGROUND AND PURPOSE

Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed.

RESULTS

Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8)  months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization.

CONCLUSIONS

The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.

Massive intracerebral hemorrhages due to peripheral middle cerebral artery aneurysm rupture: A case report with a surgical video

Background

Saccular aneurysm in the distal segment of the middle cerebral artery (DMCA) occurs very rarely and often represents with a rupture. We report a successful surgical case of a DMCA aneurysm rupture with large cerebral and subarachnoid hemorrhage.

Case Description

A 44-year-old female presented a sudden onset headache and coma (the Glasgow Coma Scale was 3). Head computed tomography (CT) revealed a subarachnoid hemorrhage around the right Sylvian fissure and large intracranial hematoma in the right parietal lobe. The CT angiography showed a saccular aneurysm in the peripheral cortical segment of the right angular branch of the right DMCA. We decided to perform a right craniotomy to evacuate hematoma and interrupt the aneurysm. Just after the dural incision, the aneurysm ruptured again. We applied a temporary clip on the artery proximal to the aneurysm before excising it.

Conclusion

Aneurysm in DMCA can be treated safely with surgical excision and risk of sudden recurrent hemorrhage needs to be anticipated.

Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review

OBJECTIVE

The use of endovascular treatment for ruptured middle cerebral artery (MCA) aneurysms, which have been more likely to be recommended for neurosurgical clipping because of the complex anatomic configuration, remains controversial. In the present study, the angiographic and clinical outcomes of endovascularly treated ruptured MCA aneurysms were systematically reviewed.

METHODS

Online databases, including Cochrane, Medline, Web of Science, and Embase, were retrospectively and systematically searched. The primary outcomes were the immediate complete occlusion rate, mortality, complication-related mortality, and procedure-related complication rate. Meta-analysis was performed using a random or fixed effect model based on heterogeneity.

RESULTS

A total of 14 studies with 1004 ruptured MCA aneurysms were included. The procedure-related mortality rate at discharge was 1.8% (95% confidence interval [CI], 0.9%-2.7%; I² = 0.0%; P = 0.623). The favorable clinical outcome rate at discharge was 65.4% (95% CI, 54.8%-76.0%; I² = 94.2%; P < 0.001) and had progressively increased to 73.2% (95% CI, 59.9%-86.5%; I² = 80.9%; P < 0.001). The overall complication rate was 22.7% (95% CI, 15.1%-30.3%; I² = 75.5%; P < 0.001).

CONCLUSION

Endovascular treatment of MCA aneurysms was related to a high incidence of procedure-related complications but a low rate of procedure-related mortality. The overall angiographic and clinical outcomes were comparable and warrant further investigation comparing clipping versus coiling for ruptured MCA aneurysms.

Endovascular treatment of distal middle cerebral artery aneurysms: Report of eight cases and literature review

BACKGROUND

Endovascular treatment is an alternative choice for the treatment of distal middle cerebral artery (dMCA) aneurysm, in addition to open surgery; but is still seldom considered. We performed this retrospective study to evaluate the outcome of dMCA in patients.

METHODS

During a period of 10 years, we were able to identify seven patients with a total of eight dMCA aneurysms that were treated endovascularly. They were five men and two women, with a mean age of 36.1 years. All of the aneurysms, including five infectious and three dissecting ones, were treated for the aneurysm and its parent artery's occlusion, using coils and/or glue.

RESULTS

The clinical follow-up (9-96 m, mean 36.8 m) showed that they all improved over baseline; except for one patient in whom a mild right hemiparesis remained, after the hematoma evacuation. Angiographic follow-up (7-24 m; mean: 14.6 m) showed that all of them were stable and without the need for recanalization.

CONCLUSIONS

Our data indicated that endovascular treatment is a safe and effective alternative for the treatment of dMCA aneurysms, and should be considered when treating these aneurysms.