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Bypass surgery of complex middle cerebral artery aneurysms—technical aspects and outcomes

  • Original Article - Vascular Neurosurgery - Aneurysm
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Abstract

Background

The main challenge of bypass surgery of complex MCA aneurysm is not the selection of the bypass type, but the initial decision making of how to exclude the affected vessel segment from circulation. The aim of our study was to review our experience with the treatment of complex MCA aneurysms using revascularization and parent artery sacrifice techniques. Based on this, we aimed at categorizing these aneurysms according to specific surgical aspects in order to facilitate preoperative planning for these challenging surgical pathologies.

Methods

We reviewed 50 patients with complex MCA aneurysms that were not clippable but required revascularization and parent artery sacrifice. We report the individual variations of surgical techniques, highlight the technical aspects, and categorize the aneurysms based on their location and orientation.

Results

Of the 50 aneurysms, 56% were giant, 16% large, and 28% < 10 mm, but fusiform. Fourteen percent were previously treated endovascular. Four percent presented with SAH. Ten percent were prebifurcational, 60% involved the bifurcation, and 30% were postbifurcational. Both parent artery sacrifice and bypass strategies were tailored to the individual localization and anatomical relationship of the aneurysm and inflow/outflow arteries (38% proximal inflow occlusion, 42% aneurysm trapping, 20% distal outflow occlusion; 14% STA-MCA bypass, 48% interposition graft, 36%, combined/complex revascularization with reimplantation/in situ techniques). Good outcome (mRS 0–2) rates at discharge and at follow-up were 64% and 84%. Based on our analysis of individual cases, we categorized complex MCA aneurysms into six types and provide individual recommendations for their surgical exploration and treatment by revascularization and parent artery sacrifice.

Conclusion

Complex MCA aneurysms are among the most challenging vascular lesions and afford highly individualized treatment strategies. Revascularization and parent artery sacrifice provide durable results that are superior to the natural history. Our classification provides a tool for planning and pre-surgical assessment of the intraoperative anatomy of complex MCA aneurysms, helping to assume possible pitfalls.

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Authors and Affiliations

  1. Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany

    Lars Wessels, Lucius Samo Fekonja & Peter Vajkoczy

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  1. Lars Wessels
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  2. Lucius Samo Fekonja
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  3. Peter Vajkoczy
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Correspondence to Peter Vajkoczy.

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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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This work was part of an oral presentation at the 5th Annual EANS Vascular Section Meeting 2018. Nice, France

This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm

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Wessels, L., Fekonja, L.S. & Vajkoczy, P. Bypass surgery of complex middle cerebral artery aneurysms—technical aspects and outcomes. Acta Neurochir 161, 1981–1991 (2019). https://doi.org/10.1007/s00701-019-04042-9

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  • DOI: https://doi.org/10.1007/s00701-019-04042-9

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